Response of Lichen Planopilaris to Pioglitazone Hydrochloride
December 2019 | Volume 18 | Issue 12 | Case Reports | 1276 | Copyright © December 2019
Erik L. Peterson BS, Daniel Gutierrez MD, Nooshin K. Brinster MD,
Kristen I. Lo Sicco MD, Jerry Shapiro MD
The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY
Lichen planopilaris (LPP) is a cicatricial alopecia that often causes permanent hair loss. Pioglitazone, a peroxisome proliferator activated receptor-gamma (PPAR- γ) agonist, has demonstrated immunomodulatory properties that may offer an effective treatment modality. This retrospective analysis describes 23 patients with LPP treated with adjunctive pioglitazone. Most (18/25) demonstrated significant reduction in patient-reported symptoms and clinical signs of inflammation. No adverse effects were reported.J Drugs Dermatol. 2019;18(12):1276-1279.
Lichen planopilaris (LPP) is a cicatricial alopecia characterized by perifollicular hyperkeratosis, erythema, permanent hair loss, and pruritus, pain or burning in affected areas. LPP demonstrates four clinical variants that share similar histologic findings: frontal fibrosing alopecia (FFA), Graham-Little-Picardi-Lasseur syndrome (GLPL) and fibrosing alopecia in a pattern distribution (FAPD).1,2 Together, these represent the most common primary scarring alopecias.1,2 Histopathology reveals lymphocytic infiltrates centered around the follicular infundibulum, interface dermatitis, and progressive perifollicular hyperkeratosis and fibrosis.7 Treatment centers on reducing disease symptomatology and decreasing inflammation to prevent scarring. Most therapeutic regimens consist of high potency topical glucocorticoids and immunosuppressants, topical minoxidil, intralesional glucocorticoids, and systemic anti-inflammatory agents such as doxycycline and hydroxychloroquine.3 While the pathogenesis of LPP is poorly understood, disease activity likely involves a combination of hormonal and androgenetic factors with autoinflammatory destruction of the hair follicle.4 The perioxisome proliferator-activated receptor gamma (PPAR- γ) pathway has been of interest as an additional tool in the treatment of LPP. One study demonstrated a reduction in PPAR- γ tissue expression in LPP,5 although these results were not reproducible in another study.6 Decreased PPAR- γ expression results in increased inflammatory lipids, local inflammation, and destruction of the pilosebaceous unit.5 Thus, PPAR- γ agonists may be efficacious in addressing the underlying pathology of LPP. This study represents single-center retrospective analysis of 23 patients with LPP who were treated with pioglitazone at a Hair and Scalp Disorders Clinic at New York University Langone Health (NYULH).
A retrospective review of all patients with LPP who presented to NYULH between October 1, 2007 and August 18, 2018 was performed. A total of 252 unique patients were identified using International Classification of Disease billing codes and natural language corresponding to LPP, FFA, or GLPL. All individuals age 18 to 89 years of age with diagnosis of LPP, FFA, or GLPL were included. When necessary, biopsy was performed for diagnostic guidance. A total of 23 patients who were treated with pioglitazone were identified. All patients were started on 15 mg orally once daily and increased to 30mg if well-tolerated.
These patients were evaluated for clinical changes in degree of inflammation and progression of alopecia. Hairline measurements from bilateral outer canthi and glabella to the frontal and temporoparietal hairline were utilized as a means of tracking progression of disease. Improvement was defined as stabilization of disease (lack of further progression of hair loss or recession of hair line) and resolution of symptoms as assessed by the patient perception. This study was approved by the NYULH Institutional Review board.