• Do not restart prednisolone or methotrexate on his own. Both need a diagnosis, monitoring, and prescription supervision.
• Permanent regrowth is unlikely in areas where follicles have already been destroyed by scarring, but treating active inflammation can preserve remaining hair. - Fitzpatrick's Dermatology, p. 1555
• Other possibilities must be ruled out, including seborrheic dermatitis, fungal scalp infection, bacterial folliculitis, discoid lupus, psoriasis, or non-scarring shedding.
• Take photos of the scalp now and weekly in the same lighting. Bring old prescriptions, biopsy reports, and the name of the previous diagnosis to the appointment.

What the dermatologist may use if inflammatory scarring alopecia is confirmed

1. Anti-inflammatory scalp treatment
   • Strong prescription corticosteroid lotion/foam/solution for the scalp
   • Steroid injections into actively inflamed patches in some cases
   • Sometimes tacrolimus or pimecrolimus as a steroid-sparing topical treatment
2. Oral treatment for active or spreading disease
   • Hydroxychloroquine or doxycycline are commonly considered initial systemic options.
   • If disease is more severe, progressive, or resistant, a specialist may consider methotrexate, mycophenolate, ciclosporin, retinoids, or a short supervised course of oral corticosteroid.
   • The aim is to stop burning, redness, itching, and further permanent follicle damage. It cannot reliably regrow hair from smooth, scarred areas where follicles are already gone. - Dermatology, 2-Volume Set, 5e, p. 1404
3. Hair-growth support
   • Topical minoxidil can sometimes help the remaining viable follicles and may be used as an add-on, but it does not control the inflammation or cure scarring alopecia.
   • Do not rely on minoxidil alone if the scalp is burning, red, or actively shedding.
4. Rule out infection before immunosuppressants
   • The dermatologist may perform dermoscopy, fungal testing/culture, and possibly a scalp biopsy from the red, scaly, hair-bearing edge. Treating an undiagnosed fungal infection with steroids or methotrexate can make it worse. A biopsy from an active margin is preferred in suspected scarring alopecia. - Fitzpatrick's Dermatology, p. 1554

Until he is seen

• Do not restart old prednisolone or methotrexate without a dermatologist. Methotrexate requires blood monitoring and folic-acid planning; steroids can mask infection and have important adverse effects.
• Avoid hair oils, harsh anti-dandruff products, chemical treatments, hair dye, scratching, tight headwear, and hot hair drying on inflamed areas.
• Use a gentle fragrance-free shampoo. If there is obvious greasy flaking, a clinician may suggest an antifungal shampoo, but that does not replace evaluation for scarring alopecia.
• Take clear weekly photos of the same scalp areas.
• Bring previous biopsy reports and old prescriptions. Knowing the exact former diagnosis changes treatment.

• Baseline CBC/platelets, liver tests, kidney function, hepatitis B/C and other infection-risk assessment as indicated
• Regular CBC, liver and renal tests, especially after starting or changing dose
• Folic acid supplementation, prescribed separately
• Review of alcohol use, other medicines, vaccinations, and pregnancy/fertility counseling where relevant

• A common initial assessment period is about 12 weeks.
• Published LPP experience includes treatment courses of roughly 4 to 24 weeks.
• If it is helping and blood tests are safe, the dermatologist may continue it for 6 months or longer, then reassess and reduce/stop gradually if the disease is inactive.

• MTX 15 mg once weekly orally or SC
• Reassess clinically and trichoscopically at 12 weeks
• Continue to 24 weeks (6 months) if there is improvement and safety labs remain acceptable
• At 6 months, if symptoms, perifollicular erythema/scale, pull test, and photographic progression are quiet, decide whether to stop, taper, or continue a maintenance strategy based on relapse risk.

• MTX 15 mg PO/SC weekly
• Folic acid per local protocol, commonly 5 mg once weekly on a non-MTX day, or 1 mg daily except MTX day
• Concurrent anti-inflammatory scalp therapy, such as potent topical steroid or intralesional triamcinolone for active margins
• CBC, AST/ALT, albumin, creatinine/eGFR at baseline, then every 1-2 weeks during initiation/dose change, and every 2-3 months once stable, consistent with SPS methotrexate monitoring guidance

• Methotrexate 10-15 mg once weekly PO or SC.
• In a young, otherwise healthy adult with clearly active/progressive disease and normal baseline screening, 15 mg once weekly is commonly used.
• If you prefer a cautious escalation, start 10 mg once weekly, then increase to 15 mg once weekly after 2-4 weeks if tolerated and activity persists.
• Never daily.

• Folic acid, per local protocol, commonly 5 mg weekly on a non-MTX day or 1 mg daily except MTX day
• Baseline CBC, LFTs including albumin, creatinine/eGFR, hepatitis B/C screening, and infection/TB risk assessment as appropriate
• CBC, LFTs, creatinine/eGFR every 1-2 weeks after initiation or dose escalation, then every 2-3 months when stable, per SPS monitoring guidance

• 2.5 to 5 mg once weekly for the first dose only if you want to assess tolerance or reduce dosing-error risk
• then 10 mg once weekly
• escalate to 15 mg once weekly after 2-4 weeks if tolerated and disease remains active

Evidence

• Both groups used clobetasol 0.05% nightly
• PRP arm received 3 intradermal PRP sessions, one month apart
• PRP plus clobetasol had lower LPPAI at months 2 and 6, better patient satisfaction, and no serious adverse effects. Behrangi et al., 2024 RCT, PMID 38525908

Practical approach

• First document activity: LPPAI, symptoms, perifollicular erythema/scale/casts, pull test, serial standardized photos and trichoscopy.
• Treat inflammation with your chosen medical regimen.
• Add PRP if active symptoms/signs persist, if systemic treatment is unsuitable, or as an adjunct where there are still viable follicles.

• 3 monthly sessions of intradermal autologous PRP, while continuing topical anti-inflammatory therapy.
• Review at months 3 and 6 using symptoms plus trichoscopy/photographs, not density alone.

Set expectations

• PRP may reduce burning, itch, perifollicular erythema/scale, and shedding.
• It may improve thickness/density only where follicles remain viable.
• It will not regrow hair in smooth shiny scarred scalp with absent follicular ostia.
• I would avoid calling it monotherapy for progressing LPP, especially in someone previously needing prednisolone/methotrexate.

1. Reconfirm activity and phenotype

• Symptoms: pruritus, trichodynia/burning, pain
• Standardized global photographs and trichoscopy
• Map active margins and assess for loss of ostia, perifollicular erythema, tubular scale/casts, positive pull test, and patch expansion
• Exclude superimposed tinea, bacterial folliculitis, contact dermatitis, psoriasis/seb derm if the presentation is atypical
• Consider a 4-mm biopsy from the active hair-bearing edge if the previous histology/diagnosis is unavailable or phenotype has changed.

2. Treat according to relapse severity

Mild, localized activity

• Clobetasol propionate 0.05% solution/foam to active margins, commonly 1-2 times/day in an induction schedule, then reduce frequency according to activity and atrophy risk.
• Intralesional triamcinolone to active inflammatory margins is reasonable for focal disease.
• Reassess with photos/trichoscopy in 6-8 weeks.

Moderate, multifocal, symptomatic, or progressive relapse

• Hydroxychloroquine: often 200 mg once or twice daily, not exceeding 5 mg/kg/day actual body weight. Suitable where disease is active but not explosively progressive. Baseline ocular assessment and risk-based retinal surveillance.
• Doxycycline: can be useful where the inflammatory burden is modest, though responses are variable.
• Methotrexate: appropriate in refractory, more active, or previously MTX-responsive disease. For this patient, if baseline screening is satisfactory, 10-15 mg once weekly, escalating to 15 mg/week if needed, is a reasonable practical approach. Use folate and standard laboratory monitoring.
• Mycophenolate mofetil is a reasonable alternative where MTX is unsuitable or ineffective.

Rapidly progressive, painful, highly inflammatory relapse

• A short oral prednisolone bridge can be considered while waiting for HCQ, MTX, or MMF to act.
• The EADV statement describes prednisone 0.5-1 mg/kg/day, reassessment after around 1 month, then taper over the following 4-6 weeks. This is a bridge strategy, not long-term maintenance. EADV management guidance
• Start the steroid-sparing systemic agent concurrently rather than waiting for relapse after steroid withdrawal.

3. A practical plan for this case

1. Document active LPP and exclude infection.
2. Start potent topical steroid to active margins, with intralesional steroid for defined active patches.
3. If multifocal/progressive, restart a systemic steroid-sparing agent. If he had a good prior MTX response and tolerated it, MTX is a rational choice.
4. Reserve short prednisolone for genuinely rapid inflammatory progression or severe symptoms, alongside rather than instead of MTX/MMF/HCQ.
5. Review at 6-8 weeks, then around 12 weeks with symptoms, photographs, patch measurements, and trichoscopy.
6. Continue effective systemic treatment long enough to establish inactivity, commonly at least 6 months, then individualize de-escalation. Relapse after discontinuation is common, so continue local anti-inflammatory treatment during and after systemic withdrawal. - Fitzpatrick's Dermatology, LPP section

4. PRP and minoxidil

• PRP can be offered as an adjunct, particularly where there are residual follicles and ongoing symptoms, but it should not replace immunomodulatory treatment in active progressive LPP.
• Topical or low-dose oral minoxidil can support remaining non-scarred follicles or concomitant androgenetic alopecia. It does not suppress the LPP inflammatory process.

5. What to measure

• Symptoms
• Active-margin erythema and perifollicular scale/casts
• Pull test
• Patch diameter and new patches
• Follicular ostia on trichoscopy
• Serial standardized photographs

Role of topical steroids in LPP

Where they fit

• First-line monotherapy for mild, localized active LPP.
• Adjunctive therapy in moderate, multifocal, or relapsing LPP when systemic therapy is used.
• Important during and after systemic treatment tapering, because relapse is common.

Typical agent and schedule

• Clobetasol propionate 0.05% solution, foam, or lotion is the usual choice for scalp LPP.
• The recent EADV position statement describes use 1-2 times daily, 3-7 days/week, with frequency adjusted to disease activity and gradual tapering once control is achieved.
• A practical induction approach is daily application to active areas for several weeks, followed by reduced-frequency maintenance according to clinical and trichoscopic activity.

Expected benefit

• Relief of burning and itch may occur earlier.
• Reduction in perifollicular erythema and scaling is expected if inflammation is responding.
• It is useful for preserving remaining follicles, but will not induce meaningful regrowth in areas with absent ostia and established fibrosis.

Limitations and adverse effects

• Scalp atrophy
• Telangiectasia/prominent capillaries, potentially mistaken for persistent erythema
• Folliculitis/acneiform eruption
• Hypopigmentation
• Rare systemic absorption with extensive prolonged use

In this 23-year-old male

• Start 1.25 mg once daily if you want a cautious introduction, especially if baseline BP is low-normal or there is concern about tolerability.
• Increase to 2.5 mg once daily after 4-8 weeks if tolerated and more density support is desired.
• In LPP literature, the median male dose was 2.5 mg/day. Doses used across hair disorders range from 0.5-5 mg/day, but I would not routinely move beyond 2.5 mg/day for this indication unless there is concomitant significant androgenetic alopecia and good tolerance.

Suggested place in the relapse plan

• Start anti-inflammatory LPP control first or concurrently: potent topical steroid to active margins, plus intralesional or systemic treatment according to activity.
• Add LDOM once daily for residual diffuse thinning, miniaturization, or background-density support.
• Assess at 6 months for shedding/thickness and photographs. Continue long term if benefiting and tolerated. Stopping can result in loss of minoxidil-dependent gains over subsequent months.

Baseline and monitoring

• BP, pulse, body weight
• Cardiovascular history: arrhythmia, heart failure, pericardial disease, ischemic symptoms, renal impairment
• Review antihypertensives, diuretics, vasodilators, PDE5 inhibitors, and other causes of hypotension

• Hypertrichosis
• Ankle/periorbital edema or weight gain
• Lightheadedness/postural symptoms
• Palpitations or tachycardia
• Headache