• 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.