Methotrexate or Hydroxychloroquine for Lichen Planopilaris?

Classic lichen planopilaris destroys hair follicles through inflammation, leaving permanent scarring. Its treatment aims to limit progression and relieve symptoms. The 2026 EADV position statement emphasizes these goals rather than promising full regrowth.¹

What did the randomized trial show?

The Iranian trial randomized 29 adults with biopsy-confirmed, treatment-resistant lichen planopilaris to methotrexate 15 mg weekly or hydroxychloroquine 200 mg twice daily for six months. Twenty-five completed treatment. These are research regimens, not instructions for your prescription.²

Among completers, the Lichen Planopilaris Activity Index fell 3.30 versus 1.51 points, favoring methotrexate (P=.01). Baseline activity was higher with methotrexate (4.63 versus 3.46), complicating interpretation. The analysis including withdrawals also favored methotrexate.²

The index combines symptoms, scalp inflammation, hair-pull findings and spreading. Masked photographic assessments showed no significant between-group difference. The trial therefore does not demonstrate that methotrexate restores scarred hair. Isfahan University funded it; authors declared no conflicts.²

Where do these medicines fit current care?

The EADV statement covers classic LPP; frontal fibrosing alopecia and other variants fall outside its scope. It generally places potent topical or injected steroids first, with systemic treatment considered for more active, progressive or resistant disease. Its treatment framework combines limited studies with expert judgment.¹

Ask the dermatologist which findings indicate ongoing activity in your scalp. Less itching, less inflammation around follicles and stable photographs should be recorded separately. Our LPP follow-up questions help prepare that discussion.

A six-month comparison in a small, previously treated sample cannot establish the best long-term sequence for every newly diagnosed patient.

What monitoring must be settled first?

Neither US label includes lichen planopilaris, making these uses off-label.³⁴

For prescribed weekly methotrexate, never substitute daily dosing. Its label reports deaths from that error. Blood counts, liver tests and kidney monitoring are required because serious toxicity can occur. For noncancer conditions, it is contraindicated during pregnancy; effective contraception is advised during treatment and for six months after the final dose for women who could become pregnant.³

Hydroxychloroquine has a different monitoring plan. Its label warns of irreversible retinal damage and recommends a baseline eye examination within the first year, with later screening adjusted for risk. Kidney impairment and tamoxifen use are among the factors that increase retinal risk. Confirm the eye-screening appointment and your actual prescribed dose.⁴

Hair, Everywhere includes “Your Hair Log,” with dated photographs and treatment start dates. It specifically sends scarring signs to a dermatologist promptly. Use the log alongside clinical monitoring; its six-month shedding observation rule is not a reason to delay care for LPP. See the book.