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An autoimmune approach for care of a patient presenting with Lichen Planopilaris.

Introduction:

Lichen Planopilaris (LPP) was first described by Pringle in 1895. (1) It is a skin disorder that selectively attacks hair follicles with a lymphocytic inflammatory process that progressively destroys the follicle, causing patchy baldness. It is considered a primary cicatricial alopecia. LPP is classified in the lymphocytic group according to the North American Hair Research Society(NAHRS). (2)

Although primary cicatricial alopecias (PCAs) are rare disorders that lead to permanent hair loss, LPP is the most common form. They have been poorly understood and resistant to treatment. Lichen planopilaris (LPP) is a prototypical PCA that results in patchy progressive permanent hair loss, mainly on the scalp. It usually affects young adult women, although the age range is wide, and it can also affect men. It commonly develops in association with lichen planus, affecting the skin, mucosa and nails. Although it is a rare condition, it is one of the common causes of scarring hair loss of the scalp.

The etiology of LPP is unknown, but is thought to be an autoimmune disorder in which T-lymphocytes attack and destroy keratinocytes, expressing unknown target antigens. (3) Triggering factors could be pharmacologic agents, contact sensitizers or infectious agents.

Lichen planopilaris typically presents as smooth white patches of scalp hair loss. The patients often present with sudden onset of hair loss and clinically significant symptoms of itching, burning, and pain of the scalp. No hair follicle openings can be seen in the areas of hair loss. At the edges of these patches there may be scale and redness around each hair follicle. Hairs can be easily pulled out. It is multifocal and small patches may merge to form larger irregular areas.

Common sites of involvement are the sides, front and lower back of the scalp. Symptoms are often absent but they may include: itch, pain, tenderness, discomfort and burning. It is usually a slowly progressive disorder.

Lichen planopilaris is suspected by the clinical presentation as well as a careful examination of the mouth, nails and skin for evidence of lichen planus elsewhere. Trichoscopy reveals absent follicles, white dots, tubular perifollicular scale and perifollicular erythema. The diagnosis may be confirmed on a scalp biopsy that includes hairs with surrounding redness and scale at the edge of an area of hair loss. Lichen planopilaris is an example of a primary lymphocytic folliculitis. It is not always possible to make a diagnosis on biopsy. Biopsy from an already scarred area of hair loss is unhelpful. Where there is only patchy scarring hair loss, and no evidence of inflammation, the diagnosis may not be able to be confirmed.

The primary treatments for LPP are anti-inflammatory and immunosuppressant medications. Overall, symptoms may improve, but hair loss is often progressive. The goal of treatment is to alleviate symptoms and signs and arrest the progression of hair loss. It is generally thought that hair regrowth is not possible after destruction of the follicles has occurred. The aggressiveness of treatment will usually be determined by the extent of the disease. (4,5) Topical and intralesional corticosteroids, oral antibiotics, and hydroxychloroquine sulfate are the most common approaches for active disease. Oral prednisone, mycophenolate mofetil, and cyclosporine have been advocated (6,7) in progressive disease states resistant to the first line therapies.

Traditional therapies directed at LPP are potentially toxic and hold the potential for unwanted side effects. At best, these therapies may halt or slow down the progression of the disorder. At worst people will not respond to LPP and the disease will progress and/or they will suffer from unwanted side effects. None of these therapies are directed toward causative factors, but rather are directed toward ameliorating the effects. LPP is thought to be an autoimmune disorder. Therefore, it is suggested in this case study, to address the condition along the lines of an autoimmune disease. A potentially long term success strategy will address the fundamental drivers of the upregulated immune system, with the purpose of stabilizing or eradicating as many of these factors as can be achieved clinically.

Case Presentation:

A 32 year old Caucasian female was admitted into our clinic on April 6, 2015, with a prior diagnosis of lichens planopilaris (LPP). She is married with 2 children, 8 and 5 years old, and works as a dental assistant.

This patient reported first noticing a small bald spot on top of the head following the birth of her first child. For three years, that small bald spot remained without progression. Following the birth of her second child, more hair starting falling out and her scalp felt like pins and needles as well as burning. The intensity of pain would average six on a 1-10 scale, but could flare up to eight to nine. After dealing with this condition for a couple years, the patient sought out a dermatologist, who diagnosed her with LPP. She displayed classic signs and symptoms of LPP and a biopsy confirmed the diagnosis.

The patient tried to use the topical solution clobetasol, scalp injections, and plaquenil without success. After six weeks of plaquenil she developed a rash on her abdomen. She decided to stop all meds to not risk more potential side effects. She continued to take naproxen for pain of the scalp. The next treatment suggested by the dermatologist was methotrexate and she refused this treatment. It was at this time that she decided to visit our clinic.

In her history, she stated that she had an episode of cat scratch fever in 4th grade. The condition was significant enough for her to be hospitalized. She also related that she had been on over ten rounds of antibiotics throughout her lifetime.

In the patient's past medical history, she reported having been diagnosed with PCOS. Unrelated to the PCOS, she had been on birth control medication from 2002 up until just prior to being pregnant with her first child. She took fertility drugs shortly before her first pregnancy. She did not use fertility drugs for the second child. Following the second child, five years prior to this visit, she began another course of birth control medication and she stopped this regime one year prior to her visit in our office.

The patient experienced random attacks where her skin was sensitive to touch in the thighs, upper arms and right side of her face. She also had random twitches of the facial muscles. Upon her initial visit into our clinic she continued to complain of a pins and needles feeling and burning on her scalp, with the overall associated pain remaining at six. She additionally complained of being shaky when hungry and a slow-starter in the morning.

The patients initial vitals were as follows: wt: 121.5 pounds, temp: 97.8 F, BP (left arm): 108/64, pulse ox: 99, pulse: 69, ht: 60 inches.

The examination revealed deficits in the CN IX, X, and XII. The patient had an absent gag reflex and the left hard palate did not elevate symmetrically on the palate elevation assessment. She demonstrated tongue fasciculation and a left tongue deviation. Rhomberg's was positive, left. Lymph node swelling was noted in the cervical chain, bilateral. She had a bounding pulse. The abdominal examination revealed tenderness in the upper right quadrant upon palpation. A paraspinal thermography examination was performed using the C-5000 Tytron infra-red instrument. (8) The purpose of this exam was to determine the temperature symmetry from one side of the cervical spine to the other. Abnormal thermographic readings have been connected to aberrant autonomic function originating from a malpositioned cranio-cervical junction. (9) A leg length inequality exam was performed with the patient in the prone position and an eight mm functional right short leg was detected. (10)

An APOM full cervical and neutral lateral x-ray examination was performed and the following relevant findings were revealed: Mild degenerative changes are noted in the mid to lower cervical spine. Of significance for this case, the odontoid process was found to be 5 mm above Chamberlain's line. This finding indicates basilar invagination or a patient on the brink of basilar invagination. There are other related malformations of Cl including agenesis of its posterior arch. The first cervical vertebra is anterior relative to its corresponding condyle and superior relative to the anterior atlas tubercle with left laterality.

Blood and urine examinations were performed for the purpose of assessing any underlying factors to this patient's condition. A lipid panel, CMP, CBC w/diff, uric acid, magnesium, phosphate, TSH, T4 total, T4 free, T3 total, T3 free, T3 uptake, reverse T3, LDH, vitamin D 25-OH, iron and ferritin were performed along with a micro UA. In addition to these blood examinations, a food sensitivity IgG ELISA was ordered for 96 foods. The following relevant findings were revealed through this examination.

The micro UA was within normal limits in all aspects. The impressions derived from the blood examination correlated with many of the presenting signs and symptoms:

1. Liver congestion with functionally low ALT, BUN and cholesterol

2. Functional hypothyroid with functional low TSH, alkaline phosphatase and free T3/rT3 ratio

3. Iron deficiency anemia with ferritin of 6 ng/mL, iron 23 mcg/dL, RBC 3.68 million/uL, hemoglobin 10.4 g/dL, hematocrit 32.0%

4. Distribution of neutrophils is 73.7% and lymphocytes 24.4% (The absolute monocyte count is clinically low along with eosinophils. Although the WBC of 6.0 thousand/uL is functionally normal there is a clinical suspicion of chronic infection)

The patient demonstrated multiple food sensitivities, including; gluten, milk, cheese, chicken eggs, almonds, green beans, pinto beans, apples, bananas, safflower, tuna, broccoli, pineapple, cabbage, bakers and brewer's yeast. Her sensitivity to bakers and brewer's yeast were significantly high and is generally related to a systemic fungal infection.

The initial care provided for this patient started with the first 2 weeks on a 14 day paleo detox which included protein powders, amino acids, digestive support and a specific diet related to the paleo style, concentrating on eliminating all grains with the exception of brown rice. Following this 14 day Paleo detox, the patient was moved to a vegan protein powder blend she mixed with a green product. The protein powder consisted of a rice, pea, hemp, chia, and cranberry blend. It also contained milk thistle, calcium d-glucorate and sulphoraphane. The green product had various fruit and vegetable extracts, an antioxidant blend, probiotic blend and digestive enzyme blend. She continued these morning shakes for breakfast throughout her care program. She continued on with the Paleo style diet as well as avoiding her known food sensitivities.

She additionally began a regime of iron (Ferrochel[R] ferrous bisglycinate chelate 27mg each), 2 tablets b.i.d. The patient was instructed to consume 1/2 teaspoon of buffered ascorbic acid equal to 2000 mg vitamin C, b.i.d. with the iron for improved assimilation of the chelated iron. The clinical reasoning behind this protocol was to improve the iron deficiency anemia. The patient was additionally recommended to drink 1/2 cup chlorella mixed with watered down juice of her choice to support the low hemoglobin levels for four weeks, for the purpose of assisting the elevation of hemoglobin. She was advised to put stevia in the chlorella mixture for toleration.

The patient underwent a course of upper cervical chiropractic care concomitant to the above protocol described. Her initial examination revealed a positive thermographic reading along with neurological exam findings to indicate possible blood flow and cerebral spinal fluid flow issues at the base of the brain. (11,12) It has been shown that an upper cervical chiropractic correction can improve blood flow at the base of the brain and therefore have a positive impact on the autonomic nervous system. In cases of autoimmune disorders, it is important that all factors be considered, that will have a positive impact on autonomic function. Knee chest upper cervical specific (KCUCS) was the upper cervical chiropractic technique employed in this case. (13-15) Her post thermographic readings and leg length equality exams demonstrated a positive outcome and the patient related feeling better following this specific portion of her care.

Three months following the initiation of care the patient remarked that her scalp pain, the feeling of pins and needles and burning scalp sensation had all disappeared since the initial two weeks care. A repeat CBC w/ diff, iron and ferritin were obtained on this visit. It revealed a ferritin that doubled at 14 ng/mL and the iron was within a functional normal at 99 mcg/dL. The RBC, hemoglobin and hematocrit have continued to improve. However, the distribution of neutrophils and lymphocytes were basically the same as the initiation of care.

It was decided on this visit, three months into the care program, to start an antimicrobial protocol using herbs and silver directed toward a systemic fungal infection. The food sensitivity examination indicated a probable systemic fungal infection. The neutrophil/lymphocyte distribution remained resistant to care even with positive clinical progress made in the other measured areas. All factors hinted at the possibility of an underlying chronic infection. Following the patients consent, we proceeded with an infection protocol focused on a fungal infection. The herbs selected were Biocidin[R] and Olivirex[R], an olive leaf extract, along with Silvercillin[R]. The patients dietary patterns remained the same as well as the protein/green breakfast shake and other supplements described previously.

Outcome:

The patient reports on her two week return visit that she no longer has to take naproxen for scalp pain. Following this initial two week regime the patient reported having no pain, pins and needles, or burning in her scalp. She related that the diet was challenging to get used to, but she was satisfied with her results. She also noticed a slight increase in energy. A repeat CBC with differential was performed at this time, two weeks into care, for the purpose of evaluating anemia, as well as, investigating any clues for chronic infection. The RBC, hemoglobin, and hematocrit all improved, but the hemoglobin remained outside of clinical range. At the three month mark of care, we initiated a protocol for the purpose of addressing fungal infection. Ten weeks following the initiation of the fungal infection protocol, a blood re-examination was performed consisting of CBC w/diff, iron and ferritin. The ferritin had increased to 22 ng/mL. The patient related that her energy level was much better. The iron was within normal limits. The CBC w/diff neutrophil and lymphocyte distribution had shifted into a functionally normal zone of 63.6% and 31.0% respectively. At the date of the last described blood work, a little over 5 months from the initiation of care, the patient had not had scalp pain or the earlier related symptoms following the first two weeks of care. She stated, "I don't want to be too quick to say, but there are very short hairs that seem to be growing sporadically throughout the bald area." The patient remarked that she no longer has random episodes of skin sensitivity on her thighs, upper arms and face. She states that her energy level has significantly improved and she has an overall sense of well-being.

Discussion:

This patient first noticed a small bald spot within a few months following the birth of her first child. The condition remained dormant for the next three years until shortly after the birth of her second child. It was at this time the condition began to progress. It is commonly known that through pregnancy a woman's immune system shifts toward more Th2 dominance. (16) It is thought that rising levels of estrogen and progesterone promote a downregulation of the Th1 pathway and upregulation of the Th2 pathway. The immune system focusing on humoral immunity and blocking the cell mediated response is an innate mechanism keeping the mother from rejecting the developing baby. Following pregnancy, there is a shift back toward the Thl pole. When there are underlying factors, this pole shift can be a tipping point for a Thl dominate autoimmune condition. (17) Lichens Planus is considered a Th1 dominant autoimmune disorder and the clinical presentation in this case fits the scenario described. (18) This case was addressed from the autoimmune approach and specifically not approached by directly addressing the presenting signs and symptoms. Our clinical pathway concentrated on addressing all known factors that would potentially upregulate the immune response. Fasano detailed the role of leaky gut in autoimmune. (19) He related how the gut barrier, consisting of the gut-associated lymphoid tissue, the neuroendocrine network, the intestinal epithelial barrier with its tight junctions, controls the equilibrium between tolerance and immunity to non-self antigens. Our initial plan was to support the gut barrier system. We did this through protein powders, amino acids, probiotics, and digestive enzyme support. A food sensitivity examination was performed with the idea of reducing the level of immune system upregulation as well as reducing stress on the gut barrier. We additionally supported the gut barrier by supporting the iron deficiency anemia. (20) The malposition detected at the cranio-cervical junction has been shown to compromise vagal function and therefore is a factor in this case to be addressed for the additional purpose of supporting intestinal permeability. (10)

The functional hypothyroid noted in the case study portion was not directly addressed, because it was thought by the clinician to be a secondary effect from the other foundational issues listed. The patient experienced improvements in symptoms by following the initial basic fundamental steps. Later in the care program, we addressed the suspicious infection due to the CBC neutrophil/lymphocyte distribution, unrelenting in its pattern. This indicated to the clinician that an underlying infection was probable. The food sensitivity examination showed significant levels of IgG antibodies to bakers and brewer's yeast and the CBC neutrophil/lymphocyte differential were consistent with fungal infection. The improvement in the post CBC neutrophil/lymphocyte distribution indicated an improved immune response to the fungal infection. It appeared clinically as though the infection protocol was the tipping point for the small amount of hair regrowth noted by the patient.

Hepatitis C has been found associated with Lichen Planus. (21) There are many anecdotal stories related lichens planus to fungal infections but it lacks solid literature support. (22) It is plausible that the infection protocol was effective in addressing a chronic infection. The sporadic hair growth in the bald spots are likely a result of the reversing of LPP. Follicles that were destroyed through the process are not probable to regrow hair. The hair growth noticed by the patient apparently is coming from follicles that were not completely destroyed through the inflammatory process. (23)

Conclusion:

A successful outcome was achieved in this case by approaching the patients, care, as would be prudent for any autoimmune disorder or disease. We used diet, lifestyle and specifically targeted nutraceuticals based on examination, including blood and urine labs, to target fundamental underlying drivers of the upregulated immune system. This is a single case study and should be interpreted on that basis. Therefore, it is hard to draw concrete conclusions. Case studies such as this one are important on the basis of providing motivation for further study. The author encourages more study to be done on the application of the methods used in this case for the successful management of autoimmune diseases.

About the Author:

Robert Kessinger, DC, DABCI, DACBN graduated Logan College of Chiropractic in 1988. He is the founder and director of the Knee Chest Upper Cervical Specific (KCUCS) Chiropractic technique as well as KCUCS World Missions. He is an instructor in the DABCI program and is currently 1st Vice President of the Missouri State Chiropractors Association. Dr. Kessinger has been in practice over 20 years in Cape Girardeau, MO. and Rolla, MO. Dr. Kessinger also participates in a weekly radio show, A Healthy Concept, every Tuesday morning. Email: rkessinger7@gmail.com.

References:

(1.) Pringle JJ: Cited by Adamson HG. Lichen pilaris spinulosus. Br J Dermatol 17:78-9, 1905.

(2.) Olsen EA, Bergfeld WF, Cotsarelis G, et al: Workshop on cicatricial alopecia. Summary of North American Hair Research Society (NAHRS)-sponsored work-shop on cicatricial alopecia, Duke University Medical Center, February 10 and 11, 2001. J Am Acad Dermatol 48:103-110, 2003

(3.) Assouly P, Reygagne P: Lichen Planopilaris: update on diagnosis and treatment.

(4.) Seminars in cutaneous medicine and surgery (Impact Factor:1.34). 04/2009; 28(1):3-10.

(5.) Mirmirani P, Willey A, Headington JT, Stenn K, McCalmont TH, Price VH. Primary cicatricial alopecia: histopathologic findings do not distinguish clinical variants. J Am Acad Dermatol. 2005;52(4):637-643.

(6.) Price VH. The medical treatment of cicatricial alopecia. Semin Cutan Med Surg. 2006;25(1):56-59.

(7.) Harries MJ, Sinclair RD, Macdonald-Hull S, Whiting DA, Griffiths CE, Paus R. Management of primary cicatricial alopecias: options for treatment. Br J Dermatol. 2008; 159(1):1-22.

(8.) Kang H, Alzolibani AA, Otberg N, Shapiro J. Lichen planopilaris. Dermatol Ther. 2008;21(4):249-256.

(9.) McCoy M, Campbell I, Stone P, Fedorchuk C, Wijayawardana S, Easley K: Intra-Examiner and Inter-Examiner Reproducibility of Paraspinal Thermography. PLoS One. 2011; 6(2): e16535.

(10.) Kessinger RC, Anderson MF, Adlington JW: Improvement in Pattern Analysis, Heart Rate Variability & Symptoms Following Upper Cervical Chiropractic Care. Journal of Upper Cervical Chiropractic Research ~ May 9, 2013 ~ Pages 32-42

(11.) Woodfield HC, Gertsman BB, Olaisen RH Johnson DF. Interexaminer reliability of supine leg checks for discriminating leg-length inequality. J Manipulative Physiol Ther 2011; 34(4): 239-246.

(12.) Damadian RV, Chu D: The possible role of cranio-cervical trauma and abnormal CSF hydrodynamics in the genesis of multiple sclerosis. Physiol Chem Phys & Med NMR (20 September 2011) 41:1-17.

(13.) Bakris G, Dickholtz M Sr, Meyer PM, Kravitz G, Avery E, Miller M, Brown J, Woodfield C. Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study. J JHum Hypertens. 2007 May;21(5):347-52. Epub 2007 Mar 2

(14.) Kessinger RC, Moe C. Improvement in Chronic Hypertension Following a Single Upper Cervical Adjustment: A Case Report. Journal of Upper Cervical Chiropractic Research ~ January 19, 2015 ~ Pages 1-5.

(15.) Kessinger RC, Matthews A. Resolution of Trigeminal Neuralgia in a 14 Year Old Following Upper Cervical Chiropractic Care to Reduce Vertebral Subluxation: A Case Study. Journal of Upper Cervical Chiropractic Research ~ August 30, 2012 ~ Pages 77-84

(16.) Kessinger RC, Boneva DV Vertigo, tinnitus, and hearing loss in the geriatric patient. June 2000. Volume 23, Issue 5, Pages 352-362

(17.) Reinhard G, Noll A, Schlebusch H, Malimann P, Ruecker AV. Shifts in the TH1/TH2 balance during human pregnancy correlate with apoptotic changes. Biochem Biophys Res Commun. 1998 Apr 28;245(3):933-8.

(18.) Doria A, Iaccarino L, Arienti S, Ghirardello A, Zampieri S, Rampudda ME, Cutolo M, Tincani A, Todesco S. Th2 immune deviation induced by pregnancy: the two faces of autoimmune rheumatic diseases. Reprod Toxicol. 2006 Aug;22(2):234-41. Epub 2006 May 15.

(19.) Wang Y, Zhou J, Fu S, Wang C, Zhou B. A Study of Association Between Oral Lichen Planus and Immune Balance of Thl/Th2 Cells. Inflammation. 2015 Oct;38(5): 1874-9.

(20.) Fasano A. Leaky gut and autoimmune diseases. Clin Rev Allergy Immunol. 2012 Feb;42(l):71-8.

(21.) deMorais MB, Lifschitz CH. Intestinal permeability to lactulose and mannitol in growing rats with iron-deficiency anemia. Biol Trace Elem Res. 2004 Summer;99(1-3):233-40.

(22.) Harden D, Skelton H, Smith KJ. Lichen planus associated with hepatitis C virus: no viral transcripts are found in the lichen planus, and effective therapy for hepatitis C virus does not clear lichen planus. J Am Acad Dermatol. 2003 Nov;49(5):847-52.

(23.) Mehdipour M, Zenouz AT, Hekmatfar S, Adibpour M, Bahramian A, Khorshidi R. Prevalence of Candida Species in Erosive Oral Lichen Planus. J Dent Res Dent Clin Dent Prospect. 2010 Winter; 4(1): 14-16.

by: Robert Kessinger, DC, DABCI, DACBN
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Date:Dec 1, 2015
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