A systematic review of procedural modalities in the treatment of lichen planopilaris, frontal fibrosing alopecia, and discoid lupus erythematosus.

Lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), and discoid lupus erythematosus (DLE) are lymphocytic cicatricial alopecias causing irreversible follicular loss. Procedural therapies have been proposed to control inflammation, remodel scarred tissue, and, occasionally, promote hair regrowth. We performed a PRISMA-guided systematic review of PubMed/Medline, Ovid Embase, and Scopus through July 28, 2025, selecting original studies of procedural interventions for LPP, FFA, and DLE. We assessed methodological quality using NIH and Murad et al. tools. Thirty-eight studies comprising 411 patients were included, reporting lasers/light therapies, platelet-derived products, adipose/exosome injections, low-level light therapy (LLLT), intralesional corticosteroids (ILCS), carboxytherapy, microneedling, and hair transplantation. Outcomes reported were both subjective (patient-reported symptom change, global physician assessment) and objective (LPPAI/FFASS activity scores, terminal hair counts, hair shaft diameter, and photographic density). Platelet products most consistently reduced activity scores and improved symptoms; several reports also documented increases in terminal hair counts or shaft diameter. LLLT led to improved patient-reported outcomes and modest, measurable gains in hair counts/thickness in small series. ILCS reliably achieved disease stabilization and reductions in activity scores but yielded inconsistent objective regrowth. Hair transplantation resulted in good early cosmetic density in quiescent patients, with several studies documenting quantitative density at 6-24 months but progressive graft loss by 3-5 years. Adipose and exosome injections showed promising case-level increases in density/thickness, although the results remained preliminary. Adverse events were generally mild and procedure-specific. In hair transplantation, long-term graft durability remains a major concern. Procedural modalities may serve as useful treatments for symptom control and limited regrowth in selected patients with scarring alopecia. These modalities are best considered adjuncts to medical therapy pending standardized, controlled trials.