It's not all traction: the pseudo 'fringe sign' in frontal fibrosing alopecia

Enhanced Insights into Frontal Fibrosing Alopecia: Advancements in Pathogenesis Understanding and Management Strategies

Frontal fibrosing alopecia (FFA) represents a distinctive form of primary lymphocytic scarring alopecia characterized by fronto-temporal hair recession and eyebrow hair loss. While predominantly affecting postmenopausal women, FFA also occurs in women of reproductive age and men, with variations observed across different ethnic groups. Genetic predisposition, environmental factors and inflammatory pathways contribute to its pathogenesis, with evolving diagnostic criteria enhancing accuracy. FFA treatment lacks standardization, encompassing topical, systemic and physical therapies, while hair transplantation remains a temporary solution. This article reviews the current understanding of FFA, aiming to provide clinicians with updated insights for its management.

Updates on disorders in curly hair

Hair disorders, including central centrifugal cicatricial alopecia (CCCA), traction alopecia (TA), and acquired trichorrhexis nodosa (ATN), commonly occur in individuals with curly textured hair. Curly textured hair in individuals of African descent has unique properties and can present diagnostic and therapeutic challenges. CCCA has been linked to uterine leiomyoma and type 2 diabetes mellitus, as well as fibroproliferation. TA often presents with a fringe sign and can arise from high-tension hairstyles presumed to be protective. Trichoscopy is useful in establishing a diagnosis; perifollicular halos are more commonly seen than perifollicular erythema or scale in CCCA. In TA, miniaturized follicles, hair casts, and "flambeau sign" can be seen. Hairstyling practices likely contribute to TA and ATN; however, the data are mixed on the role of chemical relaxers and heat styling in CCCA. Unique considerations in the presentation of frontal fibrosing alopecia in curly textured hair have also been published recently. This review provides a comprehensive, up-to-date summary of these disorders with an emphasis on their unique properties, as well as considerations in hair care for curly textured hair.

Frontal Fibrosing Alopecia: An Observational Single-Center Study of 306 Cases

(1) Background: Frontal fibrosing alopecia (FFA) is a scarring alopecia that predominantly affects postmenopausal women; (2) Methods: A retrospective, observational, single-center study was conducted in the Hospital General Universitario in Ciudad Real, Spain, including all patients diagnosed with FFA between 2010 and 2021; (3) Results: A total of 306 patients (296 women and 10 men) were included in our study. The mean age of onset was 59.5 years. The severity of this disease was evenly distributed between mild (147 patients) and severe (149 patients) forms. There was a positive, statistically significant, medium correlation between the severity of the disease and its time of progression. Moreover, hypothyroidism was present in 70 patients (22.9%) and classic signs of concomitant lichen planopilaris were observed in just 30 patients (9.8%), while other forms of lichen planus were uncommon. The estimated prevalence in our population is 0.15% and the incidence is 15.47 new cases per 100,000 inhabitants; (4) Conclusions: The time of progression was positively correlated with the severity of FFA. However, the presence of clinical signs, such as inflammatory trichoscopic signs, was not associated with the progression of this condition.

[Translated article] Trichoscopy: An Update

Trichoscopy is a simple, noninvasive office procedure that can be performed using a handheld or digital dermatoscope. This tool has gained popularity in recent years, because it provides useful diagnostic information for hair loss and scalp disorders by enabling the visualization and identification of distinctive signs and structures. We present an updated review of the trichoscopic features described for some of the most common hair loss disorders seen in clinical practice. Dermatologists should be familiar with these helpful features, as they can significantly aid the diagnosis and follow-up of numerous conditions, such as alopecia areata, trichotillomania, and frontal fibrosing alopecia.

Trichoscopy: An Update

Trichoscopy is a simple, noninvasive office procedure that can be performed using a handheld or digital dermatoscope. This tool has gained popularity in recent years, because it provides useful diagnostic information for hair loss and scalp disorders by enabling the visualization and identification of distinctive signs and structures. We present an updated review of the trichoscopic features described for some of the most common hair loss disorders seen in clinical practice. Dermatologists should be familiar with these helpful features, as they can significantly aid the diagnosis and follow-up of numerous conditions, such as alopecia areata, trichotillomania, and fibrosing frontal alopecia.

Frontal Fibrosing Alopecia and Sunscreen Use: A Cross-sectional Study of Actinic Damage

Patients with frontal fibrosing alopecia report higher rates of sunscreen use than control subjects. However, it is not known whether the higher use of sunscreens is a cause or a consequence of the alopecia. A greater use of sunscreens should be associated with a lower incidence of signs of actinic damage. The aim of this study is to assess the presence of actinic damage in patients with frontal fibrosing alopecia. A cross-sectional study was carried out on 101 patients with frontal fibrosing alopecia and 40 control subjects. The presence of actinic damage, in the form of solar lentigines, actinic keratoses, and basal and squamous cell carcinomas, was recorded in both groups, together with sunscreen use. Trichoscopy and skin biopsy were performed on patients. Actinic damage was present more frequently in patients with frontal fibrosing alopecia (69.3%) than in control subjects (50%) (p = 0.031). Patients used sunscreens more frequently than did control subjects (83.2% vs 62.5%, p = 0.008). However, the prevalence of trichoscopic inflammatory signs, peripheral alopecia, and inflammatory infiltrate and sebaceous gland involvement in skin biopsy, were similar in patients who used sunscreens and those who did not use them. In conclusion, patients with frontal fibrosing alopecia had greater actinic damage than did control subjects, and this is hypothesized as a reason for the higher use of sunscreens among patients. Thus, use of sunscreens may not be the trigger for frontal fibrosing alopecia that dermatologists have proposed.

Trichoscopy-Derived Hairline Recession Equivalent in Monitoring Frontal Fibrosing Alopecia

Introduction

Frontal fibrosing alopecia (FFA) is a relatively recently described scarring hair loss condition. Frontal hair recession is observed in a vast majority of patients; other scalp areas may be included. Assessment of hair loss progression in FFA remains challenging mainly due to difficulties in unambiguous determination of the hairline. Various patterns of scarring and subtle progression rate are among factors which make naked-eye observations of limited use.

Methods

Trichoscopy of the frontal hairline with hair-to-hair matching was conducted in patients with FFA patients with disease progression and clinically stable hairline. Hair loss was assessed based on analysis of trichoscopy-derived follicular maps. A relative hair density loss was calculated, and the hairline recession equivalent (HRE) was proposed as a novel hair loss progression measure.

Results

Two patterns of hair loss were observed: one with significant decrease of hair density within a width of 1 mm and one with diffuse loss within a width of 10 mm.

Conclusion

The hair density profile may be a useful tool to characterize different disease progression patterns. The HRE is potentially a very accurate and sensitive parameter to quantify local hair loss progression in FFA.

Frontal Fibrosing Alopecia Mimicking Alopecia Syphilitica

Frontal fibrosing alopecia is lymphocytic scarring alopecia most commonly affecting postmenopausal women. Alopecia syphilitica, an uncommon manifestation of secondary syphilis, is characterized as a nonscarring and non-inflammatory hair loss that primarily affects the scalp. Frontal fibrosing alopecia has a classic pattern of hair loss involving regression of frontotemporal hair; it also may affect the eyebrows or other sites of the body. The typical patterns of frontal fibrosing alopecia are characterized as diffuse and linear. In addition, patients with frontal fibrosing alopecia can have atypical signs and patterns of hair loss. The atypical signs and patterns of frontal fibrosing alopecia are the androgenetic-like pattern, clown alopecia pattern, cockade-like pattern, doll hairline sign, lonely hair sign, ophiasis-like pattern, pseudo-fringe sign, and upsilon pattern. We observed a woman with a traditional pattern of frontal fibrosing alopecia whose hair loss involved the frontotemporal scalp areas; however, she also had hair loss in the occipital scalp that appeared similar to the moth-eaten alopecia of alopecia syphilitica. Her rapid plasma reagin was negative and the biopsies from her frontal scalp and occipital scalp both showed scarring alopecia consistent with frontal fibrosing alopecia. Her alopecia persisted with conservative treatment, and she returned to wearing a wig. Alopecia syphilitica-like pattern of hair loss can be added to the other atypical patterns of alopecia that may potentially be observed in a patient with frontal fibrosing alopecia.

Frontal Fibrosing Alopecia survey of severity assessment methods in routine clinical practice and validation of the IFFACG measurement guidance

BACKGROUND

Lack of validated and responsive outcome measures in the management of Frontal Fibrosing Alopecia (FFA) significantly limits our ability to assess disease progression and treatment response over time.

OBJECTIVES

The aim of this study was to understand how FFA extent and progression is currently assessed in UK specialist centres, validate components of the International FFA Cooperative Group (IFFACG) statement on FFA assessment, and identify pragmatic advice to improve FFA management in clinic.

METHODS

Consultant Dermatologists with a specialist interest in hair loss (n=17) were invited to take part. Preferred FFA assessment methods were explored using questionnaires and clinical scenarios. Participants were asked to identify and mark the current hairline in 10 frontal and 10 temporal hairline images, with assessment repeated 3 months later (to assess intra-individual variability) and 12 months later (to test whether inter-individual accuracy could be improved with simple instruction).

RESULTS

All 17 clinicians (100%) completed the questionnaire at each time interval. We identified a wide variation in assessment techniques between our experts. Measurements were perceived as the most accurate method of assessing frontal recession whereas photography was preferred for temporal recession. Inter-rater reliability between clinicians measuring the frontal hairline scenarios indicated a moderate strength of agreement (ICC 0.613; 95% CI: 0.398 to 0.848), yet intra-rater reliability was found to be poor with wide limits of agreement (-8.71mm to 9.92mm) on follow-up. Importantly, when clear guidance was provided on how the hairline should be identified (questionnaire 3), inter-rater reliability improved significantly, with an ICC 0.702 suggesting moderate agreement (95% CI: 0.508 to 0.890; p<0.001). A similar pattern was seen with temporal hairline measurements, which again improved in accuracy with instruction.

CONCLUSION

We show that accuracy of measurements in FFA can be improved with simple instruction and validate components of the IFFACG measurement recommendations.

Traction Alopecia: Clinical and Cultural Patterns

Background:

Traction alopecia is common and preventable but frequently overlooked disorder.

Objective:

To evaluate patients with traction alopecia.

Patients and Methods:

This study was conducted at the Dermatology Center, Medical City, Baghdad, Iraq, during the period from November 2005 to October 2019. Demographic features like age, gender, disease duration and special hair styling practices and accessories were recorded. Clinical patterns were studied.

Results:

Thirty female patients were included in this study. Their ages ranged from 6 to 47 years with mean age ± SD was 15.63 ± 9.806. Twenty-one (70%) were below the age of 16 years. No patient had tightly curled hair. All cases were asymptomatic apart from hair loss. The fringe sign was observed in 27 (90%) of cases. The response to therapy was poor.

Conclusion:

Traction alopecia is an important type of pressure-induced hair loss evident in children and adults with or without curly hair due mainly due to cultural hair styling practices with its frequency apparently increasing in recent years. The fringe sign is common and of diagnostic importance. It is a preventable form of hair loss which can be reversed if diagnosed early; otherwise, permanent scarring alopecia results. It represents a pressure phenomenon evident worldwide in both non-Sub-Saharan lineage and Sub-Saharan lineage individuals.

Guidelines for clinical trials of frontal fibrosing alopecia: consensus recommendations from the International FFA Cooperative Group (IFFACG)

BACKGROUND

Frontal fibrosing alopecia (FFA) has become one of the most common causes of cicatricial alopecia worldwide. However, there is a lack of clear aetiology and robust clinical trial evidence for the efficacy and safety of agents currently used for treatment.

OBJECTIVES

To enable data to be collected worldwide on FFA using common criteria and assessment methods.

METHODS

A multicentre, international group of experts in hair loss was convened by email to create consensus recommendations for clinical trials. Consensus was defined at > 90% agreement on each recommended part of these guidelines.

RESULTS

Standardized diagnostic criteria, severity rating, staging, and investigator and patient assessment of scalp hair loss and other clinical features of FFA were created.

CONCLUSIONS

These guidelines should allow the collection of reliable aggregate data on FFA and advance efforts in both clinical and basic research to close knowledge gaps in this condition.

Frontal Fibrosing Alopecia: A Review

Frontal fibrosing alopecia is a scarring alopecia, the prevalence of which is increasing worldwide since its first description in 1994. The reason for this emerging epidemic may be a higher exposure to an unknown trigger, although its aethiology and pathogenesis still remain enigmatic. Clinical, trichoscopic, sonographic, and histopathologic findings are allowing clinicians to understand more aspects about this type of cicatricial alopecia. Several treatments have been used in frontal fibrosing alopecia, although the 5-alpha reductase inhibitors seem to be the most promising. The aim of this report is to provide a compilation about the published data regarding frontal fibrosing alopecia in a narrative review.

Frontal fibrosierende Alopezie – Fallbeispiele und Review

Die frontal fibrosierende Alopezie (FFA) ist eine vernarbende Alopezie, welche klinisch durch Regression des frontotemporalen Haaransatzes, disseminiert verbleibende Haare (lonely hairs) und Verlust der Brauen gekennzeichnet ist. Meist sind postmenopausale, seltener auch jüngere Frauen betroffen und gelegentlich auch Männer. Der Verlauf ist variabel, oft sehr langsam und unbeachtet. Auch Spontanremissionen sind häufig. Daher lässt sich die Inzidenz nur schätzen, jedoch ist sie wahrscheinlich zunehmend. Es werden dafür Umweltfaktoren, Sonnencremes, aber auch eine optimierte Awareness und Diagnostik diskutiert. Allerdings blieb die Pathogenese der lymphozytären Follikulitis bisher noch ungeklärt. Klinisch ist die Haut im betroffenen bandförmigen Bereich atroph und weißlich. In floriden Bereichen sind follikuläre Erytheme und Keratosen typisch. Nicht selten sind kleine, wenig erythematöse Papeln an Stirn und Wangen assoziiert („facial papules“). Evidenzbasierte Therapien existieren nicht. Lokal werden Steroide, Calcineurin-Inhibitoren oder Minoxidil angewendet, systemisch 5α-Reduktase-Hemmer, Hydroxychloroquin und Doxycyclin.

Frontal fibrosing alopecia: a disease that remains enigmatic

Frontal fibrosing alopecia (FFA) is recognized to represent a generalized process of inflammatory scarring alopecia. Apart from the classic form affecting the frontal hairline, there are a range of disease manifestations involving loss of eyebrows and of eyelashes, loss of peripheral body hair, fibrosing alopecia in a pattern distribution, facial and extrafacial skin, mucous membrane, and nail involvement. Classic linear, diffuse “zigzag”, pseudo “fringe sign”, androgenetic alopecia-like, cockade-like, ophiasis-like and incomplete patterns are distinguished. The aetiology of FFA remains obscure, but a number of pathogenetic hypotheses and treatments to halt disease progression have been proposed.

Clinical characteristics, trichoscopy, histopathology and treatment outcomes of frontal fibrosing alopecia in an Asian population: A retro-prospective cohort study

Frontal fibrosing alopecia (FFA) is a distinctive lymphocytic scarring alopecia with rapid increase in prevalence. Most FFA series are retrospectively reported from Caucasians with only few from Asians. The objective of this study was to characterize the clinical, trichoscopic and histopathological findings as well as treatment outcomes. This was a retro-prospective cohort study of patients diagnosed with FFA from 1 January 2010 to 1 November 2019. All patients were asked to present for re-examination. Clinical, trichoscopic, histopathological and laboratory data were recorded. A questionnaire was used to investigate hair care, hairstyle and facial skin care compared with age-matched normal controls. Multivariate analysis was performed in order to clarify factors associated with severity. All 58 FFA patients were female, of whom 27.6% were premenopausal, 37.7% had a history of surgical menopause, 13.8% had thyroid diseases, 69% had eyebrow loss and 32.8% facial papules. On physical examination, 10.3% showed linear pattern, 46.6% diffuse pattern and 43.1% pseudo-fringe sign. Concomitant lichen planopilaris was found in 25.9%, lichen planus pigmentosus in 24.1% and female pattern hair loss in 48.3%. The most common trichoscopic characteristics in the frontal hairline were lack of follicular ostia (91.4%), perifollicular scales (79.3%) and perifollicular erythema (63.8%). Up to 90% of patients reported FFA as improved or stable after receiving antiandrogen (finasteride or dutasteride) or antimalarial with topical treatment. Multivariate analyses revealed that facial lentiginous macules and trichoscopic perifollicular erythema at the frontal area were FFA severity-associated factors. "Front puff" Thai hairstyle was associated with FFA, while sunscreens and other cosmetic products were not. In conclusion, diffuse and pseudo-fringe sign pattern are common in Asian FFA. The most common autoimmune systemic comorbidity is thyroid disease, while common concomitant dermatological diseases are female pattern hair loss, lichen planopilaris and lichen planus pigmentosus. Antiandrogens or antimalarial plus topical treatment are the most useful therapy.

Trichoscopy of primary cicatricial alopecias: an updated review

Trichoscopy is an emerging technique for the evaluation of various hair and scalp disorders including primary cicatricial alopecias (PCAs). Early diagnosis of PCAs can lead to effective management and trichoscopy could be a useful aid during this process. Multiple studies have reported the trichoscopic features of PCAs, however, a focused review evaluating these disorders with their trichoscopic features is lacking. With the objective of evaluating the trichoscopic findings reported in the literature for various PCAs, we conducted a systematic literature search in PubMed and Embase. The search yielded 310 studies in a total of which 54 studies were included in our review. Majority of these studies originated from the Caucasian or Asian population. Through this review, we provide an overview of the frequent and specific trichoscopic findings in different PCAs with their clinical significance where applicable based on the current knowledge and identify the areas for future research.

Frontal Fibrosing Alopecia: An Update on Pathogenesis, Diagnosis, and Treatment

Frontal fibrosing alopecia (FFA), first described by Kossard in the early 1990s, is a form of primary lymphocytic cicatricial alopecia characterized by selective involvement of the frontotemporal hairline and eyebrows. Since the original description, an increasing number of cases have been reported worldwide and the clinical aspects of the disease have been better characterized. However, the pathogenesis is still unknown and several hypotheses have been made about possible triggering factors, including hormones, neurogenic inflammation, smoking, UV filters, and ingredients in leave-on facial products. A genetic basis has also been hypothesized as the disease can occur in siblings and members of the same family. Besides its pathogenesis, research is also focused on treatment; FFA is a chronic condition and at present there is no validated or approved treatment for this disorder. Commonly prescribed topical treatments include corticosteroids, minoxidil, and calcineurin inhibitors. Systemic treatments include 5α-reductase inhibitors, hydroxychloroquine, and retinoids. Intralesional triamcinolone acetonide is also utilized, especially for the eyebrows. Other possible treatments include pioglitazone, naltrexone, tofacitinib, and lasers.

A New Histologic Pattern in 6 Biopsies From Early Frontal Fibrosing Alopecia

Frontal fibrosing alopecia (FFA) is an irreversible scarring alopecia with unknown etiology and no cure. The goal is to establish the diagnosis in the early stage, before developing a hairless band of atrophy involving the frontal, temporal scalp and sideburns. Pathology is rarely needed once the disease is clinically apparent. The classic histologic features include follicular dropout with the absence or atrophy of the sebaceous glands and lichenoid lymphohistiocytic infiltrate with concentric layered fibrosis at the upper follicular level. We describe a common pattern that was repeatedly seen in 6 horizontally sectioned scalp biopsies from patients with early presentation of FFA suspected on trichoscopy by the focal presence of peripilar casts around terminal hairs. All biopsies revealed overall preserved follicular architecture with average number of 11 vellus follicles, atrophy of the sebaceous glands, and perifollicular lymphohistiocytic infiltrate involving the outer root sheath of the vellus follicles (n = 5). There was no perifollicular fibrosis of the vellus follicles and no lichenoid inflammation and perifollicular fibrosis of the terminal follicles. This new pattern of "inflammatory vellus involvement" most likely corresponds to an early onset of the disease. The absence of the classic features in such biopsies from early FFA can lead to misdiagnosis.

Patchy Frontal Fibrosing Alopecia: Description of an Incomplete Clinical Presentation

We describe 6 incomplete cases of frontal fibrosing alopecia (FFA). All patients were postmenopausal women. Their average age was 60 years; 2 of the women were Caucasian, and the remaining 4 women were of a mixed ethnicity. The disease duration ranged from 3 to 17 years. The patients' lesions presented as irregular alopecic plaques in the frontal and/or temporal regions, with few signs of perifollicular inflammation, slow progression, and progressive loss of the vellus hair in the frontal area. Loss of the eyebrows, facial hyperpigmentation, and loss of the body hair were observed in 3 patients, 1 patient, and 2 patients, respectively. Localized pruritus and dysesthesia were reported in 5 patients and 3 patients, respectively. Dermatoscopic examination indicated the absence of viable ostia at the centers and edges of the lesions and the absence of peripilar erythema; moreover, peripilar hyperkeratosis was less intense than it would be expected in classical cases of lichen planopilaris (LPP) and FFA. Histological examination revealed that all cases featured the presence of a perifollicular lichenoid infiltrate in the infundibulum and isthmus as well as concentric areas of fibrosis. All samples were subjected to direct immunofluorescence (DIF), which produced negative results. FFA has been recently diagnosed and is considered a subtype of LPP. FFA can present with incomplete clinical manifestations, a histology similar to LPP, and negative DIF findings. The correct diagnosis of FFA-associated lesions is critical for providing appropriate treatment, developing prognostic definitions, and excluding other types of scarring and nonscarring alopecia. The diagnosis of incomplete FFA is essential to avoid diagnostic and therapeutic errors.