Sensitization to benzyl salicylate and other allergens in patients with frontal fibrosing alopecia

Frontal Fibrosing Alopecia in Men: A Review of the Literature

Background: Frontal fibrosing alopecia (FFA) is a primary cicatricial alopecia, initially described in postmenopausal women but increasingly reported in men. The male form remains under-recognized, often misdiagnosed as androgenetic alopecia (AGA) or alopecia areata (AA), particularly in the beard. Objective: This review aims to summarize the current literature on the epidemiology, clinical presentation, etiopathogenesis, diagnosis, and treatment of FFA in men. Epidemiology and Clinical Features: FFA in men typically presents at a younger age compared to women. Key features include frontal and temporal hairline recession, early involvement of the beard and sideburns, and a high prevalence of eyebrow alopecia (43-94.9%). Facial papules and body hair loss are more common in men than women. Occipital involvement varies widely across studies (8-45%). Clinical features like beard alopecia, often presenting as plaque or diffuse patterns, are highly suggestive of FFA in men but are not part of current diagnostic criteria. Etiopathogenesis: FFA is postulated to have an autoimmune basis influenced by genetic, hormonal, and environmental factors. Genetic studies have identified associations with HLA-B*07:02 and CYP1B1 loci. Environmental triggers include prolonged use of facial sunscreens and moisturizers, as demonstrated in case-control studies and meta-analyses. Diagnosis: Diagnosis is predominantly clinical, supported by trichoscopy and biopsy when needed, particularly in cases overlapping with AGA or AA. Unique presentations, such as beard alopecia and the "watch sign", highlight the importance of considering FFA in atypical male cases. Treatment: Current treatment protocols in men mirror those for women and focus on disease stabilization. Oral 5-ARi (dutasteride) combined with topical corticosteroids and calcineurin inhibitors form the first line. Additional treatments include intralesional corticosteroids, oral isotretinoin for facial papules, and minoxidil for associated AGA. Surgical hair transplantation remains controversial, requiring disease control and careful patient counselling. Conclusions: FFA in men presents with distinct clinical features and challenges in diagnosis, often overlapping with other alopecia. Further studies are needed to validate diagnostic criteria and evaluate treatment efficacy in this underrepresented population.

Frontal Fibrosing Alopecia: An Update

In this review, we discuss recent developments in our understanding of frontal fibrosing alopecia, a disease that has become increasingly common and widespread since its first description in 1994. An inherited predisposition to frontal fibrosing alopecia, previously suspected from the occurrence of familial cases, has been confirmed through genetic studies. Nevertheless, the epidemiology continues to implicate environmental factors in the aetiology. The search has focussed mainly on personal skin care products such as facial moisturisers and UV filters, and there is also some evidence implicating exogenous oestrogens, but confirmation of direct causal links has so far proved elusive. The pathologic mechanisms underlying follicular deletion are being clarified, including the nature of the inflammatory component, the loss of follicular immune privilege in the bulge region and the role of epithelial-mesenchymal transition in the scarring process. Lichen planus pigmentosus, a common accompaniment to frontal fibrosing alopecia in those with darker skin, is probably a feature of the same pathology affecting interfollicular epidermis, rather than a co-morbidity, and may offer new clues to the aetiology. Treatment is still based largely on retrospective case series and variable endpoints. However, methods for assessing frontal fibrosing alopecia and monitoring treatment responses have been strengthened and randomised controlled trials with novel agents (e.g. Janus kinase inhibitors) are in progress. As the main aim of effective treatment is to prevent disease progression, early diagnosis will remain an important target, as will prevention in the longer term.

Frontal Fibrosing Alopecia: A Comprehensive Guide for Cosmetic Dermatologists

Frontal fibrosing alopecia (FFA) is an inflammatory, scarring hair loss that commonly affects postmenopausal women and presents as frontal hairline recession, facial papules, loss of eyebrows, and facial hyperpigmentation. Because of the chronic, progressive nature of this disease and its important impact on aesthetic appearance, patients often consult dermatologists to improve unwanted FFA symptoms. Cosmetic practices including the use of non-ablative lasers, autologous fat injections, and oral isotretinoin can improve FFA-associated facial vein prominence, atrophic indentations, and facial papules, respectively. On the other hand, while exact etiology underlying FFA development remains unclear, some procedures including deep chemical peels and ablative laser therapies have been shown to induce facial scarring and are contraindicated in patients with FFA. In the same way, some cosmetic ingredients can possibly be a triggering or worsening factor for FFA as well. Therefore, it is essential for dermatologists to be aware of both the benefits and risks of cosmetic treatments in patients with diagnosed or suspected FFA. This comprehensive review aims to outline the key cosmetic products and procedures that may be useful in patients with FFA and those which should be considered contraindicated.

Clinical and demographic characteristics of frontal fibrosing alopecia in a dermatology referral center in Bogota, Colombia: a descriptive cross-sectional study

Background

Frontal fibrosing alopecia (FFA) is a type of scarring alopecia that is characterized by a symmetrical recession of the frontal/temporal hairline. Despite growing interest in this pathology, there is scarce data on its epidemiology in Latin American countries such as Colombia.

Objective

To estimate the frequency and describe the clinical manifestations and factors associated with FFA.

Methods

This descriptive cross-sectional study reviewed the electronic health records of adult patients diagnosed with FFA at a referral center in the city of Bogota, Colombia, between 2018 and 2021.

Results

Of the 1506 patients diagnosed with scarring alopecia, 213 fully met the selection criteria (14.14%). Patients had a median age at diagnosis of 60 years (Q1-Q3: 49-67 years) and were more frequently female (95.31%). Concurrent eyebrow alopecia was the most frequent clinical presentation (56.34%). Perifollicular desquamation was present in 114 patients (53.52%), perifollicular erythema in 56 (26.29%), and both features simultaneously in 35 (16.43%). Sunscreen use was reported by 116 (54.46%) and facial moisturizers by 38 (17.84%), both of which have been reported as risk factors.

Limitations

The small sample size and the lack of racial and geographical diversity in the subjects.

Conclusion

This study provides baseline epidemiological data in a Colombian sample. Sex, location of alopecia, and symptoms were consistent with those reported in the literature, but age at presentation, tobacco use, use of wigs, and dyes differed from those reported in other countries.

Extra-follicular cutaneous manifestations of frontal fibrosing alopecia

Frontal fibrosing alopecia (FFA) is an inflammatory cicatricial alopecia, which is considered to be a variant of lichen planopilaris. In addition to follicular changes, FFA often presents with associated cutaneous manifestations in most patients, including lichen planus pigmentosus, implantation line hypochromia and facial papules. The objective of the present article is to provide a detailed overview of the non-follicular cutaneous clinical manifestations of FFA and discuss their impact on the diagnosis and treatment of patients with this condition.

Sensitisation to ethylhexyl salicylate: Another piece of the frontal fibrosing alopecia puzzle

BACKGROUND

There is speculation that some environmental factors may be impacting the increasing incidence of frontal fibrosing alopecia (FFA). In a recent publication, sensitisation to benzyl salicylate was shown to be prevalent among 36 patients with FFA. Ethylhexyl salicylate (EHS), a light stabiliser, ultraviolet (UV) B absorber and UV filter, frequently found in photoprotectors/cosmetics and, rarely reported as a sensitiser, was not patch tested in said research.

METHODS

From January 2021 to February 2022, 33 patients with FFA were patch-tested with the European Photopatch Series, including EHS 10% pet. in two hospitals. In addition, we conducted a literature review and a market survey.

RESULTS

Patch test reactions to EHS were identified in 9 of 33 (27.3%). Four of nine also reacted to their personal sunscreens (containing EHS). All involved women with a mean age of 54 (30-65). Five patients had been diagnosed with FFA before the patch tests; and, four were diagnosed with FFA during the patch test investigations.

CONCLUSION

Sensitisation to EHS was frequently found in a selected population of patients with FFA. We propose to expand the spectrum of contact allergens described in patients with FFA to include EHS and discuss the possible need for optimization of the patch test preparation.

Prevalence and incidence of comorbid diseases and mortality risk associated with lichen planopilaris: a Korean nationwide population-based study

BACKGROUND

Various comorbid diseases have been reported in patients with lichen planopilaris (LPP); however, data regarding the risks of incident diseases and mortality are lacking.

OBJECTIVES

To investigate the risks of incident diseases and mortality associated with LPP.

METHODS

This was a retrospective nationwide population-based study, using data from the National Health Insurance Service Database of Korea from 2002 to 2019. Patients aged ≥ 18 years with three or more documented medical visits for LPP were included. The adjusted hazard ratios (aHRs) for incident disease outcomes and mortality were compared with 1 : 20 age-, sex-, insurance type- and income-level-matched controls.

RESULTS

In total, 2026 patients with LPP and 40 520 controls were analysed. The risks of incident systemic lupus erythematosus [aHR 1.91, 95% confidence interval (CI) 1.21-3.03], psoriasis (aHR 3.42, 95% CI 2.83-4.14), rheumatoid arthritis (aHR 1.39, 95% CI 1.19-1.63), lichen planus (aHR, 10.07, 95% CI 7.17-14.15), atopic dermatitis (aHR 2.15, 95% CI 1.90-2.44), allergic rhinitis (aHR 1.29, 95% CI 1.13-1.49), thyroid diseases (hyperthyroidism: aHR 1.42, 95% CI 1.14-1.77, hypothyroidism aHR 1.19 95% CI 1.01-1.41, and thyroiditis: aHR, 1.35, 95% CI 1.08-1.69), nonmelanoma skin cancer (aHR 2.33, 95% CI 1.00-5.44) and vitamin D deficiency (aHR 1.23, 95% CI 1.03-1.47) were higher in patients with LPP. Patients with LPP had a higher mortality rate than controls (aHR 1.30, 95% CI 1.04-1.61), although the risk was not significant after adjusting for comorbidities (aHR 1.08, 95% CI 0.87-1.34).

CONCLUSIONS

Patients with LPP had a higher risk of various diseases following LPP diagnosis. Close follow-up is needed to optimize comprehensive patient care.

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.