Frontal fibrosing alopecia: clinical and prognostic classification

[Translated article] Low-dose Oral Minoxidil for Frontal Fibrosing Alopecia: A 122-patient Case Series

The objective of our study was to analyze the effectiveness of oral minoxidil on the frontotemporal hairline in patients with FFA. We conducted a retrospective, descriptive, multicenter study in 2 Brazilian and 1 Spanish centers. Responses were graded on a scale of 3 positive points. A total of 122 patients were included. Subjective improvement in the density of the frontotemporal hairline was observed in 45.1% patients, which was categorized as mild (34.4%), moderate (9.0%), and excellent (1.6%). Hair density improved in 57.4% of the patients' interparietal. Additionally, 25.4% and 3.3% of the patients experienced eyebrow and eyelash growth, respectively. Adverse effects were detected in 33.6% patients, with hypertrichosis being the most common (23.8%). In this study, oral minoxidil proved to be an additional therapy for FFA that not only improved the patients' overall hair and eyebrow growth, but also the density of the frontotemporal hairline.

Low-dose oral minoxidil for frontal fibrosing alopecia: a 122-patient case series

The objective of our study was to analyze the effectiveness of oral minoxidil on the frontotemporal hairline in patients with FFA. We conducted a retrospective, descriptive, multicenter study in 2 Brazilian and 1 Spanish centers. Responses were graded on a scale of 3 positive points. A total of 122 patients were included. Subjective improvement in the density of the frontotemporal hairline was observed in 45.1% patients, which was categorized as mild (34.4%), moderate (9.0%), and excellent (1.6%). Hair density improved in 57.4% of the patients' interparietal. Additionally, 25.4% and 3.3% of the patients experienced eyebrow and eyelash growth, respectively. Adverse effects were detected in 33.6% patients, with hypertrichosis being the most common (23.8%). In this study, oral minoxidil proved to be an additional therapy for FFA that not only improved the patients' overall hair and eyebrow growth, but also the density of the frontotemporal hairline.

Frontal Fibrosing Alopecia: A Comprehensive Review with Recent Updates

Frontal fibrosing alopecia (FFA) is a progressive scarring alopecia affecting postmenopausal women. FFA is a primary lymphocytic scarring alopecia and is considered a variant of LPP due to similar histopathology findings in both conditions. The exact etiopathogenesis of FFA is not known. However, some genetic, autoimmunity, hormonal and environmental factors are implicated. However, the loss of the immune privilege of hair follicles and the role of cosmetics and sunscreen have been postulated. The disease is characterised by frontal and temporoparietal hairline recession with shiny, atrophic skin with sideburn involvement. The common trichoscopic findings include perifollicular erythema, follicular hyperkeratosis and loss of follicular openings. The histopathology is characterised by lichenoid lymphocytic infiltrate around the upper part of the hair follicle including the bulge area and concentric perifollicular lamellar fibrosis. There are two diagnostic criteria proposed by Tolkachjov et al. and the International FFA Cooperative Group. Many topical and systemic treatment options are available, but none have shown satisfactory results. Recently, many biological agents have been tried including tofacitinib and tildrakizumab.

Isotretinoin as a promising option in the treatment of facial papules of frontal fibrosing alopecia

Frontal fibrosing alopecia (FFA) is a primary cicatricial alopecia characterized by hairline recession, pruritus, and facial papules (FP). Various therapies are used to stabilize disease activity and induce remission. However, FP of FFA is resistant to treatment in many cases. In this review, we searched the PubMed and Google Scholar databases to screen the published literature on treatment options for FP in the context of FFA. Overall, 12 studies were included in this review. Available literature suggests a noticeable improvement in resistant-to-treatment FP in FFA patients with oral isotretinoin. The available evidence is limited and is derived from retrospective studies and case reports/series. Systemic isotretinoin can be considered a promising therapeutic regimen for treating resistant-to-treatment FP of FFA patients. However, more extensive, well-designed studies are necessary for confirmatory evidence.

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.

Dutasteride in the treatment of frontal fibrosing alopecia: Systematic review and meta-analysis

Frontal fibrosing alopecia (FFA) is a scarring alopecia with fronto-temporo-parietal hairline recession. Although no proven treatment for FFA exists, dutasteride has been suggested as a potential treatment option. We aimed to evaluate the therapeutic response of oral dutasteride in FFA patients. The identification and selection of studies were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2020 criteria. To assess the risk of bias for each study, we used the Cochrane's risk of bias in non-randomized studies of interventions (ROBINS-I) assessment tool. A random effects model meta-analysis was performed. Estimated proportion of stabilization for eligible studies was calculated to evaluate the effectiveness of dutasteride for treating FFA. Among patients who achieved stabilization, subgroup analysis was conducted on those showing improvement. Seven studies including 366 patients who received oral dutasteride were identified. The estimated proportion of patients who experienced stabilization of FFA with oral dutasteride was 0.628 (95% CI: 0.398-0.859). In subgroup analyses of patients who experienced improvement, the estimated proportion of improvement was 0.356 (95% CI: 0.163-0.549). In this systematic review and meta-analysis, oral dutasteride revealed to be a good treatment option for disease stabilization or improvement in patients with FFA.

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.

The Frontal Fibrosing Alopecia Treatment Dilemma

Frontal fibrosing alopecia (FFA) is a type of cicatricial alopecia predominantly observed in postmenopausal women, with the incidence rising since its initial description in 1994. The exact etiopathogenesis of the disease has not been completely elucidated. FFA is characterized by an inflammatory process affecting the hair follicles of the fronto-temporal hairline, leading to its gradual recession. Eyebrows, particularly the lateral parts, may also be affected. Early diagnosis and an implementation of effective therapy to limit the inflammatory process are crucial in halting disease progression. Various treatment possibilities have been reported, including anti-inflammatory and immunosuppressive agents, as well as 5-alpha-reductase inhibitors, retinoids, and antimalarial agents. The use of phototherapy and surgical procedures has also been described. However, most available data have been obtained retrospectively, frequently consisting of descriptions of case reports or small case series, and not from randomized controlled trials. In addition, the etiopathogenesis of FFA remains unclear and its course unpredictable, occasionally being linked with spontaneous stabilization. Hence, no precise guidelines exist regarding treatment modalities. Therefore, the aims of this study were to provide a comprehensive review of the efficacy of existing therapeutic modalities for FFA and to highlight novel therapeutic options.

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.

Protein profiling of forehead epidermal corneocytes distinguishes frontal fibrosing from androgenetic alopecia

Protein profiling offers an effective approach to characterizing how far epidermis departs from normal in disease states. The present pilot investigation tested the hypothesis that protein expression in epidermal corneocytes is perturbed in the forehead of subjects exhibiting frontal fibrosing alopecia. To this end, samples were collected by tape stripping from subjects diagnosed with this condition and compared to those from asymptomatic control subjects and from those exhibiting androgenetic alopecia. Unlike the latter, which exhibited only 3 proteins significantly different from controls in expression level, forehead samples from frontal fibrosing alopecia subjects displayed 72 proteins significantly different from controls, nearly two-thirds having lower expression. The results demonstrate frontal fibrosing alopecia exhibits altered corneocyte protein expression in epidermis beyond the scalp, indicative of a systemic condition. They also provide a basis for quantitative measures of departure from normal by assaying forehead epidermis, useful in monitoring response to treatment while avoiding invasive biopsy.

Treatment of Frontal Fibrosing Alopecia

Introduction. Frontal fibrosing alopecia (FFA) is known as a lymphocytic primary cicatricial alopecia. The main characteristic of FFA is progressive frontotemporal hairline recession. The pathogenesis of FFA is not completely understood. Destructing the stem cells of the epithelial hair follicles causes permanent hair loss and seems to be the main cause of FFA. Studies have reported significantly decreased quality of life in patients with hair loss. On the other hand, late diagnosis and treatment of FFA can decrease the success rate of the treatment. In this regard, different topical and systemic therapies have been developed to resolve the symptoms; however, only a partial response to treatment is usually achieved. We conducted a systematic review of the literature to identify the effectiveness of the available treatment modalities used for FFA patients and the related outcomes. Methods. On April 2022, we made a wide systematic computer-assisted search of PubMed and Google Scholar databases, using “frontal fibrosing alopecia” and “treatment” keywords. We scanned 1,514 articles. All the studies concerning a therapeutic regimen for FFA were included. After removing duplicate studies, 50 studies containing the therapeutic regimen of 1,478 FFA patients were included in this review. Results. The 5-alpha-reductase inhibitors (oral finasteride/dutasteride) were the most used medications (usually prescribed as a combination therapy with other medications). Topical corticosteroids were the second commonly used medication for the treatment of FFA. Systemic corticosteroids seem to be ineffective in improving FFA progression. Oral isotretinoin (or alitretinoin) had the most promising effect on improving facial papules of FFA patients with a 92% rate of facial papule improvement. Conclusion. In our review, intralesional corticosteroid injection and 5-alpha-reductase inhibitors (finasteride/dutasteride) were reported as the most effective treatment modalities. Oral isotretinoin (or alitretinoin) is considered as the most promising treatment for improving facial papules in the context of FFA. However, it had minimal effects on hair regrowth or stabilization of hairline recession in FFA patients.

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.

Association between frontal fibrosing Alopecia and Rosacea: Results from clinical observational studies and gene expression profiles

Background

In recent years, frontal fibrosing alopecia (FFA), a type of scarring alopecia, has attracted increasing attention. Several studies have reported the frequent occurrence of rosacea in FFA; however, the association between FFA and rosacea and the underlying pathogenesis have not been thoroughly clarified. Thus, this study aimed to quantify these relationships and investigate their shared molecular mechanisms.

Methods

We evaluated the association between FFA and rosacea by analyzing clinical data from nine observational studies. We then analyzed the gene expression profiles of FFA and rosacea. First, differential expression analysis and weighted gene co-expression network analysis were used to identify the common differentially expressed genes (DEGs). Later, we conducted a functional enrichment analysis and protein-protein interaction network and used seven algorithms to identify hub genes. Then, we performed a correlation analysis between the hub genes and the gene set variation analysis scores of common pathways in the gene set enrichment analysis (GSEA). The results were validated using different datasets. Finally, transcription factors were predicted and verified, and CIBERSORT and single-sample GSEA were used to estimate the infiltrating immune cells.

Results

Patients with FFA had significantly higher odds for rosacea (pooled odds ratio [OR], 2.46; 95% confidence interval [CI], 1.78–3.40), and the pooled prevalence of rosacea in patients with FFA was 23% (95% CI, 14–23%). Furthermore, we identified 115 co-DEGs and 13 hub genes (CCR5, CCL19, CD2, CD38, CD83, CXCL8, CXCL9, CXCL10, CXCL11, CXCR4, IRF1, IRF8, and PTPRC). Seven pathways showed a high correlation with these hub genes. In addition, one TF, STAT1, was highly expressed in both diseases, and the results of the immune infiltration analysis indicated the importance of M1 macrophages and effector memory CD8+ T cells.

Conclusion

This study contributes to the understanding of the relationship between FFA and rosacea, and based on the hub genes, we reveal the potential pathologies shared by the two diseases. This finding provides new insights of underlying molecular mechanisms and it may inspire future research on this comorbidity.

Frontal fibrosing alopecia: A review of disease pathogenesis

Frontal fibrosing alopecia (FFA) is a primary patterned cicatricial alopecia that mostly affects postmenopausal women and causes frontotemporal hairline regression and eyebrow loss. Although the incidence of FFA has increased worldwide over the last decade, its etiology and pathology are still unclear. We cover the latest findings on its pathophysiology, including immunomodulation, neurogenic inflammation, and genetic regulation, to provide more alternatives for current clinical treatment. A persistent inflammatory response and immune privilege (IP) collapse develop and lead to epithelial hair follicle stem cells (eHFSCs) destruction and epithelial-mesenchymal transition (EMT) in the bulge area, which is the key process in FFA pathogenesis. Eventually, fibrous tissue replaces normal epithelial tissue and fills the entire hair follicle (HF). In addition, some familial reports and genome-wide association studies suggest a genetic susceptibility or epigenetic mechanism for the onset of FFA. The incidence of FFA increases sharply in postmenopausal women, and many FFA patients also suffer from female pattern hair loss in clinical observation, which suggests a potential association between FFA and steroid hormones. Sun exposure and topical allergens may also be triggers of FFA, but this conjecture has not been proven. More evidence and cohort studies are needed to help us understand the pathogenesis of this disease.

Lichen planopilaris and frontal fibrosing alopecia: review and update of diagnostic and therapeutic features

Lichen planopilaris and frontal fibrosing alopecia are primary scarring alopecias where diagnosis can be suggested by clinical and trichoscopy features, especially in the early stages, but scalp biopsy is the standard exam for definitive diagnosis. Frontal fibrosing alopecia is considered a variant of lichen planopilaris, as the histopathological findings are similar, with a perifollicular lymphohistiocytic infiltrate, sometimes with a lichenoid pattern. A thorough clinical examination, trichoscopy and photographic documentation are essential to assess the evolution and therapeutic response. To date, there are no validated treatments or guidelines for these diseases, but there are recommendations that vary with the individual characteristics of each patient. This article presents a comprehensive review of the literature, including an update on topics related to the diagnosis, follow-up, histopathological aspects and available treatments for lichen planopilaris and frontal fibrosing alopecia, highlighting their similarities, differences and peculiarities.

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.

Primary cicatricial alopecia: Recent advances in evaluation and diagnosis based on trichoscopic and histopathological observation, including overlapping and specific features

Primary cicatricial alopecia (PCA) is a form of alopecia in which inflammatory cells target follicles, including the bulge region containing follicular stem cells, leading to permanent alopecia. New classifications of PCA subtypes have recently been proposed, including those that account for novel trichoscopic and histopathological features of PCA, enabling greater precision in the evaluation and diagnosis of this condition. Nonetheless, diagnosis remains challenging clinically and histopathologically because the etiology of PCA is multifactorial. Inconsistent use of terminology, overlapping disease concepts, and changes in the clinical or histopathological severity of inflammation in the disease course in the same patient also make diagnosis quite challenging. The present study comprehensively reviews recent progress in diagnostic techniques, including the use of clinical, trichoscopic, and histopathological features, in evaluating each PCA subtype, containing overlapping and specific features. Elucidating the features of PCA, including those that are common to multiple subtypes as well as specific to each in both early and advanced-stage lesions, is important for accurate diagnosis. Improving the evaluation and treatment of this disease depends on having a broader clinical understanding that takes into account not only the features of the disease at a given point in time, but also the changes that occur during the entire disease course.

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.

Optimal Management of Frontal Fibrosing Alopecia: A Practical Guide

Frontal fibrosing alopecia (FFA) is a primary lymphocytic cicatricial alopecia that is often considered a clinical variant of lichen planopilaris (LPP) due to their shared histopathologic features. FFA is characterized by the recession of the frontal, temporal, or frontotemporal hairline; the clinical pattern is distinct and usually includes eyebrow hair loss, as well as other associated symptoms. Pruritus, facial papules, eyelash loss, body hair involvement, and trichodynia may also occur in addition to the frontotemporal recession and eyebrow loss classically seen. Early diagnosis and prompt treatment are critical as FFA is a progressive disorder that can result in permanent hair loss. FFA is challenging as patients may not present or be recognized until the disease has progressed. Additionally, there is currently no consensus or standard treatment regimen for FFA. While many different therapies have been reported as beneficial, there are a limited number of published guidelines for the treatment of FFA. This article is a review of the literature on treatment modalities for FFA and the objective is to offer a practical guide for clinicians on the evidence-based management options currently available in the literature.

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.

Frontal fibrosing alopecia

Frontal fibrosing alopecia (FFA) is a patterned primary cicatricial alopecia that was first described in 1994. Once rare, the incidence of FFA has increased dramatically, representing the current most common cause of cicatricial alopecia worldwide. FFA typically begins in postmenopausal women with symmetrical, progressive recession of the frontotemporal hairline together with bilateral loss of the eyebrows. FFA has a distinctive clinical phenotype, which remains a challenge. The histology is identical to lichen planopilaris (LPP), but only a small number of patients have coincidental LPP, usually of the scalp. The vast majority of patients have no evidence of lichen planus elsewhere, and the symmetry and patterned nature of the hair loss are unusual for LPP. Familial cases of FFA are reported, and gene associations have been identified in population studies; however, the pathophysiology remains controversial. Without treatment, FFA is slowly progressive, and although many treatments have been prescribed, the response is often disappointing. We review the pathogenesis, epidemiology, clinical features, histology, and treatment of FFA.

Effectiveness of dutasteride in a large series of patients with frontal fibrosing alopecia in real clinical practice

BACKGROUND

Dutasteride has been proposed as an effective therapy for frontal fibrosing alopecia (FFA).

OBJECTIVES

We sought to describe the therapeutic response to dutasteride and the most effective dosage in FFA compared with other therapeutic options or no treatment.

METHODS

This was a retrospective observational study including patients with FFA with a minimum follow-up of 12 months. Therapeutic response was evaluated according to the stabilization of the hairline recession.

RESULTS

A total of 224 patients (222 females) with a median follow-up of 24 months (range 12-108 months) were included. The stabilization rate for the frontal, right, and left temporal regions after 12 months was 62%, 64%, and 62% in the dutasteride group (n = 148), 60%, 35%, and 35% with other systemic therapies (n = 20), and 30%, 41%, and 38% without systemic treatment (n = 56; P = .000, .006, and .006, respectively). Stabilization showed a statistically significant association with an increasing dose of dutasteride (88%, 91%, and 84% with a weekly treatment of 5 or 7 doses of 0.5 mg [n = 32], P < .005). Dutasteride was well tolerated in all patients.

LIMITATIONS

Limitations included the observational and retrospective design.

CONCLUSIONS

Oral dutasteride was the most effective therapy with a dose-dependent response for FFA in real clinical practice compared with other systemic therapies or no systemic treatment.

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.

Frontal fibrosing alopecia shows robust T helper 1 and Janus kinase 3 skewing

BACKGROUND

Frontal fibrosing alopecia (FFA) is a scarring alopecia with unclear pathogenesis and a progressive course. The disease has a major impact on patients' quality of life and there is a lack of effective treatment to halt disease progression.

METHODS

We profiled lesional and nonlesional scalp biopsies collected in 2017 from patients with FFA (n = 12) compared with scalp biopsies from patients with alopecia areata (AA) (n = 8) and controls (n = 8) to evaluate gene and protein expression, including the primary outcome (CXCL9). We determined significant differences between biomarkers using a two-sided Student's t-test adjusting P-values by false discovery rate.

RESULTS

Significant increases were seen in CD8+ cytotoxic T cells, CD11c+ dendritic cells, CD103+ and CD69+ tissue-resident memory T cells in FFA and AA vs. control scalp (P < 0·05), with corresponding significantly upregulated granzyme B mRNA, particularly in FFA (P < 0·01). In AA, cellular infiltrates were primarily concentrated at the bulb, while in FFA these were mainly localized at the bulge. FFA demonstrated significant upregulation of T helper 1/intereferon (IFN) (IFN-γ, CXCL9/CXCL10), the Janus kinase/signal transducers and activators of transcription (JAK-STAT) pathway (STAT1, JAK3) and fibrosis-related products (vimentin, fibronectin; P < 0·05), with no concomitant downregulation of hair keratins and the T-regulatory marker, forkhead box P3, which were decreased in AA. The stem cell markers CD200 and K15 demonstrated significantly reduced expression only in FFA (P < 0·05).

CONCLUSIONS

These data suggest that follicular damage and loss of stem cells in FFA may be mediated through immune attack in the bulge region, with secondary fibrosis and reduced but still detectable stem cells. JAK/STAT-targeting treatments may be able to prevent permanent follicular destruction and fibrosis in early disease stages.

A Novel Atypical Presentation of Frontal Fibrosing Alopecia Involving the Frontoparietal Scalp

Frontal fibrosing alopecia (FFA) is a progressive scarring alopecia of unknown etiology that classically presents with a band of hair loss along the frontotemporal scalp. We report a case of FFA involving a band of alopecia along the frontotemporal scalp extending into 2 symmetrical triangles along the parietal scalp reminiscent of the Greek letter upsilon (υ). Trichoscopy demonstrated loss of follicular ostia and peripilar casts. Histology demonstrated altered follicular architecture with decreased follicular density and focal perifollicular fibrosis with a lichenoid infiltrate. Both the trichoscopy and histology support a diagnosis of FFA.

Follicular Map: A Novel Approach to Quantitative Trichoscopy

Background

Trichoscopy (hair and scalp dermoscopy) is gaining importance as an easy-to-use diagnostic and monitoring tool in various hair and scalp conditions.

Objective

The demand for a method to identify exactly the same site on scalp skin for subsequent examinations is growing constantly.

Methods

In total, 40,000 trichoscopic images of 70-fold magnification were analyzed. Graphical pattern recognition was used to identify hair shafts in trichoscopy images and to derive the coordinates of all follicular orifices. Determination of the relative positions of hair follicle orifices formed the Follicular Map (FMap). Processing and matching of FMaps involves conceptually simple but computationally complex numerical algorithms.

Results

FMaps were shown to be unique for specific locations on the scalp in each human individual. The follicular patterns were not affected by natural hair cycling processes and remained unchanged over the course of time. It has been tentatively verified that FMaps remain unaffected by noncicatricial alopecia.

Conclusions

The concept of FMap presents a novel approach to qualitative trichoscopy, allowing precise evaluation of treatment efficiency, clinical trial quality control, validation of diagnostic tools, and potentially other applications still to be discovered. The FMap enables the location of hair follicles to be precisely measured and recorded.

What's New in Hair Loss

The treatment of hair loss is a challenge for all dermatologists. New medications are needed due to lack of efficacy of many treatments or their side-effect profile. This article discusses the most recent literature updates on the use of retinoids in frontal fibrosing alopecia, platelet-rich plasma in androgenetic alopecia, and JAK inhibitors in alopecia areata.

Cicatricial alopecia

In the classification of the North American Hair Research Society, primary cicatricial alopecias (PCA) are divided into four groups according to their prominent inflammatory infiltrate: PCAs with lymphocytic, neutrophilic, mixed or nonspecific cell inflammation pattern. The hair loss can begin subclinically and progress slowly so that the exact onset of the disease is often difficult to determine. The diagnosis is often delayed. While most forms of cicatricial alopecia can be clearly diagnosed based on clinical presentation in the acute disease stage, diagnosis can be challenging in the subacute, early or late disease stages. At first presentation, a detailed patient history and dermatological examination of the body, including trichoscopy, should be performed. In clinically unclear cases, a biopsy should be performed. Due to the scarcity of primary cicatricial alopecia, there is little evidence on the efficacy of the various therapies. The aims of treatment are to stop or at least delay hair loss and progression of the scarring process, reduce clinical inflammation signs as well as to alleviate subjective symptoms. Hair re-growth in already scarred areas should not be expected. Anti-inflammatory treatment with topical corticosteroids class III to IV and / or with intracutaneous intralesional triamcinolone acetonide injections can be considered in most of the primary cicatricial alopecias. The choice of systemic therapy depends on the type of predominant inflammatory infiltrate and includes antimicrobial, antibiotic or immunomodulating/immunosuppressive agents. Psychological support and camouflage techniques should be offered to the patients.

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.

Frontal fibrosing alopecia: efficacy of treatment modalities

Frontal fibrosing alopecia (FFA) is a primary cicatricial alopecia characterized by loss of follicular stem cells, fibrosis, and a receding frontotemporal hairline, with frequent loss of eyebrows, and less commonly, body hair involvement. Diagnosis is clinical and the disease most often affects postmenopausal women. Treatment is difficult with the goal of disease stabilization rather than hair regrowth due to the scarring nature of FFA. To date, there are no randomized controlled trials evaluating efficacy of treatments. Therefore, much of our knowledge is based on small retrospective studies. In this review, we highlight the various and most current treatment options for FFA, including 5-α-reductase inhibitors, intralesional steroids, hydroxychloroquine, topical steroids, topical calcineurin inhibitors, systemic retinoids, pioglitazone, oral antibiotics, minoxidil, excimer laser, and hair transplantation. Currently, 5-α-reductase inhibitors, intralesional steroids, and hydroxychloroquine have the highest level of evidence for treating FFA, while the remaining therapies have variable results and require further data to draw definitive conclusions.

Peripilar "Guttate" Hypopigmentation of the Scalp and Idiopathic Guttate Hypomelanosis in Frontal Fibrosing Alopecia

Frontal fibrosing alopecia (FFA) is characterized by progressive band-like scarring alopecia involving the frontotemporal hairline and limbs and irreversible alopecia of the eyebrows. Two opposite types of pigmentary alterations have been reported in FFA: hyper- and hypopigmentation. Here, we report a 57-year-old Hispanic female with FFA who presented with peripilar hypopigmentation and idiopathic guttate hypomelanosis on the upper extremities. To our knowledge, this is the first report of peripilar white halos in a patient of a White Hispanic origin. Upon review of other previous publications on trichoscopy of FFA, this pattern has not been detected. The common pattern of focal absence of melanocytes and melanin in both is another confirmation that FFA is associated with pigmentation abnormalities.