To the Editor: Frontal fibrosing alopecia (FFA) is a primary lymphocytic scarring alopecia that mainly affects postmenopausal women.
1In the past 2 decades, an increasing number of cases have been reported.
2Recognizing FFA may be a challenge when it manifests with unusual features.
The aim of this study was to evaluate clinical and trichoscopic features of FFA in a large series of patients.
We performed a retrospective, monocentric study of trichoscopic images of 98 patients (4 men and 94 women) with FFA seen at our Dermatologic Clinic between 2003 and 2016. The diagnosis of FFA was based on clinical (symmetric frontal or frontotemporal hairline recession) and typical trichoscopic findings (absence of follicular openings, lone hairs, and single-hair pilosebaceous units). All patients were white, without familial history of FFA. Two patients were premenopausal at the onset.
In our case series in 80 patients, FFA manifested with typical clinical features, whereas in 18 postmenopausal patients (18.4%), we observed unusual patterns of disease. In particular, 12 women presented with marked and symmetric recession of frontotemporal hairlines, with a peculiar sparing of the paramedian frontal hairline, mimicking male pattern androgenetic alopecia (AGA). We named this peculiar clinical presentation “AGA-like pattern” (Fig 1, A and C). Trichoscopic examination revealed typical findings of FFA (Fig 1, B and D). Moreover, in 2 patients we observed bilateral oval patches of alopecia in the temporal regions, with peculiar sparing of a band of temporal hairlines, in addition to typical recession of frontal hairline (Fig 2, A). Trichoscopy revealed typical findings of FFA, leading to a diagnosis of FFA in a peculiar clinical pattern that we called “cockade-like pattern” (Fig 2, B). Continuous involvement of the hairline from frontal to occipital regions was present in 6 other patients (Fig 2, C). Trichoscopic examination revealed in 4 of 6 cases typical findings of FFA at all areas affected (Fig 2, D). We termed this clinical finding “ophiasis-like pattern.” Instead, in 2 of 6 cases, trichoscopic examination revealed signs of alopecia areata at the occipital region, whereas typical features of FFA were present at the frontotemporal and retroauricolar regions.
Trichoscopy is a fast, noninvasive, and cost-efficient technique that is very useful in the diagnosis of hair and scalp diseases.
3In particular, its efficacy has been demonstrated to diagnose and differentiate alopecia areata from other patchy alopecia and to diagnose early AGA.
3Recently, Fernández-Crehuet et al
4considered trichoscopy a valuable tool also in the diagnosis of FFA. The main trichoscopic features of FFA are absence of follicular openings, scarring white patches, minor perifollicular scaling, perifollicular erythema, and lone hairs.
4Vaňó-Galván et al
5reported that typical dermoscopic features could substitute for biopsy in patients with typical FFA.
We observed in a large case series that 18.4% of patients affected by FFA had unusual clinical findings; we could identify 3 patterns: (1) AGA-like pattern; (2) cockade-like pattern; and (3) ophiasis-like pattern. Trichoscopy revealed in all patients affected by FFA, both with typical and unusual clinical patterns, the same repetitive findings, namely the absence of follicular openings, scattered lone hairs, and single-hair pilosebaceous units at margins, also suggesting that when clinical presentation is not conclusive for the diagnosis of FFA, trichoscopy may be a very useful tool in the differential diagnosis.
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Funding sources: None.
© 2017 by the American Academy of Dermatology, Inc.