Frontal fibrosing alopecia

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Frontal fibrosing alopecia
Other names: FFA[1]
Frontal fibrosing alopecia.webp

Frontal fibrosing alopecia is the frontotemporal hairline recession and eyebrow loss in postmenopausal women that is associated with perifollicular erythema, especially along the hairline.[2]: 648  It is considered to be a clinical variant of lichen planopilaris.[3]

Signs and symptoms

There is loss of both terminal and vellus hairs that occurs in a bandlike pattern on the frontotemporal scalp.[4] It is a scarring alopecia that has been associated with facial papules, glabellar red dots, a loss of eyebrows, and prominent venous vasculature in the forehead.[5][6][7][8] Facial hyperpigmentation may occur in dark-skinned patients if association with lichen planus pigmentosus is present.[9]


Frontal fibrosing alopecia has been most often reported in post-menopausal women with higher levels of affluence and a negative smoking history. Autoimmune disease is found in 30% of patients.[5][10]


Although the pathogenesis of frontal fibrosing alopecia is poorly understood, autoimmune reaction and hormonal factors may play a role.[5]


Perifollicular erythema and scarring white patches are seen on dermoscopy. On scalp biopsy, lymphocytic and granulomatous perifolliculitis with eccentric atrophy of follicular epithelia and perifollicular fibrosis are visualized.[11]

Differential diagnosis

Important diagnoses to consider include female pattern hair loss (FPHL), chronic telogen effluvium (CTE), and alopecia areata (AA). FPHL is a non-scarring progressive miniaturization of the hair follicle with one of three different characteristic patterns. CTE is an idiopathic disease causing increased hair shedding and bi-temporal recession, usually in middle aged women. AA is an autoimmune attack of hair follicles that usually causes hair to fall out in small round patches.[12]


Improvement or stabilization of the condition has been reported with topical and intralesional corticosteroids, antibiotics, hydroxychloroquine, topical and oral immunomodulators, tacrolimus, and most recently, 5α-reductase inhibitors. In one study, the use of antiandrogens (finasteride or dutasteride) was associated with improvement in 47% and stabilization in 53% of patients [13] Recently, successful treatment of facial papules in patients with frontal fibrosing alopecia was described with oral isotretinoin.[14]

See also


  1. RESERVED, INSERM US14-- ALL RIGHTS. "Orphanet: Frontal fibrosing alopecia". Archived from the original on 23 October 2017. Retrieved 26 April 2019.
  2. Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. ISBN 0-07-138076-0.
  3. Lacarrubba, F; Micali, G; Tosti, A (Mar 18, 2013). "Absence Of Vellus Hair In The Hairline: A Videodermatoscopic Feature Of Frontal Fibrosing Alopecia". The British Journal of Dermatology. 169 (2): 473–4. doi:10.1111/bjd.12316. PMID 23496000.
  4. Kossard S, Lee MS, Wilkinson B. Postmenopausal alopecia: a frontal variant of lichen planopilaris. J Am Acad Dermatol. 1997;36(1):59.
  5. 5.0 5.1 5.2 Macdonald A, Clark C, Holmes S. Frontal fibrosing alopecia: a review of 60 cases. J Am Acad Dermatol. 2012;67(5):955-61.
  6. Banka N, Mubki T, Bunagan MJ, Mcelwee K, Shapiro J. Frontal fibrosing alopecia: a retrospective clinical review of 62 patients with treatment outcome and long-term follow-up. Int J Dermatol. 2014;53(11):1324-30.
  7. Pirmez R, Donati A, Valente NS, Sodré CT, Tosti A. Glabellar red dots in frontal fibrosing alopecia: a further clinical sign of vellus follicle involvement. Br J Dermatol. 2014;170(3):745-6.
  8. Vañó-galván S, Rodrigues-barata AR, Urech M, et al. Depression of the frontal veins: A new clinical sign of frontal fibrosing alopecia. J Am Acad Dermatol. 2015;72(6):1087-8.
  9. Pirmez R, Duque-Estrada B, Donati A, Campos-do-Carmo G, Valente NS, Romiti R, Sodré CT, Tosti A. Clinical and dermoscopic features of lichen planus pigmentosus in 37 patients with frontal fibrosing alopecia. Br J Dermatol. 2016 May 28. doi: 10.1111/bjd.14722.
  10. Kossard S. Postmenopausal frontal fibrosing alopecia: scarring alopecia in a pattern distribution. Arch Dermatol 1994;130:770-4.
  11. Dhurat R, Saraogi P. Hair evaluation methods: merits and demerits. Int J Trichology. 2009;1(2):108-19.
  12. Herskovitz I, Tosti A. Female pattern hair loss. Int J Endocrinol Metab. 2013;11(4):e9860.
  13. Vañó-galván S, Molina-ruiz AM, Serrano-falcón C, et al. Frontal fibrosing alopecia: a multicenter review of 355 patients. J Am Acad Dermatol. 2014;70(4):670-8.
  14. Pirmez R, Duque-Estrada B, Barreto T, Quintella DC, Cuzzi T. Successful Treatment of Facial Papules in Frontal Fibrosing Alopecia with Oral Isotretinoin. Skin Appendage Disord 2017;3:111-113. doi=10.1159/000464334

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