Alopecia frontal fibrosante en el varón: presentación de 12 casos y revisión de la literatura

A review of isotretinoin in the treatment of frontal fibrosing alopecia

INTRODUCTION

Frontal fibrosing alopecia (FFA) is characterized by scarring alopecia of the frontotemporal scalp and facial papules. Isotretinoin is a vitamin A-derived retinoid discovered in 1955 and approved for treating nodulocystic acne. This drug can also affect facial papules and frontotemporal hair loss in patients with FFA. In this article, we conducted a review of the available studies investigating the use of oral isotretinoin for FFA treatment. Our study provides insights into the efficacy and safety of isotretinoin as a potential treatment option for FFA and highlights areas for future research.

METHOD

In this study, we aimed to investigate the potential advantages and disadvantages of isotretinoin as a treatment for FFA. To identify all relevant articles, we developed a comprehensive search strategy and conducted a thorough search of three major databases: PubMed, Embase, and Science Direct. We retrieved a total of 82 articles from the search results. Two independent reviewers then screened each of the 82 articles based on our inclusion and exclusion criteria, resulting in the identification of 15 articles that were deemed relevant to our study.

RESULTS

Across the 15 articles, 232 patients who suffered from FFA were involved. Nearly 90% of patients experienced a significant reduction of symptoms after receiving oral isotretinoin at 10-40 mg daily. We conclude that isotretinoin can positively affect facial papules and help suppress hair loss.

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 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.

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.

Occipital Fibrosing Alopecia in a Young Male: A Case Report

Introduction

Lichen planopilaris (LPP) is a primary lymphocytic cicatricial alopecia with 3 recognized clinical variants. Lately, LPP clinical spectrum has expanded with new and overlapping clinical variants. First considered as a subtype of LPP affecting postmenopausal women, the increasing worldwide incidence of FFA including atypical lesions in young female and male suggests a different pathomechanism for this disease. Although LPP-spectrum disorders may share similar histopathological findings, clinical features and prognosis are different.

Case Report

A 26-year-old Caucasian male presented with occipital scarring alopecia and pruritus for the last 6 months. The patient had been treated for an associated androgenetic alopecia and superficial recurrent scalp folliculitis over the vertex scalp for the last 5 years. Trichoscopy of the occipital scalp showed mild diffuse erythema, moderate peripilar scaling, and absence of follicular openings, suggestive of a scarring process. The patient underwent an occipital scalp biopsy that confirmed the diagnosis of a LPP-spectrum disorder.

Discussion/Conclusion

Both LPP and FFA mostly affect the anterior-mid scalp of females. However, recent reports on FFA also in premenopausal women and men should make physicians aware of atypical features of this disease and unusual clinical presentation.

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: 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 and genital Lichen sclerosus: Single-center experience

BACKGROUND

Despite the incidence of Frontal fibrosing alopecia (FFA) has been increasing in last two decades, the pathophysiology and trigger factors of FFA have not been yet fully understood.

AIMS

The aim of this study was to describe epidemiology, clinical and trichoscopic features and comorbidities of FFA patients, in order to improve the understanding of this disease.

PATIENTS/METHODS

A retrospective, observational monocentric study was conducted from 2003 to 2019. Data concerning epidemiology (age, gender, age of menopause, and age of FFA onset), comorbidities, current therapies, localization of FFA (such as frontotemporal hairline, occipital, eyebrow, eyelash, beard, sideburns, and body hair), presence of papules and sign of Lichen planus (LP) at skin, mucosae and/or nail were collected for each patient included.

RESULTS

A total of 119 Caucasian, adult patients (8 men and 111 female) with FFA were enrolled in the study. Cutaneous, mucosal, or nail localization of LP were found in 16% of our subjects. Interestingly, 15 out of 119 subjects (10.61%) were affected by concomitant genital Lichen sclerosus (LS) and 5 out of these 15 patients (4.38%) presented both LS and LP in association with FFA.

CONCLUSION

Considering the high prevalence of LS in FFA patients in our case series, and the frequency of autoimmune comorbidities in both LS and FFA, it is possible to hypothesize an autoimmune process in both conditions. Further studies are needed for a better understanding of the nature of the association between LS and FFA.

Social Status May Interfere in the Prognosis of Frontal Fibrosing Alopecia in Female Patients: An Observational Study

Introduction

Frontal fibrosing alopecia (FFA) is a cicatricial alopecia whose incidence has greatly increased worldwide over the last years. The main purpose of the study was to investigate the possible association of the social status of FFA patients with the prognosis of the disease.

Methods

A total of 100 female patients with FFA, monitored at Andreas Sygros Hospital, Athens, Greece, during the last 3 years, were recruited in this observational study. The age of the women ranged from 29 to 92 years with a mean age of 61.2 years (SD = 10.3); 97% of them were Greek, with skin type II and III.

Results

In total, 46% of the patients were intermediate graduates, and 42% had received tertiary education; 82% were married and 21% had 1 child. The duration of the disease ranged from 0.5 to 20 years with a mean duration of 5.2 years. In 53% of the women, the frontal hairline recession was <1 cm, in 26% it was 1-2 cm, and in 15% it was 3-4.99 cm. Overall, 55.6% of patients were professionals, 26% were technicians and associate professionals, 23% were office workers, 9% were service and sales workers, and 13% were at elementary occupations. The severity of the disease was higher in lower-educated patients, who belong to the category of unskilled or with elementary occupation.

Conclusions

Women with high educational level and social status are more likely to be diagnosed earlier, resulting in sufficient therapeutic response.

Distinct Trichoscopic Features of the Sideburns in Frontal Fibrosing Alopecia Compared to the Frontotemporal Scalp

The trichoscopic features of frontal fibrosing alopecia (FFA) have been described in the frontotemporal area, yet there is no data detailing the trichoscopic features of the sideburns, which can be the initial or exclusive area of involvement. In this retrospective cohort study, 236 trichoscopic images of the frontotemporal and sideburn area obtained via dry trichoscopy from patients with biopsy-proven FFA were examined by two independent researchers to determine the trichoscopic features of FFA in the sideburns. The images of the sideburns were compared to 44 trichoscopic images of 11 healthy volunteers with intact sideburns. Transparent proximal hair emergence surrounded by patches of paler smooth skin was the most prominent finding in the sideburns. Peripilar casts and peripilar erythema were rare in the sideburns compared to the frontotemporal area. Although less common, transparent proximal hair emergence was also seen in the sideburns of healthy controls, yet it was shorter and restricted to individual hairs. Early FFA presenting exclusively or mostly with sideburn involvement should not be missed due to absence of peripilar casts and peripilar erythema. Dermoscopy-guided biopsy obtained from hair shafts with transparent proximal hair emergence should be considered to make the diagnosis in this location.

Frontal Fibrosing Alopecia: Update and Review of Challenges and Successes

Background:

Frontal fibrosing alopecia (FFA) is a variant of lichen planopilaris (LPP) and is characterised as a progressive cicatricial alopecia affecting the frontotemporal hairline.

Objectives:

To perform a comprehensive, up-to-date review of the etiopathogenesis, clinicopathological features, and therapeutic options for FFA.

Methods:

A literature search was conducted using PubMed (from 1946) and Cochrane (from 1991) databases on March 7, 2017. We included all retrospective and prospective studies reported in English. Only cases studies with reported treatment regimen and outcome were included. No randomised control trials were found. MeSH terms used included frontal fibrosing alopecia, postmenopausal, histopathologic, cicatricial, and treatment.

Results:

With an increasing incidence of FFA occurring predominantly in postmenopausal women, progress has been made clinically and histologically in understanding this scarring alopecia. Conflicting results have been reported with various treatments, including intralesional or oral corticosteroids, antiandrogens, antimalarials, antibiotics, and surgery. To date, no randomised control trials for treatment of FFA have been conducted.

Conclusion:

The aetiology and clinical course of FFA remain to be established. Unfortunately, despite the numerous treatment options available, no one therapeutic regimen has proven effective in stopping recession of the hairline and inducing hair growth.