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Donati A, Wu IIH. Extra-follicular cutaneous manifestations of frontal fibrosing alopecia. An Bras Dermatol 2024:S0365-0596(24)00137-5. [PMID: 39214818 DOI: 10.1016/j.abd.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/25/2023] [Accepted: 01/09/2024] [Indexed: 09/04/2024] Open
Abstract
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.
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Affiliation(s)
- Aline Donati
- Trichology Outpatient Clinic, Hospital do Servidor Público Municipal de São Paulo, São Paulo, SP, Brazil.
| | - Isabelle I Hue Wu
- Trichology Outpatient Clinic, Hospital do Servidor Público Municipal de São Paulo, São Paulo, SP, Brazil; Laser Outpatient Clinic, Hospital das Clínicas, Faculty of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
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Starace M, Cedirian S, Rapparini L, Quadrelli F, Pampaloni F, Bruni F, Piraccini BM. Enhanced Insights into Frontal Fibrosing Alopecia: Advancements in Pathogenesis Understanding and Management Strategies. Dermatol Ther (Heidelb) 2024; 14:1457-1477. [PMID: 38822213 PMCID: PMC11169308 DOI: 10.1007/s13555-024-01186-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/13/2024] [Indexed: 06/02/2024] Open
Abstract
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.
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Affiliation(s)
- Michela Starace
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Stephano Cedirian
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy.
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.
| | - Luca Rapparini
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Federico Quadrelli
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Francesca Pampaloni
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Francesca Bruni
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Bianca M Piraccini
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Porriño-Bustamante ML, Montero-Vílchez T, Pinedo-Moraleda FJ, Fernández-Flores Á, Fernández-Pugnaire MA, Arias-Santiago S. Frontal Fibrosing Alopecia and Sunscreen Use: A Cross-sectional Study of Actinic Damage. Acta Derm Venereol 2022; 102:adv00757. [PMID: 35604235 PMCID: PMC9609976 DOI: 10.2340/actadv.v102.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
| | - Trinidad Montero-Vílchez
- Dermatology Department, University Hospital Virgen de las Nieves, Avenida de Madrid, 15, ES-18012, Granada, Spain.
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Moll I. Frontal fibrosierende Alopezie – Fallbeispiele und Review. AKTUELLE DERMATOLOGIE 2021. [DOI: 10.1055/a-1351-5678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungDie 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.
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Porriño-Bustamante ML, Fernández-Pugnaire MA, Castellote-Caballero L, Arias-Santiago S. Colour Doppler ultrasound study in patients with frontal fibrosing alopecia. Skin Res Technol 2021; 27:709-714. [PMID: 33455050 DOI: 10.1111/srt.13004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/17/2020] [Accepted: 12/24/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The sonographic characteristics of frontal fibrosing alopecia have been scarcely studied. The aim of this study was to perform a colour Doppler ultrasound evaluation in frontal fibrosing alopecia. MATERIALS AND METHODS A cross-sectional study including 99 women with frontal fibrosing alopecia and 40 control subjects was performed using ultrasound equipment with a lineal 18 MHz probe. Three areas were evaluated per patient: the alopecic area (a), the hairline implantation area (b) and healthy scalp (c). The diameter (cm) and flow (m/s) of the two most significant vessels were recorded. RESULTS With regard to the hairline implantation area, patients presented higher vessel diameter (0.127 cm vs 0.103 cm, P = .03) and vessel flow (8.183 m/s vs 7.670 m/s, P = .05) than the control group. Vessel diameter was higher in the healthy scalp area in patients than in the control group (0.088 cm vs 0.078 cm, P = .03). CONCLUSION Patients presented higher vessel diameter and flow in the hairline implantation area compared to the control group.
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Affiliation(s)
| | | | | | - Salvador Arias-Santiago
- Dermatology Department, University Hospital Virgen de las Nieves, Granada, Spain.,School of Medicine, Institute of Biosanitary Investigation ibs, Granada University, Granada, Spain
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Frontal fibrosing alopecia: a disease that remains enigmatic. Postepy Dermatol Alergol 2020; 37:482-489. [PMID: 32994767 PMCID: PMC7507171 DOI: 10.5114/ada.2020.98241] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 11/27/2018] [Indexed: 12/19/2022] Open
Abstract
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.
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Marks DH, Manatis-Lornell A, Hagigeorges D, Yu J, Senna MM. No difference in relevant potential allergens in SPF-containing facial moisturizers: implications in frontal fibrosing alopecia. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00636-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Iorizzo M, Tosti A. Frontal Fibrosing Alopecia: An Update on Pathogenesis, Diagnosis, and Treatment. Am J Clin Dermatol 2019; 20:379-390. [PMID: 30659454 DOI: 10.1007/s40257-019-00424-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Matilde Iorizzo
- Private Dermatology Practice, Viale Stazione 16, 6500, Bellinzona, Switzerland.
| | - Antonella Tosti
- Fredric Brandt Endowed Professor of Dermatology, Miller School of Medicine, University of Miami, Miami, FL, USA
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Garcia-Robledo JE, Aragón CC, Nieto-Aristizábal I, Vásquez S, Montoya C, Tobón GJ. Frontal fibrosing alopecia: A new autoimmune entity? Med Hypotheses 2019; 124:13-16. [DOI: 10.1016/j.mehy.2019.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/08/2019] [Accepted: 01/23/2019] [Indexed: 01/06/2023]
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Cranwell W, Sinclair R. Sunscreen and facial skincare products in frontal fibrosing alopecia: a case–control study. Br J Dermatol 2019; 180:943-944. [DOI: 10.1111/bjd.17354] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - R. Sinclair
- Sinclair Dermatology Victoria Australia
- Department of Medicine University of Melbourne Victoria Australia
- Epworth Dermatology Victoria Australia
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Starace M, Brandi N, Alessandrini A, Bruni F, Piraccini B. Frontal fibrosing alopecia: a case series of 65 patients seen in a single Italian centre. J Eur Acad Dermatol Venereol 2018; 33:433-438. [DOI: 10.1111/jdv.15372] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 10/29/2018] [Indexed: 12/19/2022]
Affiliation(s)
- M. Starace
- Dermatology Department of Specialized, Diagnostic and Experimental Medicine University of Bologna Bologna Italy
| | - N. Brandi
- Dermatology Department of Specialized, Diagnostic and Experimental Medicine University of Bologna Bologna Italy
| | - A. Alessandrini
- Dermatology Department of Specialized, Diagnostic and Experimental Medicine University of Bologna Bologna Italy
| | - F. Bruni
- Dermatology Department of Specialized, Diagnostic and Experimental Medicine University of Bologna Bologna Italy
| | - B.M. Piraccini
- Dermatology Department of Specialized, Diagnostic and Experimental Medicine University of Bologna Bologna Italy
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Rocha V, Donati A, Contin L, Kakizaki P, Machado C, Brito F, Claudino D, Moraes P, Guerra J, Pires M. Photopatch and patch testing in 63 patients with frontal fibrosing alopecia: a case series. Br J Dermatol 2018; 179:1402-1403. [DOI: 10.1111/bjd.16933] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- V.B. Rocha
- IAMSPE, Hospital do Servidor Público Estadual de São Paulo; São Paulo Brazil
| | - A. Donati
- Department of Dermatology; University of São Paulo; São Paulo Brazil
| | - L.A. Contin
- Department of Dermatology; Hospital do Servidor Público Municipal; São Paulo Brazil
| | - P. Kakizaki
- Department of Dermatology; Hospital do Servidor Público Municipal; São Paulo Brazil
| | - C.J. Machado
- Faculty of Medicine; UFMG, Public Health; Belo Horizonte, Minas Gerais Brazil
| | - F.F. Brito
- Department of Dermatology; Hospital do Servidor Público Municipal; São Paulo Brazil
| | - D. Claudino
- Department of Dermatology; Hospital do Servidor Público Municipal; São Paulo Brazil
| | - P. Moraes
- Department of Dermatology; Hospital do Servidor Público Municipal; São Paulo Brazil
| | - J. Guerra
- Department of Dermatology; Hospital do Servidor Público Municipal; São Paulo Brazil
| | - M.C. Pires
- IAMSPE, Hospital do Servidor Público Estadual de São Paulo; São Paulo Brazil
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Abstract
Since its original report in 1994, frontal fibrosing alopecia has become increasingly common, attracting the attention of the medical community and giving rise to speculations on its etiology, specifically the possibility of environmental factors. Familial cases of frontal fibrosing alopecia point to the possible contribution of hereditary factors maybe related to androgenetic alopecia. We report thefirst case of connubial frontal fibrosing alopecia in a genetically unrelated couple pointing to the possibility of a common environmental exposure in the etiology of the condition. Our observation may be fortuitous, considering the high frequency of female frontal fibrosing alopecia. Nevertheless, the incidence of male frontal fibrosing alopecia has remained low with a consequently low statistical probability of random occurrence of the condition in a marital couple. We, therefore, suggest to systematically includes the hair condition of marital partners in the patient history of patients with frontal fibrosing alopecia, to elucidate the actual frequency of connubial frontal fibrosing alopecia and maybe a common causative agent or hair grooming practice.
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Affiliation(s)
- Ricardo da Silva Libório
- Department of Dermatology and Radiotherapy, Botucatu Medical School, Paulista State University, UNESP, São Paulo, Brazil
| | - Ralph M Trüeb
- Center for Dermatology and Hair Diseases Professor Trüeb, Zurich, Switzerland
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Schmutz JL. [The role of sunscreens in fibrosing frontal alopecia]. Ann Dermatol Venereol 2017; 144:483-484. [PMID: 28391983 DOI: 10.1016/j.annder.2017.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- J-L Schmutz
- Département de dermatologie et allergologie, CHRU, hôpital de Brabois, bâtiment des spécialités médicales Philippe-Canton, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
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