Frontal fibrosing alopecia versus lichen planopilaris: a clinicopathological study

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.

Pruritus in Lichen Planopilaris and Frontal Fibrosing Alopecia-Clinical Characteristics and Dermoscopic Correlations

Background: Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) are the most common causes of lymphocytic scarring alopecia. Itching of the scalp is a common accompanying symptom. The aim of the study was the clinical assessment of pruritus and its correlation with dermoscopic features. Methods: Sixty-one patients with scarring alopecia were analyzed (LPP = 16; FFA = 33; coexisting LPP-FFA = 12). Each patient underwent a trichoscopic examination. Itch severity and characteristics were assessed using a Visual Analogue Scale (VAS), 4-item Itch Questionnaire and 12-item Descriptive Pruritus Assessment Questionnaire. Results: Itching of the scalp occurred in 73.8% of the patients (mean maximal VAS 5.3 ± 3.1 points). Pruritus was most frequently accompanied by tingling (19.7%) or burning (14.8%) sensations. The following factors most frequently increased the severity of pruritus: sweating, heat, stress and hot water. On the other hand, cold water and cold air often relieved symptoms. There was a significant relationship between itch and perifollicular scaling (p = 0.011), hair diameter diversity (p = 0.008) and white halo (p = 0.016). Conclusions: Pruritus was the main subjective complaint reported by patients suffering from LPP and FFA. A better understanding of pruritic features may help in the selection of an effective therapeutic strategy.

Trichoscopy - a valuable tool for identifying conditions mimicking androgenetic alopecia

Androgenetic alopecia (AGA) is the most prevalent type of hair loss in women and men. Recently, a European consensus group published guidelines for the diagnostic evaluation of AGA in men, women, and adolescents. This S1 guideline presents expert opinion-based recommendations for gender-dependent steps in the diagnostic procedure, which can easily be implemented in the daily clinical routine. For diagnosing AGA, detailed anamnesis and objective learning are not enough because there are several conditions mimicking this disease. Trichoscopy can be considered an important, non-invasive tool for diagnosing hair and scalp disorders that may have similar clinical signs to AGA.

A Retrospective Study of Frontal Fibrosing Alopecia from North-East India

Background

Frontal fibrosing alopecia (FFA) is an important cause of scarring alopecia seen mostly in post-menopausal women but sometimes in pre-menopausal women and men. Although considered a variant of lichen planopilaris due to its histopathological characteristics, it has distinct clinical features and associations, which make it a unique entity. We hereby report a series of patients with FFA from North-East India.

Aims and Objective

This study aimed to analyse the clinical and histopathological characteristics of FFA.

Materials and Methods

We retrospectively analysed clinical records and histopathological features of FFA cases diagnosed in the Dermatology Outpatient Department from April 2013 to February 2023.

Results

A total of 21 patients, who were diagnosed with FFA from April 2013 to February 2023, were analysed. Of these, 19 patients were female, with a male-to-female ratio of 9.5:1. The mean age of study population was 48.33 years. The majority of the patients were from the post-menopausal age group (15/19 females, 78.94%). Lichen planus pigmentosus (6, 28.57%) was the most commonly associated disease, followed by androgenetic alopecia and lichen planopilaris (2 each, 9.52%). The main histological features noted were perifollicular lymphocytic infiltrate in 18 (85.71%), followed by hydropic degeneration of basal follicular keratinocytes in 15 (71.42%) and melanin incontinence in 14 (66.66%) patients.

Conclusion

Our study is the first study from North-East India focusing on the clinical presentation and histopathological characteristics of FFA. Furthermore, with respect to the recent development in FFA, our study attempted to determine the clinical significance of the proposed criteria for the diagnosis of FFA patients by Tolkachjov et al. (2018), viz. International FFA Cooperative Group Criteria (2021).

Alopecias: Practical Tips for the Management of Biopsies and Main Diagnostic Clues for General Pathologists and Dermatopathologists

Accurately diagnosing specific variants of alopecia remains challenging for pathologists, potentially delaying appropriate therapeutic decisions by dermatologists. Issues such as limited knowledge on optimal biopsy types and processing methods add complexity. Understanding the normal histology of hair follicles and their changes throughout the follicular cycle further complicates microscopic evaluation. This paper aims to summarize these characteristics and highlight essential diagnostic clues for pathologists to confidently suggest a diagnosis, therefore playing a key role in alopecia diagnosis. Ongoing education, collaboration with dermatologists, and staying up to date on advancements is crucial for the accurate diagnosis and effective management of different types of alopecia.

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.

Frontal Fibrosing Alopecia: A Histopathological Comparison of the Frontal Hairline with Normal-Appearing Scalp

Frontal fibrosing alopecia is characterized by the presence of a lymphocytic inflammatory infiltrate around the upper follicle and by perifollicular fibrosis, which results in the destruction of the hair follicle. Recent reports have also found the presence of those findings in clinically unaffected areas. The aim of this report is to perform a deeper analysis of the histopathological features of this apparently unaffected scalp. A cross-sectional study including 52 women with frontal fibrosing alopecia was performed. Two areas were biopsied: the frontal hairline and a normal-appearing scalp area. Sebaceous glands were reduced/absent in 80.8% of the frontal hairline samples compared to 42.3% of the "healthy scalp" samples (p = 0.001). Inflammatory infiltrate was observed in 92.3% of patients in the frontal hairline and in 86.5% of them in the "healthy scalp" area (p = 0.508), although the severity was higher in the former (p = 0.013). Follicular epithelium changes were seen in 70.6% of the frontal hairline biopsies compared to 48.1% of the "healthy scalp" biopsies (p = 0.012). Fibrous tissular changes were noted in 80.8% and 53.8% of the frontal hairline and "healthy scalp" biopsies, respectively (p = 0.003). In conclusion, the histopathological features of frontal fibrosing alopecia are shared by both affected and clinically unaffected areas.

Immune-mediated alopecias and their mechanobiological aspects

Alopecia is a non-specific term for hair loss clinically diagnosed by the hair loss pattern and histological analysis of patient scalp biopsies. The immune-mediated alopecia subtypes, including alopecia areata, lichen planopilaris, frontal fibrosing alopecia, and central centrifugal cicatricial alopecia, are common, significant forms of alopecia subtypes. For example, alopecia areata is the most common autoimmune disease with a lifetime incidence of approximately 2% of the world's population. In this perspective, we discuss major results from studies of immune-mediated alopecia subtypes. These studies suggest the key event in disease onset as the collapse in immune privilege, which alters the hair follicle microenvironment, e.g., upregulation of major histocompatibility complex molecules and increase of cytokine production, and results in immune cell infiltration, inflammatory responses, and damage of hair follicles. We note that previous studies have established that the hair follicle has a complex mechanical microenvironment, which may regulate the function of not only tissue cells but also immune cell infiltrates. This suggests a potential for mechanobiology to contribute to alopecia research by adding new methods, new approaches, and new ways of thinking, which is missing in the existing literature. To fill this a gap in the alopecia research space, we develop a mechanobiological hypothesis that alterations in the hair follicle microenvironment, specifically in the mechanically responsive tissues and cells, partially due to loss of immune privilege, may be contributors to disease pathology. We further focus our discussion on the potential for applying mechanoimmunology to the study of T cell infiltrates in the hair follicle, as they are considered primary contributors to alopecia pathology. To establish the connection between the mechanoimmunological hypothesis and immune-mediated alopecia subtypes, we discuss what is known about the role of T cells in immune-mediated alopecia subtypes, using the most extensively studied AA as our model.

Frontiers in Lichen Planopilaris and Frontal Fibrosing Alopecia Research: Pathobiology Progress and Translational Horizons

Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) are primary, lymphocytic cicatricial hair loss disorders. These model epithelial stem cell (SC) diseases are thought to result from a CD8⁺ T-cell‒dominated immune attack on the hair follicle (HF) SC niche (bulge) after the latter has lost its immune privilege (IP) for as yet unknown reasons. This induces both apoptosis and pathological epithelial‒mesenchymal transition in epithelial SCs, thus depletes the bulge, causes fibrosis, and ultimately abrogates the HFs' capacity to regenerate. In this paper, we synthesize recent progress in LPP and FFA pathobiology research, integrate our limited current understanding of the roles that genetic, hormonal, environmental, and other factors may play, and define major open questions. We propose that LPP and FFA share a common initial pathobiology, which then bifurcates into two distinct clinical phenotypes, with macrophages possibly playing a key role in phenotype determination. As particularly promising translational research avenues toward direly needed progress in the management of these disfiguring, deeply distressful cicatricial alopecia variants, we advocate to focus on the development of bulge IP and epithelial SC protectants such as, for example, topically effective, HF‒penetrating and immunoinhibitory preparations that contain tacrolimus, peroxisome proliferator-activated receptor-γ, and/or CB1 agonists.

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.

Scarring Alopecias: Pathology and an Update on Digital Developments

Primary cicatricial alopecias (PCA) represent a challenging group of disorders that result in irreversible hair loss from the destruction and fibrosis of hair follicles. Scalp skin biopsies are considered essential in investigating these conditions. Unfortunately, the recognised complexity of histopathologic interpretation is compounded by inadequate sampling and inappropriate laboratory processing. By sharing our successes in developing the communication pathway between the clinician, laboratory and histopathologist, we hope to mitigate some of the difficulties that can arise in managing these conditions. We provide insight from clinical and pathology practice into how diagnoses are derived and the key histological features observed across the most common PCAs seen in practice. Additionally, we highlight the opportunities that have emerged with advances in digital pathology and how these technologies may be used to develop clinicopathological relationships, improve working practices, enhance remote learning, reduce inefficiencies, optimise diagnostic yield, and harness the potential of artificial intelligence (AI).

Differentiation of frontal fibrosing alopecia and Lichen planopilaris on trichoscopy: A comprehensive review

Trichoscopy in dermatology has opened up the new concept in overcoming the optical challenge faced clinically. It reveals the diagnostic details to the depth of superficial dermis, and thereby increasing the clinician's diagnostic accuracy and the level of confidence. The importance of trichoscopy in cicatricial alopecia is very evident in the current scenario for its precise diagnosis. The clinical picture in delineating lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) from each other and also from other close mimickers such as androgenetic alopecia, alopecia areata, female patterned hair loss, and other cicatricial alopecia is bewildered due to its varied presentation and co-existence with the above disease. The indecisive comparative findings on histopathology make the situation even more perplexed. In this article, we have reviewed the characteristic trichoscopy patterns that can differentiate LPP and FFA and from their close mimickers.

An Approach to Patients with Alopecia

Alopecia is a dermatologic condition in which sudden or gradual loss of hair occurs on 1 or more areas of the body, most commonly the scalp. Hair loss can be acute or chronic in nature as a result of underlying inflammation, autoimmune processes, stressors, chemotherapy, or hairstyling practices. Alopecia can have substantial psychological consequences, having a negative impact on the quality of life in affected patients. The ability to both recognize and distinguish these condition holds great significance not only in providing adequate and timely treatment to improve outcomes but also meeting patient needs.

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.

Alopecia areata: a review on diagnosis, immunological etiopathogenesis and treatment options

Patients suffering from alopecia areata (AA) can lose hair in focal regions, the complete scalp, including eyelashes and eyebrows, or even the entire body. The exact pathology is not yet known, but the most described theory is a collapse of the immune privilege system, which can be found in some specific regions of the body. Different treatment options, local and systemic, are available, but none of them have been proven to be effective in the long term as well for every treatment there should be considered for the possible side effects. In many cases, treated or non-treated, relapse often occurs. The prognosis is uncertain and is negatively influenced by the subtypes alopecia totalis and alopecia universalis and characteristics such as associated nail lesions, hair loss for more than 10 years and a positive familial history. The unpredictable course of the disease also makes it a mental struggle and AA patients are more often associated with depression and anxiety compared to the healthy population. Research into immunology and genetics, more particularly in the field of dendritic cells (DC), is recommended for AA as there is evidence of the possible role of DC in the treatment of other autoimmune diseases such as multiple Sclerosis and cancer. Promising therapies for the future treatment of AA are JAK-STAT inhibitors and PRP.

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.

Features of classic lichen planopilaris and frontal fibrosing alopecia in reflectance confocal microscopy: A preliminary study

BACKGROUND

Classic lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) are primary lymphocytic cicatricial alopecia. In patients with ambiguous clinical presentation, reflectance confocal microscopy (RCM) a new noninvasive skin imaging technique, could be a helpful diagnostic tool. The aim of our study was to describe the characteristic features of classic LPP and FFA using RCM.

MATERIALS AND METHODS

Ten patients with classic lichen planopilaris and two with frontal fibrosing alopecia were examined with RCM.

RESULTS

Lichenoid inflammatory infiltrate around the hair follicle was observed in three cases of classic LPP and FFA (3/12; 25.0%). Extensive perifollicular fibrosis was seen in nine patients (9/12; 75.0%) with classic LPP and FFA. An increased number of white, ill-defined, coarse dermal fibers at the level of the superficial dermis were visible in seven cases (7/12; 58.3%). Moreover, dilated blood vessels were present in seven patients with classic LPP and FFA (7/12; 58.3%).

CONCLUSION

Summing up, reflectance confocal microscopy allows to visualize major key diagnostic features of classic lichen planopilaris and frontal fibrosing alopecia in the real time. The value of RCM examination in scarring alopecia needs to be further evaluated, but it appears to be a useful adjuvant tool for the initial diagnosis of classic LPP and FFA.

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 randomized controlled clinical study of acupuncture therapy for Seborrheic alopecia in young and middle ages: Study protocol clinical trial (SPIRIT compliant)

INTRODUCTION

Seborrheic alopecia (SA) has clinical manifestations, duration of disease, and priorities. In the current situation where there are many and complicated clinical treatments, Western medicine treatment can delay and control the development of the disease and promote hair regeneration. However, some patients may aggravate symptoms after taking the drug, and the condition is easy to repeat after stopping the drug. Acupuncture is an important method for non-surgical treatment of SA, and it has various methods, low side effects, high safety, and simple and economical. Therefore, we will use a clinical randomized controlled study to explore the effect of acupuncture on SA, and provide a new idea and reference for the treatment of this disease.

METHODS/DESIGN

We will select 60 patients diagnosed with SA. They will be randomly divided into intervention group and control groups. The control group will be given conventional treatment measures. The intervention group will receive acupuncture. Efficacy will be evaluated by comparing the skin lesion score and dermatological quality of life index before and after treatment.

DISCUSSION

This trial may provide evidence regarding the clinical effectiveness, safety, and cost-effectiveness of acupuncture for patients with SA.

TRIAL REGISTRATION NUMBER

CTR2000030430.

Profiling the human hair follicle immune system in lichen planopilaris and frontal fibrosing alopecia: can macrophage polarization differentiate these two conditions microscopically?

BACKGROUND

Frontal fibrosing alopecia (FFA) is traditionally regarded as a variant of lichen planopilaris (LPP) based on histological features. Distinct clinical presentation, demographics and epidemiology suggest that differing pathogenic factors determine the final phenotype.

OBJECTIVES

To map the hair follicle immune system in LPP and FFA by systematically comparing key inflammatory markers in defined hair follicle compartments.

METHODS

Lesional scalp biopsies from LPP and FFA and healthy controls were stained with the following immunohistochemical markers: CD1a and CD209, CD4, CD8, CD56, CD68, CD123, CXCR3, forkhead box (FOX)P3, mast cell tryptase and cKit. Macrophage polarization was explored using CD206, CD163, CD86, receptor for advanced glycation end products (RAGE), interleukin (IL)-4 and IL-13 on paired lesional and nonlesional LPP and FFA samples.

RESULTS

Increased numbers of CD8⁺ , CXCR3⁺ and FOXP3⁺ T cells and CD68⁺ macrophages were identified in the distal hair follicle epithelium and perifollicular mesenchyme in both LPP and FFA compared with controls. In both LPP and FFA, total and degranulated mast cells and CD123⁺ plasmacytoid dendritic cells were increased in the perifollicular mesenchyme adjacent to the bulge and infundibulum, whereas numbers of CD1a⁺ and CD209⁺ dendritic cells were significantly reduced in the infundibulum connective tissue sheath. However, only with CD68 staining was a significant difference between LPP and FFA identified, with greater numbers of CD68⁺ cells in LPP samples. Furthermore, the identified macrophage polarization markers downregulated CD86 and upregulated CD163 and IL-4 expression in lesional LPP compared with FFA samples.

CONCLUSIONS

This comparative immunopathological analysis is the first to profile systematically the hair follicle immune system in LPP and FFA. Our analysis highlights a potential role of macrophages in disease pathobiology and suggests that macrophage polarization may differ between LPP and FFA, allowing microscopic differentiation. Linked Comment: Kinoshita-Ise. Br J Dermatol 2020; 183:419-420.

Adipose Infiltration of the Dermis, Involving the Arrector Pili Muscle, and Dermal Displacement of Eccrine Sweat Coils: New Histologic Observations in Frontal Fibrosing Alopecia

BACKGROUND

Frontal fibrosing alopecia (FFA) is an irreversible scarring alopecia, and its incidence has reached epidemic size. Immune privilege collapse of the bulge and epithelial mesenchymal transition play a role in the pathogenesis. We have noted adipose tissue in the dermis in several specimens from FFA.

OBJECTIVE

Our primary objective was to verify the presence of adipose tissue at the isthmus level in biopsies from FFA. Additional objectives included the presence of deep inflammation and position of the sweat coils.

METHODS

Eighty-three histologic specimens of FFA diagnosed at the Dermatopathology Laboratory at the Department of Dermatology, University of Miami, within 3 years were evaluated retrospectively. All biopsies were bisected horizontally and assessed at several levels. Sixty biopsies from androgenetic alopecia served as controls. Statistical analysis was performed using the χ test. A P value of 0.05 or less was considered significant.

RESULTS

Sixty specimens met the inclusion criteria for optimal quality and classic diagnostic features. Seventy percent demonstrated fat tissue infiltration at the isthmus level as clusters of cells or small globules versus 23% of the controls. The fat infiltration in the arrector pili muscle (APM) was present in 55% versus 15% of the controls, and the sweat coils were positioned in the reticular dermis in 43% versus 1.7% of the controls. All results were statistically significant (P < 0.0001). When accounting for the simultaneous presence of any of these 3 variables, 30% of the FFA cases had triple positivity, 61.7% had double positivity, and 75% had at least 1 positive variable versus 0%, 15%, and 10%, respectively, of the controls.

CONCLUSION

New histologic findings in FFA involve the presence of adipose tissue in the dermis. We believe that the close interaction of the hair follicles and the APM with the adipose tissue may play a role in APM degeneration and in epithelial mesenchymal transition.

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.

A New Histologic Pattern in 6 Biopsies From Early Frontal Fibrosing Alopecia

Frontal fibrosing alopecia (FFA) is an irreversible scarring alopecia with unknown etiology and no cure. The goal is to establish the diagnosis in the early stage, before developing a hairless band of atrophy involving the frontal, temporal scalp and sideburns. Pathology is rarely needed once the disease is clinically apparent. The classic histologic features include follicular dropout with the absence or atrophy of the sebaceous glands and lichenoid lymphohistiocytic infiltrate with concentric layered fibrosis at the upper follicular level. We describe a common pattern that was repeatedly seen in 6 horizontally sectioned scalp biopsies from patients with early presentation of FFA suspected on trichoscopy by the focal presence of peripilar casts around terminal hairs. All biopsies revealed overall preserved follicular architecture with average number of 11 vellus follicles, atrophy of the sebaceous glands, and perifollicular lymphohistiocytic infiltrate involving the outer root sheath of the vellus follicles (n = 5). There was no perifollicular fibrosis of the vellus follicles and no lichenoid inflammation and perifollicular fibrosis of the terminal follicles. This new pattern of "inflammatory vellus involvement" most likely corresponds to an early onset of the disease. The absence of the classic features in such biopsies from early FFA can lead to misdiagnosis.

[Postmenopausal lichen planopilaris also known as fibrosing frontotemporal alopecia Kossard : An evidence-oriented practical guide to treatment from the University of the Saarland, Hair Research Center of the Dr. Rolf M. Schwiete Foundation]

Postmenopausal lichen planopilaris (PLPP), also known as fibrosing frontotemporal alopecia Kossard (FFAK), is a not uncommon inflammatory scalp disease affecting approximately 5% of patients at specialized hair centers. The overall incidence of sporadic occurrence is believed to be just under 1% in the older, predominantly female, general population. Since the disease is often undiagnosed, it is statistically likely to be underrepresented. It especially occurs in postmenopausal women who are in the 6th and 7th decade of life (90%), but also in about 10% of premenopausal women, and in men it is documented only in isolated cases. The result is a permanent scarring hair loss accentuated at the front hairline with backward movement towards the neck mostly accompanied by a typical loss of the eyebrows. The disease therefore often leads to significant mental distress and social anxiety in those affected. This is the basis for a compelling need to develop evidence-based therapeutic concepts. While numerous retrospective case series have characterized the phenomenology of FFAK very well, to date there are no randomized controlled trials on evidence-based therapy. Here, we present the Homburger Evidence-Oriented Therapy Algorithm, which is oriented along the available case series evidence: It may (1) serve as a therapy guide for practice and (2) can be used as a basis for working out reliable data based on study evidence. The article contains detailed practical information on photo documentation, biopsy and histological processing up to the practical implementation of, for example, intralesional steroid therapy as well as information on selection criteria for suitable systemic therapies.

Frontal fibrosing alopecia: An update on the hypothesis of pathogenesis and treatment

Frontal fibrosing alopecia (FFA) is a relatively new scarring alopecia that is considered a variant of lichen planopilaris (LPP) with no recognized promising treatments. In this study, we tried to clarify the underlying signaling pathways and their roles in the pathogenesis and progression of FFA. Because of several differences in clinical manifestations, response to treatments, and pathological findings, these two conditions could be differentiated from each other. Taking into account the already discussed signaling pathways and involved players such as T cells, mast cells, and sebaceous glands, different possible therapeutic options could be suggested. In addition to treatments supported by clinical evidence, such as 5 alpha-reductase inhibitors, topical calcineurin inhibitors, hydroxychloroquine, peroxisome proliferator-activated receptor gamma agonists, and oral retinoid agents, various other treatment strategies and drugs, such as phototherapy, Janus kinase inhibitors, dehydroepiandrosterone, sirolimus, cetirizine, and rituximab, could be suggested to mitigate disease progression. Of course, such lines of treatment need further evaluation in clinical trials.

Frontal Fibrosing Alopecia in Women: The Mayo Clinic Experience With 148 Patients, 1992-2016

OBJECTIVE

To characterize the clinicopathologic findings, comorbidities, and treatment outcomes of women with frontal fibrosing alopecia.

PATIENTS AND METHODS

Retrospective review of women with frontal fibrosing alopecia at Mayo Clinic from January 1, 1992, to February 22, 2016. The terms "scarring alopecia," "lichen," "planopilaris," "fibrosing," and "alopecia" were used for the search of female patients aged 1 to 100 years. A total of 686 patients were reviewed to confirm the diagnosis of frontal fibrosing alopecia. Patients were included if they met diagnostic criteria.

RESULTS

A total of 148 women with frontal fibrosing alopecia were identified, with a mean age of 62 years; 60.1% presented with eyebrow loss; 67.6% and 27.7% described preceding or concurrent pruritus and trichodynia, respectively; 44.6% had a history of hypothyroidism; 13% had a history of surgical menopause; and 63.3% had a history of hormone replacement therapy. A total of 18.2% had lichen planus at other body sites, and 26.3% achieved disease stabilization, often requiring combination therapies. The mean time to remission was 1.8 years.

CONCLUSION

Patients with frontal fibrosing alopecia typically present with frontotemporal and eyebrow alopecia with preceding symptoms. Hypothyroidism and a history of hysterectomy may be more common than previously reported. Time to presentation, diagnosis, and stabilization is often months to years. Patients who lack treatment response may present with eyebrow loss, eyelash loss, and facial papules. Combination therapy is helpful in achieving slowing of disease progression or disease stabilization, although recurrence is common. Additional studies on treatment and efficacy are needed. Limitations to this study include the retrospective design and varied follow-up.

Coexistence of chronic cutaneous lupus erythematosus and frontal fibrosing alopecia

Lupus erythemathosus is a chronic, relapsing disease with acute, subacute, and chronic lesions. Effluvium telogen occurs in the setting of systemic activity of the disease, and cicatricial alopecia results from discoid lesionsin on the scalp. Other types of alopecia, like alopecia areata, may rarely be found in lupus. Frontal fibrosing alopecia is characterized by frontotemporal hairline recession and eybrow loss. Histophatologically, it cannot be differentiated from lichen planopilaris.It is controversial whether frontal fibrosing alopecia is a subtype of lichen planopilaris.. A pacient with chronic lichenoid lupus erythematosus is described with clinical, histophatological and dermoscopic features of frontal fibrosing alopecia.We have not been able to find in the literature cases of frontal fibrosing alopecia as a clinical manifestation of lupus.

Lichen planopilaris and frontal fibrosing alopecia cannot be differentiated by histopathology

BACKGROUND

Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) represent 2 entities that cause primary cicatricial alopecia. These entities are clinically different; nevertheless, the literature suggests that FFA represents a form of LPP. The main argument in support of this hypothesis is that previous studies comparing the histologic findings have not found obvious differences between these diseases.

METHODS

Our objective was to more critically compare and contrast 20 histologic findings of these diseases in a large number of patients in order to determine any significant histologic differences between LPP and FFA.

RESULTS

We found 3 parameters that were statistically different, namely the presence of terminal catagen-telogen hairs (50% FFA vs 23.5% LPP; P = .020); a severe perifollicular inflammatory infiltrate (29.4% LPP vs 4.6% FFA; P = .010) and a zone of concentric lamellar fibroplasia (85.3% LPP vs 63.6% FFA; P = .041).

CONCLUSIONS

Although a few histologic features differ between FFA and LPP, we believe that these differences are too subtle or non-specific to distinguish between them with confidence. Therefore, clinical correlation is essential to establish the diagnosis.

Development of Frontal Fibrosing Alopecia with a History of Alopecia Areata

Frontal fibrosing alopecia (FFA), a scarring type of alopecia, developed in two patients with a history of alopecia areata (AA). Both patients had biopsies to confirm this interesting series of pathology. Etiology and pathogenesis of this AA-to-FFA sequence will be discussed.

Does Complement Have a Role in the Pathogenesis of Alopecia Areata?

Alopecia areata (AA) is an autoimmune disorder in which immune attack of the anagen follicle causes hair loss in approximately 2% of the population. Although the pathogenesis of AA has not been fully determined, most likely it is mediated by a variety of factors including cellular/humoral immunity and genetic predisposition. Researchers have been interested in the possible role of the complement pathway in AA since the 1970s. Given recent evidence suggesting that complement plays a role in many immunologic and inflammatory dermatologic diseases including systemic lupus erythematosus, bullous diseases, angioedema, lipodystrophy, and skin infections, it is likely that complement also contributes to AA pathogenesis. Although early serum studies and immunohistochemical staining have been unimpressive, recent genetics studies may provide evidence that complement does indeed contribute to AA. By determining if complement plays a role in AA, options for novel targeted treatments will become available for those patients with refractory disease.

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.

Primary cicatricial alopecia: Lymphocytic primary cicatricial alopecias, including chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome

Both primary and secondary forms of cicatricial alopecia have been described. The hair follicles are the specific target of inflammation in primary cicatricial alopecias. Hair follicles are destroyed randomly with surrounding structures in secondary cicatricial alopecia. This 2-part continuing medical education article will review primary cicatricial alopecias according to the working classification suggested by the North American Hair Research Society. In this classification, the different entities are classified into 3 different groups according to their prominent inflammatory infiltrate (ie, lymphocytic, neutrophilic, and mixed). Part I discusses the following lymphocytic primary cicatricial alopecias: chronic cutaneous lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, and Graham-Little syndrome.

The Use of Direct Immunofluorescence in Frontal Fibrosing Alopecia

BACKGROUND

Frontal fibrosing alopecia (FFA) differs from lichen planopilaris (LPP) in many clinical aspects, but histology fails to distinguish between these entities. Direct immunofluorescence (DIF) is a diagnostic technique used for autoimmune diseases, including those affecting skin and hair.

OBJECTIVE

To characterize DIF patterns in patients with FFA.

METHOD

Data was collected retrospectively from FFA cases presenting to the Centre de Santé Sabouraud Hair Clinic in Paris from November 2013 to November 2014.

RESULTS

Of 149 patients with FFA, 44 cases underwent DIF. Thirteen cases showed positive results with DIF. Patterns characteristic of LPP and lupus erythematosus were observed, with nearly half showing nonspecific staining.

CONCLUSION

DIF patterns in patients with FFA were variable. This diagnostic technique should be used with caution in cases of cicatricial alopecia, particularly FFA.