Case series of familial frontal fibrosing alopecia and a review of the literature

Enhanced Insights into Frontal Fibrosing Alopecia: Advancements in Pathogenesis Understanding and Management Strategies

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.

Genotyping of the rs1800440 Polymorphism in CYP1B1 Gene and the rs9258883 Polymorphism in HLA-B Gene in a Spanish Cohort of 223 Patients with Frontal Fibrosing Alopecia

The pathogenesis of frontal fibrosing alopecia has been linked to specific genetic variants. CYP1B1 codes for a component of the cytochrome p450 machinery that is involved in the metabolism of xenobiotic oestrogens. The study of the prevalence of polymorphisms in this gene may help to understand their role in the development of frontal fibrosing alopecia. The aim of this study is to describe the frequency of genetic variations in the alleles HLA-B*07:02 and CYP1B1 in patients with frontal fibrosing alopecia. A cross-sectional study was designed to evaluate blood samples from patients with frontal fibrosing alopecia who attended the Dermatology Department at University Hospital Ramón y Cajal (Madrid, Spain), in search of the polymorphisms rs9258883 and rs1800440 in the alleles HLA-B*07:02 and CYP1B1, respectively. A total of 223 patients were included in the study. Among the 83.8% of patients who carried the rs9258883 polymorphism in HLA-B*07:02, 58.7% were heterozygous for this variant and it was not present in 14.8% of the cases. The majority of patients with frontal fibrosing alopecia lacked the protective rs1800440 polymorphism in CYP1B1 (75.2%). This suggests a relevant role of this variant in development of frontal fibrosing alopecia. The genetic approach to this condition might influence patient prognosis and therapy options.

Case Series of Frontal Fibrosing Alopecia and Fibrosing Alopecia in a Pattern Distribution: Is There a Familial Correlation?

Introduction

Frontal Fibrosing Alopecia (FFA) and Fibrosing Alopecia in a Pattern Distribution (FAPD) are two distinct entities of cicatricial pattern hair loss that share histological features of perifollicular lichenoid inflammation associated with concentric fibrosis. Although the pathophysiology of FFA and FAPD are still unknown, recently published reports of familial cases indicate a possible genetic correlation.

Case Presentation

We report 6 cases of familial alopecia composed of mothers and daughters: five with FFA and one with FAPD. We describe clinical, trichoscopy and histological correlation in cases of familial alopecia.

Conclusions

These cases of mother and daughter disease association suggest a potential benefit of and role for performing systematic scalp examinations of all first-degree relatives of patients with pattern cicatricial alopecia.

Evaluating the combined efficacy of oral isotretinoin and topical tacrolimus versus oral finasteride and topical tacrolimus in frontal fibrosing alopecia-A randomized controlled trial

OBJECTIVE

Treatment of frontal fibrosing alopecia (FFA) is complicated and challenging. In this study, we evaluated the efficacy of combining topical tacrolimus with isotretinoin versus finasteride in patients with FFA.

METHODOLOGY

Thirty-one patients with FFA were divided randomly into two groups. Therapeutic regimen of the first group (group A, n = 16) was isotretinoin and tacrolimus (Capsule isotretinoin 20 mg daily and topical tacrolimus 0.1% BD). The second group (group B, n = 15) was given finasteride and tacrolimus (Tablet finasteride 2.5 mg daily and topical tacrolimus 0.1% BD). Patients were treated and followed up periodically for 12 weeks. Evaluation of the treatment efficacy was based on Patient Global Assessment and Physician Global Assessment scales. Objective evaluation was based on improving the severity of skin lesions by viewing serial images taken from the affected areas.

RESULTS

Physician Global Assessment (PGA) was significantly better in the group A as compared with the group B at 4 weeks (p = 0.038). Physician satisfaction in the group A was better than the group B at 12 weeks, but this was not statistically significant (p > 0.05). Patient Global Assessment and patient satisfaction in the group A was better than the group B at 8 and 12 weeks, but it was not statistically significant (p > 0.05).

CONCLUSION

Although both therapeutic regimens were effective in the treatment of FFA, treatment with tacrolimus and isotretinoin is significantly more effective than tacrolimus and finasteride.

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.

Familial Frontal Fibrosing Alopecia: Report of a case and systematic review of the literature

Frontal fibrosing alopecia (FFA) is an emerging disease in Western countries. We present the cases of three sisters who were referred simultaneously to the Department of Dermatology, Hospital Universitario San Cecilio, Granada, Spain, in 2018. All patients suffered from at least partial frontotemporal hairline recession and eyebrow loss. Following trichoscopic examination, the three sisters were diagnosed with FFA. Only one of the sisters agreed to be treated; she was prescribed with topical clobetasol propionate solution and minoxidil and achieved disease control at the three-month follow-up. These patients represent a new case of familial FFA wherein three sisters as well as their mother were affected by FFA. A systematic review found a total of 24 cases of familial FFA, of which this report is the 25th. In the majority of families, only females were affected (88%) while in the remainder both males and females (8%) were affected; there was only one family where only males were affected (4%). The relationship between the affected individuals was predominately between sisters (56%) followed by mother and daughter (32%). The median age was 61 years old (range: 14–88 years) and the duration of the disease ranged between 3–360 months. Family groups of FFA are an infrequently described phenomenon with unknown prevalence.

Frontal Fibrosing Alopecia: Is There a Link in Relatives?

Frontal fibrosing alopecia (FFA) is an acquired primary lymphocytic cicatricial alopecia characterized by frontotemporal hairline recession, leading to scarring alopecia with a band-like distribution. Prevalence is increasing worldwide, being the most frequent cause of primary scarring alopecia. The natural history of this condition is variable; however, slow progression with spontaneous remission is the most frequent reported outcome. The etiopathogenesis of FFA remains to be elucidated; numerous hypotheses concerning hormonal effects, environmental factors, and genetic predisposition have been proposed. Special interest on genetic basis has emerged since the first familial case was reported. Only a few more familial cases have been published. We report 6 additional cases of female patients with familial FFA (F-FFA) from 3 different families. Sixty-six percent had a family history of autoimmune disease in first-degree relatives; these same patients had a personal history of autoimmune disease. The families described in this cohort study plus the personal and family history of autoimmune disease, as well as the recently described involved genomic loci; reinforced the hypothesis of this disease being genetic. It is important to consider studying this entity since there are scarce data regarding familial cases and this might give us a better insight toward understanding its pathogenesis.

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.

Frontal fibrosierende Alopezie – Fallbeispiele und Review

Die 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.

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.

Clinical-histopathological profile of the frontal fibrosing alopecia: a retrospective study of 16 cases of a university hospital

BACKGROUND

Frontal fibrosing alopecia is a condition of unknown origin, histologically similar to classic lichen planopilaris and generally observed in postmenopausal women with alopecia of the frontal-temporal hairline.

OBJECTIVES

To describe the clinical, dermatoscopic, and histopathological characteristics and the treatment used in patients who have frontal fibrosing alopecia at the Alopecia Outpatient Clinic in a university hospital.

METHODS

Retrospective descriptive study performed by reviewing medical charts and biopsies of the scalp.

RESULTS

Sixteen patients were analyzed, all of them female, 93.75% of them postmenopausal, and 56.25% brown-skinned. All had frontal alopecia (100%), followed by temporal alopecia (87.5%) and madarosis (87.5%). On dermatoscopy, perifollicular erythema and tubular scales were found as a sign of disease activity. Of the patients, 68.75% had associated autoimmune diseases, including lupus, thyroid disease and vitiligo. Of the 13 biopsies from 8 patients, 10 showed microscopic aspects compatible with frontal fibrosing alopecia. Laboratory tests did not show major abnormalities and minoxidil was the most used treatment.

STUDY LIMITATION

Data collection limited by the study's retrospective design associated to flaws while filling in the medical charts and absence in standards to the collection and processing of the pathology and histopathological examination.

CONCLUSIONS

A demographical, clinical, and histopathological description of 16 patients diagnosed with frontal fibrosing alopecia, which remains a challenging disease, of unknown origin, and frequently associated with autoimmune diseases. This study reinforces literary findings. However, more research is needed to establish the pathogenesis and effective treatments.

Genome-wide association study in frontal fibrosing alopecia identifies four susceptibility loci including HLA-B*07:02

Frontal fibrosing alopecia (FFA) is a recently described inflammatory and scarring type of hair loss affecting almost exclusively women. Despite a dramatic recent increase in incidence the aetiopathogenesis of FFA remains unknown. We undertake genome-wide association studies in females from a UK cohort, comprising 844 cases and 3,760 controls, a Spanish cohort of 172 cases and 385 controls, and perform statistical meta-analysis. We observe genome-wide significant association with FFA at four genomic loci: 2p22.2, 6p21.1, 8q24.22 and 15q2.1. Within the 6p21.1 locus, fine-mapping indicates that the association is driven by the HLA-B*07:02 allele. At 2p22.1, we implicate a putative causal missense variant in CYP1B1, encoding the homonymous xenobiotic- and hormone-processing enzyme. Transcriptomic analysis of affected scalp tissue highlights overrepresentation of transcripts encoding components of innate and adaptive immune response pathways. These findings provide insight into disease pathogenesis and characterise FFA as a genetically predisposed immuno-inflammatory disorder driven by HLA-B*07:02.

Frontal fibrosing alopecia (FFA) features lichenoid cutaneous inflammation and scarring hair loss. Here, Tziotzios et al. identify four genetic loci associated with FFA by GWAS followed by Bayesian fine-mapping, co-localisation and HLA imputation which highlights HLA-B*07:02 as a risk factor.

Study of Human Leukocyte Antigen (HLA) in 13 cases of familial frontal fibrosing alopecia: CYP21A2 gene p.V281L mutation from congenital adrenal hyperplasia linked to HLA class I haplotype HLA-A*33:01; B*14:02; C*08:02 as a genetic marker

BACKGROUND/OBJECTIVES

The aetiology of frontal fibrosing alopecia is unknown, and its genetic aspect remains uncharacterised. The aim of this report is to elucidate if major histocompatibility complex is associated with familial frontal fibrosing alopecia.

METHODS

A case-control study was performed of 13 patients with frontal fibrosing alopecia belonging to six families. Their human leukocyte antigen profiles were compared to the data of 636 healthy controls without frontal fibrosing alopecia. Patients underwent high-resolution genomic typing for human leukocyte antigen class I and II loci by PCR-SSO for Luminex. In addition, CYP21A2 gene (major histocompatibility complex class III) mutations were detected by PCR-SSO on strips.

RESULTS

61.5% of patients shared CYP21A2 gene p.V281L linked to the F16A human leukocyte antigen class I haplotype (HLA-A*33:01; B*14:02; C*08:02; Pc < 0.000001). The patients F16A-negative shared other human leukocyte antigen class I haplotypes: Y16A (3/13) and S26 (2/13).

CONCLUSION

CYP21A2 gene p.V281L mutation can be used as a genetic marker for susceptibility to familial frontal fibrosing alopecia. Both the linkage of the mutation to F16A and the fact that F16A-negative patients share other human leukocyte antigen class I haplotype, point to an antigen-driven mechanism in susceptible patients with these haplotypes.

Familial frontal fibrosing alopecia: A cross-sectional study of 20 cases from nine families

BACKGROUND/OBJECTIVES

Frontal fibrosing alopecia (FFA) is a scarring alopecia whose prevalence is increasing. The pathogenesis of this disease is not well known. Genetic, environmental, hormonal and autoimmunity related factors have been considered; however, only a few cases of familial frontal fibrosing alopecia have been reported.

MATERIAL AND METHODS

A cross-sectional study was performed at University Hospital in Granada (Spain). Twenty patients with frontal fibrosing alopecia belonging to nine different families were included, and clinical and dermoscopic features were analysed.

RESULTS

Overall, 90% of the patients studied were women (mean age 61.4 years). About 50% of the patients had grade II frontal fibrosing alopecia at the time of diagnosis, whilst 35% had grades III or V. Mean recession was 2.83 cm in the frontal area and 1.99 cm in the temporo-parietal area. Daughters presented a shorter recession area and earlier debut of the disease than mothers. Androgenetic alopecia was found in only two patients (10%). The dermoscopic signs most commonly found were perifollicular erythema (85%), hyperkeratosis (85%), and absence of vellus hair in the hairline (78.9%).

CONCLUSION

This study adds to the growing evidence that there is a genetic component to frontal fibrosing alopecia. The clinical pattern of frontal fibrosing alopecia was not different from that found in non-familial cases, but the debut of the disease in daughters of mothers with frontal fibrosing alopecia may be earlier.

A Retrospective Analysis of Efficacy and Safety of Intralesional Triamcinolone Injections in the Treatment of Frontal Fibrosing Alopecia Either as Monotherapy or as a Concomitant Therapy

Context:

Frontal fibrosing alopecia (FFA) is a primary cicatricial alopecia characterized by progressive recession of frontal, and often temporoparietal, hairline mainly in postmenopausal women. Currently, there are no guidelines or proposed evidence-based treatment for FFA.

Aims:

The aim of this study was to retrospectively evaluate the effect and safety of intralesional triamcinolone acetonide injections (ITAIs) either as monotherapy or as concomitant treatment in the management of hairline recession in FFA.

Subjects and Methods:

All patients with FFA, who visited our specialist hair clinic from July 2012 to October 2016 and were treated with ITAI either as monotherapy or as concomitant treatment, were enrolled in our study. Measurements were performed from five different points on the scalp. The analysis of data included demographics, associated symptoms, clinical and dermoscopic findings, comorbidities, family history of FFA, concomitant medication, treatment outcome, and recording of adverse events.

Statistical Analysis:

Statistical analysis was performed using the Statistical Package for the Social Sciences, version 22.0.

Results:

A total of 40 patients, all females were enrolled in our study. The mean age of the patients was 65.88 ± 8.18 whereas the mean age of the diagnosis was 61.24 ± 7.4. A total of 39 patients were treated with a combination of treatments, including ITAI, and only one with ITAI as monotherapy. There was a halting of the progress of the disease, and no significant adverse events were noted, apart from mild pain.

Conclusions:

A halting in the progression of FFA was achieved, with unremarkable adverse events. ITAI could serve as an effective and safe option for the treatment of FFA, although difficult to assess it as monotherapy. Further randomized controlled trials are needed to evaluate its efficacy and safety as the sole treatment in the management of FFA.

Autologous Hair Transplantation in Frontal Fibrosing Alopecia

We report a patient with frontal fibrosing alopecia (FFA), in whom autologous hair transplantation was successfully performed despite evidence of active disease. Since the underlying pathology of FFA is usually lichen planopilaris, reservations, and caveats have been expressed with respect to the risk of köbnerization phenomena following hair transplantation surgery. An important question that arises is how the lichenoid tissue reaction pattern is generated around the hair follicles in FFA. Follicles with some form of damage or malfunction might express cytokine profiles that attract inflammatory cells to assist in damage repair or in the initiation of apoptosis-mediated organ deletion. Alternatively, an as yet unknown antigenic stimulus from the damaged or malfunctioning hair follicle might initiate a lichenoid tissue reaction in the immunogenetically susceptible individual. Therefore, it might be expected that the transplantation of whole healthy hair follicles might less give rise to an inflammatory reaction than the disease itself, as revealed in our case report of successful hair transplantation in FFA.

Case Report of Connubial Frontal Fibrosing Alopecia

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.

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.

Cutaneous Lupus Erythematosus Presenting as Frontal Fibrosing Alopecia: Report of 2 Patients

Frontal fibrosing alopecia represents a peculiar condition with a quasi-symmetrical, marginal scarring alopecia along the frontal and temporal hairline. The condition has been associated with further histopathologic and/or clinical evidence of lichen planopilaris. Since its emergence with the original report of Kossard in 1994, frontal fibrosing alopecia has been recognized to be associated with a number of comorbidities, including lupus erythematosus. So far, respective case reports and case series have given account of frontal fibrosing alopecia with the histopathologic features of lichen planopilaris associated or overlapping with lupus erythematosus. In contrast, we present cases of histopathologically proven cutaneous lupus erythematosus presenting as frontal fibrosing alopecia with a good response to the respective treatment with oral hydroxychloroquine and/or intralesional triamcinolone acetonide.

Familial Cicatricial Alopecia: Report of Familial Frontal Fibrosing Alopecia and Fibrosing Alopecia in a Pattern Distribution

Frontal fibrosing alopecia (FFA) and fibrosing alopecia in a pattern distribution (FAPD) as originally reported by Kossard in 1994 and by Zinkernagel and Trüeb in 2000, respectively, represent two distinct patterns of cicatricial pattern hair loss. Both share a patterned distribution and histological evidence of a lichenoid follicular inflammation with fibrosis. FFA is characterized by a marginal alopecia along the frontotemporal hairline, and FAPD by a progressive alopecia of the centroparietal scalp. Since the original reports, evidence has accumulated that there exists considerable clinical overlap among FFA, FAPD, and lichen planopilaris, with coexistence of features of the three conditions within the same individual. Moreover, familial cases of FFA have been reported, pointing to a possible genetic background to the condition. Our observation of familial occurrence of FFA and FAPD in daughter and mother, respectively, further underscore a nosologic relationship between the two conditions with respect to both an androgenetic background and the (lichenoid) inflammatory reaction pattern.

A Case of Frontal Fibrosing Alopecia in a Patient with Primary Biliary Cirrhosis and Polymyalgia Rheumatica

Frontal fibrosing alopecia (FFA) is a form of scarring hair loss that is characterized by hair follicle destruction in a fronto-temporo-parietal distribution. Its etiology is unknown; however, most authors presently favor an immune pathogenesis. Associated autoimmune connective tissue diseases have been reported in patients with FFA. We present a case of FFA in a woman with primary biliary cirrhosis and polymyalgia rheumatica, suggesting an association between these clinical entities and supporting a potential autoimmune etiology of FFA.

Histopathology of keratotic papules of the limbs in frontal fibrosing alopecia

Frontal fibrosing alopecia (FFA) is a scarring type of alopecia that presents clinically as progressive frontotemporal hairline regression and eyebrow loss, mainly in postmenopausal women. An additional common finding is keratotic papules on the face or (less commonly) on the trunk and extremities. The histopathology of the facial keratotic papules associated with FFA is the same as that of lichen planopilaris. There are very few FFA cases with biopsies from extrafacial sites and no cases of folliculocentric keratotic papules with biopsies from extrafacial sites. In the current report, we describe the histopathology of one such keratotic papule from the arm of a 75-year-old woman with FFA and show that the morphology is that of lichen planopilaris and that the papules are identical to those found in Graham-Little-Piccardi syndrome.

A Comment on Frontal Fibrosing Alopecia (Axel Munthe's Syndrome)

Frontal fibrosing alopecia (FFA) represents a peculiar condition with a quasi-symmetrical, marginal alopecia along the frontal and temporal hairline with scarring. Steven Kossard is credited with the original description of the condition in 1994. Since its first description, FFA has become increasingly common while its etiology has remained obscure. While FFA has been related to lichen planopilaris, in fact, the pattern of clinical disease presentation might be more specific for the condition than the underlying inflammatory autoimmune reaction. It has been speculated as to whether FFA existed before Kossard's original report since artistic depictions dating from the 15^th to 16^th century often show a high frontotemporal hairline. Rather, these represent fashionable forms of frontal pseudo-alopecia than FFA. Nevertheless, there is compelling evidence that FFA existed well before 1994 from the Swedish Physician Axel Munthe's (1857-1948) account of the distinctive features of the condition in his book of memoirs "The Story of San Michele." Therefore, Axel Munthe is to be acknowledged the first description of FFA in 1929.