Frontal Fibrosing Alopecia: Role of Dermoscopy in Differential Diagnosis

The efficacy of antimalarial drugs in the therapy of selected forms of cicatricial alopecia

INTRODUCTION

Frontal fibrosing alopecia (FFA) is primary lymphocytic cicatricial alopecia with a clinically characteristic progressive recession of the frontotemporal hairline, perifollicular erythema, as well as symptoms of itching and burning. It occurs mainly in postmenopausal women. FFA is considered as a subtype of lichen planopilaris (LPP). The treatment of those diseases is presently empirical.

AIM

To define the efficacy of treating FFA and LPP with hydroxychloroquine.

MATERIAL AND METHODS

We performed a retrospective analysis of 95 women, including 35 with FFA and 60 with LPP. We collected the relevant demographic and clinical data. The response to treatment with hydroxychloroquine was assessed using LPPAI. Also, adverse events were monitored.

RESULTS

Treatment with hydroxychloroquine has a statistically significant effect on decreasing the disease activity after 6 and 12 months of therapy. The results of statistical tests do not confirm the existence of a relationship between age range and treatment efficacy. However, there is a correlation between the duration and efficacy of treatment (p < 0.05).

CONCLUSIONS

Administration of hydroxychloroquine can be considered as one of the treatment methods for FFA and LPP in everyday clinical practice. The presented study is the first attempt at using hydroxychloroquine to treat such large patient groups for FFA and LPP. Hydroxychloroquine efficaciously alleviates the symptoms in LPP patients and gives maximum benefits in long-term therapy (12 months). The preliminary results obtained in the presented retrospective analysis should be confirmed in a randomized prospective clinical trial, which remains a future challenge for researchers.

Frontal fibrosing alopecia

Frontal fibrosing alopecia (FFA) is a patterned primary cicatricial alopecia that was first described in 1994. Once rare, the incidence of FFA has increased dramatically, representing the current most common cause of cicatricial alopecia worldwide. FFA typically begins in postmenopausal women with symmetrical, progressive recession of the frontotemporal hairline together with bilateral loss of the eyebrows. FFA has a distinctive clinical phenotype, which remains a challenge. The histology is identical to lichen planopilaris (LPP), but only a small number of patients have coincidental LPP, usually of the scalp. The vast majority of patients have no evidence of lichen planus elsewhere, and the symmetry and patterned nature of the hair loss are unusual for LPP. Familial cases of FFA are reported, and gene associations have been identified in population studies; however, the pathophysiology remains controversial. Without treatment, FFA is slowly progressive, and although many treatments have been prescribed, the response is often disappointing. We review the pathogenesis, epidemiology, clinical features, histology, and treatment of FFA.

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.

Dermoscopy in General Dermatology: A Practical Overview

Over the last few years, dermoscopy has been shown to be a useful tool in assisting the noninvasive diagnosis of various general dermatological disorders. In this article, we sought to provide an up-to-date practical overview on the use of dermoscopy in general dermatology by analysing the dermoscopic differential diagnosis of relatively common dermatological disorders grouped according to their clinical presentation, i.e. dermatoses presenting with erythematous-desquamative patches/plaques (plaque psoriasis, eczematous dermatitis, pityriasis rosea, mycosis fungoides and subacute cutaneous lupus erythematosus), papulosquamous/papulokeratotic dermatoses (lichen planus, pityriasis rosea, papulosquamous sarcoidosis, guttate psoriasis, pityriasis lichenoides chronica, classical pityriasis rubra pilaris, porokeratosis, lymphomatoid papulosis, papulosquamous chronic GVHD, parakeratosis variegata, Grover disease, Darier disease and BRAF-inhibitor-induced acantholytic dyskeratosis), facial inflammatory skin diseases (rosacea, seborrheic dermatitis, discoid lupus erythematosus, sarcoidosis, cutaneous leishmaniasis, lupus vulgaris, granuloma faciale and demodicidosis), acquired keratodermas (chronic hand eczema, palmar psoriasis, keratoderma due to mycosis fungoides, keratoderma resulting from pityriasis rubra pilaris, tinea manuum, palmar lichen planus and aquagenic palmar keratoderma), sclero-atrophic dermatoses (necrobiosis lipoidica, morphea and cutaneous lichen sclerosus), hypopigmented macular diseases (extragenital guttate lichen sclerosus, achromic pityriasis versicolor, guttate vitiligo, idiopathic guttate hypomelanosis, progressive macular hypomelanosis and postinflammatory hypopigmentations), hyperpigmented maculopapular diseases (pityriasis versicolor, lichen planus pigmentosus, Gougerot-Carteaud syndrome, Dowling-Degos disease, erythema ab igne, macular amyloidosis, lichen amyloidosus, friction melanosis, terra firma-forme dermatosis, urticaria pigmentosa and telangiectasia macularis eruptiva perstans), itchy papulonodular dermatoses (hypertrophic lichen planus, prurigo nodularis, nodular scabies and acquired perforating dermatosis), erythrodermas (due to psoriasis, atopic dermatitis, mycosis fungoides, pityriasis rubra pilaris and scabies), noninfectious balanitis (Zoon's plasma cell balanitis, psoriatic balanitis, seborrheic dermatitis and non-specific balanitis) and erythroplasia of Queyrat, inflammatory cicatricial alopecias (scalp discoid lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia and folliculitis decalvans), nonscarring alopecias (alopecia areata, trichotillomania, androgenetic alopecia and telogen effluvium) and scaling disorders of the scalp (tinea capitis, scalp psoriasis, seborrheic dermatitis and pityriasis amiantacea).

The diagnostic value of trichoscopy in systemic sclerosis

BACKGROUND/OBJECTIVES

Systemic sclerosis is a connective tissue disease, which is characterized by fibrosis of the skin and internal organs, presence of specific antibodies and vascular involvement. Capillaroscopy is a useful method for the diagnosis and follow-up of patients with systemic sclerosis. Trichoscopy is a rapid, non-invasive technique, which has become a standard procedure in differential diagnosis of scalp and hair diseases. The aim of this study was to assess whether trichoscopy may be applied in imaging microvessels in patients with systemic sclerosis.

METHODS

The study included 17 patients with systemic sclerosis, and 31 healthy patients. In every patient 10 trichoscopy images were taken with Fotofinder II.

RESULTS

In patients with systemic sclerosis trichoscopy of the frontal scalp area revealed polymorphic microvessels in 64,7% of patients, spider vessels (76,4%), capillary loops (52,9%), arborising vessels (41,1%) and avascular areas (35,2%). In healthy individuals these features were observed in polymorphic microvessels 6,4% of patients, spider vessels 6,4%, capillary loops 100%, arborising vessels 16,1%, avascular areas 9,6%, respectively.

CONCLUSIONS

In conclusion, the presence of polymorphic vessels in frontal area in trichoscopy is characteristic for systemic sclerosis.

Evaluation and diagnosis of the hair loss patient: part II. Trichoscopic and laboratory evaluations

The use of trichoscopy for evaluating a number of hair and scalp disorders is gaining popularity. It is a simple and noninvasive in vivo tool for visualizing hair shafts and the scalp. Recently, alopecias have been classified according to their trichoscopic findings. The second part of this 2-part continuing medical education article reviews recent advances in this field and describes a systematic approach for using the differential diagnostic findings of trichoscopy in alopecia.

Use of Topical Minoxidil, 17α-Estradiol and Hydrocortisone Butyrate in Frontal Fibrosing Alopecia

A valid approach to treating frontal fibrosing alopecia (FFA), a scarring alopecia, does not yet exist. The aim of this study is to evaluate the efficacy of a topical application composed of minoxidil, hydrocortisone butyrate, 17α-estradiol, ciclosilicone pentamer, and alcohol in women affected by FFA. Forty women affected by FFA were treated with 2 ml of a topical lotion composed of 2% minoxidil base, 0.08% hydrocortisone butyrate, 0.05% 17α-estradiol, 16% ciclosilicone pentamer, 96° alcohol, applied once a day on the scalp. A score index, based on the comparison of the photos, taken at the beginning (T0) and after 36 months (T36), was used. The topical lotion led to an improvement in 20 patients, stabilization in 15 patients and worsening of the clinical condition in 5 women. This topical lotion induces a considerable improvement or stabilization of frontal fibrosing alopecia.

Perifollicular erythema as a trichoscopy sign of progression in frontal fibrosing alopecia

INTRODUCTION

Frontal fibrosing alopecia (FFA) in an entity characterized by the recession of the frontotemporal hairline (FTHL) with alopecic scarring change. In recent years there are numerous articles discussing the usefulness of dermoscopy for the clinical diagnosis of different types of scarring alopecia.

MATERIALS AND METHODS

We value 79 patients diagnosed with FFA, evaluating some trichoscopical findings described as typical for FFA: Absence of follicular opening, follicular hyperkeratosis, follicular plugs and erythema.

RESULTS

In a population of 79 women, 100% showed no follicular opening, 72.1% follicular hyperkeratosis, 66.3% perifollicular erythema and 44.8% follicular plugs. Thus, 100% of patients had at least one of the dermoscopic elements described as suggestive of FFA, 53% two of them, 45% three and 27%, all those elements. Perifollicular erythema was present in 95% of cases in which the disease was active.

CONCLUSIONS

We consider that the presence of perifollicular erythema will be a direct marker of FFA activity.

Frontal Fibrosing Alopecia and Lichen Planopilaris: Clinical, Dermoscopic and Histological Comparison

Frontal fibrosing alopecia (FFA) and lichen planopilaris (LPP) are classified as scarring alopecia. Most authors consider FFA as a clinical variant of LPP on the basis of their similar histological findings; other authors think these pathologies are two different entities. We studied 48 cases of FFA and 86 cases of LPP. Clinical diagnosis was histologically confirmed and all patients underwent videodermoscopy. Moreover, histological study, identifying the main targets of these diseases, results helpful to confirm the diagnosis. FFA selectively affects vellus-like hair in the frontoparietal region and is characterized by a mild skin atrophy and a total loss of follicular openings. In LPP an involvement of total preterminal, terminal and vellus-like follicles, partial or total loss of follicular openings, diffuse hair thinning and twisting, perifollicular erythematous or violaceous papules and mild/severe spinous follicular hyperkeratosis with scalp sclerosis are the features observed. Videodermoscopy improves diagnostic capability, appearing to be helpful to underline FFA and LPP features, confirmed by histologic studies which identify and show different intensity of inflammatory process. Therefore, the two diseases could be considered two different entities on the basis of the different clinical features and the different targets, that can be related to a different pathogenetic mechanism.

Trichoscopy: how it may help the clinician

Trichoscopy (or dermoscopy of hair and scalp) is an easy in-office technique that may be performed with a handheld dermoscope or a digital videodermoscopy system. This method is gaining increasing popularity, because it may be applied in differential diagnosis of multiple hair and scalp diseases. The focus of this article is application of trichoscopy in differential diagnosis of the most frequent hair and scalp diseases in dermatologic practice. Trichoscopy of genetic hair shaft abnormalities are briefly addressed. A new classification of perifollicular and interfollicular skin surface abnormalities is proposed.

Trichoscopy update 2011

Trichoscopy performed with a handheld dermoscope or a videodermoscope became an indispensable tool in differential diagnosis of hair and scalp diseases. Current research is focusing on trichoscopy of: 1) non-cicatricial alopecia, 2) cicatricial alopecia, 3) hair shaft disorders, and 4) inflammatory scalp diseases. This review summarizes current knowledge in these four fields of research. In all non-cicatricial alopecias presence of empty follicular openings is a common trichoscopy finding. In alopecia areata black dots and micro-exclamation mark hairs and tapered hairs correlate with disease activity, whereas yellow dots and vellus hairs correlate with disease severity. In androgenic alopecia trichoscopy shows hair shaft thickness heterogeneity, multiple thin and vellus hairs, yellow dots, perifollicular discoloration, and predominance of follicular units with only one hair. These features predominate in the frontal area. In all forms of cicatricial alopecia, trichoscopy shows milky-red or ivory-white areas lacking follicular openings. In classic lichen planopilaris trichoscopy shows perifollicular inflammation, tubular perifollicular scaling, elongated, concentric blood vessels and "classic white dots", which merge to form white areas. Frontal fibrosing alopecia shows mild perifollicular scaling. Folliculitis decalvans is characterized by tufted hairs, large follicular pustules with emerging hair shafts and perifollicular starburst pattern hyperplasia. In dissecting cellulitis characteristic findings are "3D" yellow dots imposed over dystrophic hairs, large, yellow amorphous areas and pinpoint white dots with a whitish halo. Trichoscopy is particularly useful to diagnose hair shaft abnormalities in trichorrhexis nodosa, trichorrhexis invaginata, monilethrix, pili torti, and pili annulati. The method may be also useful in diagnosing inflammatory scalp diseases. In discoid lupus erythematosus trichoscopy shows large arborizing vessels and large hyperkeratotic folliculilar yellow dots. Trichoscopy of scalp psoriasis shows regularly distributed twisted and lacelike blood vessels, whereas in seborroic dermatitis thin arborizing vessels may be observed. In tinea capitis trichoscopy shows comma, corkscrew and zigzag hairs. Examination tinea capitis may be facilitated by UV-light enhanced trichoscopy (UVET). In conclusion, trichoscopy is a non-invasive method which may be applied in differential diagnosis of most hair and scalp diseases.

Cicatricial (scarring) alopecias: an overview of pathogenesis, classification, diagnosis, and treatment

Cicatricial (scarring) alopecia forms a group of disorders in which the common final pathway is the destruction of the hair follicle unit that is replaced by fibrous tissue. Hair loss may occur as a primary event when the follicle is the main target of the disease process (primary cicatricial alopecias) or as a secondary event when the follicle act as an 'innocent bystander' in the course of a disease occurring outside of the follicular unit (secondary cicatricial alopecias). Permanent hair loss may also occur in the late phases of some nonscarring alopecias that are called 'biphasic alopecias.' Primary cicatricial alopecia accounts for 5% of all trichologic consultations at the Section of Dermatology, University of Genoa, Genoa, Italy. Considering that hair loss has a strong impact on patients' psychology and quality of life, and that cicatricial alopecias can be associated with underlying systemic implications, it is extremely important that every clinician is familiar with the diagnosis and treatment of the different types of cicatricial alopecia. An accurate clinical assessment integrated with (video) dermatoscopy and histopathologic studies permits a high standard performance of correct diagnoses. A brief review of our current knowledge of disease pathogenesis and the hypothetical disease mechanisms is presented. Some practical considerations for improving the 2001 North American Hair Research Society working classification of the primary cicatricial alopecias are suggested. The aim of treatment is to slow or stop the progression of the inflammatory waves and the scarring process at the earliest phase of involvement. Recommendations for therapy are based upon a literature review, personal experience, expected adverse effects, and some pragmatic considerations such as the cost and patient compliance.

Dermoscopy guided scalp biopsy in cicatricial alopecia

BACKGROUND

Scalp biopsies are crucial for the diagnosis of cicatricial alopecia. However, the pathologic interpretation may not be diagnostic if biopsy is not obtained from the correct site. This is particularly relevant for cicatricial alopecia as the disease may be focal and disease activity difficult to appreciate by the naked eye.

OBJECTIVE

To report a new simple technique to select the optimal biopsy site in cicatricial alopecia.

METHODS

In the last 2 years we performed dermoscopy guided scalp biopsies using handled dermatoscopes in 80 patients with different forms of cicatricial alopecia. Biopsy site was selected based on presence of the following dermatoscopic features: perifollicular concentric white scales in lichen planopilaris, frontal fibrosing alopecia (FFA) and discoid lupus erythematosus (DLE); hair tufts in folliculitis decalvans, hairs surrounded by a peripilar grey-white halo in central centrifugal cicatricial alopecia and follicular red dots or keratotic plugs in DLE.

RESULTS

The dermoscopy guided biopsies yielded a definitive pathological diagnosis in 95% of the cases.

COMMENT

The advantage of this method is that it is a fast, precise way to identify even individually affected follicles in early or focal cicatricial alopecia. It also allows for the morphologic characterization of particular follicular structures.