Clinical and Dermoscopic Approaches to Diagnosis of Frontal Fibrosing Alopecia: Results From a Multicenter Study of the International Dermoscopy Society

Abstract

Introduction: Frontal fibrosing alopecia (FFA) is a form of primary lymphocytic scarring alopecia characterized by a progressive recession of the fronto-temporal hairline. Although the clinical presentation of FFA is very typical, biopsy for histopathological examina­tion is still recommended to confirm the diagnosis. Currently, a growing number of skin and mucosal inflammatory diseases are diagnosed with modern noninvasive techniques such as dermoscopy without the necessity of a biopsy. Objectives: The International Dermoscopy Society (IDS) aimed to test the ability of its members to diagnose classic FFA through clinical and dermoscopic parameters and to compare acquired data to the largest cohort studies published since 1994. Methods: This is an observational, cross-sectional study describing patient demographics, clinical presentation and diagnostic tools used in a sample of FFA patients collected by IDS members. A literature search was then performed using Pubmed to review studies reporting more than 100 cases. Results: IDS members submitted 188 cases demonstrating a predominant female population (98.4%). In 71.8% of the cases, the clinical presentation and the trichoscopic findings allowed for the diagnosis. Out of 24 revised studies, 13 showed that clinical and trichoscopic features were decisive for the diagnosis in almost all cases. Conclusions: Demographic and clinical data of our cohort were mostly comparable to previous reported data on FFA. The relevant role of the clinical and trichoscopic features in diagnosing FFA was confirmed by our study and the reviewed literature. Trichoscopy could be considered a worldwide-acknowledged non-invasive technique for the diagnosis of FFA.

The spectrum of fibrosing alopecias

“…51 Concomitant LPP is noted in up to 18.6% of FFA patients. 6,10 The association with lichen planus pigmentosus has been described. [52][53][54] Trichodynia and pruritus may be reported.…”

“…Facial micropapules, as a sign of the involvement of facial vellus hair, are commonly detected in the temporal areas 51 . Concomitant LPP is noted in up to 18.6% of FFA patients 6,10 . The association with lichen planus pigmentosus has been described 52–54 .…”

“…In 2000, Zinkernagel and Truëb coined the term ‘FAPD’ to refer to a group of 19 patients with a form of progressive scarring alopecia limited to the crown area sharing characteristics of both androgenetic alopecia (AGA) and LPP (Figure 5a). 4 Since its first description, several cases of FAPD have been reported with a predilection for postmenopausal woman 5,65–69 . The overlap and the familial occurrence of FAPD with FFA have been observed 5,68,70 …”

“…5 Moreover, it is widely recognised that these different entities may concur in the same subject. 6 The remarkable clinical and histological overlap between these entities has led to the concept that these diseases exist along a spectrum. 7,8 The aim of this study is to describe the main features of the aforementioned pathologies, providing practical advice on their histologic and trichologic diagnosis as well as therapeutic recommendations, focusing, in particular, on their similarities and differences.…”

“…Classical LPP, FFA, FAPD and LPPDP share trichoscopic (cicatricial areas, absence of follicular openings, perifollicular erythema and hyperkeratosis) and histologic features (interface dermatitis involving follicular epithelium and concentric fibrosing around the isthmus and infundibulum) 5 . Moreover, it is widely recognised that these different entities may concur in the same subject 6 . The remarkable clinical and histological overlap between these entities has led to the concept that these diseases exist along a spectrum 7,8 …”