Clinical characteristics, trichoscopy, histopathology and treatment outcomes of frontal fibrosing alopecia in an Asian population: A retro‐prospective cohort study

Abstract

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.

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

“…The hairline recession in FFA and the frequent concomitant androgenetic alopecia (AGA) that occurs in patients with LPP and FFA have led some authors to propose a role for androgen excess in FFA, largely on the basis of the postmenopausal predominance of affected females ( Dawn et al., 2003 ; Ranasinghe et al., 2017 ). Although definitive evidence for this hypothesis is missing, reports of clinical benefits seen in some patients treated with 5α-reductase inhibitors (5ARIs) such as dutasteride ( Jerjen et al., 2021 ; Lobato-Berezo et al., 2018 ; Panchaprateep et al., 2020 ; Pindado-Ortega et al., 2021 ; Vañó-Galván et al., 2016 ) have been interpreted as supporting it. However, the results of retrospective cohort studies of moderate quality where patients were treated with concomitant therapies in addition to 5ARIs and/or serum androgen and estrogen levels were not measured should be interpreted cautiously ( Murad and Bergfeld, 2021 ).…”

Frontal Fibrosing Alopecia: A Review

“…Regarding the human race, FFA has been described worldwide, although most cases have been reported in European and North American countries, mainly among Caucasians and fewer among black-skinned populations [ 16 ], whereas only a few cases have been reported in Asia, where the incidence may be lower [ 21 , 22 , 23 , 24 ]. Indeed, a recent study regarding the prevalence of FFA and LPP in New York City observed that the prevalence of the combined group LPP/FFA was highest among non-Hispanic Caucasians (0.091%) [ 6 ].…”

“…LPPigm may be associated to FFA, mainly in dark skin types, such as Hispanic/Latino and black-skinned patients (44–54%) [ 24 , 69 ], as well as Asians [ 24 ]. It appears as brown to grey macular pigmentation mostly on the face and neck, but also in flexural areas [ 15 , 68 , 138 ].…”

Guidelines for clinical trials of frontal fibrosing alopecia: consensus recommendations from the International FFA Cooperative Group (IFFACG)*

“…1,2 It is most commonly seen in postmenopausal women, [3][4][5][6][7][8] but it has also been observed in premenopausal women [4][5][6][7] and men. 5,9,10 While the majority of the reported patients have been of European descent, FFA has also occurred in black 5,8,11,12 and Asian patients 13,14 from various nations. The incidence of FFA is unknown, but the number of women seeking diagnosis and help for this condition has markedly increased in recent years, currently representing the majority of new cases of cicatricial alopecia.…”