Fibrosing Alopecia in a Pattern Distribution (FAPD) in 16 African-Descent and Hispanic Female Patients: A Challenging Diagnosis

Abstract

Background: Fibrosing alopecia in a pattern distribution (FAPD) has only been described in Caucasian patients, and it is not clear whether it can develop in dark-skin ethnicities. Materials and Methods: Sixteen Brazilian female patients, 12 of African descent and 4 Hispanic, with progressive scarring alopecia in a pattern distribution were analyzed. Results: Dermatoscopic features showed perifollicular erythema and scaling (14/16), hair fiber diameter diversity (16/16), loss of follicular ostia (16/16), and follicular keratosis (3/16). Late stages showed a honeycomb pigmented network (12/16), a hyperpigmented perifollicular halo (12/16), and small white patches (12/16). Histopathological features showed lichenoid perifollicular infiltrate (14/16), follicular miniaturization (16/16), concentric fibrosis (16/16), perifollicular lymphocytic infiltrate (16/16), and vellus hair involvement (10/16). Premature desquamation of the inner root sheath was found in 11 patients. Conclusions: The concomitant findings of cicatricial pattern hair loss (with or without the recess of the front hair line), hair fiber diversity, perifollicular erythema and scaling, a whitish perifollicular halo, and histological findings of androgenetic alopecia, with vacuolar interface alteration of the upper portion of the follicular epithelium, are the main key features to suggest the diagnosis of FAPD. FAPD is a possible diagnosis in patients of color with cicatricial pattern hair loss. Clinical, dermatoscopic, and histopathological examination allow a proper final differential diagnosis.

Alopecia Fibrosante em Padrão de Distribuição Androgenética: Patogénese, Diagnóstico e Tratamento

“…2,8 Androgens may play a role, considering that anti-androgen therapy decreases scalp inflammation in some cases and stabilizes hair loss progression. 2,9,10 There is one report of familial occurrence of FFA and FAPD in both mother and daughter, suggesting nosological relationship between the two conditions with respect to both the androgenetic background and the inflammatory reaction pattern. 10,13 Further studies are necessary to understand the pathophysiology of FAPD.…”

“…2,16 Physical exam reveals low hair density and sometimes peri-follicular erythema, follicular hyperkeratosis and absence of follicular openings may be detected by open eye. 2,9 Rare skin findings are frontal hairline recession similar to FFA, red dots in reticulated pattern on the chest and facial papules. 2,17,18 FAPD may affect the eyebrows, but unlike FFA, FAPD is not known to affect eyelashes or other body hair.…”

“…It is characterized by a combination of clinical, trichoscopic and histopathological features of both lichen planopilaris (LPP) and androgenetic alopecia (AGA). 1,[2][3][4][5][6][7][8][9][10][11] FAPD may also coexist with frontal fibrosing alopecia (FFA). 2 AGA is the most common form of non-scarring alopecia, caused by hair thinning on androgen dependent scalp.…”

“…Unlike AGA, we find many focal areas of cicatricial alopecia, peripilar erythema and peripilar hyperkeratosis in trichoscopy and lichenoid inflammation in histopathology. 1,2,[6][7][8][9] It has been first described in Caucasians but may also affect Hispanics and African-descents. 2,6,9 It is more common in women, most often in post-menopause or peri-menopause.…”

“…It is rare in men and may develop at a younger age. 2,6,9,[11][12][13][14][15] This entity may easily be misdiagnosis as AGA with concurrent seborrheic dermatitis, with delay in the diagnosis and consequent fibrosis progression, leading to irreversible alopecia.…”