Frontal Fibrosing Alopecia

Abstract

An otherwise healthy adult woman presented with progressive hair loss of 6 months' duration associated with pruritus and burning of the anterior scalp. Physical examination revealed frontal and temporal hair loss, with associated "lonely hairs," perifollicular erythema, and scaling. Loss of eyebrow hair, depression of temporal and frontal veins, and numerous yellow papules on the forehead and temples were also noted (Figure). A clinical diagnosis of frontal fibrosing alopecia (FFA) was made. Treatment was initiated with 400 mg/d of hydroxychloroquine, 2.5 mg/d finasteride, and topical clobetasol propionate, 0.05%. In addition, 10 mg/d of isotretinoin was also prescribed for the treatment of facial papules. One month into therapy, pruritus had resolved and facial papules had notably decreased in size and number. Perifollicular erythema and scaling were also improved. Treatment with isotretinoin was discontinued after 4 months with near complete resolution of facial papules. Treatment with hydroxychloroquine and finasteride was continued with pimecrolimus, 1%, topical cream, without further progression.Frontal fibrosing alopecia is a lymphocytic scarring alopecia of unknown etiology that mainly affects postmenopausal women. The incidence of FFA is increasing, 1,2 which may be a result of the growing awareness of physicians and patients. Frontal fibrosing alopecia is characterized by a frontal or frontotemporal symmetric band of alopecia, although several additional clinical features can be observed, such as loss of eyebrows and eyelashes, hair loss from the extremities or the face, depression of frontal and temporal veins, glabellar red dots, pigmented skin patches, lichenoid alterations of mucosae and nails, 1 and yellow facial papules. [3][4][5] Medications, such as topical and intralesional corticosteroids, topical calcineurin inhibitors, hydroxychloroquine, retinoids, 5α-reductase inhibitors (finasteride or dutasteride), and even immunosuppressants may be needed to halt progression. 1 Facial papules in FFA can affect the temples, cheeks, or the entire face. 3 Histologic analysis of facial papules reveals hypertrophic sebaceous glands lacking associated vellus hair follicles or lichenoid inflammation. 3 Recently, some reports have suggested that low-dose oral isotretinoin can be a treatment of facial papules to improve the appearance. [3][4][5]