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Frontal fibrosing alopecia in postmenopausal women

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Background

Frontal fibrosing alopecia is a variety of cicatricial alopecia characterized by a band of frontal/frontoparietal hair recession and marked decrease or a complete loss of the eyebrows, typically observed in women who are postmenopausal.

Objective

The purpose of this study was to report clinical and histopathologic findings and results of treatment in a group of women affected by the disease.

Method

A total of 14 women with alopecia of the frontal hairline were evaluated from June 2000 through July 2003 in our outpatient consultation for hair disorders.

Results

Clinical examination revealed a band of symmetric recession of the frontoparietal hairline extending to the preauricular areas associated with loss of follicular orifices, mild skin atrophy, and perifollicular erythema at the scalp margin. In all, 9 patients also had partial or total loss of the eyebrows. The histologic features of the scalp specimens were similar in all our patients with a reduction of the number of hair follicles, and a high number of intermediate and velluslike follicles. Intemediate and velluslike follicles were more commonly affected than terminal follicles by the lymphocytic inflammatory infiltrate and perifollicular fibrosis.

Conclusion

Frontal fibrosing alopecia is a cicatricial alopecia that follows destruction of hair follicles by an inflammatory lymphocytic infiltrate that is localized around the upper portion of the hair follicle. It differs from lichen planopilaris because the lymphocytic infiltrate and fibrosis affect selectively the intermediate and the velluslike follicles of the frontal margin and eyebrows. The reason for this selective involvement is still unknown. Frontal fibrosing alopecia may represent a variety of lichen planopilaris with selective involvement of certain androgen-dependent areas. The affected follicles may have typical biologic markers that could explain the clinical and histologic features found in the disease. It is interesting to note that some of the patients treated with finasteride (2.5 mg/d) showed an arrest in the progression of the disease. Even if there is no proof for a hormonal basis of the disease, the effectiveness of finasteride in some patients may indicate that androgens might be partially responsible of the pathogenesis of the disease.

Section snippets

Case report

From June 2000 to July 2003 we saw 14 women, aged between 54 and 78 years (mean age: 62 years), with alopecia of the frontal hairline. Of these patients, 9 also had partial or total loss of the eyebrows. The clinical data of our patients are summarized in Table I.

In all cases hair loss had started after menopause (2-12 years) and progressed slowly, with gradual recession of the frontal hairline and exposure of a bare frontal skin. In 8 patients the time of onset was not precisely established

Discussion

Since 1994, when Kossard1 first described the clinical features of FFA, several cases from different countries have been reported in the literature, indicating that the disease is probably not rare but often not diagnosed.

Patients affected by FFA seek dermatologic advice for hair loss and often their symptom appears excessive compared with the scarce clinical severity. This probably explains why, in our experience, these patients were evaluated by several dermatologists and given different

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Funding sources: None.

Conflicts of interest: None identified.

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