Frontal fibrosing alopecia
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|Frontal fibrosing alopecia|
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Frontal Fibrosing Alopecia is the frontotemporal hairline recession and eyebrow loss in postmenopausal women that is associated with perifollicular erythema, especially along the hairline.:648 It is considered to be a clinical variant of lichen planopilaris.
There is loss of both terminal and vellus hairs that occurs in a bandlike pattern on the frontotemporal scalp. It is a scarring alopecia that has been associated with a loss of eyebrows, facial papules, glabellar red dots, and prominent venous vasculature in the forehead. Facial hyperpigmentation may occur in dark-skinned patients, if association with lichen planus pigmentosus is present.
Although the pathogenesis of Frontal Fibrosing Alopecia is poorly understood, autoimmune reaction and hormonal factors may play a role.
Perifollicular erythema and scarring white patches are seen on dermoscopy. On scalp biopsy, lymphocytic and granulomatous perifolliculitis with eccentric atrophy of follicular epithelia and perifollicular fibrosis are visualized.
Important diagnoses to consider include female pattern hair loss (FPHL), chronic telogen effluvium (CTE), and alopecia areata (AA). FPHL is a non-scarring progressive miniaturization of the hair follicle with one of three different characteristic patterns. CTE is an idiopathic disease causing increased hair shedding and bi-temporal recession, usually in middle aged women. AA is an autoimmune attack of hair follicles that usually causes hair to fall out in small round patches.
Improvement or stabilization of the condition has been reported with topical and intralesional corticosteroids, antibiotics, hydroxychloroquine, topical and oral immunomodulators, tacrolimus, and most recently, 5-alpha-reductase inhibitors. In one study, the use of anti-androgens (finasteride or dutasteride) was associated with improvement in 47% and stabilization in 53% of patients  Recently, successful treatment of facial papules in patients with frontal fibrosing alopecia was described with oral isotretinoin. 
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- Vañó-galván S, Rodrigues-barata AR, Urech M, et al. Depression of the frontal veins: A new clinical sign of frontal fibrosing alopecia. J Am Acad Dermatol. 2015;72(6):1087-8.
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- Pirmez R, Duque-Estrada B, Barreto T, Quintella DC, Cuzzi T. Successful Treatment of Facial Papules in Frontal Fibrosing Alopecia with Oral Isotretinoin. Skin Appendage Disord 2017;3:111-113. doi=10.1159/000464334