Photo Rounds
Scarring alopecia in a woman with psoriasis
Was this patient’s plaque psoriasis causing her progressive hair loss—or was it something else?
Diagnosis: Frontal fibrosing alopecia
The patient was referred to our dermatology clinic, which specializes in hair loss. Based on the clinical findings, we suspected that this was a case of frontal fibrosing alopecia (FFA), a primary lymphocytic cicatricial (scarring) alopecia. A dermatopathologist confirmed the diagnosis via histologic review.
A condition on the rise. The incidence of FFA has been steadily increasing internationally since the condition was first described in 1994.1 Among patients referred to a specialty clinic for hair loss, diagnosis of FFA has increased from 1.6% in 2000 to 17% in 2011.2
FFA is characterized by symmetric band-like hair loss with evidence of scarring in the frontal and temporal regions of the scalp. (The extent of hair loss can be assessed by retracting the patient’s hair and having the patient raise his or her eyebrows and wrinkle the forehead in a surprised look.) FFA is accompanied by eyebrow loss in 73% to 95% of patients.2,3 Mild to severe perifollicular (and possibly more generalized) erythema and scale are usually present. In addition, erythematous or skin-colored papules may appear on the face,3 and marked exaggeration of the temporal veins is a common finding.
Most patients with FFA (83%) are postmenopausal women and nearly all (98.6%) have Fitzpatrick skin type 1 or 2 (white skin that burns easily and doesn’t readily tan).4 Other pertinent findings include the absence of oral lesions, nail changes, or other skin diseases.
A subtype of another condition? Because they are similar histologically, some consider FFA to be a subtype of lichen planopilaris. (See “Scarring alopecia in a woman with psoriasis,” J Fam Pract. 2015;64:E1-E3.)
A punch biopsy to confirm the diagnosis of FFA should be taken from the leading edge of the hair loss and, ideally, reviewed by a dermatopathologist. Histologic examination will reveal a lichenoid lymphocytic infiltrate (predominantly around the hair follicle where the follicular stem cells reside), resulting in fibrosis and scarring.5
Rule out other causes of hair loss
In addition to confirming the diagnosis with histologic examination, you’ll also need to have ruled out the following conditions in the differential.
Alopecia areata may mimic the ophiasis (band-like) pattern of hair loss seen with FFA, but it is a non-scarring disorder that typically lacks any signs of inflammation.
Female pattern hair loss is characterized by a decrease in hair density and thinning. The condition is non-scarring and usually involves the frontal and vertex (crown) regions of the scalp.
Discoid lupus erythematosus is characterized by circular scarring hair loss with a central patch of inflammation, as well as depigmentation.
Central centrifugal cicatricial alopecia predominantly affects black women and is characterized by circular hair loss of the vertex, with perifollicular inflammation and scarring.
Traction alopecia can occur in the same location as FFA, but is not usually associated with perifollicular inflammation. This condition can cause scarring if traction has been longstanding and persistent. There is usually a history of certain hairstyles (such as braiding) associated with chronic tension on hair fibers.