Clinical and Dermoscopic Approaches to Diagnosis of Frontal Fibrosing Alopecia: Results From a Multicenter Study of the International Dermoscopy Society

Author Affiliation(s)


Introduction: Frontal fibrosing alopecia (FFA) is a form of primary lymphocytic scarring alopecia characterized by a progressive recession of the fronto-temporal hairline. Although the clinical presentation of FFA is very typical, biopsy for histopathological examina­tion is still recommended to confirm the diagnosis. Currently, a growing number of skin and mucosal inflammatory diseases are diagnosed with modern noninvasive techniques such as dermoscopy without the necessity of a biopsy.

Objectives: The International Dermoscopy Society (IDS) aimed to test the ability of its members to diagnose classic FFA through clinical and dermoscopic parameters and to compare acquired data to the largest cohort studies published since 1994.

Methods: This is an observational, cross-sectional study describing patient demographics, clinical presentation and diagnostic tools used in a sample of FFA patients collected by IDS members. A literature search was then performed using Pubmed to review studies reporting more than 100 cases.

Results: IDS members submitted 188 cases demonstrating a predominant female population (98.4%). In 71.8% of the cases, the clinical presentation and the trichoscopic findings allowed for the diagnosis. Out of 24 revised studies, 13 showed that clinical and trichoscopic features were decisive for the diagnosis in almost all cases.

Conclusions: Demographic and clinical data of our cohort were mostly comparable to previous reported data on FFA. The relevant role of the clinical and trichoscopic features in diagnosing FFA was confirmed by our study and the reviewed literature. Trichoscopy could be considered a worldwide-acknowledged non-invasive technique for the diagnosis of FFA.

Keywords : frontal fibrosing alopecia, trichoscopy, techniques, diagnosis, non-invasive


1. Kossard S. Postmenopausal frontal fibrosing alopecia. Scarring alopecia in a pattern distribution. Arch Dermatol. 1994;130(6):770-774. 2. Kossard S, MS Lee, B Wilkinson. Postmenopausal frontal fibrosing alopecia: a frontal variant of lichen planopilaris. J Am Acad Dermatol. 1997;36(1):59-66. DOI: 10.1016/s0190-9622(97)70326-8. PMID: 8996262. 3. Tziotzios C, Stefanato CM, Fenton DA, Simpson MA, McGrath JA. Frontal fibrosing alopecia: reflections and hypotheses on aetiology and pathogenesis. Exp Dermatol. 2016;25(11):847-852. DOI: 10.1111/exd.13071. PMID: 27198858. 4. Photiou L, Nixon RL, Tam M, Green J, Yip L. An update of the pathogenesis of frontal fibrosing alopecia: What does the current evidence tell us? Australas J Dermatol. 2019 May;60(2):99-104. DOI: 10.1111/ajd.12945. PMID: 30362109. 5. Kossard S. Frontal fibrosing alopecia, just lichen planopilaris? J Am Acad Dermatol. 2019;81(2):e51. DOI: 10.1016/j.jaad.2019.02.072. PMID: 30978423. 6. Bernárdez C, Molina-Ruiz AM, Vañó-Galvan S, et al. Sex hormone status in premenopausal women with frontal fibrosing alopecia: a multicentre review of 43 patients. Clin Exp Dermatol. 2017;42(8):921-923. DOI: 10.1111/ced.13221. PMID: 28940746. 7. Alegre-Sánchez A, Saceda-Corralo D, Bernárdez C, Molina-Ruiz AM, Arias-Santiago S, Vañó-Galván S. Frontal fibrosing alopecia in male patients: a report of 12 cases. J Eur Acad Dermatol Venereol. 2017;31(2):e112-e114. DOI: 10.1111/jdv.13855. PMID: 27505452. 8. Starace M, Brandi N, Alessandrini A, Bruni F, Piraccini BM. Frontal fibrosing alopecia: a case series of 65 patients seen in a single Italian centre. J Eur Acad Dermatol Venereol. 2019;33(2):433-438. DOI: 10.1111/jdv.15372. PMID: 30472804. 9. Pirmez R, Duque-Estrada B, Abraham LS, et al. It's not all traction: the pseudo 'fringe sign' in frontal fibrosing alopecia. Br J Dermatol. 2015;173(5):1336-8. DOI: 10.1111/bjd.14005. PMID: 26138941. 10. Guan NN, Fan WX. Diagnostic and therapeutic assessment of frontal fibrosing alopecia. J Clin Dermatology. 2010;39(3):195-197. DOI:10.1016/S1578-2190(07)70524-3. 11. Banka N, Mubki T, Bunagan MJ, McElwee K, Shapiro J. Frontal fibrosing alopecia: a retrospective clinical review of 62 patients with treatment outcome and long-term follow-up. Int J Dermatol. 2014;53(11):1324-1330. DOI: 10.1111/ijd.12479. PMID: 24738979. 12. Imhof R, Tolkachjov SN. Optimal Management of Frontal Fibrosing Alopecia: A Practical Guide. Clin Cosmet Investig Dermatol. 2020;13:897-910. DOI: 10.2147/CCID.S235980. PMID: 33293846; PMCID: PMC7718862. 13. Mulinari-Brenner FA, Guilherme MR, Peretti MC, Werner B. Frontal fibrosing alopecia and lichen planus pigmentosus: diagnosis and therapeutic challenge. An Bras Dermatol. 2017;92(5 Suppl 1):79-81. DOI: 10.1590/abd1806-4841.20175833. PMID: 29267454; PMCID: PMC5726685. 14. Requena L. Update on Frontal Fibrosing Alopecia. Actas Dermosifiliogr. 2017;108(4):293-304. DOI: 10.1016/ PMID: 28117051. 15. López-Pestaña A, Tuneu A, Lobo C, Ormaechea N, Zubizarreta J, Vildosola S, Del Alcazar E. Facial lesions in frontal fibrosing alopecia (FFA): Clinicopathological features in a series of 12 cases. J Am Acad Dermatol. 2015;73(6):987.e1-6. DOI: 10.1016/j.jaad.2015.08.020. PMID: 26432059 16. Mirmirani P, Tosti A, Goldberg L, Whiting D, Sotoodian B. Frontal Fibrosing Alopecia: An Emerging Epidemic. Skin Appendage Disord. 2019;5(2):90-93. DOI: 10.1159/000489793. PMID: 30815440; PMCID: PMC6388564. 17. Dlova N, Goh CL, Tosti A. Familial frontal fibrosing alopecia. Br J Dermatol. 2013;168(1):220-222. DOI: 10.1111/j.1365-2133.2012.11101.x. PMID: 22716508.. 18. Tziotzios C, Fenton DA, Stefanato CM, McGrath JA. Familial frontal fibrosing alopecia. J Am Acad Dermatol. 2015 Jul;73(1):e37. DOI: 10.1016/j.jaad.2015.01.057. PMID: 26089074. 19. Tziotzios C, Petridis C, Dand N, et al. Genome-wide association study in frontal fibrosing alopecia identifies four susceptibility loci including HLA-B*07:02. Nat Commun. 2019;10(1):1150. DOI: 10.1038/s41467-019-09117-w. PMID: 30850646; PMCID: PMC6408457.. 20. Fernandez-Flores A. Frontal pseudoalopecia in history: Part 1— Fashionable forms. Clin Dermatol. 2012;30(5):548-552. DOI: 10.1016/j.clindermatol.2011.08.003. PMID: 22902229. 21. Olsen EA, Harries M, Tosti A, et al. Guidelines for Clinical Trials of Frontal Fibrosing Alopecia: Consensus Recommendations from the International FFA Cooperative Group (IFFACG). Br J Dermatol. 2021. DOI: 10.1111/bjd.20567. Epub ahead of print. PMID: 34105768. 22. Iorizzo M, Tosti A. Frontal Fibrosing Alopecia: An Update on Pathogenesis, Diagnosis, and Treatment. Am J Clin Dermatol. 2019;20(3):379-390. DOI: 10.1007/s40257-019-00424-y. PMID: 30659454. 23. Gálvez-Canseco A, Sperling L. Lichen planopilaris and frontal fibrosing alopecia cannot be differentiated by histopathology. J Cutan Pathol. 2018;45(5):313-317. DOI: 10.1111/cup.13112. PMID: 29369400. 24. Thompson CT, Tosti A. A method for more precise sampling of the scalp and eyebrows in frontal fibrosing alopecia. J Am Acad Dermatol. 2019;80(6):e155-e156. DOI: 10.1016/j.jaad.2018.12.033. PMID: 30586611. 25. Fernández-Crehuet P, Rodrigues-Barata AR, et al. Trichoscopic features of frontal fibrosing alopecia: results in 249 patients. J Am Acad Dermatol. 2015;72(2):357-359. DOI: 10.1016/j.jaad.2014.10.039. PMID: 25592346.. 26. Cervantes J, Miteva M. Distinct Trichoscopic Features of the Sideburns in Frontal Fibrosing Alopecia Compared to the Frontotemporal Scalp. Skin Appendage Disord. 2018;4(1):50-54. DOI: 10.1159/000479116. PMID: 29457017; PMCID: PMC5806192. 27. Anzai A, Pirmez R, Vincenzi C, Fabbrocini G, Romiti R, Tosti A. Trichoscopy findings of frontal fibrosing alopecia on the eyebrows: A study of 151 cases. J Am Acad Dermatol. 2021;85(5):1130-1134. DOI: 10.1016/j.jaad.2019.12.023. PMID: 31857108. 28. Kurzeja M, Czuwara J, Walecka I, Olszewska M, Rudnicka L. Features of classic lichen planopilaris and frontal fibrosing alopecia in reflectance confocal microscopy: A preliminary study. Skin Res Technol. 2021;27(2):266-271. DOI: 10.1111/srt.12940. PMID: 32743819. 29. Vazquez-Herrera NE, Eber AE, Martinez-Velasco MA, et al. Optical coherence tomography for the investigation of frontal fibrosing alopecia. J Eur Acad Dermatol Venereol. 2018;32(2):318-322. DOI: 10.1111/jdv.14571. PMID: 28859221. 30. Pindado-Ortega C, Saceda-Corralo D, Moreno-Arrones ÓM, et al. Effectiveness of dutasteride in a large series of patients with frontal fibrosing alopecia in real clinical practice. J Am Acad Dermatol. 2021;84(5):1285-1294. DOI: 10.1016/j.jaad.2020.09.093. PMID: 33038469. 31. Ramos PM, Anzai A, Duque-Estrada B, et al. Risk factors for frontal fibrosing alopecia: A case-control study in a multiracial population. J Am Acad Dermatol. 2021;84(3):712-718. DOI: 10.1016/j.jaad.2020.08.076. PMID: 32835739. 32. McSweeney SM, Christou EAA, Dand N, et al. Frontal fibrosing alopecia: a descriptive cross-sectional study of 711 cases in female patients from the UK. Br J Dermatol. 2020;183(6):1136-1138. DOI: 10.1111/bjd.19399. PMID: 32652611. 33. Trager MH, Lavian J, Lee EY, et al. Medical comorbidities and sex distribution among patients with lichen planopilaris and frontal fibrosing alopecia: A retrospective cohort study. J Am Acad Dermatol. 2021;84(6):1686-1689. DOI: 10.1016/j.jaad.2020.08.015. PMID: 32781188.. 34. Grassi S, Tadiotto Cicogna G, et al. Frontal fibrosing alopecia and genital Lichen sclerosus: Single-center experience. J Cosmet Dermatol. 2021;20(2):615-620. DOI: 10.1111/jocd.13573. PMID: 32590887. 35. Papanikou S, Xydeas-Kikemenis A, Nicolaidou E, et al. Social Status May Interfere in the Prognosis of Frontal Fibrosing Alopecia in Female Patients: An Observational Study. Skin Appendage Disord. 2019;5(6):355-358. DOI: 10.1159/000501888. PMID: 31799262; PMCID: PMC6883467. 36. Brenner FM, Oldoni C. Frontal fibrosing alopecia: epidemic? An Bras Dermatol. 2019;94(4):482. DOI: 10.1590/abd1806-4841.20198300. PMID: 31644628; PMCID: PMC7007025. 37. Vañó-Galván S, Saceda-Corralo D, Blume-Peytavi U, et al. Frequency of the Types of Alopecia at Twenty-Two Specialist Hair Clinics: A Multicenter Study. Skin Appendage Disord. 2019 Aug;5(5):309-315. DOI: 10.1159/000496708. PMID: 31559256; PMCID: PMC6751437. 38. Kanti V, Constantinou A, Reygagne P, Vogt A, Kottner J, Blume-Peytavi U. Frontal fibrosing alopecia: demographic and clinical characteristics of 490 cases. J Eur Acad Dermatol Venereol. 2019;33(10):1976-1983. DOI: 10.1111/jdv.15735. PMID: 31179579. 39. Moreno-Arrones OM, Saceda-Corralo D, Rodrigues-Barata AR, et al. Factors influencing frontal fibrosing alopecia severity: a multicentre cross-sectional study. J Eur Acad Dermatol Venereol. 2019;33(9):e315-e316. DOI: 10.1111/jdv.15590. PMID: 30895660. 40. Moreno-Arrones OM, Saceda-Corralo D, Rodrigues-Barata AR, et al. Risk factors associated with frontal fibrosing alopecia: a multicentre case-control study. Clin Exp Dermatol. 2019;44(4):404-410. DOI: 10.1111/ced.13785. PMID: 30259544. 41. Cranwell WC, Sinclair R. Sunscreen and facial skincare products in frontal fibrosing alopecia: a case-control study. Br J Dermatol. 2019;180(4):943-944. DOI: 10.1111/bjd.17354. PMID: 30367472. 42. Buendía-Castaño D, Saceda-Corralo D, Moreno-Arrones OM, et al. Hormonal and Gynecological Risk Factors in Frontal Fibrosing Alopecia: A Case-Control Study. Skin Appendage Disord. 2018;4(4):274-276. DOI: 10.1159/000484210. PMID: 30410895; PMCID: PMC6219213. 43. Imhof RL, Chaudhry HM, Larkin SC, Torgerson RR, Tolkachjov SN. Frontal Fibrosing Alopecia in Women: The Mayo Clinic Experience With 148 Patients, 1992-2016. Mayo Clin Proc. 2018;93(11):1581-1588. DOI: 10.1016/j.mayocp.2018.05.036. PMID: 30392542. 44. Saceda-Corralo D, Fernández-Crehuet P, Fonda-Pascual P, Pindado-Ortega C, Moreno-Arrones OM, Vañó-Galván S. Clinical Description of Frontal Fibrosing Alopecia with Concomitant Lichen Planopilaris. Skin Appendage Disord. 2018;4(2):105-107. DOI: 10.1159/000479799. PMID: 29765970; PMCID: PMC5939712. 45. Pindado-Ortega C, Saceda-Corralo D, Buendía-Castaño D, et al. Frontal fibrosing alopecia and cutaneous comorbidities: A potential relationship with rosacea. J Am Acad Dermatol. 2018;78(3):596-597.e1. DOI: 10.1016/j.jaad.2017.09.004. PMID: 29447678. 46. Donati A, Gupta AK, Jacob C, Cavelier-Balloy B, Reygagne P. The Use of Direct Immunofluorescence in Frontal Fibrosing Alopecia. Skin Appendage Disord. 2017;3(3):125-128. DOI: 10.1159/000469665. PMID: 28879188; PMCID: PMC5582472. 47. Moreno-Arrones OM, Saceda-Corralo D, Fonda-Pascual P, et al. Frontal fibrosing alopecia: clinical and prognostic classification. J Eur Acad Dermatol Venereol. 2017;31(10):1739-1745. DOI: 10.1111/jdv.14287. PMID: 28426907. 48. Aldoori N, Dobson K, Holden CR, McDonagh AJ, Harries M, Messenger AG. Frontal fibrosing alopecia: possible association with leave-on facial skin care products and sunscreens; a questionnaire study. Br J Dermatol. 2016;175(4):762-767. DOI: 10.1111/bjd.14535. PMID: 26987767. 49. Vañó-Galván S, Molina-Ruiz AM, Serrano-Falcón C, et al. Frontal fibrosing alopecia: a multicenter review of 355 patients. J Am Acad Dermatol. 2014;70(4):670-678. DOI: 10.1016/j.jaad.2013.12.003. PMID: 24508293. 50. Dlova NC. Jordaan HF, Skenjane A,, Khoza N, Tosti A. Frontal fibrosing alopecia: A clinical review of 20 black patients from South Africa. Br J Dermatol. 2013;169(4):939-941. DOI: 10.1111/bjd.12424. PMID: 23647261. 51. Navarro-Belmonte MR, Navarro-López V, Ramírez-Boscà A, et al. Case series of familial frontal fibrosing alopecia and a review of the literature. J Cosmet Dermatol. 2015;14(1):64-9. DOI: 10.1111/jocd.12125. PMID: 25614294. 52. Ranasinghe GC, Piliang MP, Bergfeld WF. Prevalence of hormonal and endocrine dysfunction in patients with lichen planopilaris (LPP): A retrospective data analysis of 168 patients. J Am Acad Dermatol. 2017;76(2):314-320. DOI: 10.1016/j.jaad.2016.05.038. PMID: 28088992. 53. Samrao A, Chew AL, Price V. Frontal fibrosing alopecia: a clinical review of 36 patients. Br J Dermatol. 2010;163(6):1296-300. DOI: 10.1111/j.1365-2133.2010.09965.x. PMID: 20698851. 54. Moreno-Ramírez D, Camacho Martínez F. Frontal fibrosing alopecia: a survey in 16 patients. Eur Acad Dermatol Venereol. 2005;19(6):700-705. DOI: 10.1111/j.1468-3083.2005.01291.x. PMID: 16268874. 55. Ladizinski B, Bazakas A, Selim MA, Olsen EA. Frontal fibrosing alopecia: a retrospective review of 19 patients seen at Duke University. J Am Acad Dermatol. 2013;68(5):749-755. DOI: 10.1016/j.jaad.2012.09.043. PMID: 23375454. 56. Waśkiel-Burnat A, Rakowska A, Kurzeja M, et al. The value of dermoscopy in diagnosing eyebrow loss in patients with alopecia areata and frontal fibrosing alopecia. J Eur Acad Dermatol Venereol. 2019;33(1):213-219. DOI: 10.1111/jdv.15279. PMID: 30290016.

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