At the 2023 AAD Annual Meeting, Isabella Doche, MD PhD, kicked off her session, “Frontal Fibrosing Alopecia (FFA): Update on Clinical Diagnosis,” with the background and useful tools in the diagnosis of FFA. 

Dr Doche started the session by mentioning her involvement in a study of consensus for clinical trials wherein they suggested methods to analyze clinical data for clinical trials, outlined diagnostic criteria for classic and probable FFA, showed extra-scalp signs for FFA, and suggested quality of life (QoL) questionnaires for patients and scores to assess efficacy and safety of individual treatments based mostly on signs and symptoms of inflammation. 

Dr Doche described 3 patterns of frontal hairline recession: linear pattern, diffusion pattern, and double-line pattern (pseudo fringe), “Diffusion pattern usually has the worst prognosis, whereas in ‘pseudo fringe’ pattern, eyebrows are usually spared, and it has best prognosis.”

Next, Dr Doche mentioned eyebrow alopecia in which severity may vary, “[Eyebrow alopecia] can be an important diagnostic clue in 73% to 95% [of patients].” Eyelashes can be affected but eyebrows “can regrow after systemic or topical therapy despite scalp treatment.”

Furthermore, Dr Doche recommended checking facial hairs and all the hairline with trichoscopy because “occipital alopecia may also be present in up to 20% to 30% of the cases.”

Extra-scalp hair loss especially in androgen-dependent areas can also help diagnosis of FFA. “[There is] loss of axillary and pubic hairs in up to 50% of the cases,” she mentioned. “Lesions may show trichoscopic and histopathological typical features of FFA.”

“Facial papules are another important feature that can be associated with FFA,” said Dr Doche. “[Facial papules] tend to occur in 20% of the patients but in my experience, it’s more. [Facial papules] usually occur in the temporal area but sometimes can also occur on the chin.” Biopsy findings vary but “there are textural changes in the facial skin with small yellow to flesh-colored lesions.”

Dr Doche explained that depression of facial veins can be common but sometimes underdiagnosed, “Prominent veins usually occur on the lateral sides of the front but can also be on the center and retroauricular zones.”

Dr Doche also talked about hyperpigmentation and hypopigmentation:

• Hyperpigmentation (lichen planus pigmentosus)
  • Most frequent in dark-skinned patients over the face, neck, and flexures
  • Lichenoid infiltrate and pigmentary incontinence
  • Variable trichoscopic patterns
• Hypopigmentation
  • Hypopigmentation over the frontal scalp (band or patchy lesions) and eyebrows
  • Vitiligo can be associated in some cases

Rosacea-like eruption can also occur in around 30% of cases, “mostly erythematotelangiectatic subtype of mild to moderate severity.”

Lastly, Dr Doche presented the finding of a study about QoL associated with extra-scalp lesions. “Quality of life is more related to the presence of extra-scalp lesions in patients with FFA, like facial papules or eyebrows alopecia, than with disease activity,” she said. “Psychological status should also be assessed during therapeutic approach.”

Dr Doche summarized her session with important take-home pearls. “FFA can be considered as a generalized disease that can have diverse scalp and extra-scalp features.” she concluded. “Psychological aspects should be included in the management of this disease, especially if facial lesions are present,” she added.

Reference
Doche I. Frontal fibrosing alopecia: update on clinical diagnosis. Presented at: AAD Annual Meeting; March 17–21, 2023; New Orleans, LA.