Frontal Fibrosing Alopecia Presenting as Androgenetic Alopecia in an African American Woman

A 53-year-old African American woman presented with a 6-month history of asymptomatic, moderately severe hair loss along the frontal hairline, which had not stabilized or improved with minoxidil 2% solution BID. Physical exam revealed decreased hair density affecting the frontal scalp, suggestive of androgenetic alopecia (Figure1). Dermoscopic examination showed decreased follicular ostia without perifollicular scaling or erythema. Eyebrow alopecia, facial papules, and glabellar red dots were absent, and there was no associated loss of body hair. A 4-mm punch biopsy sent for histopathologic examination revealed dense, chronic, perifollicular inflammation affecting the mid and upper portions of the follicles, with loss of associated sebaceous glands. Involved hairs demonstrated vacuolar interface disruption of the basilar and epibasilar layers at the level of the isthmus and infundibulum, with prominent exocytosis of lymphocytes into the outer root sheath. There was no miniaturization, dermal mucin, or inflammation affecting the epidermis, arrector pili muscles, and eccrine glands (Figure 2).

A diagnosis of FFA was confirmed by these findings. Our patient was managed with intralesional triamcinolone acetonide (10mg/cc) injections, clobetasol 0.05% ointment BID, hydroxychloroquine 200 mg PO BID, and minoxidil 5 mg PO daily. Unfortunately, her alopecia did not stabilize with these measures.

 

FFA is a primary lymphocytic cicatricial alopecia that is currently regarded as a variant of lichen planopilaris. It is characterized by band-like frontotemporal hairline recession, often with associated eyebrow alopecia, perifollicular erythema, and scaling. Clinical findings are frequently accompanied by pruritus and burning of the affected scalp. Since it was first described in 1994,¹ FFA has largely been viewed as an alopecia of post-menopausal Caucasian women. This archetype has been maintained by patient demographics of subsequent published case series.^2,3 FFA may thus be underdiagnosed in black women, in whom traction alopecia, central centrifugal cicatricial alopecia, and androgenetic alopecia are assumed to be more common. Furthermore,