FFA can manifest uniquely in black women, who may be premenopausal4,5 and asymptomatic4 at the time of presentation. Classic signs of FFA may be subtle or absent among black patients, as increased pigmentation may render erythema difficult to appreciate, while oils and hair care products may diminish the appearance of scale.
It is important for dermatologists to both recognize that FFA is not uncommon in the black population,4,5 and to acknowledge how it initially came to be regarded as a disease of post-menopausal white women. Several of the larger published series come from geographic areas that lack a substantial skin of color population.2,3 There are also socioeconomic factors to consider. One series comprised exclusively of Caucasian women found their patients to be more affluent, which was speculated to be a surrogate marker for an unknown risk factor associated with the development of FFA.3 What these authors did not discuss, however, is that affluence enables access to specialty medical care. Affluence affects insurance status, which has been shown to vary widely among racial groups.6 Insurance status in turn bears upon who has access to dermatologic care, and who is ultimately included in a case series.
Although there are no universal treatment guidelines for FFA, the goal of management is to halt progression of the disease before follicles are irrevocably lost to fibrosis. Initiation of appropriate treatment requires a correct diagnosis, which is contingent upon a clinician’s willingness to consider certain conditions in patients who do not fit the paradigm that they have been taught. FFA must be considered in any black patient who presents with frontotemporal alopecia.
It is important for dermatologists to both recognize that FFA is not uncommon in the black population,4,5 and to acknowledge how it initially came to be regarded as a disease of post-menopausal white women. Several of the larger published series come from geographic areas that lack a substantial skin of color population.2,3 There are also socioeconomic factors to consider. One series comprised exclusively of Caucasian women found their patients to be more affluent, which was speculated to be a surrogate marker for an unknown risk factor associated with the development of FFA.3 What these authors did not discuss, however, is that affluence enables access to specialty medical care. Affluence affects insurance status, which has been shown to vary widely among racial groups.6 Insurance status in turn bears upon who has access to dermatologic care, and who is ultimately included in a case series.
Although there are no universal treatment guidelines for FFA, the goal of management is to halt progression of the disease before follicles are irrevocably lost to fibrosis. Initiation of appropriate treatment requires a correct diagnosis, which is contingent upon a clinician’s willingness to consider certain conditions in patients who do not fit the paradigm that they have been taught. FFA must be considered in any black patient who presents with frontotemporal alopecia.
REFERENCES
1. Kossard S. Postmenopausal frontal fibrosing alopecia. Scarring alopecia in a pattern distribution. Arch Dermatol. 1994;130(6):770-74. 2. Vañó-Galván S, Molina-Ruiz A, 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.
3. MacDonald A, Clark C, Holmes S. Frontal fibrosing alopecia: A review of 60 cases. J Am Acad Dermatol. 2012;67(5):955-961. doi: 10.1016/j. jaad.2011.12.038.
4. Callender VD, Reid SD, Obayan O, et al. Diagnostic clues to frontal fibrosing alopecia in patients of African descent. J Clin Aesthet Dermatol. 2016;9(4):45-51.
5. Dlova NC, Jordaan HF, Skenjane A, et al. Frontal fibrosing alopecia: A clinical review of 20 black patients from South Africa. Br J Dermatol. 2013;169(4):939-41.
6. Henry J. Kaiser Family Foundation. Key facts on health and health care by race and ethnicity. http://www.kff.org/report-section/key-facts-on-healthand- health-careby-race-and-ethnicity-section-4-health-coverage/. Accessed December 8, 2018.
3. MacDonald A, Clark C, Holmes S. Frontal fibrosing alopecia: A review of 60 cases. J Am Acad Dermatol. 2012;67(5):955-961. doi: 10.1016/j. jaad.2011.12.038.
4. Callender VD, Reid SD, Obayan O, et al. Diagnostic clues to frontal fibrosing alopecia in patients of African descent. J Clin Aesthet Dermatol. 2016;9(4):45-51.
5. Dlova NC, Jordaan HF, Skenjane A, et al. Frontal fibrosing alopecia: A clinical review of 20 black patients from South Africa. Br J Dermatol. 2013;169(4):939-41.
6. Henry J. Kaiser Family Foundation. Key facts on health and health care by race and ethnicity. http://www.kff.org/report-section/key-facts-on-healthand- health-careby-race-and-ethnicity-section-4-health-coverage/. Accessed December 8, 2018.
AUTHOR CORRESPONDENCE
Kimberly Huerth MD MEd Kimberly.Huerth@gmail.com
