Fibrosing Alopecia in a Pattern Distribution (FAPD) in 16 African-Descent and Hispanic Female Patients: A Challenging Diagnosis

Abstract

Background: Fibrosing alopecia in a pattern distribution (FAPD) has only been described in Caucasian patients, and it is not clear whether it can develop in dark-skin ethnicities.

Materials and methods: Sixteen Brazilian female patients, 12 of African descent and 4 Hispanic, with progressive scarring alopecia in a pattern distribution were analyzed.

Results: Dermatoscopic features showed perifollicular erythema and scaling (14/16), hair fiber diameter diversity (16/16), loss of follicular ostia (16/16), and follicular keratosis (3/16). Late stages showed a honeycomb pigmented network (12/16), a hyperpigmented perifollicular halo (12/16), and small white patches (12/16). Histopathological features showed lichenoid perifollicular infiltrate (14/16), follicular miniaturization (16/16), concentric fibrosis (16/16), perifollicular lymphocytic infiltrate (16/16), and vellus hair involvement (10/16). Premature desquamation of the inner root sheath was found in 11 patients.

Conclusions: The concomitant findings of cicatricial pattern hair loss (with or without the recess of the front hair line), hair fiber diversity, perifollicular erythema and scaling, a whitish perifollicular halo, and histological findings of androgenetic alopecia, with vacuolar interface alteration of the upper portion of the follicular epithelium, are the main key features to suggest the diagnosis of FAPD. FAPD is a possible diagnosis in patients of color with cicatricial pattern hair loss. Clinical, dermatoscopic, and histopathological examination allow a proper final differential diagnosis.

Keywords: Androgenetic alopecia; Cicatricial alopecia; Female alopecia; Fibrosing alopecia in a pattern distribution.

Fig. 1

a Cicatricial alopecia in a male androgenetic distribution. Bitemporal (arrow) and parietal hair loss. a1 Hyperpigmented perifollicular halo, scattered white small patches, hair diameter diversity, loss of follicular ostia. a2 AGA, horizontal section, papillary dermis with some terminal and many vellus hairs. b Cicatricial alopecia in a female androgenetic distribution. b1 Perifollicular erythema and scaling, loss of follicular ostia, keratotic follicular plugs, and hair diameter diversity. b2 Concentric fibrosis and fibrous tracts. c Cicatricial alopecia in a female androgenetic distribution. ­Arrow shows cicatricial parietal involvement. c1 Loss of follicular ostia, white perifollicular ostia, hair diameter diversity, and a honeycomb ­hyperpigmented network. c2 Concentric fibrosis with intense perifollicular lymphocytic infiltrate. Terminal and vellus hair involvement. d Cicatricial alopecia in a female androgenetic distribution with parietal involvement. d1 Loss of follicular ostia, perifollicular erythema and scaling, and hair diameter diversity. d2 AGA features with a lichenoid infiltrate around the vellus hair. Premature desquamation of the inner root sheath.e Diffuse hair thinning associated with recession of the frontotemporal hairline. Arrows showing the recession and the eyebrow thinning. e1 Perifollicular scaling, loss of follicular ostia, a white perifollicular halo and perifollicular scaling, and hair diameter diversity. e2 Concentric fibrosis with perifollicular lymphocytic infiltrate. f Cicatricial alopecia in a female andro­ge­netic distribution with a central non­affected parietal area (arrow). f1 Loss of follicular ostia, a whitish and hyperpigmented perifollicular halo, white patches, hair diameter diversity, and a honeycomb pigmented network. f2 Vellus hair involvement. g Diffuse hair thinning with a temporal nonaffected area. g1 Loss of follicular ostia, a whitish and hyperpigmented perifollicular halo, white patches, hair diameter diversity, and a honeycomb pigmented network. g2 Premature desquamation of the inner root sheath.