Frontal Fibrosing Alopecia: An Observational Single-Center Study of 306 Cases

Abstract

(1) Background: Frontal fibrosing alopecia (FFA) is a scarring alopecia that predominantly affects postmenopausal women; (2) Methods: A retrospective, observational, single-center study was conducted in the Hospital General Universitario in Ciudad Real, Spain, including all patients diagnosed with FFA between 2010 and 2021; (3) Results: A total of 306 patients (296 women and 10 men) were included in our study. The mean age of onset was 59.5 years. The severity of this disease was evenly distributed between mild (147 patients) and severe (149 patients) forms. There was a positive, statistically significant, medium correlation between the severity of the disease and its time of progression. Moreover, hypothyroidism was present in 70 patients (22.9%) and classic signs of concomitant lichen planopilaris were observed in just 30 patients (9.8%), while other forms of lichen planus were uncommon. The estimated prevalence in our population is 0.15% and the incidence is 15.47 new cases per 100,000 inhabitants; (4) Conclusions: The time of progression was positively correlated with the severity of FFA. However, the presence of clinical signs, such as inflammatory trichoscopic signs, was not associated with the progression of this condition.

Keywords: alopecia; erythema; follicular hyperkeratosis; frontal fibrosing alopecia; hair loss; lichen planopilaris; trichology.

Figure 1

Recession of the frontotemporal hairline in a patient with severe frontal fibrosing alopecia (AFF), leaving behind a pale uniform alopecic band associated with a total eyebrow alopecia.

Figure 2

Graphic representing the Spearman rank correlation rho between severity (grades I to V; x axis) and progression time (in years, y axis). Each dot represents a data point from each patient, and columns represent the density of these data. The slope of the line indicates a positive, statistically significant and medium (rho = 0.26, S = 3.18 × 10⁶, p < 0.001) correlation between both variables.

Figure 3

Usual patterns of presentation of AFF: (a) Pattern I: a homogeneous symmetric and linear recession of the frontotemporal hairline; (b) Pattern II: hair density loss affecting the frontotemporal scalp, sparring the original hairline and leading to diffuse alopecia; (c) Pattern III: alopecic band affecting the frontotemporal area, sparring the primitive hairline.

Figure 4

Histological features of patients affected by FFA. Images correspond to a 66-year-old woman with five years of FFA evolution. Image (A) shows a skin biopsy stained with hematoxylin–eosin at low magnification, where it is possible to observe an absence of hair follicles (HF), some HF remnants (HF and black arrow), cicatricial changes within the dermis (red arrows) and inflammatory elements (Inf and arrows). Image (B) shows the inflammatory elements within the dermis at higher magnification (Inf and arrows). Image (C) shows the remnants of HF (white asterisk) and the erector pili smooth muscle (EP). Scale bar: 200 µm (A), 50 µm (B,C).