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Melissa Piliang, MD, Discusses Frontal Fibrosing Alopecia at AAD Meeting

Frontal fibrosing alopecia (FFA) is a diagnosis sometimes missed by dermatologists, especially when it presents atypically, said Melissa Piliang, MD, from Cleveland Clinic, at the 2019 American Academy of Dermatology Summer Meeting in New York.1

Commonly confused with androgenetic alopecia and alopecia areata, FFA often occurs in younger women and men, commonly involves the eyebrows, and may proceed scalp hair loss, Dr Piliang said.

Other key factors that could complicate diagnosing FFA? “The scarring is subtle, the inflammation can be very minimal or absent, and if the biopsy doesn’t have much information, then your pathologist might miss [this diagnosis] also,” she added.

Although FFA can sometimes be an elusive diagnosis, a number of clues can be helpful in distinguishing FFA from similar conditions, explained Dr Piliang. These include:

  • Atrophy
  • Hypopigmentation (This can be more difficult to detect in fair skin. For patients with fair skin, Dr Piliang recommended using a Wood light to detect hypopigmentation.)
  • Prominent, widely dilated veins
  • Perifollicular erythema

FFA in younger women can be particularly challenging to diagnose due to minimal inflammation and unusual patterns of presentation, Dr Piliang said. In these patients, it can be very helpful to look for hair loss behind the ears and lift the bangs if patients have them, because bangs can cover hair loss near the frontal hairline and eyebrow loss.

“Patients are experts at hiding this hair loss,” she explained. “If you don’t thoroughly examine the scalp and lift the bangs, you won’t see it.”

FFA also occurs in African American patients, she noted, referencing a 2016 paper by Callender et al on diagnostic clues to diagnosing FFA in patients of African descent.2

In discussing the cases presented by Callender et al,2 Dr Piliang said, “biopsy is very helpful in making this diagnosis because you see the classic features of [FFA], with that concentric myxoid fibroplasia.” The absence of pain, pruritus, and “Fringe sign” can also help distinguish FFA from traction alopecia in this patient population.

She concluded her discussion on FFA by sharing some key clinical takeaways:

  • Keep in mind that FFA affects more than just the frontal hairline.
  • Look for atypical presentations.
  • Keep an eye out for atrophy, hypopigmentation, and subtle perifollicular erythema.

—Christina Vogt

References:

1. Piliang M. Pearls from members: hairy pearls. Presented at: 2019 American Academy of Dermatology Summer Meeting; July 25, 2019; New York, NY. https://www.aad.org/scientificsessions/sam2019/SessionDetails.aspx?id=12730.

2. Callender VD, Reid SD, Obayan O, Mcclellan L, Sperling L. Diagnostic clues to frontal fibrosing alopecia in patients of African descent. J Clin Aesthet Dermatol. 2016;9(4):45-51. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898584/.

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