Frontal Fibrosing Alopecia in Patients with Darker Skin

00:01 Now let's talk about frontal fibrosing alopecia (FFA).

00:07 This is a patent form of scarring alopecia along the frontal scalp hair margin, around here. It has been classified as a variant of lichen planopilaris.

00:19 The first reported case was in 1994.

00:22 However, there is limited epidemiological data available on this condition.

00:28 It can affect people of any age and skin color.

00:32 Many reports suggest high prevalence in postmenopausal women.

00:37 The incidence is reported to be increasing worldwide even in premenopausal women.

00:45 The etiology is unknown, but possible contributing factors include genetics, few case reports of familial FFA have been reported, hormones and the environment.

01:03 Clinically, it presents as a uniform, linear band of hair loss along the front and sides of the scalp hair margin.

01:10 Some associated features include loss of eyebrows, pruritus, and pain, which can occur before any visible loss of hair, perifollicular erythema, scaling, and diminished follicular orifices.

01:27 The diagnosis rests mainly on history and physical examination.

01:32 Use of dermoscopy and on dermoscopy one sees perifollicular plugging and perifollicular erythema, that is, erythema or redness around the hair follicle, and a bit of scaling. A biopsy may be required to exclude other forms of scarring alopecia and features are identical to those of lichen planopilaris where once is vacuolar, interface changes with scattered lymphocytes and perifollicular fibrosis.

02:01 The differential diagnosis includes traction alopecia, particularly amongst black patients, and the fringe sign may assist to differentiate between the two.

02:14 And of course, on histology, the two conditions are totally different.

02:19 Alopecia areata. The ophiasis pattern could resemble frontal fibrosing alopecia, but this is non-scarring alopecia and the follicular ostia remain intact.

02:31 Female and male pattern hair loss.

02:33 You see miniaturized hairs which are easily visualized on dermoscopy or histopathological examination. How do we manage these patients with frontal fibrosing alopecia? It's a very difficult condition to treat, but the goals of treatment are to stabilize the disease and stop recession of the hairline and feather hair loss.

02:56 Resolution of other signs of the disease, like perifollicular erythema and hyperkeratosis, are also shown when the patient is on treatment.

03:08 Treatment is challenging due to unknown etiology and pathogenesis, and FFA affects the patient psychologically and impacts on the quality of life of affected patients. We do see it in males as well, but not as common. The treatment involves as listed on the slide.

03:31 And of course, cosmetic measures need to be recommended for patients who have extensive hair loss. And this can be done through micro tattooing of the scalp, as well as using wigs for cosmetic camouflage.

03:48 Hair transplantation is a high risk with very poor long term outcomes.

03:54 And it's not recommended for patients with cicatricial alopecia that has not been stabilized for at least one year.

04:02 So we've spoken about the medical treatment of some of the common scarring and non-scarring alopecia.

04:10 It's important to know that the holistic treatment of alopecia, whether there is scarring or non-scarring, also involves proper hair grooming habits.

04:25 I think it's almost like treating diabetes without talking about diet.

04:31 So we need to make sure that we educate the patients to avoid hair grooming habits that may affect the healthy hair shaft and scalp.

04:46 We need to limit heat on hair, limit use of chemicals, as well as try and shampoo the hair weekly.

04:57 In fact, this is a recommendation for African patients where seborrheic dermatitis has been shown to be quite prevalent.

05:05 So shampooing the hair once a week ensures that we decrease the concentration of malassezia furfur, which has implicated in dandruff,