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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Primary cicatricial alopecias &#40;PCA&#41; are a diverse group of inflammatory hair disorders of unknown aetiology&#44; clinically characterised by the loss of hair shafts&#44; visible follicular ostia&#44; and variable degrees of scalp inflammation&#46; The hair follicle is the primary target of the disease process and persistent inflammation leads to irreversible damage to the hair follicle&#39;s stem cells&#46; Ultimately&#44; replacement of follicular structures by scar-like fibrous tissue occurs&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a> Frontal fibrosing alopecia &#40;FFA&#41; is one of the most common types of PCA&#46; The clinical diagnosis is typically straightforward&#59; FFA is considered to be a subtype of lichen planopilaris &#40;LPP&#41; and is based on similar histopathological findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> An effective medical treatment remains elusive and evidence-based recommendations are weak&#58; intralesional triamcinolone acetonide&#44; finasteride&#44; dutasteride&#44; oral and topical corticosteroids &#40;level of evidence D&#41;&#44; and antimalarials &#40;level of evidence E&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5&#44;6</span></a> Despite medical treatment&#44; the course of FFA is uncertain and&#44; in the best scenario&#44; these drugs can only stop disease progression&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In daily practice&#44; we have observed that the cosmetic impact of FFA on women is a frequent cause of anxiety&#44; and just halting the alopecia process is generally not sufficient in most cases&#46; Some patients with FFA insistently demand a hair transplant despite being properly informed of the high risk of hair loss a few months after the procedure&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">How could hair transplantation be part of the solution for FFA&#63; Literature regarding hair transplantation for FFA is scarce&#46; Publications by Nusbaum et al&#46; and Jim&#233;nez et al&#46; report similar results&#58; despite the growth of the hair shafts for 1&#46;5&#8211;2 years after transplantation&#44; more than 50&#37; of the transplanted hairs had been lost after 3 years&#46; Histological confirmation of FFA in the remaining transplanted follicles suggests that FFA displays recipient dominance&#46; Post-transplant medical therapy is not mentioned in either of the publications&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> Gurfinkiel et al&#46; reported a successful case of hair transplantation in a female patient with FFA and vulvar lichen sclerosus with a follow-up of 6 years&#44; maintaining systemic finasteride 1<span class="elsevierStyleHsp" style=""></span>mg&#47;day and topical minoxidil 2&#37; bid as post-transplant maintenance therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Unger et al&#46; have recently proposed two new categories of cicatricial alopecia&#58; unstable and stable&#46; Unstable cicatricial alopecias &#40;UCA&#41; have a tendency to progress and recur intermittently over the course of time&#44; in either new or previously affected areas &#40;e&#46;g&#46;&#44; discoid cutaneous lupus erythematous&#44; LPP&#41;&#46; Stable cicatricial alopecias are secondary to isolated events that cause permanent scarring in a hair-bearing region &#40;e&#46;g&#46;&#44; burn&#44; surgical scar&#41;&#59; once successfully corrected surgically&#44; there is no need for further therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The chronic and relapsing nature of FFA&#44; even after hair transplantation&#44; is the paradigm of UCA&#46; It has become clear that this procedure can only be considered for FFA after a certain period of observation with no disease activity&#44; and recommendations range from 1 to 5 years<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#8211;8</span></a>&#59; we do not usually consider hair transplantation in FFA until 2 years of clinical stability have been observed&#46; However&#44; once hair transplantation has been performed&#44; these patients should be kept on maintenance medical treatment for affected areas&#44; even if no clinical signs of disease activity are visible&#46; The usefulness of performing trichoscopy to monitor disease activity and response to therapy cannot be emphasised enough&#58; look for the presence of perifollicular hyperkeratosis&#47;desquamation and perifollicular erythema&#44; which are correlated with disease activity in FFA&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Regarding the maintenance medical treatment to be prescribed after hair transplantation for FFA&#44; clobetasol propionate 0&#46;05&#37; lotion twice a week could be considered as a possible maintenance scheme&#59; from our clinical practice experience&#44; the risk of adverse effects with this regimen appears to be very small&#46; As an alternative&#44; a topical calcineurin inhibitor such as tacrolimus 0&#46;1&#37; ointment or pimecrolimus 1&#37; cream could also be considered &#40;tolerability&#58; pimecrolimus<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>tacrolimus&#41;&#46; In our experience&#44; maintaining concomitant post-transplant therapy with systemic finasteride 5<span class="elsevierStyleHsp" style=""></span>mg&#47;day and topical minoxidil 5&#37; is also advisable&#44; particularly if androgenetic alopecia is concomitantly present&#46; Dutasteride has been recently attempted as an alternative to finasteride&#59; although dutasteride might appear at least equally effective&#44; its superiority and more favourable safety profile are not yet proven&#46; Follow-up visits should be frequent&#44; and more aggressive anti-inflammatory therapy must be initiated in case of clinical relapse&#44; not only to &#8220;protect&#8221; transplanted hairs but also to prevent alopecia progression to previously uninvolved areas&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To summarise&#44; the need for post-transplant medical therapy for FFA is&#44; in our opinion&#44; absolutely decisive for the success of the transplantation&#46; Prior to surgery&#44; two requirements for FFA hair transplantation must be met&#58; 2 years of clinical stability and the patient&#39;s commitment to follow-up visits and adherence to post-transplant medical therapy&#46; Strong evidence-based recommendations for the medical and surgical treatment of FFA are warranted&#46;</p></span>"
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Opinion Article
Hair Transplantation for Frontal Fibrosing Alopecia: Part of the Solution?
Trasplante de pelo en la alopecia fibrosante frontal: ¿parte de la solución?
P. Mendes-Bastosa,
Corresponding author
pmendesbastos@gmail.com

Corresponding author.
, A. Camps-Fresnedab,c
a Department of Dermatology and Venereology, Curry Cabral Hospital, Central Lisbon Hospital Centre, Lisbon, Portugal
b Department of Dermatology, Catalonia General Hospital, Barcelona, Spain
c Teknon Medical Centre, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Primary cicatricial alopecias &#40;PCA&#41; are a diverse group of inflammatory hair disorders of unknown aetiology&#44; clinically characterised by the loss of hair shafts&#44; visible follicular ostia&#44; and variable degrees of scalp inflammation&#46; The hair follicle is the primary target of the disease process and persistent inflammation leads to irreversible damage to the hair follicle&#39;s stem cells&#46; Ultimately&#44; replacement of follicular structures by scar-like fibrous tissue occurs&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a> Frontal fibrosing alopecia &#40;FFA&#41; is one of the most common types of PCA&#46; The clinical diagnosis is typically straightforward&#59; FFA is considered to be a subtype of lichen planopilaris &#40;LPP&#41; and is based on similar histopathological findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> An effective medical treatment remains elusive and evidence-based recommendations are weak&#58; intralesional triamcinolone acetonide&#44; finasteride&#44; dutasteride&#44; oral and topical corticosteroids &#40;level of evidence D&#41;&#44; and antimalarials &#40;level of evidence E&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5&#44;6</span></a> Despite medical treatment&#44; the course of FFA is uncertain and&#44; in the best scenario&#44; these drugs can only stop disease progression&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In daily practice&#44; we have observed that the cosmetic impact of FFA on women is a frequent cause of anxiety&#44; and just halting the alopecia process is generally not sufficient in most cases&#46; Some patients with FFA insistently demand a hair transplant despite being properly informed of the high risk of hair loss a few months after the procedure&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">How could hair transplantation be part of the solution for FFA&#63; Literature regarding hair transplantation for FFA is scarce&#46; Publications by Nusbaum et al&#46; and Jim&#233;nez et al&#46; report similar results&#58; despite the growth of the hair shafts for 1&#46;5&#8211;2 years after transplantation&#44; more than 50&#37; of the transplanted hairs had been lost after 3 years&#46; Histological confirmation of FFA in the remaining transplanted follicles suggests that FFA displays recipient dominance&#46; Post-transplant medical therapy is not mentioned in either of the publications&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> Gurfinkiel et al&#46; reported a successful case of hair transplantation in a female patient with FFA and vulvar lichen sclerosus with a follow-up of 6 years&#44; maintaining systemic finasteride 1<span class="elsevierStyleHsp" style=""></span>mg&#47;day and topical minoxidil 2&#37; bid as post-transplant maintenance therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Unger et al&#46; have recently proposed two new categories of cicatricial alopecia&#58; unstable and stable&#46; Unstable cicatricial alopecias &#40;UCA&#41; have a tendency to progress and recur intermittently over the course of time&#44; in either new or previously affected areas &#40;e&#46;g&#46;&#44; discoid cutaneous lupus erythematous&#44; LPP&#41;&#46; Stable cicatricial alopecias are secondary to isolated events that cause permanent scarring in a hair-bearing region &#40;e&#46;g&#46;&#44; burn&#44; surgical scar&#41;&#59; once successfully corrected surgically&#44; there is no need for further therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The chronic and relapsing nature of FFA&#44; even after hair transplantation&#44; is the paradigm of UCA&#46; It has become clear that this procedure can only be considered for FFA after a certain period of observation with no disease activity&#44; and recommendations range from 1 to 5 years<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#8211;8</span></a>&#59; we do not usually consider hair transplantation in FFA until 2 years of clinical stability have been observed&#46; However&#44; once hair transplantation has been performed&#44; these patients should be kept on maintenance medical treatment for affected areas&#44; even if no clinical signs of disease activity are visible&#46; The usefulness of performing trichoscopy to monitor disease activity and response to therapy cannot be emphasised enough&#58; look for the presence of perifollicular hyperkeratosis&#47;desquamation and perifollicular erythema&#44; which are correlated with disease activity in FFA&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Regarding the maintenance medical treatment to be prescribed after hair transplantation for FFA&#44; clobetasol propionate 0&#46;05&#37; lotion twice a week could be considered as a possible maintenance scheme&#59; from our clinical practice experience&#44; the risk of adverse effects with this regimen appears to be very small&#46; As an alternative&#44; a topical calcineurin inhibitor such as tacrolimus 0&#46;1&#37; ointment or pimecrolimus 1&#37; cream could also be considered &#40;tolerability&#58; pimecrolimus<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>tacrolimus&#41;&#46; In our experience&#44; maintaining concomitant post-transplant therapy with systemic finasteride 5<span class="elsevierStyleHsp" style=""></span>mg&#47;day and topical minoxidil 5&#37; is also advisable&#44; particularly if androgenetic alopecia is concomitantly present&#46; Dutasteride has been recently attempted as an alternative to finasteride&#59; although dutasteride might appear at least equally effective&#44; its superiority and more favourable safety profile are not yet proven&#46; Follow-up visits should be frequent&#44; and more aggressive anti-inflammatory therapy must be initiated in case of clinical relapse&#44; not only to &#8220;protect&#8221; transplanted hairs but also to prevent alopecia progression to previously uninvolved areas&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To summarise&#44; the need for post-transplant medical therapy for FFA is&#44; in our opinion&#44; absolutely decisive for the success of the transplantation&#46; Prior to surgery&#44; two requirements for FFA hair transplantation must be met&#58; 2 years of clinical stability and the patient&#39;s commitment to follow-up visits and adherence to post-transplant medical therapy&#46; Strong evidence-based recommendations for the medical and surgical treatment of FFA are warranted&#46;</p></span>"
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