Case and Research Letters
Frontal Fibrosing Alopecia and Discoid Lupus Erythematosus: More Than a Coincidence
Alopecia frontal fibrosante y lupus eritematoso discoide: más allá de la coexistencia
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Histologic examination showing a cellular proliferation of spindled cells in the dermis, with overlying epidermal acanthosis (2a, H&E stain, x 40). Higher magnification shows that the spindle cells entrap normal dermal collagen bundles (2b, H&E stain, x 200).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Giavedoni, A. Combalia, R. Pigem, J.M. Mascaró" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Giavedoni" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Combalia" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Pigem" ] 3 => array:2 [ "nombre" => "J.M." 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Fernández-Crehuet, R. Ruiz-Villaverde" "autores" => array:2 [ 0 => array:3 [ "nombre" => "P." "apellidos" => "Fernández-Crehuet" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "R." "apellidos" => "Ruiz-Villaverde" "email" => array:1 [ 0 => "ismenios@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Dermatología Médico-Quirúrgica y Venereología, Hospital Reina Sofía de Córdoba, Córdoba, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Campus de la Salud de Granada, Granada, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Alopecia frontal fibrosante y lupus eritematoso discoide: más allá de la coexistencia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 775 "Ancho" => 2084 "Tamanyo" => 213972 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Atrophic plaques of alopecia with areas of erythema and inflammation in the temporal region. B, Red dots, white cicatricial patches, prominent branched capillaries (megacapillaries), and keratin plugs.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 57-year-old woman with hypertension (in treatment with enalapril) and without any known drug allergies or family history of interest attended our dermatology clinic for diffuse hair loss with onset 1 year earlier and inflammatory plaques that had recently appeared in the alopecic areas.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Clinical examination of the scalp revealed a slightly receding frontal hairline, isolated or <span class="elsevierStyleItalic">lonely</span> hairs, of different diameters, perifollicular hyperkeratosis, and mild erythema (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The patient also showed hair loss on the arms and total alopecia of the eyebrows although the eyelashes were unaffected (<a class="elsevierStyleCrossRef" href="#fig0005">Figs. 1</a>B and C). Trichoscopy of the frontal area showed white patches, arborizing vessels, hairs of different diameters, and follicular hyperkeratosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). Atrophic plaques of alopecia with areas of erythema and inflammation were present in temporal and occipital regions (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Trichoscopy of the temporal area showed the presence of red dots, white cicatricial patches, prominent branched capillaries (megacapillaries), and keratin plugs (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Facial papules and frontal vein depression were not present. She did not have skin lesions in other regions or nail or mucosal lesions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Histopathological examination of a biopsy taken from the inflammatory area of the parietal area showed the presence of chronic perifollicular and periadnexal inflammatory infiltrate with vacuolar thickening and degeneration of the basal layer and mucin deposition consistent with discoid lupus erythematosus (DLE) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Direct immunofluorescence (DIF) was positive for immunoglobulin G and C3 with depositions throughout the basement membrane of the skin of affected areas of the scalp and follicular epithelium. Histology of the frontal alopecic region showed a dense chronic lichenoid infiltrate with interface dermatitis in the area of the follicular epithelium free of mucin. DIF was negative.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Complementary tests, including hematology workup, general biochemistry, antinuclear antibodies and extractable nuclear antigens, thyroid hormones, proteinogram, and complement reported normal values.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The simultaneous presence of frontal fibrosing alopecia (FFA) and DLE is an association rarely described in the literature. This association has been reported more frequently in women,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> although cases have been occasionally reported in men.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> FFA is a lymphocytic primary cicatricial alopecia of growing importance given its increasing prevalence in recent years, as reflected by the large number of articles published recently about its clinical presentation, diagnosis, and treatment. The most recent lines of investigation point to pathogenesis and pathophysiology related to application of certain hair products and sunscreens. We should also not forget the theories that point to a clear hormonal imbalance, more frequent in postmenopausal women, in the development of this disease. Recently, new diagnostic criteria have been proposed to facilitate identification of this condition. These are divided into major criteria (frontal or temporal cicatricial alopecia without keratotic papules on the body and diffuse and bilateral alopecia of the eyebrows) and other minor criteria (typical trichoscopy, occipital involvement, facial or body hair, and facial papules).<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> Our patient presented with 2 major criteria and 2 minor ones. Likewise, severity scales have been validated<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> and the trichoscopic features have been defined in large series of patients led by Spanish working groups.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Although the association of FFA with other types of alopecia has been reported several times in the literature, no series have been published of cases that study the characteristics of these patients. An association has been reported with lichen planopilaris,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> androgenic alopecia,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> and DLE.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,2,8</span></a> Not all patients with both types of cicatricial alopecia (FFA and DLE) have a history of cutaneous lupus erythematosus.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Our patient was also taking enalapril among her medications. This drug has been linked to lichenoid eruptions<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> and cutaneous lupus.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> We could not find any cases in the literature supporting a relationship with FFA.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the context of cicatricial alopecia, DLE and FFA show subtle histologic differences based on presence or absence of mucin and differences in the characteristics of the lymphocytic infiltrate. In DLE, there is a greater lymphoplasmacytic predominance and presentation is usually at perifollicular, perivascular, and adnexal sites, whereas FFA is usually confined to perifollicular presentation.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> However, it seems clear that concurrent presentation should point us to the presence of a common immunological pathway of the innate type that is responsible for the appearance of both processes in genetically predisposed individuals.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The use of hydroxychloroquine or chloroquine as monotherapy does not appear to be effective as therapy.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> We should proceed to joint treatment of both entities using topical/intralesional corticosteroids and the combination of antimalarial agents with 5-alfa-reductase inhibitors to ensure a more complete therapeutic coverage in these patients.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández-Crehuet P, Ruiz-Villaverde R. Alopecia frontal fibrosante y lupus eritematoso discoide: más allá de la coexistencia. Actas Dermosifiliogr. 2019;110:419–420.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1615 "Ancho" => 2500 "Tamanyo" => 451743 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Receding hairline and isolated hairs (known as <span class="elsevierStyleItalic">lonely</span> hairs). B, Total alopecia of the eyebrows, with preservation of the eyelashes. C, Hair loss on the arms. D, White patches, arborizing vessels, hairs of different diameters, and follicular hyperkeratosis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 775 "Ancho" => 2084 "Tamanyo" => 213972 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Atrophic plaques of alopecia with areas of erythema and inflammation in the temporal region. B, Red dots, white cicatricial patches, prominent branched capillaries (megacapillaries), and keratin plugs.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 811 "Ancho" => 900 "Tamanyo" => 287885 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin and eosin stain<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2, chronic inflammatory perifollicular and periadnexal infiltrate with vacuolar thickening and degeneration of the basal layer.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coexistence of frontal fibrosing alopecia and discoid lupus erythematosus of the scalp in 7 patients: Just a coincidence?" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 13 | 26 |
| 2024 October | 113 | 59 | 172 |
| 2024 September | 126 | 42 | 168 |
| 2024 August | 142 | 80 | 222 |
| 2024 July | 125 | 50 | 175 |
| 2024 June | 119 | 49 | 168 |
| 2024 May | 141 | 47 | 188 |
| 2024 April | 105 | 30 | 135 |
| 2024 March | 98 | 46 | 144 |
| 2024 February | 114 | 57 | 171 |
| 2024 January | 95 | 35 | 130 |
| 2023 December | 84 | 20 | 104 |
| 2023 November | 93 | 35 | 128 |
| 2023 October | 100 | 42 | 142 |
| 2023 September | 77 | 36 | 113 |
| 2023 August | 65 | 27 | 92 |
| 2023 July | 108 | 50 | 158 |
| 2023 June | 72 | 33 | 105 |
| 2023 May | 110 | 32 | 142 |
| 2023 April | 78 | 25 | 103 |
| 2023 March | 116 | 32 | 148 |
| 2023 February | 151 | 27 | 178 |
| 2023 January | 82 | 24 | 106 |
| 2022 December | 76 | 42 | 118 |
| 2022 November | 61 | 45 | 106 |
| 2022 October | 66 | 26 | 92 |
| 2022 September | 54 | 59 | 113 |
| 2022 August | 47 | 39 | 86 |
| 2022 July | 43 | 48 | 91 |
| 2022 June | 27 | 25 | 52 |
| 2022 May | 73 | 29 | 102 |
| 2022 April | 86 | 36 | 122 |
| 2022 March | 98 | 58 | 156 |
| 2022 February | 104 | 21 | 125 |
| 2022 January | 100 | 40 | 140 |
| 2021 December | 65 | 35 | 100 |
| 2021 November | 64 | 48 | 112 |
| 2021 October | 59 | 56 | 115 |
| 2021 September | 70 | 42 | 112 |
| 2021 August | 108 | 24 | 132 |
| 2021 July | 49 | 18 | 67 |
| 2021 June | 54 | 31 | 85 |
| 2021 May | 76 | 39 | 115 |
| 2021 April | 186 | 61 | 247 |
| 2021 March | 85 | 22 | 107 |
| 2021 February | 80 | 23 | 103 |
| 2021 January | 49 | 15 | 64 |
| 2020 December | 52 | 13 | 65 |
| 2020 November | 43 | 17 | 60 |
| 2020 October | 46 | 8 | 54 |
| 2020 September | 51 | 8 | 59 |
| 2020 August | 48 | 9 | 57 |
| 2020 July | 62 | 12 | 74 |
| 2020 June | 31 | 24 | 55 |
| 2020 May | 35 | 14 | 49 |
| 2020 April | 16 | 9 | 25 |
| 2020 March | 17 | 6 | 23 |
| 2020 February | 3 | 0 | 3 |
| 2019 May | 3 | 0 | 3 |
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