Original article
Facial lesions in frontal fibrosing alopecia (FFA): Clinicopathological features in a series of 12 cases

https://doi.org/10.1016/j.jaad.2015.08.020Get rights and content

Background

Facial lesions in frontal fibrosing alopecia (FFA) have been poorly described in published series.

Objective

We sought to describe facial lesions in FFA.

Methods

We reviewed our series of 55 cases of FFA, selecting 12 cases with clinically significant facial lesions. We performed a histologic study of these lesions.

Results

In addition to the observations already described in the literature such as facial papules or follicular red dots, we observed perifollicular and diffuse erythema, sometimes with a reticular pattern, and the gradual appearance of pigmented macules on facial skin. Biopsy specimens from the areas with facial erythema showed perifollicular and interfollicular lymphocytic infiltrate and fibrosis around vellus hair follicles. Histologic evaluation of pigmented macules sometimes exhibited an increased epidermal pigmentation and on occasions, pigmentary incontinence.

Limitations

More patients are needed to determine the prevalence of these lesions in FFA.

Conclusion

On facial skin of patients with FFA, we can observe papules or perifollicular erythema secondary to vellus hair follicle involvement. We describe diffuse erythema, owing to follicular and interfollicular lichenoid infiltrate, and the gradual appearance of pigmented macules, which could be secondary to an increased epidermal pigmentation or to pigmentary incontinence.

Section snippets

Clinical cases

Twelve women with FFA presented with facial skin lesions (Table I). They all were Caucasian, with a mean age of 54 years, 7 of them premenopausal. The hairline recession was minor in 5 cases, and moderate in 7. They showed total or partial eyebrow alopecia and substantial vellus hair loss on limbs. In 11 of 12 patients, noninflammatory papules were observed over the temples, cheeks, or chin. In some cases there were scattered papules with keratin-filled dilated infundibula, simulating open

Discussion

In FFA, the lichenoid inflammation of facial vellus hair follicles classically manifests as facial papules.6 According to the longest series published up to now, which includes 355 cases, 14% of patients presented these lesions.4 We observed facial papules in 20% of our patients. However, we believe that the recognition of these papules may be very subjective, because of their subtle clinical expression. Moreover, wrinkles and solar elastosis occurring in aged patients may complicate their

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    These papules most commonly are keratotic, presenting as skin roughness on the forehead and frontotemporal portion of the scalp; however, they have also been reported on the chest, back, and extremities.7 The pathogenesis of facial papules in frontal fibrosing alopecia remains unclear.3,8,9 Histologic examination demonstrates mild follicular hyperkeratosis and lichenoid dermatitis involving the infundibulum and isthmus of vellus hair follicles with or without fibrosis, similar to findings observed in lichen planopilaris.10,11

  • Frontal fibrosing alopecia: A new autoimmune entity?

    2019, Medical Hypotheses
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    The eyelashes may be affected in 3% of patients; other areas, such as the underarms, pubis and limbs, are rarely involved, with prevalence ranging from 0% to 77% [8,9,11]. Additional findings are perifollicular–reticular erythema, predominantly on the zygomatic arch and hyperkeratosis, which represents active disease [8–10]. Pruritus and facial papules may be seen in up to 72% of patients and may indicate greater severity; these are recognised by their skin-colour pattern, monomorphism and noninflammatory rough appearance [6–10].

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Funding sources: None.

Conflicts of interest: None declared.

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