A 55-year-old woman presented with alopecia, "lonely hairs" and diminished eyebrows. The diagnosis was made clinically. Treatment for this patient involved:

• Discontinuation of all leave-on cosmetic products, and in particular sunscreens.
• Discussion of patch testing (common allergens include Balsum of Peru, Benzophenones, fragances) but declined for now.
• Topical therapy with minoxidil 5% 5/week and clobetasol solution 0.05% 2/week .
• Dutasteride initially 3/week (MWF) with a target of 5-7 pills per week.

FRONTAL FIBROSING ALOPECIA

Frontal fibrosing alopecia (FFA) is a scarring alopecia that prefers the anterior hairline of women.

• The average age of onset is in the 50's.
• The incidence of FFA appears to be dramatically increasing.
• FFA has been associated with increased use of topical leave-on cosmetic products and in particular sunscreen. The increasing incidence of FFA and the increased use of sunscreens makes one wonder, "Is there causation?" This has been found for both men and women.
  
• Patch test reactions to linalool hydroperoxide and balsam of Peru were more frequent in FFA patients.
• It is thought to be a variant of lichen planopilaris
• Progressive recession of the frontotemporal hair line with loss of follicular openings occurs. On average, the frontotemporal hairline recedes by 0.4-1.7 mm per month.
• It is important to examine patients presenting with FFA (or lichen planopilaris) for evidence of vulval or oral LP as these may be associated.
• The use of sex hormones has been associated, e.g. HRT (hormone replacement therapy), birth control pills, anabolic steroids, exogenous androgens. (consider stopping)

Progressive recession of the frontal hairline in a postmenopausal woman associated with perifollicular erythema is characteristic. The alopecia is concentrated in the front, but may extend to the lateral margins. Lonely hairs, surrounded by areas of fibrosis, are present in most patients. Complete or extensive loss of the eyebrows is common.

Hypopigmentation of the forehead is associated and may be better appreciated with Wood's light examination. This hypopigmentation is associated with fewer epidermal melanocytes.

FFA does occur in men. Loss of sideburns and facial hair is seen.

The "lonely hair sign" refers to the presence of single, isolated terminal hairs within a scarred area of hair loss, which can be a helpful diagnostic clue for FFA.

Facial Papules

Multiple, facial, flesh-colored to whitish papules occur in FFA. They appear as multiple, grouped, noninflammatory follicular papules, most often inside the temporal area, and may be described as "roughness" by the patient. Histologic examination shows hypertrophic sebaceous glands with no associated vellus hair follicle. It is hypothesized that the FFA destroys the vellus hair follicle, but the sebaceous gland remains. Low dose isotretinoin 10 mg every other day greatly reduced the appearance of the bumps. This author notes a striking similarity of the facial papules of frontal fibrosing alopecia with hamartoma moniliformis.

Differential diagnosis

Chronic marginal traction alopecia may be difficult to distinguish. A biopsy may be necessary.

Progressive recession of the frontal hairline, atrophy with more prominent vessels, perifollicular erythema and "lonely hairs" in a postmenopausal woman is characteristic.

Significant recession of the hairline.

Loss of eyebrow hair is common.

Multiple, facial, flesh-colored to whitish papules occur in FFA. They appear as multiple, grouped, noninflammatory follicular papules and may be described as "roughness" by the patient.

RegionalDerm

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