A 35 y/o male presents with progressive bi-temporal hair loss x 5 years. He has been on finasteride 1mg daily and minoxidil 5% foam twice daily for the past two years. The patient has felt that his hair loss has continued to progress in spite of being compliant with these medications.
Q: What is the diagnosis?
A: Although this male has obvious androgenetic alopecia (AGA), he also has superimposed frontal fibrosing alopecia (FFA).
Q: What are the clues that suggest FFA?
A: The first clue is the poor clinical response to medication. Most patients with early AGA respond well to a combination of finasteride and minoxidil, with perhaps only 5% continuing to bald during the first two years of treatment. FFA should be treated with anti-inflammatory drugs.
The second clue is the smooth appearance and lack of follicular ostia at the hairline which suggests focal scarring. There is also an absence of miniaturization at the hairline, which is the hallmark of AGA. In FFA, as well as LPP, one can also observe erythema and peri-follicular hyperkeratosis; however, it’s absence should not rule out the diagnosis.
The fact that this is a young male (rather than an elderly female) should not lessen your suspicion, as we often see FFA and LPP in male patients. On histology, the biopsy showed myxoid fibrosis and a peri-follicular mononuclear infiltrate at the level of the isthmus typical of FFA and LPP.
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