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Year : 2015  |  Volume : 7  |  Issue : 2  |  Page : 64-66  

Nail involvement in frontal fibrosing alopecia

1 Ruben David Azulay Dermatology Institute, Santa Casa da Misericordia, Rio de Janeiro, Brazil
2 Center for Dermatology and Hair Diseases, Zurich Wallisellen, Switzerland

Date of Web Publication7-Jul-2015

Correspondence Address:
Ralph Michel TrŁeb
Center for Dermatology and Hair Diseases, Bahnhofplatz 1A, CH-8304 Wallisellen
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Source of Support: None, Conflict of Interest: None

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A case of frontal fibrosing alopecia with nail involvement is presented. Nail involvement provides evidence for underlying lichen planus, and that the disease represents a rather generalized than localized process. Favorable response of the scalp condition to oral dutasteride points to an inflammatory reaction on the background of androgenetic alopecia.

Keywords: Androgenetic alopecia, dutasteride, frontal fibrosing alopecia, lichen planus, nail involvement

How to cite this article:
Macpherson M, Hohendorf-Ansari P, TrŁeb RM. Nail involvement in frontal fibrosing alopecia. Int J Trichol 2015;7:64-6

How to cite this URL:
Macpherson M, Hohendorf-Ansari P, TrŁeb RM. Nail involvement in frontal fibrosing alopecia. Int J Trichol [serial online] 2015 [cited 2023 Feb 7];7:64-6. Available from: https://www.ijtrichology.com/text.asp?2015/7/2/64/160107

   Introduction Top

Frontal fibrosing alopecia represents a peculiar condition originally described by Kossard in women in the postmenopause. [1] The condition presents with a symmetric, marginal alopecia along the frontal and frontotemporal hairline, often with concomitant thinning or complete loss of eyebrows. Affected women typically present with the complaint of asymptomatic, progressive recession of their frontal hairline. The affected scalp skin is pale and smooth with loss of follicular orifices, often perifollicular erythema and follicular keratinization is observed marking the underlying inflammatory process. Since Kossard's original description in 1994, the number of cases has exploded exponentially worldwide, while its etiology has remained obscure. Based on histopathologic and immunohistochemical studies, Kossard et al. eventually interpreted the condition as a frontal variant of lichen planopilaris. [2] Trüeb and Torricelli's original report of oral lichen planus in a patient with postmenopausal frontal fibrosing alopecia further supported the evidence that the condition actually may represent a variant of lichen planus. [3] Herein we report on lichen planus-typical nail involvement in frontal fibrosing alopecia.

   Case report Top

A 60-year-old female patient presented with a history of asymptomatic progressive recession of the frontal hairline and loss of eyebrows. She was formerly unsuccessfully treated with topical minoxidil by her local dermatologist.

Clinical examination revealed a marginal alopecia along the fronto-temporal hairline and loss of eyebrows [Figure 1]. The affected scalp skin was pale and smooth, loss of follicular orifices, perifollicular erythema, and follicular keratinization. The nail plate of the right fifth digit demonstrated ridging, fissuring and superficial fragility [Figure 2]a], the left fifth digit initial atrophy and scarring with pterygium formation [Figure 2]b].
Figure 1: Frontal fibrosing alopecia: symmetric, marginal alopecia along the frontal and frontotemporal hairline, with concomitant thinning or complete loss of eyebrows

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Figure 2: Lichen planus-typical nail involvement (a) with superficial nail fragility, and (b) pterygium formation

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A hair pluck (trichogram) demonstrated 23% telogen roots and 33% anagen roots without hair root sheaths in the frontal pluck, with normal figures (telogen rate of 9%, and 18% anagen roots without hair root sheaths) in the occipital pluck, consistent with androgenetic alopecia.

Treatment was started with 0.5 mg oral dutasteride and 0.05% topical clobetasole propionate with reduction of signs of follicular inflammation by dermoscopic examination at 3 months follow-up.

   Discussion Top

Lichen planus is a primary inflammatory disease of the skin, which may affect the mucous membranes, hair follicles, and nails. When the hair follicle is selectively targeted, it is also referred to as follicular lichen planus or lichen planopilaris.

The cause of lichen planus has largely remained unknown, but it is understood to represent a T-cell mediated autoimmune reaction with an unknown initial trigger, with striking analogies to cutaneous graft-versus-host disease. This autoimmune process triggers apoptosis of epithelial cells. When a triggering agent is occasionally identified, this is termed a lichenoid reaction rather than lichen planus. Recognized triggering agents include: Drugs (gold salts, beta-blocking agents, antimalarials, thiazide diuretics), amalgam tooth fillings (in lichen planus of the buccal mucosa), and hepatitis B or C infection.

Since Kossard's original description of postmenopausal frontal fibrosing alopecia in 1994, [1] Zinkernagel and Trüüeb reported in 2000 yet another form of fibrosing alopecia in a pattern distribution affecting the centroparietal area of the scalp, histologically with a lichenoid type of follicular inflammation and fibrosis. [4] The authors addressed the question how the lichenoid tissue reaction is generated around the individual androgenetic hair follicle, and came up with the proposition that follicles with some form of damage or malfunction might express cytokine profiles that attract inflammatory cells to assist in damage repair or in the initiation of apoptosis-mediated organ deletion. Alternatively, an as yet unknown antigenic stimulus from the damaged or malfunctioning hair follicle might initiate a lichenoid tissue reaction in the immunogenetically susceptible individual.

Ultimately, in 2005 Olsen acknowledged existence of clinically significant inflammatory phenomena and fibrosis in androgenetic alopecia and proposed the term "cicatricial pattern hair loss," [5] while in 2010 Kossard suggested that frontal fibrosing alopecia may hold the key to understanding the complex relationship of pattern alopecia, sex-related differences, and triggers for autoimmune follicular destruction. [6]

Eventually, frontal fibrosing alopecia has been recognized to represent a rather generalized than localized process of inflammatory scarring alopecia, [7],[8] with extension beyond the frontotemporal hair line, loss of eyebrows and of eyelashes, loss of peripheral body hair, mucous membrane involvement, and finally, nail involvement.

Moreover, cutaneous lupus erythematosus has been reported to be capable of mimicking frontal fibrosing alopecia, [9],[10],[11] suggesting that the pattern of clinical disease presentation might be more specific for the condition than the underlying inflammatory autoimmune reaction. Nevertheless, lichen planus remains the single most frequent pathology underlying frontal fibrosing alopecia, and associated lichenoid mucous membrane or nail involvement may provide clues to the underlying pathology.

There is no cure for lichen planus or frontal fibrosing alopecia, but a number of treatments have been proposed to control symptoms or halt disease progression. [12],[13] Where androgenetic alopecia represents a co-morbid condition, topical minoxidil and oral dutasteride may be of benefit, [14],[15],[16] in addition to topical and/or systemic anti-inflammatory treatment modalities (topical or intralesional corticoseroids, topical calcineurin inhibitors, and oral doxycycline, hydroxychloroquine, or mycophenolate mofetil, respectively).

The presented case of frontal fibrosing alopecia with nail involvement provides the evidence for underlying lichen planus, whereas favorable response to oral dutasteride may be related to co-morbid androgenetic alopecia.

   References Top

Kossard S. Postmenopausal frontal fibrosing alopecia. Scarring alopecia in a pattern distribution. Arch Dermatol 1994;130:770-4.  Back to cited text no. 1
Kossard S, Lee MS, Wilkinson B. Postmenopausal frontal fibrosing alopecia: A frontal variant of lichen planopilaris. J Am Acad Dermatol 1997;36:59-66.  Back to cited text no. 2
Trüeb RM, Torricelli R. Lichen planopilaris simulating postmenopausal frontal fibrosing alopecia (Kossard). Hautarzt 1998;49:388-91.  Back to cited text no. 3
Zinkernagel MS, Trüeb RM. Fibrosing alopecia in a pattern distribution: Patterned lichen planopilaris or androgenetic alopecia with a lichenoid tissue reaction pattern? Arch Dermatol 2000;136:205-11.  Back to cited text no. 4
Olsen EA. Female pattern hair loss and its relationship to permanent/cicatricial alopecia: A new perspective. J Investig Dermatol Symp Proc 2005;10:217-21.  Back to cited text no. 5
Kossard S. Post-menopausal frontal fibrosing alopecia. In: Trüeb RM, Tobin DJ, editors. Aging Hair. Berlin, Heidelberg: Springer; 2010. p. 33ff.  Back to cited text no. 6
Armenores P, Shirato K, Reid C, Sidhu S. Frontal fibrosing alopecia associated with generalized hair loss. Australas J Dermatol 2010;51:183-5.  Back to cited text no. 7
Chew AL, Bashir SJ, Wain EM, Fenton DA, Stefanato CM. Expanding the spectrum of frontal fibrosing alopecia: A unifying concept. J Am Acad Dermatol 2010;63:653-60.  Back to cited text no. 8
Gaffney DC, Sinclair RD, Yong-Gee S. Discoid lupus alopecia complicated by frontal fibrosing alopecia on a background of androgenetic alopecia. Br J Dermatol 2013;169:217-8.  Back to cited text no. 9
Khan S, Fenton DA, Stefanato CM. Frontal fibrosing alopecia and lupus overlap in a man: Guilt by association? Int J Trichology 2013;5:217-9.  Back to cited text no. 10
Del Rei M, Pirmez R, Sodré CT, Tosti A. Coexistence of frontal fibrosing alopecia and discoid lupus erythematosus of the scalp in 7 patients: Just a coincidence? J Eur Acad Dermatol Venereol 2014. [DOI: 10.1111/jdv.12642. [Epub ahead of print]].  Back to cited text no. 11
Banka N, Mubki T, Bunagan MJ, McElwee K, Shapiro J. Frontal fibrosing alopecia: A retrospective clinical review of 62 patients with treatment outcome and long-term follow-up. Int J Dermatol 2014;53:1324-30.  Back to cited text no. 12
Vañó-Galván S, Molina-Ruiz AM, Serrano-Falcón C, Arias-Santiago S, Rodrigues-Barata AR, Garnacho-Saucedo G, et al. Frontal fibrosing alopecia: A multicenter review of 355 patients. J Am Acad Dermatol 2014;70:670-8.  Back to cited text no. 13
Katoulis A, Georgala, Bozi E, Papadavid E, Kalogeromitros D, Stavrianeas N. Frontal fibrosing alopecia: Treatment with oral dutasteride and topical pimecrolimus. J Eur Acad Dermatol Venereol 2009;23:580-2.  Back to cited text no. 14
Georgala S, Katoulis AC, Befon A, Danopoulou I, Georgala C. Treatment of postmenopausal frontal fibrosing alopecia with oral dutasteride. J Am Acad Dermatol 2009;61:157-8.  Back to cited text no. 15
Ladizinski B, Bazakas A, Selim MA, Olsen EA. Frontal fibrosing alopecia: A retrospective review of 19 patients seen at Duke University. J Am Acad Dermatol 2013;68:749-55.  Back to cited text no. 16


  [Figure 1], [Figure 2]


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