|LETTER TO EDITOR
|Year : 2022 | Volume
| Issue : 4 | Page : 147-149
Male frontal fibrosing alopecia with generalized body hair loss
Aashim Singh1, Arshdeep1, Meenakshi Batrani2, Asha Kubba2
1 Delhi Dermatology Group - Kubba Skin Clinic, New Delhi, India
2 Dermatology Practice, Delhi Dermpath Lab, New Delhi, India
|Date of Submission||06-May-2020|
|Date of Decision||23-Jul-2020|
|Date of Acceptance||12-Jan-2021|
|Date of Web Publication||16-Jul-2022|
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Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh A, Arshdeep, Batrani M, Kubba A. Male frontal fibrosing alopecia with generalized body hair loss. Int J Trichol 2022;14:147-9
Frontal fibrosing alopecia (FFA) is a variant of lichen planopilaris (LPP), commonly involving the fronto-temporal scalp. FFA presents most commonly in postmenopausal women and is rarely reported in males., Body hair loss has been described earlier in FFA, mainly as clinically nonscarring loss of eyebrows, axillary and pubic hair and less commonly truncal and limbal hair loss. Recent literature has shown that body hair loss in FFA also reveals histological follicular scarring, thereby confirming that LPP is a generalized disease process.,, Herein, we describe a case of FFA in a male patient with generalized body hair loss.
A 37-year-old male of South-East Asian origin presented with receding of frontal hairline along with loss of eyebrows and eyelashes [Figure 1]a and [Figure 1]b. He had also noticed hair loss over the body since childhood, which was gradually progressive to involve the whole body [Figure 1]c, [Figure 1]d, [Figure 1]e. Family history and systemic examination were unremarkable. Frontal hairline recession of approximately 8 cm from the glabella was noted along with “lonely hair” sign. Hair loss was seen in the frontal, temporal as well as occipital hairline in a band-like pattern, with follicular erythema on the residual frontal hairline. Loss of lateral two-thirds of eyebrows and patchy loss of eyelash cilia with mild erythema over the eyelid margins was noted [Figure 1]a. Generalized body hair loss involving axillae, pubic hair, trunk and limbs was observed, sparing few areas on the legs. While truncal hair alopecia including axillary and pubic hair, was observed as clinically nonscarring [Figure 1]c and [Figure 1]d; discrete follicular atrophic scarring was present over bilateral thighs, legs, and arms [Figure 1]e.
|Figure 1: (a) Clinical photograph of patient showing fronto-temporal hairline recession along with loss of eyebrows and eyelashes. (b) Loss of side burns in the patient. (c) Loss of body hair on chest in a clinically non-scarring presentation. (d) Loss of axillary hair in a clinically non-scarring presentation. (e) Loss of body hair on legs with discrete follicular atrophic scars|
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Trichoscopic examination of scalp from frontal hairline showed loss of follicular openings and absence of vellus hairs along the hair margin. Peripilar casts and perifollicular erythema were seen at the level of hair shaft emergence on scalp hairline and eyebrows and eyelashes [Figure 2]a and [Figure 2]b. Dermoscopy of limbs showed loss of body hair with discrete follicular scars and subtle peripilar casts on the residual body hair [Figure 2]c.
|Figure 2: (a) Trichoscopy of the frontal hairline showing absence of vellus hairs and scarring along the hair margin with peripilar casts and perifollicular erythema (Fotofinder videodermoscope, ×20 polarized). The ink-marked site was chosen for biopsy. (b) Dermoscopy of eyelid margin showing loss of eyelashes, erythema and subtle peripilar cast on the remaining eyelash (Fotofinder videodermoscope, ×20 polarized with ultrasound gel as contact medium). (c) Dermoscopy of leg showing loss of follicular openings and subtle peripilar cast on residual body hair (Fotofinder videodermoscope, ×20 polarized)|
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A trichoscopy-guided 4 mm punch biopsy was taken from the residual frontal hairline of the scalp. Histopathological examination showed follicular scars replacing occasional follicular units. The intact follicular units show partial loss of sebaceous glands and perifollicular lamellar fibrosis with surrounding lymphocytic infiltrate along isthmus and infundibular region. Lymphocytes were seen infiltrating outer follicular epithelium showing vacuolization and multiple apoptotic keratinocytes, thereby confirming the histological diagnosis of LPP [Figure 3]a and [Figure 3]b. Biopsy was not undertaken from body hair, in the absence of any active skin lesion. A diagnosis of FFA with generalized involvement of body hair was made based on clinical, dermoscopic and histopathological examination. The patient was started on hydroxychloroquine 200 mg twice daily, finasteride 1 mg once daily, and topical tacrolimus.
|Figure 3: (a) Transverse section of scalp biopsy showing follicular scar, perifollicular lamellar fibrosis and surrounding lymphocytic infiltrate, (H and E, ×40). (b) Lichenoid pathology seen as lymphocytes infiltrating outer follicular epithelium showing vacuolization and multiple apoptotic keratinocytes, (H and E, ×200)|
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FFA is usually seen in women of the older age group, however, our patient started developing his disease in childhood. There are only four reported cases in the literature in the pediatric age group who were all girls. The prevalence of FFA in males is quite low and has not been reported in Asians. It may be under-recognized in males. FFA needs to be differentiated from androgenetic alopecia (AGA) by trichoscopic examination, which reveals the absence of vellus hairs in the former, as also seen in our case. FFA has selective predilection for vellus hair while they are spared in AGA and clinical scarring is evident in FFA.
The most striking feature in the index case is the loss of body hair associated with clinical atrophic scarring, which has not been described earlier in literature. Dermoscopy highlighted the atrophic follicular scars but the absence of histology is a limitation in our case. Previous reports have always shown clinically nonscarring alopecia of body hair, even though histologically a lichenoid pathology and scarring process has been documented, thereby conforming that LPP is a generalized disease process.,,, Hence, our case is unique in the clinical presentation of scarring alopecia of body hair in association with FFA.
Furthermore, in our case, FFA was quite extensive owing to the involvement of the occipital scalp in a band-like fashion with eyebrow and eyelash loss as well. Occipital involvement has been reported in 15% cases (48 women and only 4 men) in a multicentre study involving 355 total patients, reflecting a more severe disease. Furthermore, body hair involvement and eyelash loss are associated with the disease severity of FFA.
To conclude, this case of FFA in an Asian male with generalized body hair involvement in the form of clinically scarring alopecia on the limbs depicts a severe generalized disease and extends the spectrum of body hair involvement in FFA. Trichoscopy is a valuable tool for differentiating FFA from AGA and delineating body hair involvement in FFA.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]