Frontal fibrosing alopecia: a clinicopathological study of 22 cases from Shiraz, Southern Iran

Since its recognition, frontal fibrosing alopecia (FFA) has increasingly been studied globally in terms of its diverse aspects. Having found no studies describing this condition in Southern Iran, we examined the different clinicopathological features of patients with FFA who referred to Faghihi Hospital, Southern Iran, between 2013 and 2018. We searched the archives of the Pathology Department of Faghihi Hospital for the cases with a diagnosis of FFA. Due to its similar histopathologic features with lichen planopilaris, the final diagnosis was made using clinical correlations. Twenty-two patients were enrolled; all were female. Fifteen (68.2%) presented with the disease before menopause. Besides frontal and/or temporal hairline involvement in all the patients, eyebrow alopecia, eyelash loss, body hair loss, and facial papules were present in 81.8%, 27.3%, 50%, and 68.2% of them, respectively. Dermoscopic findings included follicular opening loss (100%), honeycombing of the scalp (81.8%), multiple white dots (77.3%), perifollicular erythema (63.6%), and perifollicular scales (59.1%). The histopathologic examination revealed follicular dropout (95.4%), perifollicular lymphocytic infiltration in the infundibulum and isthmus of the follicles (81.8%), perifollicular fibroplasia (77.3%), intact interfollicular epidermis (59.1%), mild perivascular lymphocytic infiltration in the upper dermis (54.5%), and apoptotic keratinocytes in the infundibulum and isthmus (50%). The most common comorbidity was hypothyroidism (40.9%).  Thediagnosis of FFA should be considered in both premenopausal and postmenopausal women. Eyebrow alopecia, eyelash loss, body hair involvement, and facial papules are helpful clues in the diagnosis. The coexistence of hypothyroidism with FFA suggests immunological involvement in the pathogenesis.