Untitled Observation | Dermatol Pract Concept 2015;5(2):26 129 DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com The patient A 69-year-old postmenopausal woman consulted for frontal hair loss for two years. She had started menopause at the age of 50 years old and had been taking bisphosphonates for her osteoporosis for two years. Her clinical history, including gynecological data, was otherwise negative. Anamnestic data ruled out the possibility of traction alopecia. Dermatological examination revealed a Fitzpatrick skin type III. She had a linear frontotemporal recession with perifollicular erythema, lonely hairs on the frontal region, and scarring alopecia (Fig- ure 1). The patient had a total loss of eyebrows but she did not have body hair loss. There were no other skin or mucosal abnormalities. Thyroid hormone function was also normal. Dermoscopy with a non-contact polarizing FotoFinder der- matoscope x20 (FotoFinder Systems, Inc, Bad Birnbach, Germany) revealed perifollicular erythema and very mild perifollicular scaling in addition to hair shaft dystrophy and broken hair. Furthermore, dermoscopy noted the presence of white dots coexisting with irregular white and pink areas devoid of hair follicular openings (Figure 2). No prior topical treatment was used before our consultation. A 4 mm scalp punch biopsy from the frontal hairline was performed. His- Frontotemporal hairline recession in a postmenopausal woman Anissa Zaouak1, Houda Hammami Ghorbel1, Talel Badri1, Wafa Koubaa2, Samy Fenniche1 1 Department of Dermatology, Habib Thameur Hospital, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia 2 Department of Anatomopathology, Habib Thameur Hospital, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia Key words: frontal fibrosing alopecia, dermoscopy, menopausal, histology Citation: Zaouak A, Ghorbel HH, Badri T, Koubaa W, Fenniche S. Frontotemporal hairline recession in a postmenopausal woman. Dermatol Pract Concept 2015;5(2):26. doi: 10.5826/dpc.0502a26 Received: September 27, 2014; Accepted: January 9, 2015; Published: April 30, 2015 Copyright: ©2015 Zaouak et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. All authors have contributed significantly to this publication. Corresponding author: Anissa Zaouak, MD, Assistant professor, Department of Dermatology, Habib Thameur Hospital, 8 Street Ali Ben Ayed, Montfleury 1008, Tunis, Tunisia. Tel. +21627952419; Fax. +216 71399115. Email: anissa_zaouak@yahoo.fr Figure 1. Scarring alopecia affecting the frontotemporal hairline. [Copyright: ©2015 Zaouak et al.] 130 Observation | Dermatol Pract Concept 2015;5(2):26 The hormonal imbalance caused by the decrease of estrogens associated with menopause could be the main trigger that creates the inflammatory scarring reaction of FFA in predis- posed patients [2]. It is a disease that is diagnosed clinically in most cases. The progressive recession of the frontotemporal hairline is the most constant and characteristic clinical mani- festation of FFA. It occurs symmetrically and bilaterally giv- ing rise to a band of alopecia between 0.5 cm and 8 cm from the original hairline. Hair loss from the lateral third of the eyebrows is also characteristic of FFA [3]. Histologic features of FFA and lichen planopilaris are similar: both demonstrate a follicular lichenoid inflammatory infiltrate involving the isthmus and infundibulum, perifollicular fibrosis and fibrous tracts as seen in our patient [4]. Typical dermoscopic find- ings, as seen in our patient, include mainly the absence of follicular openings, perifollicular scaling and perifollicular erythema [5,6]. Trichoscopy appears to be a non-invasive diagnostic tool for the diagnosis and follow-up of FFA. In fact, in a recent study including 79 patients [5], the authors concluded that perifollicular erythema may represent a direct trichoscopic marker of disease activity in FFA. Our patient had a scarring alopecia of the scalp mar- gin and FFA was diagnosed mainly on clinical apprecia- tions. However, in front of an early stage of FFA, dermos- copy appears to be helpful to establish differential diagnosis topathological examination revealed perifollicular lamellar fibrosis, loss of sebaceous glands and a lichenoid lymphocytic infiltrate targeting the infundibulum and isthmus (Figure 3). What is your diagnosis? Diagnosis Frontal fibrosing alopecia Clinical course The patient was treated with minoxidil 2% with a slight improvement of her scarring alopecia. Discussion Frontal fibrosing alopecia (FFA) is a relatively recently rec- ognized condition of unknown origin and was first described in 1994 [1]. It is generally considered as a variant of lichen planopilaris primarily affecting postmenopausal women. Figure 2A. Perifollicular erythema, very mild perifollicular scaling, acquired hair shaft dystrophy and broken hair. [Copyright: ©2015 Zaouak et al.] Figure 2B. White dots with irregular white and pink areas devoid of hair follicular openings. [Copyright: ©2015 Zaouak et al.] Figure 3. Perifollicular lamellar fibrosis, loss of sebaceous glands and a lichenoid lymphocytic infiltrate targeting the infundibulum and isthmus (H&E X40). [Copyright: ©2015 Zaouak et al.] Observation | Dermatol Pract Concept 2015;5(2):26 131 dermoscopy could improve diagnostic accuracy of hair and scalp disorders. References 1. Kossard S. Postmenopausal frontal fibrosing alopecia. Arch Der- matol 1994;130(6):770-4. 2. Moreno-Ramirez D, Camacho Martinez F. Frontal fibrosing alopecia: a survey in 16 patients. J Eur Acad Dermatol Venereol 2005;19(6):700-5. 3. Moreno-Ramirez D, Ferrandiz L, Camacho FM. Diagnostic and therapeutic assessement of frontal fibrosing alopecia. Actas Der- masifiliogr 2007;98(9):594-602. 4. MacDonald A, Clark C, Holmes S. Frontal fibrosing alopecia: A review of 60 cases. J Am Acad Dermatol 2012;67(5):955-61. 5. Toledo-Padtrana T, Garcia Hernandez MJ, Camacho Martinez FM. Perifollicular erythema as a tricoscopy sign of progression in frontal fibrosing alopecia. Int J Trichology 2013;5(3):151-3. 6. Inui S, Nakajima T, Shono F, Itami S. Dermoscopic findings in frontal fibrosing alopecia: report of four cases. Int J Dermatol 2008;47(8):796-9. 7. Miteva M, Tosti A. Hair and scalp dermatoscopy. J Am Acad Dermatol 2012;67(5):1040-8. 8. Rubegni P, Mandato F, Fimiani M. Frontal fibrosing alopecia: role of dermoscopy in differential diagnosis. Case Rep Dermatol 2010;2(1):40-5. 9. Rudnicka L, Rakowska A, Olszewska M. Trichoscopy: how it may help the clinician. Dermatol Clin 2013;31(1):29-41. 10. Goldberg LJ. Cicatricial marginal alopecia: is it all traction? Br J Dermatol 2009;160(1):62-8. 11. Miteva M, Tosti A. Dermoscopic features of central centrifugal cicatricial alopecia. J Am Acad Dermatol 2014;71(3):443-9. 12. Vano-Galvan S, Molina-Ruiz AM, Serrano-Falcon C, et al. Frontal fibrosing alopecia: a multicenter review of 355 patients. J Am Acad Dermatol 2014;70(4):670-8. between traction alopecia, alopecia areata and cicatricial mar- ginal alopecia. In fact, our patient had a cicatricial alopecia with the absence of yellow dots and dystrophic hairs, which are the most relevant dermoscopic findings in alopecia areata. Anamnestic data ruled out the possibility of traction alopecia characterized by the absence of miniaturized hairs, white dots and fractured hair shafts at dermoscopic examination [7-9]. As for cicatricial marginal alopecia (CMA), this entity is characterized by an area of permanent hair loss that involves mainly the crown and vertex and spreads centrifugally. CMA is characterized dermoscopically by low hair density, loss of follicular ostia with a peripilar white gray halo around the emergence of hairs that were absent in our patient [10,11]. Currently, no treatment protocols exist for FFA. Stabiliza- tion of hair loss is occasionally observed with various topical or systemic therapies such as oral 5-α-reductase inhibitors, hydroxychloroquine, minoxidil and topical or intralesional corticosteroids. The aim of the treatment is to arrest hair loss. Improvement of FFA was most often seen when treated with oral finasteride or dutasteride, but a spontaneous stabilization of the disease may also occur. The regrowth of hair is usually minimal and always located at the hairline [12]. Some treat- ments may reduce inflammation, but the impact on progres- sion of alopecia is uncertain. We report this case not only for the rarity of the disease but also to underline the role of dermoscopy as a very useful tool in the diagnosis of frontal fibrosing alopecia. In fact, the characteristic clinical presentation together with typical dermoscopic features could help in avoiding unnecessary biopsies in patients with frontal fibrosing alopecia. Hence,