Dermatology: Practical and Conceptual Review | Dermatol Pract Concept. 2025;15(1):4481 1 Trichoscopic Features of Lichen Planopilaris versus Frontal Fibrosing Alopecia: A Systematic Review Shreya K Gowda1, Enzo Errichetti2, Biswanath Behera1, Vishal Thakur1, Sonika Garg1, Deepak Kumar Sahu1, Madhusmita Sethy3, Pavithra Ayyanar3 1 Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, India 2 Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Piazzale Santa Maria della Misericordia, Udine, Italy 3 Department of Pathology, All India Institute of Medical Sciences, Bhubaneswar, India Key words: Frontal fibrosing alopecia, Lichen planopilaris, Trichoscopy, Dermoscopy, Primary cicatricial alopecia, Scalp Citation: Gowda SK, Errichetti E, Behera B, et al. Trichoscopic features of lichen planopilaris versus frontal fibrosing alopecia: A systematic review. Dermatol Pract Concept. 2025;15(1):4481. DOI: https://doi.org/10.5826/dpc.1501a4481 Accepted: October 10, 2024; Published: January 2025 Copyright: ©2024 Gowda et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Dr. Biswanath Behera, Associate Professor, Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, India-751019, Phone +91-7978351200. E-mail: biswanathbehera61@gmail.com Dr. Enzo Errichetti, Associate Professor, Institute of Dermatology, “Santa Maria della Misericordia” University Hospital, Piazzale Santa Maria della Misericordia, Udine, Italy, E-mail: enzoerri@yahoo.it Introduction: Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) are primary scarring alo- pecias that few authors consider the same entity, and some consider them different. Only a few reviews focus on trichoscopic findings in delineating these two alopecias. Objective: We describe and summarize the trichoscopic features of both conditions. Methods: We performed an extensive literature search using the PubMed and Google Scholar data- bases. The Chi-square test was applied to compare the trichoscopic features in LPP and FFA. P-values less than 0.05 were considered statistically significant. Results: Out of 60 articles, 33 (16 LPP, 17 FFA) were considered for quantitative analysis due to avail- ability in English literature with full text. We found that peripilar cylindrical casts and perifollicular erythema with arborizing vessels were predominant features suggesting early LPP. In contrast, yellow dots, perifollicular erythema, and scattered pigmentation suggested active FFA. Shiny-white area was seen in both groups in the inactive stages. The target arrangement of blue-grey dots, milky-red areas, and irregularly arranged white fibrotic dots were seen in late LPP, and black dots, lonely hairs, and loss of vellus hairs were detected in the later stages of FFA. Features such as blue-grey structureless areas, blue-white veil, and variability in morphologies of hair shafts were not significantly different between the two groups. Conclusion: This article provides a comprehensive literature review on the trichoscopic features of LPP and FFA, including comparing the similarities, differences, and peculiarities of both conditions. ABSTRACT 2 Review | Dermatol Pract Concept. 2025;15(1):4481 Introduction Scalp alopecias constitute a major part of routine outpatient dermatological diseases and are broadly divided into scar- ring and nonscarring types. Scarring alopecia is due to dam- age to the stem cell niche [1,2]. Primary cicatricial alopecia [PCA] is further subdivided based on the type of inflamma- tory infiltrate. Among Lymphocytic spectrum, discoid lupus erythematosus, central centrifugal cicatricial alopecia, lichen planopilaris [LPP], pseudopelade of Brocq, frontal fibrosing alopecia [FFA], and alopecia mucinosa are included. Neutro- philic spectrum includes erosive pustular dermatosis, acne ne- crotica, and acne keloidalis nuchae. A mixed infiltrate is noted in dissecting cellulitis of the scalp and folliculitis decalvans [3]. Even though histopathology (sensitivity of 40% and speci- ficity of 92% in LPP) and direct immunofluorescence (sensi- tivity of 34% and specificity of 95% in LPP) are recognized as diagnostic tools in delineating the PCA, trichoscopy helps in diagnosing scalp conditions without an invasive procedure and also serves as a prognostic aid during follow-up [4-6]. LPP is the most common etiology of PCA [7]. It can ei- ther present as violaceous papules initially, which are later replaced by follicular plugs and scarring, or white smooth atrophic plaques. It involves axillae, limb flexures, and in- guinal folds apart from the scalp [6]. LPP is classified into three clinical variants: classical type, FFA, and Graham Little-Piccardi-Lassueur syndrome. Fibrosing alopecia of pattern distribution and cicatricial pattern hair loss are the rare and less common subtypes of LPP. FFA is a chronic, gradually progressive cicatricial alopecia that presents as scalp itching and trichodynia. It is characterized by fron- totemporal recession with or without loss of eyebrows and non-inflammatory yellow facial papules. There is dispute over the independent existence of FFA; few authors consider both the same entity, and others consider them different. This study aimed to summarize the trichoscopic features of LPP and FFA and compare their trichoscopic findings in terms of the proportion of the following features: follicular findings, perifollicular features, interfollicular involvement, vascular pattern, and hair shaft abnormalities. Materials and Methods This review included cross-sectional, cohort, and case- control studies, case series, and case reports on both videodermo- scopic and handheld trichoscopic findings describing LPP and FFA per the International Dermoscopic Society terms of any skin type. Articles with no full text and not in English were excluded from the analysis. The level of evidence was assessed per the Oxford Centre of Evidence-Based Medicine. Per PRISMA (“Preferred Reporting Items for Systematic Re- views and Meta-Analyses”) guidelines, the systematic review and analysis were performed. A detailed search in PubMed and Google Scholar was performed, and articles published on LPP and FFA fulfilling the inclusion criteria until Septem- ber 2023 were analyzed. The search terms used were: “lichen planopilaris” OR “frontal fibrosing alopecia” OR “primary cicatricial alopecia” combined with “dermatoscopy” OR “dermoscopy” OR “trichoscopy” OR “videodermoscopy” OR “videodermatoscopy”. The proportions of trichoscopic features of LPP and FFA were analyzed in five headings: follicular findings, perifollicular features, interfollicular area, vascular pattern, and hair shaft abnormalities. The chi- square test was applied to identify the differences in the prev- alence of trichoscopic features in LPP and FFA, and p-values less than 0.05 were considered statistically significant. Results Out of 60 articles, 33 (16 LPP, 17 FFA) articles with full text and in English were included for analysis (Figures 1 and 2). Of the 16 articles pertaining to LPP, eight were cross- sectional, one was case-control, one was a case series, and six were case reports. For FFA, the following were the differ- ent types of articles: ten were cross-sectional, two were case- control, two were case series, and three were case reports. Table 1 summarizes the trichoscopic differentiating features of LPP and FFA [8-10]. Hair Follicular Findings The absence of follicular opening was seen in 40% to 55% of the cases in both groups. The dilated follicular ostia were seen in one LPP case. Pinpoint white dots and fibrotic white dots corresponded to the opening of eccrine glands and the fibrotic hair column, respectively [1,11]. Both pinpoint and fibrotic white dots were significantly higher in the LPP group (P <0.01). Yellow dots were found in both groups, with slight preponderance in the FFA group (P <0.01). Follicular kera- totic plugs were significantly seen in the FFA group [12,13]. Perifollicular Features Perifollicular erythema was seen in both groups. Peripilar scales were significantly higher in FFA than in LPP, while the perifollicular tubular or cylindrical casts were seen predom- inantly in LPP (P <0.01) [1,14]. Perifollicular blue-gray dots were seen in both groups, but the distribution of the dots in the “target pattern” was demonstrated in LPP (P <0.01). Perifollicular gray-to-blue-gray structureless areas were seen in the LPP group. Interfollicular Involvement The pigment patterns found in the analysis were honeycomb (P <0.01) and scattered blue-gray pigmentation (P <0.01), Review | Dermatol Pract Concept. 2025;15(1):4481 3 which corresponded to increased melanin in epidermal rete ridges and melanophages, respectively, on histopathology, and these features were seen in LPP. Honeycomb pigmenta- tion can be seen even in normal individuals due to chronic sun exposure [1,14]. Pink-white (P = 0.13) and milky-white (P <0.01) background pigmentation were seen in FFA and LPP, respectively. The blue-white veil was seen in a few cases of LPP [1,15]. Another feature in LPP in the interfollicular area was scattered blue-gray dots (P <0.01). An interfollicular structureless white area in scarring alopecias corresponded to acanthotic epidermis and dermal fibrosis. Interfollicular scale was seen in FFA. Interfollicular erythema was seen sig- nificantly in LPP. Interfollicular brown and red globules and blue structureless areas were seen significantly in LPP [1,16]. Blood Vessel Patterns Four patterns of blood vessels were seen on trichoscopy of LPP and FFA: arborizing, dotted, hairpin, and linear ves- sels. Thin arborizing vessels are telangiectasia with tree-like branching and were seen predominantly in LPP (P <0.01). Dotted, linear, and hairpin vessels were seen in LPP. The cu- taneous vasculatures were not frequently visualized in skin of color [17]. Hair Shaft Abnormalities Black dots were found to be significant in FFA (P <0.01) [16]. The emergence of two to three hair shafts from follicular opening and isolated single hair (lonely hair sign) in the fron- tal area was seen in LPP and in FFA, respectively (P <0.01) [17-19]. Pili torti was more commonly seen in FFA (P <0.01) [13]. Loss of vellus hair was seen in both groups, and a study done by Miteva et al. showed the involvement of vellus hairs in FFA, but the reason remains unclear [20]. Regrowing ter- minal hairs and tapered hairs were seen significantly in LPP, and vellus hairs in FFA [1]. Transparent proximal hair emer- gence was seen in sideburns of FFA and also in LPP. These findings were described even in healthy controls [21]. Circu- lar pigtail hairs were seen significantly in LPP [1]. Discussion This systematic review compares the trichoscopic features of scalp LPP and FFA, besides delineating the features of both conditions and correlating them with their pathological find- ings. Tables 2 and 3 summarize the trichoscopic features of LPP and FFA described in various studies [21-52]. Figure 1. Flowchart of systematic review for lichen planopilaris. *Pubmed and Google scholar data base **Not English literature Full text not available 4 Review | Dermatol Pract Concept. 2025;15(1):4481 therapy, has a chronic course, and has no standardized treat- ment regime. Treatment options include steroids, antiandro- gens, retinoids, and doxycycline. The progression of LPP can be stabilized with steroids, hydroxychloroquine, retinoids, pioglitazone, methotrexate, and cyclosporine [22]. For a long time, histopathology, and immunofluores- cence have been considered the standard tools for diagnosing PCA. Besides its invasive nature, the need for two specimens, and the expertise of the pathologist, various other factors limit 100% sensitivity and specificity [4-6]. Trichoscopy, a noninvasive diagnostic tool, aids in un- veiling the diagnosis of different scarring alopecias [1]. For the successful use of trichoscopy in the diagnosis and differ- entiation of various PCAs, including LPP and FFA, the use of standardized trichoscopy terms and a standard approach in analyzing various features are basic steps. As in line with clinical examination, during the tricho- scopic approach to alopecia, the loss of follicular orifices (Figure 3) indicates cicatricial alopecia. Our analysis revealed that around half of the patients with LPP (40%) and FFA There are contrasting opinions regarding the existence of FFA as an independent PCA. The clinical presentation of FFA (Figure S1) differs from LPP (Figure S2-4) by frontotemporal hairline recession associated with eyebrow loss, loss of body hairs, and facial papules. Classical LPP shows single or mul- tiple irregular areas of hair loss in any site, but it is more frequent on the vertex [22]. Both show moderate-to-dense perifollicular lymphohistiocytic inflammation and vacuolar degeneration of basal keratinocytes with perifollicular fi- brosis, but the inflammation is predominantly located in the infundibulum and isthmus in LPP and in FFA, respectively. Apoptotic keratinocytes in the follicles are described mostly as being associated with FFA [23]. Direct immunofluores- cence (DIF) shows globular deposits, cytoid bodies, Immuno- globulin (Ig M), irregular fibrinogen, and C3 deposits in the papillary dermis in LPP. The positivity in DIF is more common in LPP than in FFA. Immunohistochemistry (IHC) analysis of LPP showed a significant increase in CD68, CD163, and IL4 and decreased expression of CD86 when compared to FFA [24]. Differentiation is needed as FFA is nonresponsive to Figure 2. Flowchart of systematic review for frontal fibrosing alopecia. *Pubmed and Google scholar data base **Not English literature Full text not available Review | Dermatol Pract Concept. 2025;15(1):4481 5 Table 1. Trichoscopic Features of Lichen Planopilaris and Frontal Fibrosing Alopecia. LPP Scalp FFA Trichoscopic features N=279 (%) N=513 (%) p-value Hair follicle features Follicular plugs 11 (3.94) 86 (16.76) <0.01 Absence of follicular openings 159 (56.98) 201 (39.18) <0.01 Reduced follicular ostia 0 (0) 4 (0.78) 0.34 Dilated follicles 1 (0.35) 0 (0) 0.25 Yellow dots 50 (17.92) 205 (39.96) <0.01 Fibrotic white dots 189 (67.75) 123 (41.52) <0.01 Perifollicular features Perifollicular scales 14 (5.08) 85 (16.57) <0.01 Perifollicular tubular cast 60 (21.50) 23 (4.48) <0.01 Perifollicular erythema 119 (42.65) 167 (32.55) 0.055 Perifollicular blue-gray dots/globules 26 (9.31) 21 (4.09) 0.054 Target sign 73 (26.16) 0 (0) <0.01 Perifollicular gray-to-blue-gray structureless area 4 (1.43) 0 (0) 0.014 Interfollicular features Scales 0 (0) 1 (0.19) 0.95 Interfollicular erythema 9 (33.34) 0 (0) <0.01 White structureless areas 118 (42.29) 0 (0) <0.01 Pink-white background 0 (0) 7 (1.36) 0.13 Interfollicular brown globules 21 (7.52) 0 (0) <0.01 Blue-white veil 3 (1.07) 0 (0) 0.10 Red globules 10 (3.58) 0 (0) <0.01 Milky white areas 13 (49.46) 1 (0.19) <0.01 Honeycomb pigment pattern 17 (6.09) 0 (0) <0.01 Epidermal atrophy 5 (1.79) 2 (0.38) 0.046 Bluish deep discoloration 14 (5.01) 0 (0) <0.01 Scattered pigmentation 93 (33.34) 1 (0.19) <0.01 Starry sky pattern 0 (0) 12 (2.34) 0.07 Vascular pattern Arborizing 110 (39.42) 3 (0.57) <0.01 Dotted 7 (2.50) 0 (0) <0.01 Hairpin vessels 2 (0.71) 0 (0) 0.09 Linear 2 (0.71) 2 (0.38) 0.537 Hair shaft abnormalities Black dots 0 (0) 101 (19.68) <0.01 Broken hairs 5 (1.7) 6 (1.16) 0.481 Lonely hair sign 1 (0.35) 40 (7.79) <0.01 Tufting 11 (3.94) 0 (0) <0.01 Pili Torti 0 (0) 16 (3.11) <0.01 Loss of vellus hair 4 (1.43) 10 (1.94) 0.605 Circular pigtail hairs 16 (5.73) 0 (0) <0.01 Pustules 1 (0.35) 0 (0) 0.25 Vellus hairs 22 (7.88) 118 (23.00) <0.01 Regrowing hairs 22 (7.88) 0 (0) 0.95 Tapered hairs 21 (7.52) 21 (4.09) 0.051 Proximal hair emergence 40 (14.35) 65 (12.16) 0.564 Broom hair 0 (0) 1 (0.19) 0.95 6 Review | Dermatol Pract Concept. 2025;15(1):4481 Table 2. Trichoscopic Features of Lichen Planopilaris Included in This Study. Author Study Design Number of LPP Dermoscopy Results LOE Lajevardi et al. 2019 Cross-sectional study 117 Follicular pattern: Loss of follicular opening 111 (95%) Perifollicular: Perifollicular erythema 70 (60%) Targetoid pigmentation 72 (62%) Perifollicular scale 102 (88%) Perifollicular vessel 69 (59%) Scattered pigmentation 94 (80%) Interfollicular: Big irregular white areas 110 (94%) Milky-red areas 110 (94%) Hair shaft: Shaft deformities 43(37%), circular pigtail hairs 12 (10%) broken hairs 41 (35%) pustules 6 (5%) loss of Vellus hair 36 (31%) tuft of 4 hairs and more 26 (22%) yellow dots 5 (4%) III Estrada et al. 2010 Cross-sectional study 4 Follicular: Reduction in follicular ostia 4 (100%) Perifollicular: perifollicular scales 4 (100%) Interfollicular: pigment network 2 (50%) white dots 3 (75%) white patch 2 (50%) blue gray dots 1 (25%) III Woo-Haing et al. 2014 Cross-sectional study 8 Follicular: Reduced follicular ostia 8 (100%) Perifollicular: Perifollicular hyperkeratosis 7 (88%) Perifollicular erythema 7 (88%) Interfollicular: Pigment network 3 (38%) Vasculature: Atypical red vessels 5 (63%) Hair shafts: Black dots 1 (13%) III Olga Warszawik et al. 2012 Case-control study 28 Trichoscopy of LPP revealed Perifollicular: Silver-white tubular structure around the emerging hair shafts, usually reaching about 1 mm to 3 mm above scalp surface 28 (100%) Interfollicular: white dots 28 (100%), bluish deep discoloration 15 (53%) white and milky-red areas lacking follicular openings 28 (100%) Vasculature: Elongated vascular loops 15 (53%) located in close proximity to hair shaft openings. II Review | Dermatol Pract Concept. 2025;15(1):4481 7 Author Study Design Number of LPP Dermoscopy Results LOE Panchaprateep et al. 2020 Cross-sectional (Retro- prospective) study 58 Follicular: Lack of follicular ostia 53 (91%) Perifollicular: perifollicular scales 46 (79%) perifollicular erythema 37 (63.8%) Interfollicular: brownish hyperpigmentation 19 (32%) Hair shafts: transparent proximal hair emergence 40 (69%) Vasculature: telangiectasia 13 (22%) III Thakur et al. 2015 Cross-sectional (Retrospective) study 5 Trichoscopy of LPP showed Follicular: absent follicular opening 5 (100%) Perifollicular: peripilar cast 5 (100%) perifollicular erythema 3 (60%) perifollicular scales 5 (100%) Interfollicular: Epidermal atrophy 5 (100%) cicatricial white patch 5 (100%) scattered brown discoloration 2 (40%) Vasculature: Elongated linear blood vessels 2 (40%) III Rossi et al. 2013 Cross-sectional (Retrospective) study 86 Dermoscopy of LPP revealed involvement of total preterminal, diffuse hair thinning, perifollicular blue-gray dots, terminal and vellus-like follicles, a partial or total loss of follicular openings, with white structureless areas corresponding to scalp sclerosis III Abhijeet et al. 2018 Cross-sectional (Retrospective) study 6 Follicular: decreased follicular ostia 6 (100%) Perifollicular: Perifollicular scaling 6 (100%) Perifollicular erythema 6 (100%) Interfollicular: White dots 6 (100%) White structureless area 3 (50%) Blue-gray dots 3 (50%) Blue-white veils 3 (50%) III Eftekhari et al. 2019 Cross-sectional study 44 Follicular pattern: Small yellow dots 6 (13%) white dots pinpoint 34 (77%) large yellow dots 8 (18%) white dots fibrotic 7 (15%) Perifollicular: Tubular scales 20 (45%) Interfollicular: Peripilar sign yellowish brown 6 (13%) black-blue peripilar pigment 23 (52%) honeycombing 13 (29%) Vascular pattern: Dilated lesional telangiectatic vessels 26 (59%) perilesional thick vessels 11 (25%) pinpoint red dots 7 (16%) Red blotches 5 (11%) Hair shaft: Vellus hair 22 (50%) regrowing hairs 22 (50%) coiled twisted hairs 14 (31%) tufting 7 (16%) V Table 2 continues 8 Review | Dermatol Pract Concept. 2025;15(1):4481 plug (Figure 5) corresponded with the hyperkeratosis and plugging of the follicular orifice with keratotic material on histopathology; this feature is characteristic of discoid lupus erythematosus (DLE) but was seen predominantly in FFA [1,44]. This concurs with the absence of clinical follicular plugging in cases of FFA [45]. Fibrotic white dots (Figure 4) are delineated from pinpoint white dots by the presence of a peripheral hyperpigmented halo. The white fibrotic dots coalesce to form white structureless areas, which correlate with the vertical arrangement of scar tissue in histology. This points towards the loss of follicular ostia by fibrous tissue and is a poor prognostic sign. The pinpoint white dots corre- spond to openings of eccrine sweat gland ducts or follicular orifices [46]. (55%) may not show this feature, indicating the early stage of the disease. This may be crucial from management’s point of view, as the patients will have favorable responses [42]. The red dots correspond to the opening of the follicular orifice with visible vasculature. Per Rakowska et  al., the presence of red and gray dots was considered a favorable prognostic marker of the disease, whereas loss of follicu- lar ostia was seen in the late stage of FFA [18]. The next most frequent finding noted in our analysis of FFA was yellow dots (Figure 4), which were better detected in po- larized mode. The yellow dots correlate with the follicular ostia filled with sebaceous secretions [1]. This represents the intactness of follicular ostia, which is the most common finding in nonscarring alopecias [44,45]. Follicular keratotic Author Study Design Number of LPP Dermoscopy Results LOE Arshdeep et al. 2018 Case series 4 cases involving scalp (all), face (1), forearm (2), and back (2) Case 1 trichoscopy revealed showed multiple discrete peripilar casts. Dermoscopy of the trunk revealed the absence of follicular openings and residual body hair with no peripilar casts, suggestive of “burnt-out” disease. Case 2: Dermoscopy of scalp showed discrete peripilar casts, blue-gray dots in targetoid pattern, and white patches of scarring alopecia Case 3: Dermoscopy of right cheek with facial papules (lichen planus) showed partial loss of vellus hairs in patients of LPP with LP Case 4: Dermoscopy of follicular plugs on the back in patient of LPP showed gray-brown dots (peppering) around the follicular ostia with broken hairs and discrete peripilar casts. V Batra et al. 2020. Case report 2 Trichoscopy showed elimination of hyperkeratosis and evidence of inflammation on the frontal hairline V Ankad et al. 2013 Case report 1 LPP: Trichoscopy showed diminished follicular ostia, perifollicular scales (black stars), and white dots (red stars). Blue-gray dots (yellow arrows) around the follicular structures (“target” pattern) V Friedman et al. 2015 Case report 1 Trichoscopy revealed perifollicular whitish-gray scaling associated with erythema, multiple irregular cicatricial alopecic areas, absence of follicular openings, arboriform vessels, and follicular plugging V Góes et al. 2017 Case report 1 Periphery of the plaque: erythema and perifollicular scaling Central areas: Erythematous and shiny No scaling Absence of follicular ostia V Kaliyadan et al 2015 Case report 1 Violaceous pattern over the normal pseudo-network of the region associated with whitish striations (corresponding to Wickham’s striae) and prominent pigment clumps (corresponding to the dermal melanophages) V Andziukeviciute et al. 2016 Case report 1 Trichoscopy showed follicular hyperkeratosis, zones of extinct hair follicles, and erythema V Abbreviations: LPP: lichen planopilaris, DLE: scalp discoid lupus erythematosus, FFA: frontal fibrosing alopecia, LP: lichen planus, LOE: Level of evidence Table 2. Trichoscopic Features of Lichen Planopilaris Included in This Study. (continued) Review | Dermatol Pract Concept. 2025;15(1):4481 9 Table 3. Trichoscopic Features of Frontal Fibrosing Alopecia Described in Various Studies. Author Study Design Study Participants Dermoscopy Results LOE Cervantes et al. 2018 Case-control (Retrospective) study 40 Trichoscopy of the frontotemporal scalp (38 cases) revealed: Perifollicular: Peripilar casts 24 (63%) Peripilar erythema 22 (57%) Hair shaft: Transparent proximal hair shaft emergence 6 (15%) Pili torti-like hairs 6 (15%) Broken hairs 4 (10%). Trichoscopy of the sideburns region (24 cases): Perifollicular: Peripilar casts (fine and less adherent) 4 (16%) Peripilar erythema 4 (16%) Pili torti-like hairs 4( 16%) Hair shafts: Transparent proximal hair shaft emergence 19 (79%) broken hairs 2/24 (8.3%) II Olga Warszawik et al. 2012 Case-control study 19 Dermoscopy of FFA revealed Perifollicular scaling 15 (78%) White dots 1 (5.2%) Follicular red dots 6 (31.6%) II Panchaprateep et al. 2020 Cross-sectional (Retrospective) study 58 patients: 46 retrospective and 12 prospective Follicular: Lack of follicular ostia 53 (91%) Perifollicular: Perifollicular scales 46 (79%) Perifollicular erythema 37 (63.8%) Interfollicular: Brownish hyperpigmentation 19 (32%) Hair shafts: Transparent proximal hair emergence 40 (69%) Vasculature: Telangiectasia 13 (22%) III Rossi et al. 2013 Cross-sectional (Retrospective) study 48 White structureless areas (100%) Loss of vellus hairs (100%) Involvement of occiput (10.42%) Frontoparietal region (89.58%). III Farag et al. 2020 Cross-sectional (Retrospective) study 50 Follicular: Yellow dots 140 (92%), Multiple pinpoint dots 120 (79.5%) Hair shaft: Short thin hairs/vellus 115 (76%), Black dots 100 (66%) Dystrophic hairs 92 (60%) Tapering hairs 21 (13%) Dystrophic hairs 92 (60%). V Perifollicular and interfollicular erythema (Figure 3), a feature seen in both LPP and FFA, represents early active inflammation around the hair follicles and is a good prog- nostic sign [13]. Perifollicular tubular casts are 3 mm cir- cumferential adherent scales and tend to climb away from the scalp; this finding was thought to be specific to LPP but was later described in many conditions such as folliculitis decalvans, pemphigus foliaceous, and scalp DLE [1,18]. This corresponds to perifollicular hyperkeratosis on histol- ogy [14]. In contrast, perifollicular scaling was significantly found in FFA. However, this feature can be nonspecific, can be found in other types of PCAs, and can be influenced by Table 3 continues 10 Review | Dermatol Pract Concept. 2025;15(1):4481 Author Study Design Study Participants Dermoscopy Results LOE Karadag Köse et al. 2019 Cross-sectional study 7 Follicular: Absent follicular opening 69 (100%) Yellow dots 20 (28%) White fibrotic dots 28 (42%) Pinpoint dots 10 (14%) Perifollicular: Perifollicular scaling 50 (71%), Peripilar cast 10 (14%). Interfollicular features: Pink–white appearance 69 (100%) Honeycomb pattern 50 (71%) Brown scattered pattern 10 (14%) Hair shafts: Absence of vellus hairs 20 (28%), Short vellus hairs 28 (42%), Broken hairs 10 (14%), Pili torti 50 (71%), Black dots 28 (42%). III Estrada et al. 2010 Cross-sectional study 5 FFA dermoscopy showed Follicular: Reduction in follicular ostia 4 (80%) Perifollicular: Perifollicular scales 3 (60%) Perifollicular erythema 3 (60%) Interfollicular: Pigment network 2 (40%) White patch 1 (20%) White dots 2 (40%) Vasculature: Branching capillaries 3 (60%) Hair shafts: Vellus hairs 1 (20%) III Thakur et al. 2015 Cross-sectional (Retrospective) study 5 Dermoscopy of FFA revealed Follicular: Classic white dots 1 (50%), absent follicular opening 2 (100%), Perifollicular: Perifollicular erythema 2 (100%) Perifollicular scales 2 (100%) Peripilar cast 2 (100%) Interfollicular: Epidermal atrophy 2 (100%) cicatricial white patch 2 (100%) Blue-gray dots 1 (50%) Scattered brown discoloration 2 (100%) Vasculature: Elongated linear blood vessels 2 (100%) III Martínez- Velasco et al. 2018 Cross-sectional study 20 Study was done to correlate the peripilar cast thickness and degree of lymphocytic infiltration. Cast less than 2 mm had less than 5 lymphocytes/ field/40 X, 2 to 4.4 mm had 5 to 10 lymphocytes/ field/40 X and more than 4.4 mm had more than 10 lymphocytes/field/40 X. Thus, a strong correlation was observed between the severity of peripilar cast and the degree of lymphocytic infiltrate. V Table 3. Trichoscopic Features of Frontal Fibrosing Alopecia Described in Various Studies. (continued) Review | Dermatol Pract Concept. 2025;15(1):4481 11 Author Study Design Study Participants Dermoscopy Results LOE Toledo- Pastrana et al. 2013 Cross-sectional study 79 Trichoscopy revealed Follicular: Loss of follicular opening 79 (100%) Follicular hyperkeratosis 65 (72%) Follicular plugs 35 (44%) Perifollicular: Perifollicular erythema 52 (66%) Perifollicular erythema was present in 95% of cases in which the disease was active, with statistically significant differences between the two groups (active vs. inactive disease) (P < 0.01) V Sicińska et al. 2022 Cross-sectional study 6 Trichoscopic hairline monitoring in FFA patients. The baseline image aligned with the follow-up image and hair density profile. Trichoscopy with hair-to-hair matching for disease progression. V Rodrigues- Barata et al. 2018 Cross-sectional study 12 Ultraviolet-enhanced trichoscopy with a wavelength of 365 nm, when applied to the skin, will produce fluorescence due to p. acne that generates red-orange fluorescence due to porphyrin production. while compact keratin produces white- yellow fluorescence. If fluorescence due to p. acne indicates viability of follicle hence, regrowth can be expected in FFA on therapy. V Starace et al. 2019 Case series 65 Empty follicles/yellow dots 65 (100%) Absence of follicular ostia 65 (100%) Mild follicular hyperkeratosis 51 (78%) Perifollicular erythema 46 (70%) Lonely hair 40 (61%) V Miteva et al. 2019 Case series 6 Six cases of FFA, trichoscopic guides biopsy was done. Trichoscopy revealed a perihilar cast (100%) and preserved vellus hairs (100%). The histopathology revealed perifollicular lichenoid layered or patchy infiltrate around vellus hairs and the atrophy of the sebaceous glands. V Ferrari et al. 2019 Case report 1 Loss of vellus hair Prominent peripilar casts Absence of follicular openings Dermoscopy of eyebrows: Black dots Hair growing in different directions Numerous pili torti V Thompson et al. 2022 Case report 1 Tuft of 2 hairs, surrounded by a dilated follicular ostium and a peripilar cast Three-dimensional imaging: The disease is confined to the infundibulum and superficial isthmus, where two follicles have fused to form a compound follicle V Rocchetto et al. 2019 Case report 1 Absence of vellus hairs and follicular openings Perifollicular scaling Broken hairs Broom hair fibers V Abbreviations: FFA: frontal fibrosing alopecia, p acne: Propionibacterium acne, LOE: level of evidence. 12 Review | Dermatol Pract Concept. 2025;15(1):4481 “ground-glass” hue, initially thought to be specific to malig- nant melanoma but later described in many conditions [1]. In LPP, a blue-white veil corresponds to hyperkeratosis over- lying lichenoid infiltrate with melanophages in the upper dermis, and this was seen in a few cases [10,15]. Per Ro- drigues-Barata et  al., on ultraviolet-enhanced trichoscopy, a unique “starry sky” pattern was described in FFA, which positively predicts the therapeutic response in FFA with med- ical management. Those patients with a “starry sky pattern” partial response to medical management were seen when compared to negative fluorescence [16]. Arborizing vessels correspond to the subpapillary plexus in histopathology. It can be thick or thin, divided in relation to hair shaft diameter. Thin arborizing vessels around the fol- licle were significantly seen in LPP [1,45]. Arborizing vessels are classical features encountered in scalp DLE. Thin arbor- izing vessels are normal findings of the scalp frequently seen in the vertex and occipital regions of the scalp and less com- mon in the frontal area. The involvement of these regions of the scalp can be a possible explanation for the frequent findings of the arborizing vessels in LPP, apart from the use of intralesional steroids in alopecia patches [47]. Nonfol- licular dotted and linear vessels were seen in some patients with LPP. Hairpin vessels are seen in normal scalp, but the density of the vascular pattern was increased in a few cases of LPP. Apart from density, the characteristic circumferential perifollicular arrangement of hairpin vessels was seen in LPP [47,48]. Vellus hairs are thin hair shafts of diameter less than 0.03 mm with less pigmentation, while the regrowing hairs are darkly pigmented upright shafts with tapered ends. Both these were seen predominantly in LPP [49]. FFA (Figures 6, 7 and 8) mostly affects vellus hairs. Hence, loss of vellus hairs on trichoscopy is noted, and the ‘lonely hair sign’ is also due the following: the use of oil by the patients, the application of immersion fluid by a physician, and associated common dermatoses of the scalp like pityriasis capitis. In LPP, a characteristic “target pattern” of the blue-gray dot (Figure 3) is described, which helps discriminate it from other PCAs. In addition, it can be a guiding area for doing a biopsy to visualize the perifollicular pathology. Further- more, it was a more significant feature in LPP than FFA, as interface changes involving the follicular area with sparing interfollicular areas are seen in LPP [14]. The pink-white background in LPP corresponds to par- tial fibrosis and inflammatory infiltrates. The blue-white veil is characterized by central white areas and peripheral irregular patches of blue-brown pigment with an overlying Figure 3. Trichoscopy of lichen planopilaris shows loss of follicular orifices, perifollicular scale and erythema, and perifollicular blue- gray dots in a target pattern (arrow). Figure 4. Trichoscopy of lichen planopilaris shows fibrotic white dots (blue arrow). Figure 5. Trichoscopy of lichen planus over the scalp shows fol- licular plugging, interfollicular brown-gray structureless area, and perifollicular shiny white structures. Review | Dermatol Pract Concept. 2025;15(1):4481 13 ostia, resulting in “tufts of hair” in LPP [49]. Pili torti is a hair shaft abnormal either due to congenital or acquired eti- ology and characterized by 180° twisting at regular intervals. It was described in FFA per our review [51]. While shiny white structureless areas were common in both the groups in the end or inactive stages, the target arrangement of blue- gray dots, milky-red areas, and irregular white fibrotic dots was seen in inactive LPP, and black dots, lonely hairs, loss of vellus hairs was detected in later stages of FFA. Black dots are due to breakage of hair at the origin from the scalp, which was significantly seen in the FFA of eyebrows but not described in the scalp variant, and exact pathomechanism is not described [52]. Limitations of the review were the missing data due to inconsistency and variability in the usage of dermoscopic terminologies, and data on variations in the findings with polarized and nonpolarized modes, and differences in der- matoscopy and video dermatoscopy were not extrapolated. All skin types were included, and the variations in skin of color were not assessed. In conclusion, the presence of predominant peripilar tu- bular casts, perifollicular erythema, target blue-gray dots, milky-red areas, and arborizing vessels support the diagnosis of LPP. In contrast, FFA is indicated by yellow dots, perifol- licular erythema, scattered pigmentation, black dots, lonely hairs, and loss of vellus hairs. Features such as blue-gray structureless areas, blue-white veil, and variability in mor- phologies of hair shafts were nonspecific. The overlapping trichoscopic features may indicate that FFA and LPP are two different entities of the same spectrum to the progressive destruction of vellus hairs, leading to the persistence of isolated terminal hairs [50]. In the early stages of FFA, the disease process initiates in the frontal hairline, where the density of vellus hair is high and is frequently de- stroyed by the disease process. However, there are case re- ports of pseudo “fringe sign,” which describes intact vellus hairs in the frontal hairline. 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