Frontal fibrosing alopecia: A retrospective review of 19

patients seen at Duke University

Barry Ladizinski, MD,a Andrea Bazakas, BS,a M. Angelica Selim, MD,b and Elise A. Olsen, MDa
Durham, North Carolina

Background: Frontal fibrosing alopecia (FFA) is a type of scarring hair loss primarily observed in
postmenopausal women and characterized by fronto-tempero-parietal hairline recession, perifollicular
erythema, and loss of eyebrows. The incidence is unknown, but the number of women presenting with this
condition has significantly increased in recent years. No effective therapy has been established.

Objective: The purpose of this study is to present pertinent demographic and clinical findings of patients
with FFA seen at an academic hair loss clinic and their responses to various therapeutic interventions.

Methods: Patients seen at the Duke University Hair Disorders Research and Treatment Center, Durham,
NC, between 2004 and 2011 who met FFA inclusion criteria and signed an informed consent form for
participation in the Duke University Hair Disorders Research and Treatment Center database were included
in this review.

Results: Nineteen female patients with FFA met our inclusion criteria, the majority of whom were white
and postmenopausal. A number of treatments, including topical and intralesional steroids, antibiotics, and
immunomodulators, were used with disappointing results in most patients. However, the majority of
patients on dutasteride experienced disease stabilization.

Limitations: This was a retrospective review and outside clinic records were occasionally incomplete.

Conclusions: FFA is an increasingly common form of scarring hair loss, but the origin remains unknown.
Without clear understanding of the pathogenesis and evolution of this condition, it is not surprising that
treatments to date have been minimally or not effective. At our institution, dutasteride was most effective in
halting disease progression, although no therapy was associated with significant hair regrowth. ( J Am Acad
Dermatol 2013;68:749-55.)

Key words: cicatricial alopecia; frontal fibrosing alopecia; lichen planopilaris; scarring hair loss.

F rontal fibrosing alopecia (FFA) is a form of

cicatricial hair loss characterized by fronto-
tempero-parietal hairline recession, perifollic-
ular erythema in areas of scalp hair loss, and loss of
Abbreviations used:
5aR:
5aRi:
FAPD:
5-alpha reductase
5-alpha reductase inhibitor
fibrosing alopecia in a pattern distribution
eyebrows (Fig 1). Histologically, the scalp biopsy FFA: frontal fibrosing alopecia
specimen in FFA shows findings typical of lichen FPHL: female pattern hair loss
LPP: lichen planopilaris
planopilaris (LPP), another scarring hair loss disor-
der, which is characterized clinically by patches of
hair loss rather than the regional hair loss seen with
FFA.1 The origin and prevalence of FFA is unknown, condition has markedly increased in recent years.
although the number of women presenting with this Furthermore, no effective treatment regimens have

From the Hair Disorders Research and Treatment Centera and Accepted for publication September 18, 2012.
Department of Pathology,b Duke University Medical Center. Reprints not available from the authors.
Supported by Duke University Hair Disorders Research and Correspondence to: Barry Ladizinski, MD. E-mail: barryladizinski@
Treatment Center. gmail.com.
Disclosure: Dr Olsen received a research grant and fellowship Published online February 4, 2013.
grant from Johnson and Johnson. Dr Ladizinski, Ms Bazakas, 0190-9622/$36.00
and Dr Selim have no conflicts of interest to declare. Ó 2012 by the American Academy of Dermatology, Inc.
Conflicts of interest: None declared. http://dx.doi.org/10.1016/j.jaad.2012.09.043

749
750 Ladizinski et al J AM ACAD DERMATOL
MAY 2013

been established, although various reports have of whom had already failed anti-inflammatory treat-
noted some improvement or stabilization with ments at the time of presentation. If premenopausal,
topical and intralesional corticosteroids, antibiotics, women were treated with finasteride 1 to 2.5 mg
hydroxychloroquine, topical and oral immunomod- daily in combination with oral contraceptive therapy,
ulators, and 5-alpha reductase (5aR) inhibitors and if postmenopausal, they were treated with either
(5aRis).1-8 finasteride or dutasteride, the latter in doses of 0.5
mg daily for 2 weeks and then 0.5 mg weekly
METHODS thereafter. Although the dos-
After receiving institu- ing frequency of dutasteride
tional review board approval, CAPSULE SUMMARY used for FFA was lower than
a retrospective review was the daily dosing approved
d
Frontal fibrosing alopecia is a type of
performed of the Duke for prostate hyperplasia, it
scarring hair loss usually observed in
University Hair Disorders has an extremely long bio-
postmenopausal women and
Research and Treatment logic half-life of 5 weeks.10
characterized by fronto-tempero-parietal
Center, Durham, NC for all Moreover, a prior study has
hairline recession, perifollicular
patients meeting criteria for shown efficacy of finasteride,
erythema, and eyebrow loss. No
FFA. Diagnostic criteria for a drug with a much shorter
uniformly effective treatment regimen
FFA included: (1) symmetric half-life (6-8 hours) than du-
has been established.
or irregular (‘‘moth-eaten’’) tasteride,11 when used on a
bandlike frontal hairline re- dWe present the demographics, clinical weekly basis in the treatment
cession plus at least one of the findings, and treatment responses of 19 of FPHL.12 Because blockage
following: eyebrow alopecia, patients to further understanding of this of 5aRi in men with male
interfollicular erythema, peri- condition and potentially new pattern baldness has led to a
follicular erythema, or perifol- therapeutic options. decrease in DHT and an in-
licular papules in the area of d
At our institution, dutasteride was most crease in testosterone and
scalp hair loss; and (2) a scalp successful in disease stabilization, estrogen, we checked estra-
biopsy specimen from an although long-term follow-up is diol, DHT, and testosterone
area of involvement (usually necessary to establish prolonged levels after 5 alfa reductase in
from the frontal or central efficacy. postmenopausal women not
scalp) showing a lympho- on hormone replacement
cytic cicatricial alopecia therapy and DHT and testos-
consistent with LPP. All biopsy specimens (includ- terone in premenopausal women not on oral con-
ing those performed at outside hospitals) were read traceptive pills.
at the Duke University Medical Center by our Response to therapy was graded on a 3-point
dermatopathologist (M. A. S.). scale from 1 to 11 that corresponded to worsening,
Patients meeting criteria for FFA were further stabilization, and improvement, and was based on
assessed clinically and photographically for concom- clinical notes and global photographic assessment.
itant central scalp hair loss disorders including Improvement was defined as any regrowth of hair;
female pattern hair loss (FPHL) and fibrosing alope- stabilization was defined as arrest of hairline reces-
cia in a pattern distribution (FAPD). In cases where sion; and worsening was defined as progression of
the clinical diagnosis was uncertain, a central scalp hairline recession. Changes in erythema or scalp
biopsy was performed. Diagnostic criteria for FAPD symptoms were considered separately from changes
included diffuse central scalp hair loss and a central in hair loss.
scalp biopsy specimen consistent with LPP.
Patients routinely had the following laboratory RESULTS
tests performed as part of their initial workup: Table I summarizes demographic and clinical
complete blood cell count, thyroid-stimulating hor- characteristics for the 19 female patients (18 white,
mone, free T4, serum iron, total iron-binding capac- 1 African American) with FFA seen at the Duke
ity, and ferritin. University Hair Disorders Research and Treatment
Given that antiandrogen therapy has reportedly Center from September 2004 through October 2011,
been effective in FFA2-5 and in FAPD,9 and given who met clinicopathologic diagnostic criteria for
the paucity of data supporting the effectiveness of FFA; no male patients with FFA were seen. Of 6
anti-inflammatory therapy in FFA, we elected to try a patients with central scalp hair loss, FAPD was
5aRi in many of the patients. The 5aRis had not present in 21% (4 of 19) and FPL in 11% (2 of 19).
previously been tried in these referral patients, many The average age of hair loss onset was 55.9 (40-78)
J AM ACAD DERMATOL Ladizinski et al 751
VOLUME 68, NUMBER 5

topical immunomodulators, oral antibiotics, hydrox-

ychloroquine). No patient had any visible regrowth
of scalp hair or eyebrow hair on any prior or Duke
Universityedirected treatment despite the concom-
itant use of topical minoxidil in many instances.
However, stabilization of hair loss was seen in 7 of 10
(70%) patients treated with dutasteride (2 in combi-
nation with doxycycline and 1 in combination with
topical tacrolimus and topical class I steroid) over a
mean of 28 (13-52) months and 1 of 3 (33%) patients
treated with finasteride over a mean of 10 (3-20)
months. Of the 4 patients with concomitant FAPD, 2
on dutasteride and 1 on methotrexate experienced
stabilization of both FFA and FAPD, and 1 was started
on finasteride, but did not return for follow-up.
There were no side effects on either 5aRi, including
no significant changes in dihydrotestosterone, tes-
tosterone, or estradiol.
Stabilization of hair loss was also observed in 2 of
Fig 1. Frontal fibrosing alopecia (FFA). A, Fronto- 4 (50%) patients on hydroxychloroquine (400 mg/d),
temporal hairline recession in a bandlike distribution, 1 of 3 (33%) on methotrexate (15-25 mg/wk), and
perifollicular erythema, lonely hairs, and bilateral loss of 1 of 2 (50%) on minocycline (in combination with
eyebrow hair in a patient with FFA. B, Lateral view of topical tacrolimus). Other agents that were used and
severe perifollicular erythema, eyebrow loss, and pro- failed to show stabilization of hair loss included
minent venous vasculature on the forehead, typically acitretin, azathioprine, interferon alfa, and pioglita-
observed in FFA. zone. No significant adverse effects were reported in
any of the patients on topical or systemic therapy and
years and 17 of 19 patients were postmenopausal at no patients ceased therapy because of an adverse
initiation of hair loss. Menopause was surgical in 4 drug reaction.
patients and natural in 15. Hormone replacement Of the 4 patients with FFA who ceased all therapy
therapy was used by 9 patients after menopause. in which we have follow-up data, 3 stabilized
Five patients were on antihypertensive medications, (2 responders and 1 nonresponder) over a mean of
2 on an antilipid agent, and 6 on osteoporosis 2 years and 1 continued to experience slight pro-
medications at their initial visit. gression of hair loss over a mean of 4 years.
Frontal hairline recession was present in 100%
(19 of 19) of patients. In the area of scalp hair loss, DISCUSSION
perifollicular erythema was present in 79% (15 of 19) First described in 6 postmenopausal women by
of patients and perifollicular papules in 37% Steven Kossard1 in 1994, FFA is a type of cicatricial
(7 of 19). Eyebrow loss was present in 95% alopecia characterized by hair follicle destruction in
(18 of 19) of patients, eyelash loss in 26% (5 of 19), a fronto-tempero-parietal distribution.1 The origin is
and body hair loss in 26% (5 of 19); only 3 patients unknown, but FFA is most commonly detected in
demonstrated concomitant eyebrow, eyelash, and postmenopausal women, suggesting a possible hor-
body alopecia. The ‘‘lonely hair’’ sign, described by monal cause. This is further supported by occasional
Tosti et al13 as single terminal scalp hairs at the improvement with antiandrogen therapy such as the
original hairline site, was observed in 53% (10 of 19) 5aRis (finasteride and dutasteride), although pa-
of patients. All scalp biopsy specimens were consis- tients do not typically have elevated androgen levels
tent with LPP (eg, scarring alopecia with perifollic- or other hormonal abnormalities.1,2 FFA has also
ular lamellar fibrosis, loss of sebaceous glands, and a been observed in premenopausal women3,6,8,14-16
lichenoid lymphocytic infiltrate targeting the infun- and in men.17-19 Although a genetic component has
dibulum and isthmus). not been established, FFA has been reported in
Table II summarizes responses to treatments several families.20-22 The incidence of FFA is un-
initiated or continued at Duke University for the 19 known, but hair experts across the globe agree that
patients with FFA. Of note, many of the patients the number of women seeking diagnosis and help
referred to our institution had previously failed other for this condition has markedly increased in recent
therapies (eg, topical and intralesional steroids, years. As was the case with our patients, women with
 752 Ladizinski et al
Table I. Demographic and clinical characteristics of 19 patients with frontal fibrosing alopecia seen at the Duke University Hair Disorders Research and
Treatment Center, Durham, NC
Age at onset Age at Menopausal status Time between onset Frontal hairline Perifollicular Perifollicular Eyebrow Eyelash Body Lonely
Patient No. Sex Race of hair loss, y presentation, y at presentation and presentation, y recession erythema papules loss loss hair loss hair sign
1 F W 70 80 Post 3.2 1 1 1 1 1
2 F W 48 57 Post 3.0 1 1 1 1
3 F W 51 60 Post 4.5 1 1 1 1 1 1 1
4 F W 58 64 Post 1.4 1 1 1 1 1 1
5 F W 54 63 Post 4.7 1 1 1
6 F B 49 63 Post 10.4 1 1 1
7 F W 57 63 Post 2.3 1 1 1
8 F W 59 64 Post 1.4 1 1 1
9 F W 54 61 Post 3.4 1 1 1 1
10 F W 55 63 Post 5.5 1 1 1 1 1
11 F W 65 70 Post 1.1 1 1 1 1 1 1 1
12 F W 46 68 Post 20.7 1 1 1
13 F W 40 44 Pre 2.9 1 1 1 1
14 F W 58 60 Post 1.3 1 1 1
15 F W 62 65 Post 2.9 1 1 1 1 1
16 F W 55 60 Post 3.07 1 1 1
17 F W 57 63 Post 5.47 1 1 1
18 F W 78 79 Post 1 1 1 1
19 F W 46 49 Pre 3.39 1 1 1 1 1

B, Black; F, female; W, white.

J AM ACAD DERMATOL
MAY 2013
J AM ACAD DERMATOL Ladizinski et al 753
VOLUME 68, NUMBER 5

Table II. Treatment responses of 19 patients with frontal fibrosing alopecia seen at the Duke University Hair
Disorders Research and Treatment Center, Durham, NC
Stabilization
Duke University therapy n Mean duration, mo n
Dutasteride 10 28 (13-52) 7/10
Dutasteride monotherapy 5 30 (15-44) 4/5
Dutasteride 1 doxycycline 3 31 (18-52) 2/3
Dutasteride 1 class I steroid* 1 topical tacrolimus* 1 17 1/1
Dutasteride 1 class I steroid* 1 13 0/1
Finasteride 3 10 (3-20) 1/3
Finasteride monotherapy 1 3 1/1
Finasteride 1 methotrexate 1 16 0/1
Finasteride 1 acitretin 1 topical imiquimod 1 20 0/1
Methotrexate 3 16 (13-19) 1/3
Methotrexate monotherapy 2 16 (13-19) 1/2
Hydroxychloroquine 4 20 (7-42) 2/4
Hydroxychloroquine monotherapy 2 26 (10-42) 2/2
Hydroxychloroquine* 1 tacrolimus* 1 class I steroid* 1 18 0/1
Hydroxychloroquine 1 class I steroid* 1 7 0/1
Minocycline 2 15 (5-25) 1/2
Minocycline* 1 topical tacrolimus* 1 25 1/1
Minocycline 1 topical imiquimod 1 5 0/1
Imiquimod 2 26 (12-40) 1/2
Imiquimod 1 class I steroid* 1 40 1/1
Acitretin 1 4 0/1
Interferon alfa-2b 1 2 0/1
Azathioprine 1 4 0/1
Pioglitazone 1 8 0/1

*Initiated pre-Duke University Hair Disorders Research and Treatment Center visit, but continued after consultation.

FFA appear to be healthy and no definite causative central frontal hairline, not across the entire frontal
factor is apparent based on history taking or routine scalp as seen with FFA.
blood tests. Most patients with FFA exhibit some degree of
Clinically, FFA presents with a symmetric or irreg- eyebrow diminution, now recognized as a charac-
ular (moth-eaten) bandlike pattern of fronto- teristic feature of this disorder,1-8,13-16,18,22,27-30 and
tempero-parietal recession with loss of follicular evident in the majority of our patients. Further,
orifices in the area of hair loss, with or without limb hair loss is reported with increasing
interfollicular or perifollicular erythema, perifollicu- frequency4,8,13,15,16,22,27-29 and biopsy specimens
lar papules, follicular keratosis, and prominent ve- from scalp and limb alopecia sites have
nous vasculature on the forehead.1 The moth-eaten shown similar histopathologic characteristics.27-29
pattern of hairline recession is unusual with other Axillary2-5,14,16,27-29 and pubic2,27,29 hair loss has
causes of frontal hair loss and the lonely hair sign is also been described in patients with FFA, although
characteristic of this type of loss. Venning and this is also a common symptom of postmenopausal
Dawber23 reported frontoparietal recession in 37% women in general.
of postmenopausal women with FPHL, but did not FFA has been associated with other types of hair
note a cicatricial process. Hamilton24 described fron- loss including FPHL,3,4 male pattern hair loss,17 and
tal hair loss in women with androgenetic alopecia, FAPD.9 The presence of FFA in patients with FAPD,
including fronto-temporal recession extending to the latter in the distribution of FPHL, raises the
3 cm posterior to a coronal plane between each question of whether these 2 conditions may have
external auditory meatus’. The Ludwig25 pattern of overlapping features with the cicatricial subtype of
diffuse central pattern hair loss in women, on the FPHL.31 Further, FFA has been seen with other signs
other hand, always included retention of the frontal of lichen planus including cutaneous7,8,14,15 and
fringe of hair. Olsen26 has described a breach of the oral7,8,32 lesions, and with other skin conditions
frontal hairline in some women with FPHL, but in an including vitiligo,21 Sj€ogren syndrome,33 and vulvar
inverted ‘‘V’’ or Christmas-tree distribution in the lichen sclerosus et atrophicus.30 FFA has also been
754 Ladizinski et al J AM ACAD DERMATOL
MAY 2013

described in patients following cosmetic procedures

(eg, hair transplantation and face-lift surgery).16,34
One of our patients had previous face-lift surgery
and another had rhinoplasty surgery, although a
temporal relationship is unclear.
The natural history of FFA remains unknown and
is quite variable, although treatment has been uni-
formly disappointing. Several studies demonstrate
that disease progression can be self-limited, advanc-
ing slowly and spontaneously stabilizing regardless
of treatment continuation,2,3,8,16 whereas recession
Fig 2. Frontal fibrosing alopecia (FFA). Over 70% scalp
in some patients progresses despite therapeutic hair loss in a patient with refractory FFA that eventually
intervention and can eventually involve the entire stabilized.
scalp.8 One of our patients who was not responsive
to multiple topical and systemic therapies eventually
experienced hair loss involving 70% of the scalp Unfortunately, our 1 patient treated with pioglita-
(Fig 2), but subsequently ceased all therapies and zone had progressive hair loss. Further trials are
stabilized. necessary to examine the effectiveness of this agent
No treatments have been evaluated in controlled in decreasing both inflammation and hair loss in FFA
clinical trials or documented to be uniformly effec- and to ensure its safety profile in an otherwise
tive. One obstacle is the definition of ‘‘effective’’ in healthy population.
cicatricial alopecia as it is unlikely that hair regrowth
will occur; therefore, we introduced stabilization of
hair loss as the goal in our patients. Seven of 10
patients on dutasteride had stabilization of hair loss CONCLUSION
and 1 of 3 on finasteride: these numbers are too small The incidence of FFA continues to increase. The
and uncontrolled to draw far-reaching conclusions, origin is unknown, but it is typically observed in
but they are suggestive of a positive effect of 5aRIs postmenopausal women without significant hormo-
on the process of FFA. Dutasteride is a more potent nal abnormalities. Although histologically similar to
inhibitor of 5aR than finasteride because it inhibits classic LPP, FFA is clinically characterized by moth-
both type 1 and type 2 5aR versus only type 2 5aRi eaten recession of the fronto-tempero-parietal hair-
with finasteride.35 As a result, in men, dutasteride has line, perifollicular erythema, and eyebrow loss.
been shown to decrease dihydrotestosterone levels There is no established therapy for FFA, but stabi-
by greater than 90%, compared to about 66% with lization of hair loss is occasionally observed with
finasteride.35 There were no reports of any untoward various topical or systemic therapies; further, it is
side effects with the use of either finasteride or possible that the natural history of FFA is to stabilize
dutasteride and no significant hormonal changes. over time with or without intervention. The majority
Post 5aRi estradiol levels measured in postmeno- of our patients using 5aRis, specifically dutasteride,
pausal women not on hormone replacement therapy experienced stabilization of hair loss, warranting
ranged from 5 to 10 pg/mL, with less than 30 pg/mL further investigation of 5aRis in the treatment of this
being the upper limit of normal for untreated post- condition. A recent consensus meeting held at
menopausal women. Duke University established methodology for con-
Of note, dutasteride, like finasteride, is terato- trolled clinical trials in FFA and a questionnaire to
genic in male fetuses (pregnancy category X) and examine potential causative factors, measures that
can cause male genital feminization as a result of may help provide the necessary data to unravel this
decreased dihydrotestosterone; thus, given the pro- condition.
longed half-life, premenopausal women should
REFERENCES
probably not use dutasteride. Generally, women of 1. Kossard S. Postmenopausal frontal fibrosing alopecia: scarring
childbearing potential should always use 5aRIs in alopecia in a pattern distribution. Arch Dermatol 1994;130:
combination with an oral contraceptive. 770-4.
Pioglitazone is a peroxisome proliferator- 2. Tosti A, Piraccini BM, Iorizzo M, Misciali C. Frontal fibrosing
activated receptor-g agonist that has recently been alopecia in postmenopausal women. J Am Acad Dermatol
2005;52:55-60.
reported by Mirmirani and Karnik36 to treat LPP. 3. Moreno-Ramırez D, Camacho Martınez F. Frontal fibrosing
Given that FFA is a variant of LPP, it is hypothesized alopecia: a survey in 16 patients. J Eur Acad Dermatol Venereol
that pioglitazone might be effective in FFA. 2005;19:700-5.
J AM ACAD DERMATOL Ladizinski et al 755
VOLUME 68, NUMBER 5

4. Georgala S, Katoulis AC, Befon A, Danopoulou I, Georgala C. 20. Junqueira Ribeiro Pereira AF, Vincenzi C, Tosti A. Frontal
Treatment of postmenopausal frontal fibrosing alopecia with fibrosing alopecia in two sisters. Br J Dermatol 2010;162:1154-5.
oral dutasteride. J Am Acad Dermatol 2009;61:157-8. 21. Miteva M, Aber C, Torres F, Tosti A. Frontal fibrosing alopecia
5. Katoulis A, Georgala, Bozi E, Papadavid E, Kalogeromitros D, occurring on scalp vitiligo: report of four cases. Br J Dermatol
Stavrianeas N. Frontal fibrosing alopecia: treatment with oral 2011;165:445-7.
dutasteride and topical pimecrolimus. J Eur Acad Dermatol 22. Dlova N, Goh CL, Tosti A. Familial frontal fibrosing alopecia. Br
Venereol 2009;23:580-2. J Dermatol 2013;168:220-2.
6. Chiang C, Sah D, Cho BK, Ochoa BE, Price VH. Hydroxychlor- 23. Venning VA, Dawber RP. Patterned androgenic alopecia in
oquine and lichen planopilaris: efficacy and introduction of women. J Am Acad Dermatol 1988;18:1073-7.
Lichen Planopilaris Activity Index scoring system. J Am Acad 24. Hamilton JB. Patterned loss of hair in man; types and
Dermatol 2010;62:387-92. incidence. Ann N Y Acad Sci 1951;53:708-28.
7. Samrao A, Chew AL, Price V. Frontal fibrosing alopecia: a 25. Ludwig E. Classification of the types of androgenetic alopecia
clinical review of 36 patients. Br J Dermatol 2010;163:1296-300. (common baldness) occurring in the female sex. Br J Dermatol
Junqueira Ribeiro Pereira AF, Vincenzi C, Tosti A. Frontal 1977;97:247-54.
fibrosing alopecia in two sisters. Br J Dermatol 2010;162: 26. Olsen EA. The midline part: an important physical clue to the
1154-5. clinical diagnosis of androgenetic alopecia in women. J Am
8. Tan KT, Messenger AG. Frontal fibrosing alopecia: clinical Acad Dermatol 1999;40:106-9.
presentations and prognosis. Br J Dermatol 2009;160:75-9. 27. Chew AL, Bashir SJ, Wain EM, Fenton DA, Stefanato CM.
9. Zinkernagel MS, Tr€ ueb RM. Fibrosing alopecia in a pattern Expanding the spectrum of frontal fibrosing alopecia: a
distribution: patterned lichen planopilaris or androgenetic unifying concept. J Am Acad Dermatol 2010;63:653-60.
alopecia with a lichenoid tissue reaction pattern? Arch 28. Miteva M, Camacho I, Romanelli P, Tosti A. Acute hair loss on
Dermatol 2000;136:205-11. the limbs in frontal fibrosing alopecia: a clinicopathological
10. Avodart [package insert]. Research Triangle Park, NC: study of two cases. Br J Dermatol 2010;163:426-8.
GlaxoSmithKline; 2012. 29. Armenores P, Shirato K, Reid C, Sidhu S. Frontal fibrosing
11. Sudduth SL, Koronkowski MJ. Finasteride: the first 5 alpha- alopecia associated with generalized hair loss. Australas J
reductase inhibitor. Pharmacotherapy 1993;13:309-25; discus- Dermatol 2010;51:183-5.
sion 325-9. 30. Feldmann R, Harms M, Saurat JH. Postmenopausal frontal
12. Thai KE, Sinclair RD. Finasteride for female androgenetic fibrosing alopecia. Hautarzt 1996;47:533-6.
alopecia. Br J Dermatol 2002;147:812-3. 31. Olsen EA. Female pattern hair loss and its relationship to
13. Tosti A, Miteva M, Torres F. Lonely hair: a clue to the permanent/cicatricial alopecia: a new perspective. J Investig
diagnosis of frontal fibrosing alopecia. Arch Dermatol 2011; Dermatol Symp Proc 2005;10:217-21.
147:1240. 32. Tr€ueb RM, Torricelli R. Lichen planopilaris simulating post-
14. Abbas O, Chedraoui A, Ghosn S. Frontal fibrosing alopecia menopausal frontal fibrosing alopecia (Kossard). Hautarzt
presenting with components of Piccardi-Lassueur-Graham-Little 1998;49:388-91.
syndrome. J Am Acad Dermatol 2007;57(Suppl):S15-8. 33. Sato M, Saga K, Takahashi H. Postmenopausal frontal fibrosing
15. Faulkner CF, Wilson NJ, Jones SK. Frontal fibrosing alopecia alopecia in a Japanese woman with Sj€ ogren’s syndrome.
associated with cutaneous lichen planus in a premenopausal J Dermatol 2008;35:729-31.
woman. Australas J Dermatol 2002;43:65-7. 34. Chiang YZ, Tosti A, Chaudhry IH, Lyne L, Farjo B, Farjo N, et al.
16. Kossard S, Lee MS, Wilkinson B. Postmenopausal frontal Lichen planopilaris following hair transplantation and face-lift
fibrosing alopecia: a frontal variant of lichen planopilaris. surgery. Br J Dermatol 2012;166:666-70.
J Am Acad Dermatol 1997;36:59-66. 35. Olsen EA, Hordinsky M, Whiting D, Stough D, Hobbs S, Ellis ML,
17. Kossard S, Shiell RC. Frontal fibrosing alopecia developing et al, Dutasteride Alopecia Research Team. The importance of
after hair transplantation for androgenetic alopecia. Int J dual 5 alpha-reductase inhibition in the treatment of male
Dermatol 2005;44:321-3. pattern hair loss: results of a randomized placebo-controlled
18. Stockmeier M, Kunte C, Sander CA, Wolff H. Kossard frontal study of dutasteride versus finasteride. J Am Acad Dermatol
fibrosing alopecia in a man. Hautarzt 2002;53:409-11. 2006;55:1014-23.
19. Nusbaum BP, Nusbaum AG. Frontal fibrosing alopecia in a 36. Mirmirani P, Karnik P. Lichen planopilaris treated with a
man: results of follicular unit test grafting. Dermatol Surg peroxisome proliferator-activated receptor gamma agonist.
2010;36:959-62. Arch Dermatol 2009;145:1363-6.