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Frontal fibrosing alopecia in an Afric an man .
Published as: Dlova NC, Goh CL. Frontal fibrosing alopecia in an African man. Int J Dermatol 2013 [Cited 18 December 2014] DOI: 10.1111/j.1365-4632.2012.05821.x. [Epub ahead of print]
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Case report
Frontal fibrosing alopecia in an African man
Ncoza C. Dlova1, MBChB, FCDerm, and Chee-Leok Goh2, MD, MBBS, MRCP (UK), FRCPE
1Department of Dermatology, Nelson R.
Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa, and
2National Skin Centre, Singapore, Singapore
Correspondence
Ncoza C. Dlova,MBChB,FCDerm
Department of Dermatology
Nelson R. Mandela School of Medicine University of KwaZulu-Natal
Private Bag X7, Congella Durban 4013
South Africa
E-mail: [email protected] Conflicts of interest: none.
doi: 10.1111/j.1365-4632.2012.05821.x
Case report
A 35-year-old African man developed an asymptomatic progressive recession of the frontal hairline over 1 year.
Clinical examination revealed frontotemporal recession with loss of follicular orifices and partial loss of both eye- brows (Fig. 1a,b). Routine examination of the remaining scalp was normal. Further close inspection of the hair margin with a dermatoscope showed perifollicular plug- ging and very subtle erythema masked by pigmentation (Fig. 1c). The rest of the body, including the hair, nails and mucosa, was unaffected. The subjects general medical and drug history were insignificant. His family history showed no evidence of similar or any other scarring alo- pecia. The patient had always maintained natural virgin hair and had no history of using chemicals or mechanical manipulation for hair grooming purposes. Thyroid screen, antinuclear factor, complete blood count and hepatitis screen were normal.
Two 4-mm transverse and horizontal histopathological sections of the affected margin of the scalp revealed fea- tures typical of lichenplanopilaris,1–3 including reduced follicular density, a lichenoid lymphocytic infiltrate involving the outer root sheaths of the upper follicles, mild perifollicular fibrosis and follicular dropout (Fig. 2).
A diagnosis of frontal fibrosing alopecia (FFA) was confirmed and the patient was commenced on hydroxy- chloroquine 200 mg twice per day for 6 months, topical
steroid (clobetasol diproprionate), 0.1% tacrolimus and 2% minoxidil. The patient was followed up for 1 year and showed a good response to treatment evidenced by the slow progression of the disorder.
Discussion
Frontal fibrosing alopecia has been classified as a variant of lichenplanopilaris (LPP) based on some reports docu- menting an association with classical multifocal LPP over the vertex of the scalp and other sites, in addition to the typical histological findings.1Although LPP is uncommon, Ochoa et al. 4 have reported annual incidence rates of 1.15–7.59% in hair referral centers in the USA.
Typically, FFA presents with a frontoparietal pattern of hair loss and is usually associated with the loss of eye- brows.2It may also be associated with hair loss on other peripheral body hair sites, which was recently confirmed histopathologically.3,5The condition may be accompanied by pruritus, as well as evidence of perifollicular erythema, scaling and diminished follicular orifices.1 Although our patient did not have evidence of hair loss from peripheral body sites at the time of examination, he did show clini- cal evidence of bilateral eyebrow hair loss; however, he declined eyebrow biopsy. Chewet al.3performed biopsies on eyebrows and the upper limbs of affected patients to show that LPP with scarring alopecia is a generalized pro- cess rather than one that is localized to the frontal scalp.
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Although our patient revealed intact peripheral body hair at the time of examination, it is possible that further evolution of the disease and ongoing follow-up will enable us to confirm Chewet al.s findings.3
The etiology of this primary cicatricial alopecia remains uncertain and its treatment is therefore challenging.
Suggested treatments comprise topical corticosteroids, tacrolimus, chloroquine, finasteride and dutasteride.6–8 Frontal fibrosing alopecia predominantly occurs in post- menopausal women, but there are a few reports of its emergence in premenopausal women6 and its sporadic occurrence in White men is well known.1,9 In 2012, Mitevaet al.10reported the first male of African-American descent with FFA amongst 10 Black female patients with FFA in a retrospective chart review study conducted in the USA and UK.
To our knowledge, the present patient is the second Black male and the first male of African descent from Africa with FFA to be reported in the English-language literature. The presentation, and clinical and histopatho- logical findings in this case were similar to those in other male cases reported in the literature.1,9,11 The present case, together with the series reported by Mitevaet al.,10 indicates that FFA occurs in patients of African, African- American and Afro-Caribbean descent and is not confined to White and Asian populations, and that practitioners should be alert to this condition in Black males, who, unlike Black females, may not be subject to traction alo- pecia. Frontal fibrosing alopecia has not been reported in the African continent previously. Hence, this case illus- trates that the condition exists in Africa, where frontal hair recession is often attributed to traction alopecia.
Figure 2 Histopathology shows vacuolar interface changes with scattered lymphocytes and perifollicular fibrosis in keeping with lichenplanopilaris. (Hematoxylin and eosin stain; original magnification9100)
(a)
(b)
(c)
Figure 1 (a) Scarring alopecia presents with lighter skin and the loss of eyebrow hair. (b) Frontoparietal hairline recession is apparent. (c) Close examination shows perifollicular plugging and dusky erythema
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Case report Frontal fibrosing alopecia in an african man Dlovaet al.
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Acknowledgments
Mick Forder,MD, AMPATH Laboratories, Durban, South Africa and Esra Masinga, MD, Lancet Laboratories, Durban, South Africa, are thanked for reporting on the histology in this case.
References
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9 Zinkernagel MJ, Trueb RM. Fibrosing alopecia in a pattern distribution: patterned lichen planopilaris or androgenic alopecia with a lichenoid tissue reaction pattern?Arch Dermatol2000;136: 205–211.
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