Hair Transplant in Patchy Scarring Alopecia of the Fronto-Temporal Area

Abstract

Introduction

Patchy scarring alopecia in the fronto-temporal areas presents a diagnostic challenge, requiring accurate recognition for proper management. Cicatricial marginal alopecia (CMA) and frontal fibrosing alopecia (FFA) are key differential diagnoses, distinguishable through histopathology. FFA has variable prognosis, depending on typical or atypical patterns. Literature on hair transplantation (HT) in CMA and FFA is limited, with inconsistent outcomes and little data on FFA subtypes. This study aimed to describe HT outcomes in patients with atypical FFA patterns.

Case Presentation

Patients were followed at the Municipal Public Servant Hospital of São Paulo, Brazil, from 2016 to 2023. Three postmenopausal women with patchy FFA confirmed by clinical and histological criteria underwent HT using the follicular unit transplantation technique. Over 5 to 6 years of follow-up, two patients had mild graft loss, and one experienced more significant loss. No clinical signs of disease reactivation were observed.

Conclusion

Despite the small sample size and retrospective design, this study offers valuable insight into long-term graft survival in atypical FFA. Mild hair density reduction occurred after more than 5 years, with all patients reporting high satisfaction with aesthetic results. Larger prospective studies are needed to confirm long-term HT efficacy in this population.

Established Facts

• Literature on hair transplantation (HT) in scarring alopecia is scarce, and the results are conflicting, with no data related to frontal fibrosing alopecia patterns. Most authors agree that HT should only be performed after a period of disease stabilization.

Novel Insights

• We present a series of cases of atypical AFF, which we believe have a better prognosis based on clinical experience, that were submitted to follicular unit transplantation and their follow-up for more than 5 years.

Introduction

Patchy scarring alopecia of the fronto-temporal area presents a diagnostic challenge, and accurate recognition can lead to more effective clinical and surgical management. Cicatricial marginal alopecia (CMA), a noninflammatory primary scarring alopecia, was first described by Goldberg [1] in 2008. It is characterized by cicatricial alopecia along the scalp margins without a history of traction. Histologically, CMA shows a reduced number of hair follicles, preserved sebaceous glands, and fibrosis.

Frontal fibrosing alopecia (FFA) represents the main differential diagnosis. Histopathology typically reveals a lichenoid perifollicular inflammatory infiltrate in the infundibulum and isthmus, concentric perifollicular fibrosis, and absence of sebaceous glands [2]. FFA exhibits variable prognoses depending on whether typical or atypical patterns are present [2–5]. It primarily affects the frontal and temporal hairline. Three atypical FFA patterns have been described: the plaque pattern, male pattern, and ophiasic pattern [2–5].

The literature regarding hair transplantation (HT) in CMA or patchy FFA is sparse and often yields conflicting results [6–8], with no data specifically addressing HT outcomes based on FFA subtypes. Despite the lack of robust evidence, most experts recommend that HT should only be performed after a stable disease period ranging from 1 to 5 years, with an average of 2 years [6]. This study aimed to describe the long-term outcomes of HT in a series of patients with atypical FFA patterns.

Case Report

Patients were followed at the Municipal Public Servant Hospital of São Paulo, Brazil, between 2016 and 2023. Three postmenopausal women diagnosed with patchy FFA based on clinical and histopathological criteria [3] underwent HT using the follicular unit transplantation technique. The donor site was the occipital scalp. Recipient site incisions were made using a 1-mm blade, followed by graft placement with forceps. Patient characteristics are summarized in Table 1.

Table 1.

Characteristics of patchy FFA patients submitted to HT

Patient	Fitzpatrick skin photo-type	Age, years	Time of stability before HT	Previous treatment	HT procedure	Post-HT intercurrences	Post-HT treatment	Follow-up time and evolution
1 – female	II	58	1 year	ILC	FUT: 623 FU	Perifollicular scaling and erythema after 1 year		6 years
								20% loss of grafts
2 – female	IV	59	2 years	Doxycycline, finasteride, topical minoxidil	FUT: 3 HT sessions (number of FU not available)	Perifollicular scaling and erythema	Doxycycline and topical minoxidil immediate 1st post-HT – for 16 months	6 years
								<10% loss of grafts
3 – female	IV	75	11 months	Hydroxychloroquine, doxycycline, methotrexate, and finasteride	2 HT sessions: 1st 260 FU, 2nd 542 FU (HT was carried out only in the FFA area)	No clinical signs of activity	Topical minoxidil	5-year follow-up
								4 years and 4 months after the 2nd session, 20% loss of grafts

AGA, androgenetic alopecia; FU, follicular unit; ILC, intralesional corticosteroid; FUT, follicular unit transplantation.

During a follow-up period of 5 to 6 years, 2 patients experienced mild graft loss, while one presented more pronounced loss, all in the absence of clinical signs of disease reactivation. Based on photographic comparison, estimated graft loss was approximately 20% in patient 1 (Fig. 1), less than 10% in patient 2 (Fig. 2), and about 20% in patient 3 (Fig. 3). This assessment was based on visual comparison, with acknowledged limitations due to variations in hair color and style over time. A more accurate evaluation would involve trichoscopy and graft counting in defined areas, although such methods may not represent the entire transplanted region.

Fig. 1.

Patient 1 – bilateral temporal areas before transplantation, and at 1-year, 2-year, and 6-year follow-up after hair transplant. An estimated graft loss of approximately 20% was observed over this period.

Fig. 2.

Patient 2 – temporal areas before transplantation and at 4-year follow-up after the final procedure. An estimated graft loss of less than 10% was observed.

Fig. 3.

Patient 3 – frontal area before transplantation, at 1-year follow-up after the first procedure, and at 3-year follow-up after the final procedure. An estimated graft loss of approximately 20% was observed during follow-up.

Some patients missed follow-up visits during the COVID-19 pandemic and did not receive treatment during that period. This report follows the CAse REport (CARE) guidelines.

Discussion

The cases presented are consistent with prior reports involving patients with atypical FFA patterns [2–5]. These were distinguished from CMA based on histological findings of sebaceous gland loss and perifollicular inflammation.

Differences in HT outcomes between patients may be explained by the underlying inflammatory activity in FFA, which may predispose to progressive graft loss. Recognizing this differential diagnosis is essential to anticipate potentially unfavorable outcomes.

Although many authors have reported unsatisfactory long-term results of HT in FFA [7], Liu et al. [8] documented favorable outcomes after 3 years. While they did not specify the FFA subtype, the clinical images suggested pattern III involvement [8].

Some studies recommend maintaining immunomodulatory therapy post-HT, even in the absence of active disease [7]. In our series, only one patient received such treatment following transplantation.

In the largest series to date, Vañó-Galván et al. [7] observed progressive graft attrition over time, irrespective of remission duration. However, FFA subtypes were not reported. Type II or “zig-zag” variants are associated with poorer prognosis. Additionally, the posttransplantation treatment regimens used were not disclosed, although no disease reactivation was reported. The etiology of graft failure remains unclear.

This study is limited by its small sample size and retrospective nature. Nonetheless, it provides valuable insight into long-term graft retention in patients with atypical FFA, particularly the patchy subtype, demonstrating only mild visible density loss after more than 5 years. Importantly, all patients reported high satisfaction with the outcomes.

In our view, graft loss may result from postoperative disease reactivation or subclinical inflammation in the donor area. Less aggressive FFA variants, such as the patchy pattern, may be associated with improved long-term graft survival. The CARE Checklist has been completed by the authors, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000546631).

Statement of Ethics

The study complies with the guidelines for human studies, and the research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. The study was reviewed and approved by Hospital of the Municipal Civil Servant of São Paulo (Hospital do Servidor Público Municipal de São Paulo) IRB, Approval No. #83488524.2.0000.5442. Written informed consent was obtained from participants to participate in the study and for publication of the details of their medical case and any accompanying images, and proof of consent is available upon request.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

The authors declare that there was no funding for this study.

Author Contributions

Leticia Arsie Contin and Gustavo Baptista de Almeida Faro: acquisition, analysis, interpretation of data for the work, drafting the work, and final approval of the version to be published. Leopoldo Duailibe Nogueira Santos and Vanessa Barreto Rocha: drafting the work, revising it critically for important intellectual content, and final approval of the version to be published.

Funding Statement

The authors declare that there was no funding for this study.

Data Availability Statement

All data generated or analyzed during this study are included in this article and its online supplementary material. Further inquiries can be directed to the corresponding author.