Frontal Fibrosing Alopecia in a Male Presenting with Sideburn Loss

Abstract

Frontal fibrosing alopecia (FFA) is a cicatricial alopecia that affects mainly postmenopausal women. It is typically characterized by recession of frontotemporal hairline. Hair loss of eyebrows, eyelashes, axillae, limbs, and pubic area may be observed. Here, we describe a case of FFA in a male patient presenting with only localized loss of sideburns. Skin biopsy findings were consistent with lichen planopilaris. To our knowledge, this is the only reported case of FFA patient with only localized loss of sideburns.

INDRODUCTION

Frontal fibrosing alopecia (FFA) is mainly a disease of postmenopausal women,[1,2,3] and it is rarely seen in men. To the best of our knowledge and belief, only 23 cases of men with FFA have been reported in the literature.[1,2,3,4,5,6,7,8,9,10] FFA in a male patient was first described in 2002 by Stockmeier et al. in a 69-year-old man who presented with recession of the frontal hairline, and loss of eyebrows and sideburns.[4] In women, FFA is typically characterized by progressive recession of frontotemporal hairline and usually associated with loss of eyebrow.[1,2,3] In men, the beard area may be affected, and loss of the sideburns can be a prominent feature.[2]

CASE REPORT

A 46-year-old man consulted for small patches of alopecia involving the sideburns and the beard area. Patient stated the disease had developed 3 years before and was diagnosed as alopecia areata. Treatment with intralesional and topical steroids did not produce regrowth. Clinical examination showed patchy alopecia of the beard and small atrophic patches of alopecia on sideburns [Figure 1a]. Dermoscopy showed loss of follicular openings and thin peripilar casts [Figure 1b]. A punch biopsy was obtained using the dermoscopy guided biopsy technique and was bisected as horizontal sections. It showed overall preserved follicular architecture with a focal area of follicular dropout and disappearance of the sebaceous glands. The follicular density was significantly reduced to five follicles (three terminal follicles and two intermediate size follicles) [Figure 2a]. At the level of the isthmus, one follicle showed perifollicular fibrosis and a mild lichenoid infiltrate in perifollicular distribution [Figure 2b]. Naked hair shafts were observed in the dermis within fibrotic tracts. These features were consistent with lichen planopilaris (LPP).

Figure 1.

(a) Small atrophic patches of alopecia on sideburns (b) Dermoscopy showed loss of follicular openings and thin peripilar casts

Figure 2.

(a) Significant decrease in follicular density with only five follicles (three terminal follicles and two intermediate size follicles) (b) At the level of the isthmus, one follicle showed perifollicular fibrosis and a mild lichenoid infiltrate in perifollicular distribution

DISCUSSION

Frontal fibrosing alopecia first described by Kossard in 1994 in 6 postmenopausal women as a progressive scarring frontal alopecia.[11] FFA mainly affects postmenopausal women, although it can be seen in premenupausal women and men.[1,2,3] It is considered as a variant of LPP.[1,2,3,6] The exact pathogenesis is unknown although hormonal factors and an autoimmune process may play a role.[2] FFA presents usually with a progressive recession of frontotemporal hairline and loss of eyebrows.[1,2,3] Other clinical features of FFA include hair loss involving eyelashes, axillae, pubic area and extremities, pruritus, burning sensation, trichodynia, and facial papules.[1,2,3,6,8] On examination, perifollicular erythema, perifollicular hyperkeratosis, and lonely hairs may be seen.[1,2,3,6,8] Pathology of FFA shows lichenoid lymphocytic infiltrate, follicular fibrosis with destruction of hair follicles.[1,3,6] Treatment is challenging, and different modalities have been used including corticosteroids (topical, intralesional and systemic), antimalarial (hydroxychloroquine or chloroquine), finasteride or dutasteride, doxycycline, topical calcineurin inhibitor, and topical minoxidil.[12]

We describe in this report a male patient with FFA presenting only with the loss of sideburns and beard area. Table 1 lists the reported cases of male patients of FFA with loss of sideburns. Ramaswamy et al.[6] described sideburn loss as a unique presentation of FFA in men and reported three patients with loss of sideburns and some other features of FFA as shown in Table 1. In contrast to our case, the patient we reported had only localized loss of sideburns with no other features of FFA. Accordingly, loss of sideburns can be the only presenting feature in men with FFA. In such patients, the diagnosis of FFA may be overlooked. We recommend that all patients presenting the loss of sideburns should be examined thoroughly for the other clinical features of FFA, and a skin biopsy has to be done to confirm the diagnosis.

Table 1.

Lists the reported cases of male patients of FFA with loss of sideburns