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Isolated eyebrow loss in frontal fibrosing alopecia: relevance of early diagnosis and treatment

DEAR EDITOR, Frontal fibrosing alopecia (FFA) is a primary lymphocytic cicatricial alopecia. It is characterized by progressive loss of the frontotemporal hairline and eyebrows and affects mainly postmenopausal women. Eyebrow loss is observed in the majority of patients, with a negative impact on quality of life. Eyebrow alopecia is thought to precede scalp alopecia in 39% of cases, and prompt investigation of eyebrow alopecia may lead to early diagnosis and treatment. Herein we describe three patients with FFA who presented with isolated eyebrow loss (Fig. 1). Their clinical, dermoscopic and histological findings are described in Table 1. All patients were female and premenopausal and presented with progressive diffuse partial loss of the eyebrows over a 5–6-month period. Two patients also had facial skin-coloured papules. The family history for FFA was positive in one patient, whose mother had received a diagnosis of FFA a few years before. On dermoscopy, all three had dystrophic broken hairs on the eyebrows. Biopsies of the eyebrows showed lichenoid perifolliculitis, confirming the diagnosis of FFA in all cases. At follow-up, two patients maintained eyebrow density and one patient improved but developed moderate atrophy on distal parts of both sides due to steroid injections. None of them evolved with loss of frontotemporal hairs after 1 (patient two), 2 (patient three) and 3 (patient one) years of follow-up. Treatment included intralesional triamcinolone acetonide 2 5 mg mL 1 (two patients), hydroxychloroquine 400 mg per day (all patients), topical tacrolimus 0 1% (all patients), finasteride 5 mg per day (one patient) and topical minoxidil 5% foam daily (one patient). The incidence of FFA is increasing worldwide, and it affects most frequently postmenopausal women. Eyebrow involvement, lichen planus pigmentosus and other facial lesions, such as facial papules, follicular red dots and perifollicular or diffuse erythema, are considered early signs of the disease. They precede the scalp hair loss by several months to years and have been described in premenopausal women in a high frequency. All of our patients were premenopausal.