Portal de Periódicos da CAPES

Trichoscopic features of frontal fibrosing alopecia: Results in 249 patients

2015; Elsevier BV; Volume: 72; Issue: 2 Linguagem: Inglês

10.1016/j.jaad.2014.10.039

1097-6787

Pablo Fernández‐Peñas, Ana Rita Rodrigues-Barata, Sérgio Vañó-Galván, C. Serrano‐Falcón, A.M. Molina‐Ruiz, Salvador Arias‐Santiago, A. Martorell, Ramón Grimalt, Gloria Garnacho‐Saucedo, Salvio Serrano, José C. Moreno, Pedro Jaén, Francisco M. Camacho-Martínez,

Cutaneous lymphoproliferative disorders research

To the Editor: Currently, dermoscopy constitutes an essential noninvasive tool for dermatologists. It helps discern between different types of alopecia, it provides a more precise follow-up, and it can be used to identify an adequate biopsy site.1Miteva M. Tosti A. Dermoscopy guided scalp biopsy in cicatricial alopecia.J Eur Acad Dermatol Venereol. 2013; 27: 1299-1303PubMed Google Scholar Frontal fibrosing alopecia (FFA) is a primary lymphocytic scarring alopecia with a distinctive clinical pattern of progressive frontotemporal hairline recession and eyebrow loss that mainly affects postmenopausal women.2Moreno-Ramírez D. Ferrándiz L. Camacho F.M. Diagnostic and therapeutic assessment of frontal fibrosing alopecia.Actas Dermosifiliogr. 2007; 98: 594-602Crossref PubMed Scopus (34) Google Scholar The main objective of our study was to describe the trichoscopic features of FFA in a large series of patients and to correlate these findings with several relevant parameters of FFA.2Moreno-Ramírez D. Ferrándiz L. Camacho F.M. Diagnostic and therapeutic assessment of frontal fibrosing alopecia.Actas Dermosifiliogr. 2007; 98: 594-602Crossref PubMed Scopus (34) Google Scholar, 3Miteva M. Tosti A. Hair and scalp dermatoscopy.J Am Acad Dermatol. 2012; 67: 1040-1048Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar We performed a descriptive, retrospective, observational, multicenter study of digital trichoscopic images, obtained between 1994 and 2013, of 238 women with FFA at 12 Spanish centers.4Vañó-Galván S. Molina-Ruiz A.M. Serrano-Falcón C. et al.Frontal fibrosing alopecia: a multicenter review of 355 patients.J Am Acad Dermatol. 2014; 70: 670-678Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar Diagnostic criteria included typical clinical signs and/or histopathologic features consistent with FFA.2Moreno-Ramírez D. Ferrándiz L. Camacho F.M. Diagnostic and therapeutic assessment of frontal fibrosing alopecia.Actas Dermosifiliogr. 2007; 98: 594-602Crossref PubMed Scopus (34) Google Scholar Images were obtained with either a nonpolarizing or a polarizing dermoscope. Two dermatologists expert in dermoscopy evaluated the images if the registered trichoscopic features of FFA (cicatricial white patches, perifollicular erythema, follicular hyperkeratosis, lonely hairs, and hair diameter diversity) and yellow dots typical of androgenetic alopecia were present on the frontotemporal hairline.3Miteva M. Tosti A. Hair and scalp dermatoscopy.J Am Acad Dermatol. 2012; 67: 1040-1048Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar Both a descriptive and an analytic study to correlate these parameters with the degree of severity and other clinical variables were performed using SPSS 15.0 software. Clinical and severity variables included female pattern hair loss (FPHL), presence or absence of menopause, FFA severity (I: 1 cm, II: 1-2.99 cm, III: 3-4.99 cm, IV: 5-6.99 cm, and V: >7 cm), and years of evolution, pruritus, trichodynia, facial papules, occipital involvement, eyebrow and eyelash loss, pubis hair loss, and body hair involvement. A bivariate analysis including trichoscopic findings and the aforementioned variables was carried out, and those variables with statistical significance in X2 test were included in a multivariate logistic regression analysis adjusted for age and excluding lost cases. No new dermoscopic signs were found. Descriptive dermoscopic results are listed in Table I. Both the intraobserver and interobserver agreement for the assignment of a dermoscopic pattern for each lesion were excellent (κ = 0.82, P < .001; κ = 0.80, P < .001, respectively). The trichoscopic features that were statistically significantly associated (P < .05) with some clinical parameters in the bivariate and multivariate logistic regression analysis are listed in Table II.Table IFrequency of trichoscopic features of patients diagnosed with FFA: Relationship between trichoscopic features and FFA severity, pruritus, and trichodyniaFFA severity (X2 test∗P value calculated with X2 test with P values. Differences were considered significant at P ≤ .05.)Pruritus (X2 test∗P value calculated with X2 test with P values. Differences were considered significant at P ≤ .05.)Trichodynia (X2 test∗P value calculated with X2 test with P values. Differences were considered significant at P ≤ .05.)Trichoscopic featuresMild (I-II)Severe (III-V)NoYesNoYesFollicular hyperkeratosis89.6%NS90.9%NS85.2%96% (P = .007)88.6%94.3%NSPerifollicular erythema77%NS65.9%NS68.3%83% (P = .01)75.1%73.6%NSLonely hair67.9%NS77.3%NS54.9%78% (P = .001)54.9%83% (P = .001)Hair diameter diversity45%NS56.8%NS32.8%64% (P = .001)36%81.1% (P = .001)Cicatricial white patches22.3%NS43.2% (P = .018)24.4%29%NS24.1%34%NSYellow dots21.9%NS20.5%NS19.7%24%NS21.3%22.6%NSFFA, Frontal fibrosing alopecia; NS, nonsignificant.∗ P value calculated with X2 test with P values. Differences were considered significant at P ≤ .05. Open table in a new tab Table IITrichoscopic features statistically significantly associated with clinical parameters in the bivariate and multivariate logistic regression analysisTrichoscopic featuresBivariate analysis (X2 test∗P value calculated with X2 test with P values. Differences were considered significant at P ≤ .05.)Multivariate logistic regression analysis (IC: 95%) (X2 test∗P value calculated with X2 test with P values. Differences were considered significant at P ≤ .05.)Follicular hyperkeratosis (213/238 patients)Pruritus (P = .007) and menopause (P = .05)PruritusP = .12OR = .24Perifollicular erythema (173/238 patients)Pruritus (P = .01)PruritusP = .02OR = .47Lonely hair (212/238 patients)Pruritus (P = .001), trichodynia (P = .001)PruritusP = .007OR = .41Hair diameter diversity (110/238 patients)Pruritus (P = .001), trichodynia (P = .001), FPHL (P = .001) and severity (P = .001), axillary hair loss (P = .001), pubic hair loss (P = .004)FPHL severityP = .04OR = .11Cicatricial white patches (59/238 patients)FPHL (P = .01) and severity (P = .023), FFA severity (P = .018), occipital (P = .04), axillary (P = .01) and pubis hair loss (P = .001)FFA severityP = .047OR = .24and pubic hair lossP = .03OR = .20Yellow dots (48/238 patients)FPHL (P = .001), occipital (P = .03), and pubic hair loss (P = .05)FPHL P = .0001OR = .29, occipital P = .024OR = .39FFA, Frontal fibrosing alopecia; FPHL, female pattern hair loss.∗ P value calculated with X2 test with P values. Differences were considered significant at P ≤ .05. Open table in a new tab FFA, Frontal fibrosing alopecia; NS, nonsignificant. FFA, Frontal fibrosing alopecia; FPHL, female pattern hair loss. Dermoscopic features of FFA have previously been described in some isolated studies.2Moreno-Ramírez D. Ferrándiz L. Camacho F.M. Diagnostic and therapeutic assessment of frontal fibrosing alopecia.Actas Dermosifiliogr. 2007; 98: 594-602Crossref PubMed Scopus (34) Google Scholar, 3Miteva M. Tosti A. Hair and scalp dermatoscopy.J Am Acad Dermatol. 2012; 67: 1040-1048Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar Toledo-Pastrana et al5Toledo-Pastrana T. García Hernández M.J. Camacho Martínez F.M. Perifollicular erythema as a trichoscopy sign of progression in frontal fibrosing alopecia.Int J Trichology. 2013; 5: 151-153Crossref PubMed Scopus (34) Google Scholar retrospectively analyzed the dermoscopic images of 79 patients with FFA. They found that 100% of the patients showed no follicular openings, 72.1% showed follicular hyperkeratosis, 66.3% showed perifollicular erythema, and 44.8% showed follicular plugs. Interestingly, they also found that perifollicular erythema was statistically associated to the activity of FFA. In our study, we correlated the dermoscopic features with another outcome: the severity of the disease in terms of extension of the hairline.4Vañó-Galván S. Molina-Ruiz A.M. Serrano-Falcón C. et al.Frontal fibrosing alopecia: a multicenter review of 355 patients.J Am Acad Dermatol. 2014; 70: 670-678Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar Remarkably, we found that the presence of cicatricial white patches was statistically associated with the severity of FFA. This dermoscopic feature correlates with the histopathologic findings of hair follicle destruction and severe tissue fibrosis.3Miteva M. Tosti A. Hair and scalp dermatoscopy.J Am Acad Dermatol. 2012; 67: 1040-1048Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar Therefore, it is understandable that severe FFA presents cicatricial white patches more frequently than mild FFA, reflecting the increased number of hair follicles destroyed. Another interesting finding was the association between perifollicular erythema and follicular hyperkeratosis with pruritus, supporting the hypothesis that the erythema is produced by the lichenoid infiltrate seen on histopathological examination, producing pruritus and representing a marker of activity of FFA.5Toledo-Pastrana T. García Hernández M.J. Camacho Martínez F.M. Perifollicular erythema as a trichoscopy sign of progression in frontal fibrosing alopecia.Int J Trichology. 2013; 5: 151-153Crossref PubMed Scopus (34) Google Scholar The yellow dots and hair diameter diversity were observed in patients with associated FPHL, with hair diameter diversity being related to Ludwig's classification. Patients with pubic hair loss presented more cicatricial white patches. Our study presents three main limitations: the retrospective design, the presence of only 2 observers evaluating each patient, and the fact that neither the treatment for alopecia nor the activity of the disease was included in the analysis. In conclusion, the presence of perifollicular erythema and cicatricial white patches is independently associated with pruritus and the severity of FFA, respectively. Trichoscopy is a valuable tool not only in the diagnosis of FFA, but also in estimating the activity, symptoms, and severity of the disease.