Retrospective review of 18 British South Asian women
with frontal ﬁbrosing alopecia
Frontal ﬁbrosing alopecia (FFA) was ﬁrst described in 1994.
While FFA was initially described exclusively in post-
menopausal Caucasian women, it has since been reported in
Hispanic, African, Afro-Caribbean, and Asian individuals, pre-
menopausal women, and men.
There is no epidemiological
data on the incidence or prevalence of FFA in the general
population, but anecdotal evidence from multiple specialist
centers suggests that the incidence is increasing.
the high prevalence of South Asians in the United Kingdom
(5%, UK Census 2011), there is paucity of published informa-
tion about South Asians with FFA.
We conducted a retrospective review of 578 FFA patients
from four hair specialist units in the United Kingdom. We identi-
ﬁed 18 women of Indian, Pakistani, and Bangladeshi origin
(3.1%). The mean age at diagnosis was 52 (range 41–71). Ten
of 18 (56%) were premenopausal. Eleven (60%) had perifollicu-
lar erythema and/or hyperpigmentation over the affected areas
on the scalp. Fourteen (77%) had associated eyebrow loss, and
nine (50%) had body hair loss. Eight of the 18 women (44%)
had facial hyperpigmentation clinically consistent with lichen pla-
nus pigmentosus (LPPigm), and this was conﬁrmed histologi-
cally in four patients. The hyperpigmentation affected the face
and neck, and the pattern was diffuse in six cases, speckled in
one, and there were multiple macules in two cases (Fig. 1).
One patient presented with facial papules.
Interestingly, the majority of South Asians with FFA (56%)
were premenopausal in contrast to a much smaller proportion of
premenopausal Caucasian women with FFA (14–17%).
coexistence of FFA with facial hyperpigmentation due to
LPPigm was ﬁrst described 4 years ago.
due to LPPigm seems to be a unique feature of FFA seen in
darker skin types, as seen in our cohort (44%) and in previously
published cohorts from South Africa (54%)
, although the back-
ground prevalence of LPPigm (without FFA) in this population is
Study limitations include the retrospective design, potential
skewing of numbers due to access or referral practices, and
the fact that not all of our patients with facial hyperpigmenta-
tion had skin biopsies or patch testing to exclude alternative
diagnoses. There is growing evidence that lichenoid/pigmented
contact dermatitis is associated with leave-on facial cosmetics,
patch test reactions, and FFA pathogenesis.
chloroquine-induced pigmentation may mimic LPPigm clinically
and dermoscopically, as antimalarials are commonly prescribed
There are limited data about the coexistence of FFA and
The question that arises from these
observations is whether LPPigm is part of the spectrum of
FFA or whether LPPigm is a distinct entity which occurs coin-
cidently with FFA in darker skin types. Supporting the same
spectrum theory is that both have histological similarities,
LPPigm seems more common in South Asian individuals with
FFA, and both conditions are more common in women.
the other hand, LPPigm is less common than FFA and is
extremely rare in Caucasians, while FFA is more common in
Caucasians. Finally, FFA is more common in postmenopausal
women, while LPPigm affects younger premenopausal women
This retrospective review has demonstrated that LPPigm is
seen in a high proportion of patients of South Asian origin
with FFA – this seems to be a unique feature in darker skin
types given the similar ﬁnding in South African patients.
addition, a greater majority of Asian patients with FFA are
premenopausal compared with Caucasian cohorts – this
ideally needs validation with larger series. Given that almost
half of all women in our series had coexistent LPPigm, we
would strongly advocate that careful clinical examination of
the frontal hairline should be considered in South Asian
patients presenting with LPPigm to look for coexisting FFA.
We would also consider patch testing and skin biopsies in
patients with FFA and LPPigm to exclude other causes of
These photos show a Pakistani woman with
frontotemporal recession, eyebrow loss, and facial and
temporal hyperpigmentation in a diffuse pattern. Histology
showed lichenoid changes consistent with lichen planus
International Journal of Dermatology 2018, 57, 490–501 ª 2018 The International Society of Dermatology