F9   POSTMENOPAUSAL FRONTAL FIBROSING ALOPECIA: 20 CASES

Vaisse v. Matard b. Assouly P. Jouannique C. Reygagne P. Sabouraud center. Saint Louis hospital, Paris, France

Postmenopausal frontal fibrosing alopecia (PFFA) described by Kossard in 1994 does not seem to be rare. 20 cases of PFFA seen between March 1994 and December 1999 (six of our cases have been previously reported: Washington 1998 now allow us to specify the features of this entity). 19 patients were postmenopausal. For one patient the onset of the scarring alopecia had begun before menopause. The duration of menopause before the onset of alopecia ranged from 2 years to 33 years.12 patients have an hormonal replacement therapy at the onset of the scarring alopecia. The age at onset of the alopecia ranged from 47 to 82 years (mean age 63.8 years). The duration since the onset of the alopecia ranged from 7month to 11 years. The patients developed a progressive scarring fronto temporo parietal hairline recession, ranged from 1 to 7 cm.At the hairline, perifollicular erythema and follicular keratinization were often present .6 to 20 have a marked decrease to complete loss of their eyebrows.One of the patient had  signs of lichen planus at other site confirmed by skin biopsy. One patient had an androgenetic alopecia (AGA). Skin biopsies were done in 8 cases and had shown a histological aspect of lichen planopilaris which evolves into fibrosing scarring. Direct immunofluorescence  were negative in all cases. Treatment including topical corticosteroid (14 cases), oral corticosteroid (2 cases) ,antimalarial drugs (13cases) and acitretin (4cases) were not effective .The patients has been observed for 1 month to 45 months .The course of this scarring alopecia was slow and we observed a stabilisation of the alopecia.The lichenoid  clinical and histological  aspects of the on going lesions of PFFA, the possible association with lesions of lichen planus at other site in 2 patients (case 4 and one described by Trüb RM. Hautzart 1998;49:388-391) lead to consider PFFA as a clinical form of lichen plano pilaris .The reasons of the clinical specificity of this scarring alopecia in elderly women remain unknown. Most of the time they were  postmenopausal, except 2 patients, our case 17 and one case described by Kossard . The link with AGA seems to be complex as it is suggested by the recent report of 19 cases (Arch. Dermatol .2000; 136:205-211) described 19 cases (15 women and 4 men) of lichenoid fibrosing alopecia specifically localised on the site of AGA. Two of them (1 woman and 1 man) also presented a fronto temporo parietal fibrosing alopecia. Nevertheless 6 cases reported by Kossard and one of our cases (case 6) have a PFFA associated with AGA but the scarring alopecia spared the site of AGA. These cases suggest the hypothesis that antigenic targets could be revealed in-patients with genetic predisposition during some attacks of the hair follicle as dermatoheliosis and, or AGA.