One-third of patient with FFA have eyelash loss - but the number doubles if you look closer!

Trichoscopy helps Identify Women with FFA with Early Eyelash FFA

Frontal fibrosing alopecia is a scarring alopecia which may affect not only the frontal hairline but also the eyebrows, eyelashes and body hair. Other features are also a part of the condition including facial papules, rosacea and depression of the forehead veins.

In 2014, Dr Vano-Galvan and colleagues showed that eyelash loss was important to document because it was one of the  key independent factors associated with severe FFA. The other two were facial papules and body hair involvement.

 Salas-Callo C I et al 2022

Authors of a new study set out to evaluate the clinical and trichoscopic characteristics of eyelash loss in FFA.

The study was a prospective cross-sectional study in 50 patients with FFA, including 44 women (39 postmenopausal) and 6 men. The average age was 58 years (range, 34-77 years).None of the patients had applied any medication to the eyelids or eyelashes. Eyebrow loss was observed in 48 patients and non-facial body hair in 44 patients. 17 (34%) of patients had clinical involvement of the eyelashes. Interestingly, a greater proportion of patients 32 (64%) of patients had trichoscopic signs.

Common trichoscopic signs were dystrophic hairs (75%), visualization of hair bulbs (50%), black dots (50%), and ingrown hairs (46.9%). The visualization of hair bulbs was more frequent in the upper eyelashes  and focal atrichia was more commonly observed in the lower eyelashes. Trichoscopic changes were observed in all patients with clinical involvement and patients with severe clinical involvement presented with more signs.

One third of patients had eyelash regrowth in distinct directions. This may be due to fibrosis but the study was not set up to determined why growth occurs in different directions. The authors also observed ingrown hairs, which have been reported in primary scarring alopecias on the scalp. In addition, the authors showed significant association between facial papules and eyelash involvement.

Discussion

 This is a helpful study to document eyelash involvement in FFA. It would appear that about 1/3 of patients have eyelash involvement but when examined trichoscopically it’s clear this number is much higher at about 2/3. It could be that some trichoscopic signs predict further loss but this was not studied here and can only be hypothesized.

There are differences between the upper and lower lashes. The visualization of hair bulbs was significantly more frequent in the upper eyelashes, and focal atrichia was observed only in the lower eyelashes. The reasons are not clear. In trichotillomania, upper eyelashes are more commonly involved and in alopecia areata upper eyelashes are slightly more common than lower eyelashes.

It appears that the pathways that drive hair loss of the eyelashes may drive facial papules as well as the two seem quite linked.

REFERENCE

Salas-Callo C I et al. Eyelash involvement in frontal fibrosing alopecia: A prospective study. J Am Acad Dermatol 2022 Jul;87(1):232-234.

Vano Galvan et al. Frontal fibrosing alopecia: A multicenter review of 355 patients Journal of the American Academy of Dermatology. Volume 70, Issue 4, April 2014, Pages 670-678.