Comparing Female Pattern Hair Loss to Frontal Fibrosing Alopecia

Female Pattern Hair Loss (FPHL) vs Frontal Fibrosing Alopecia (FFA)

Frontal fibrosing alopecia is a scarring alopecia that affects an estimated 1 in 2,000 women age 50 and older. Androgenetic alopecia or female pattern hair loss affects about 1 in every 2 women 50 and over. The features of the two conditions are different although it’s not uncommon for FFA to be misdiagnosed as androgenetic alopecia. Some women can have both conditions. FFA affects the frontal hairline in many women with FFA (but not all) and also affects other scalp hairs in many affected patients as well. Loss of eyebrows, eyelashes, body hair is common. Female pattern hair loss can affect the frontal areas and temples to some degree but greater loss is typical behind the hairline and into the middle of the scalp or crown. Some women with female pattern hair loss have a diffuse loss which affects all scalp hair.

Trichoscopy is valuable to help differentiate FPHL from FFA. FPHL shows variations in the thickness of hairs and an accumulation of small thin vellus hairs. The scalp is not inflamed although varying degrees of scale can be seen depending on whether dandruff and seborrheic dermatitis are also present. The key is that thinning of hairs can be appreciated- this includes a thinning of the normal bundles as they reduce from bundles of 2 and 3 hairs to bundles of 1 and 2 hairs as well as actual thinning of the caliber of hairs. FFA is a destructive proceed and this thinning is not seen. FFA destroys vellus hairs and these are generally not seen as the disease becomes more advanced. An absence of tiny vellus hairs should be clues to FFA. FFA also causes loss of the normal architecture with a “sea of singles” meaning what remains is an accumulation of hair follicles with just a single hair emerging from them. Perifolllicular scale and redness is often seen in FFA.