Does My Scalp Biopsy Suggest FFA or LPP?
My Biopsy Result - Does it Mean FFA/LPP?
I’ve selected this question below for this week’s question of the week. It allows us to review some key features of the biopsy of frontal fibrosing alopecia (FFA)
Question
My question is in regards to understanding scalp biopsies. I'm curious if a biopsy showing fibrosis and/or lymphocytic infiltration can only point to a scarring alopecia like FFA or LPP?
In my case I have long standing psoriasis of my hands and feet, and am wondering whether it's possible that the redness and scaling along my hairline could be psoriasis vs FFA or LPP. I had a biopsy done that showed "some suggestive fine fibrosis of the stroma and some mild perivascular lymphocytic infiltration" and was diagnosed with FFA. There was no comment on sebaceous glands in the biopsy report. The punch biopsy samples were taken from the very front of my hairline, one vertical measuring 0.2cm diameter and 0.4cm depth and one horizontal 0.2 cm in diameter and 0.3 depth. I was concerned they weren't deep enough but was told that the samples shrink considerably in the formalin solution so they were deep enough when taken. I'm a bit skeptical of my dermatologists experience level however. I'm in multiple facebook groups for both FFA and LPP and questions re: understanding biopsy reports are quite common but unfortunately no one in those groups is very helpful with the technical medical stuff!
Oh and in that same vein another question- does eyebrow loss only point to FFA? I've experienced small patches of eyebrow loss every now and then for about a year but they always grow back and fill in. I also have chronically low iron levels (vegetarian for 30 yrs) as well as psoriasis so am wondering if my eyebrow loss could be related to either of those conditions instead of FFA.
I should add that I am not unconvinced that FFA is my correct diagnosis, its just that my dermatologist spent about 2 minutes min with me, enough time to take a biopsy basically and that was the extent of the investigations so I've been trying to research this myself as much as possible. Thanks so much for all you do and esp how much information you provide on your website and YOU tube channel - I know I speak for not just myself when I say that without the expertise and information you provide getting thru this extremely challenging time would be much more difficult.
I am a 47 yr old female. I'm currently only taking 2.5mg of finasteride daily (started that 2 weeks ago, before that was on doxycycline for 3 months and hydroxy chloroquine for 3 weeks but stopped the hydroxy as I developed an intense burning/itchy rash. don't think the doxy helped much so have not continued. I have also been thru a variety of topicals- dovobet, enstilar foam, Betamethasone liquid and now duobrii which is helping with the extreme redness the most I think. The duobrii was prescribed for my feet and has done wonders for my plantar psoriasis so I started using it on my hairline as well and its working better than anything else I've tried so far. I have mild itching of my scalp, no burning or soreness, maybe more of a pressure feeling, like my sunglasses are on my head when they are not. also occasionally a feeling of crawling. its concentrated to the top front, about 1-2" in - its just really really red and kind of scaly looking at times. Started with just a thin red line along the top front of my hairline about a year and a half ago, and then slowly started creeping back. around the same time this red line appeared I developed mild psoriasis on my palms. I have had psoriasis on the soles of my feet for about 20 years. hair has been thinning along the top front 1"-2" or so as well for the past year, my hairline hasn't moved yet tho. patches of eyebrow loss periodically, always have grown back tho (knock on wood!). I think I probably shed more than normal but I am going for an iron infusion soon to try to get my iron levels up past 30 which is as high as i've ever been able to get them with diet and supplements. Hoping higher ferritin levels might help with general shedding/growth.
Answer
The answer to both questions is no. So let’s look at them in turn.
There are many reasons for fibrosis and lymphocytic infiltration. Even biopsies of androgenetic alopecia have fibrosis and lymphocytic infiltration. It can even be a normal finding in the scalp and does not automatically point to scarring alopecia. If the fibrosis is moderate or dense and inflammation is intense and destroying hairs follicle cells (what we term lichenoid inflammation) - then we likely have something different going on in the scalp. As you pointed out, if sebaceous glands are reduced, that too points to scarring alopecia.
But the presence of fibrosis and inflammation like you described carry no real diagnostic significance whatsoever. It need to be quantified and tied in to the other scalp biopsy findings.
I don’t know what diagnosis you have because I have not had a chance to see your scalp (or see photos) but a really good scalp examination is probably where the answer to your diagnosis lies. I suspect a proper history together with a proper examination with ‘trichoscopy” can get to your diagnosis. A great deal of the time, a biopsy is not needed in situations like this.
As far as eyebrow loss, there are 100 causes. Again, I don’t have photos from you and I haven’t had a chance to examine the area but certainly lots and lots of reasons are possible.
To answer your question - eyebrow loss does not just point to FFA. No. Eyebrow loss and regrowth like you describe would be a bit unusual for FFA actually. Not impossible - just a bit unusual. We don’t often see SPONTANEOUS regrowth all that often although some regrowth can occur sometimes with treatment of course.
I agree with a history of psoriasis and eyebrow loss and scalp frontal hairline changes one needs to rule out a diagnosis of FFA. However, a whole range of other conditions are possible too including alopecia areata and others.
Thanks again for the question.