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Frontal Fibrosing Alopecia and Alopecia Areata: Mimickers?

- In: Clinical Practice

Frontal fibrosing alopecia (FFA) and Alopecia Areata (AA) appear to be very different entities; however, they share certain similarities, making it difficult to distinguish between them. 

FFA is a scarring alopecia in a patterned distribution that is considered a variant of lichen planopilaris (LPP) (Kerkemeyer et al., 2021). The classic presentation is symmetric, “bandlike”,  alopecia on the frontal scalp with symmetric loss of eyebrows and gradual recession of the frontal hairline, bilateral parietal scalp, and sometimes occiput. Rarely do patients have both LPP and FFA; FFA patients rarely have lichen planus elsewhere. The pathology of FFA is identical to that of LPP with perifollicular fibrosis and lymphocytic inflammation (Kerkemeyer et al., 2021). Patients may experience itch, burning, sensitivity, or trichodynia (scalp pain). On trichoscopy, active disease presents with perifollicular erythema and scale; scarred, atrophic white/hypopigmented patches; perifollicular erythema and scale; follicular hyperkeratosis; yellow dots; and hair shaft diameter variation. “Lonely hairs”, terminal hairs without surrounding vellus hairs, may be seen with and without trichoscopy. A biopsy can help to confirm FFA and rule out other diagnoses, but it may not be necessary.

Alopecia areata is an autoimmune, non-scarring alopecia in which activated T lymphocytes target the hair follicle (Hamosch et al., 2017). Classic AA presents with patchy areas of non-scaly hair loss in circles on the scalp, eyebrows, eyelashes, beard, or body hair (Barton et al., 2022). Patients may have other autoimmune diseases or a family history of AA. One presentation of AA is called ophiasis, where patients lose hair on the frontal hairline, parietal scalp above the ears, and occiput. Since AA patients may also lose their eyebrows, ophiasis can mimic FFA. On trichoscopy, AA displays yellow dots, exclamation point hairs, short vellus hairs, broken hairs, pigtail hairs, and a lack of perifollicular erythema and scale (Gómez-Quispe et al., 2023). Patients may experience scalp burning or trichodynia. 

Common features seen on pathology include peribulbar lymphocytes (the so-called “swarm of bees”), primarily affecting anagen hairs; decreased terminal anagen hairs; increased telogen hairs; miniaturized hairs; and empty follicular infundibula; with or without peribulbar eosinophils, plasma cells, and sebaceous gland atrophy(Wong, Robinson, Tan, & Burgin, 2025). 

It is essential to keep an open mind when treating patients with alopecia. If traditional treatment is not effective, re-examine the patient, inquire about scalp symptoms, utilize trichoscopy, and consider performing scalp biopsies as needed. 

 

Key differences between FFA and AA:

Frontal fibrosing alopecia

Alopecia areata
  • Most common in women 55-65 y/o 
  • Progress does not improve on its own
  • Visible inflammation
  • Perifollicular erythema and scale
  • Loss of vellus hairs
  • “Lonely hairs”
  • Itch, burning, sensitivity
  • Trichoscopy: 
    • Scarred, atrophic, white/hypopigmented patches
    • Perifollicular erythema and scale
    • Follicular hyperkeratosis
    • Yellow dots
    • Variation in hair shaft diameter 
    • “Lonely” hairs
  • Pathology pearl: indistinguishable from LPP. Perifollicular fibrosis and lymphocytic inflammation.   
  • Most common ages 5-40
  • More common in patients with  Down Syndrome
  • No scale
  • It may come and go spontaneously
  • No loss of vellus hairs
  • May have trichodynia
  • Trichoscopy: 
    • Yellow dots
    • Exclamation point hairs
    • Short vellus hairs
    • Broken hairs
    • “Pigtail” hairs
  • Pathology pearl: “swarm of bees” lymphocytes around the bulb



 

References:

Barton, V.R., Toussi, A., Awasthi, S., & Kiuru, M. (2022). Treatment of pediatric alopecia areata: A systematic review. Journal of the American Academy of Dermatology 86(6), 1318-34. 

Gómez-Quispe, H., Muñoz Moreno-Arrones, O., Hermosa-Gelbard, A., Vañó-Galván, S., & Saceda-Corralo, D. (2023). [Translated article] Trichoscopy in Alopecia Areata. 

Actas Dermo-Sifiliográficas,, 114(1), T25-32.

Hamosh A, McKusick VA. % 104000: Alopecia areata 1; AA1. OMIM - Online Mendelian Inheritance in Man. https://www.omim.org/entry/104000. Updated 2017 Nov 16. Accessed 2024 Jan 24.

Kerkemeyer, K. L., Eisman, S., Bhoyrul, B., Pinczewski, J., & Sinclair, R.D. (2021). Frontal fibrosing alopecia. Clinical dermatology, 39(2), 183-93. 

Wong, V., Mercurio, M.G., & Burgin, S. Frontal fibrosing alopecia. Accessed on 5/21/25 from: https://www.visualdx.com/visualdx/dxDetails.do?moduleId=46&diagnosisId=54648&age=4

Wong, V., Robinson, S., Tan, B., & Burgin, S.  Alopecia areata. Accessed on 5/21/25 from: https://www.visualdx.com/visualdx/diagnosis/?moduleId=101&age=4&contentModuleId=102&diagnosisId=51085&lang=en_US#view=text

Victoria Garcia-Albea, BSN, MSN, RN, PNP, DCNP, is a medical dermatology nurse practitioner at Lahey Clinic in Burlington, MA. She is the director of the Lahey Clinic Dermatology NP Training Program. She spends most of her free time with her husband and two school-aged boys, and volunteers at her public library.