BH28 Breaking the pattern: frontal fibrosing alopecia in men, a case series

Abstract Frontal fibrosing alopecia (FFA) is a scarring alopecia, predominantly affecting postmenopausal White women, with male cases being rare and under-reported. It is considered a variant of lichen planopilaris, likely driven by a type IV hypersensitivity reaction. While its pathogenesis remains unclear, genetic, hormonal and environmental factors have been implicated. Here, we present two unusual cases of FFA in male patients. The first patient was a 51-year-old White man who developed scarring alopecia of the frontal hair margin 6 weeks after receiving his first COVID-19 vaccination, with further progression following the second dose. Examination revealed perifollicular erythema, scaling, frontal hairline recession and facial papules. Histopathology confirmed scarring alopecia with perifollicular fibroblasts and fibrotic replacement of follicles. Treatment with topical corticosteroids, lymecycline, doxycycline and hydroxychloroquine led to partial stabilization, although significant psychological distress persisted. His son concurrently developed oral lichen planus after COVID-19 vaccination, suggesting a possible immune-mediated response. Our second patient is a 44-year-old South Asian man who presented with a progressive facial rash with burning sensation, which was previously misdiagnosed as sun sensitivity. Examination revealed prominent monomorphic facial papules with hyperpigmentation. Further examination revealed perifollicular inflammation and frontal hair margin retraction. Scalp biopsy showed perifollicular fibrosis and a marked reduction in follicular density, confirming FFA. Histology from facial papules showed epidermal pigmentation without melanocytic proliferation. His presentation of extensive facial papules was notably severe, raising questions about their pathogenesis and optimal management strategies. FFA remains an under-recognized cause of scarring alopecia in men, with an estimated prevalence of only 1–2% in reported cases. We are beginning to see FFA cross clinical boundaries, including possible vaccine-related immune triggers and a pronounced facial papular phenotype, especially in men. In 2023 a genome-wide association study also identified two genes associated with male FFA, which were different from genes implicated in women. These cases highlight the potential for further research into possible environmental and genetic triggers and novel treatment approaches.