BH10: Connecting the dots: facial papules as an early sign of early frontal fibrosing alopecia

Louise Bovijn and Catriona Wootton

Oxford University Hospitals, Oxford, UK

A 42-year-old patient had a 12-year history of a symmetrical, skin-coloured, micropapular rash over her forehead, temples and cheeks. Biopsies taken at presentation demonstrated no specific features other than slightly prominent sebaceous glands. She was diagnosed with sebaceous hyperplasia, and treatment with isotretinoin was initiated. It was well tolerated and effective in improving the appearance of the lesions. The treatment was prescribed intermittently over the following 8 years; the condition responded well but gradually recurred over time after stopping isotretinoin. The patient more recently discontinued treatment with isotretinoin for over a year as she wanted to explore microblading for her eyebrows, which she felt had become thinner the previous 2 years. Later in the same year it was noticed, during a clinic appointment, that her central hairline had receded and, on closer examination, she had perifollicular inflammation. A biopsy confirmed frontal fibrosing alopecia (FFA). This diagnosis tied all of her symptoms together: frontal scarring alopecia, loss of eyebrow hair and facial papules. The patient is currently managed with isotretinoin and hydroxychloroquine. Facial papules associated with FFA were first reported in 2007 (Abbas O, Chedraoui A, Ghosn S. Frontal fibrosing alopecia presenting with components of Piccardi–Lassueur–Graham–Little syndrome. J Am Acad Dermatol 2007; 57(2 Suppl.): S15–18). They are typically asymptomatic, tiny noninflammatory papules, yellow-to-skin coloured, and present most commonly on the forehead and temples. Histological analyses has demonstrated several common features such as prominent sebaceous glands with dilated ducts, perifollicular lichenoid reaction with fibrosis and the involvement of vellus hairs (Pirmez R, Barreto T, Duque-Estrada B et al. Facial papules in frontal fibrosing alopecia: beyond vellus hair follicle involvement. Skin Appendage Disord 2018; 4: 145–9). There have been case reports of facial papules being successfully treated with isotretinoin. The time delay between the presentation of facial papules, subsequent cicatricial alopecia of the eyebrows and, finally, clinically apparent FFA was around 8–10 years. Facial papules can present earlier in the disease and are easier to recognize when patients are younger. In the years leading up to our patient developing clinically apparent FFA, she had been treated with intermittent isotretinoin; despite this, her condition progressed. Had her facial papules been identified as part of the FFA spectrum and appropriate treatment initiated earlier, might we have been able to prevent her progression to scarring alopecia and the psychological impact that this has had? We present this case to highlight the potentially significant lag between the associated features of FFA and the importance of facial papules as a sign of this disease.