Eyebrow hair loss as a prognostic factor for frontal fibrosing alopecia.

To the Editor: Frontal fibrosing alopecia (FFA) is a lymphocytic scarring alopecia with characteristic frontal or frontotemporal hair loss., Although 50% to 83% of patients with FFA report eyebrow involvement, few studies have compared the outcomes in patients with eyebrow loss to those in patients without eyebrow loss. Our objective was to assess eyebrow involvement in patients with FFA, comparing outcomes for those with and without eyebrow loss.

We performed a retrospective chart review of patients with a diagnosis of FFA at Mayo Clinic in Rochester, Minnesota, from January 1, 1992, through February 5, 2019. Patients were included if they met the current FFA diagnostic criteria. Patients with FFA were further stratified on the basis of eyebrow involvement. Treatments and outcomes were assessed through a review of clinical notes, which included clinical examination findings and clinical impressions at follow-up appointments. Response to treatment was categorized using the following terminology: unaltered disease progression (UDP), slowing of disease progression (SDP), and disease stabilization (DS). UDP was defined as extension of hair loss or clinical signs of active disease (perifollicular erythema, pruritus, scale, or scarring). SDP was defined as improvement in clinically evident disease at the sites of involvement or minimal progression of hair loss. DS was defined as the point at which no further progression of clinical features of disease (hair loss, perifollicular erythema, pruritus, or scale) was noted by the clinician. Statistical analysis was performed using the JMP Pro statistical software package (SAS Institute Inc). Comparisons were evaluated using Fisher’s exact (probability) test. All P values of <.05 were considered statistically significant.

A total of 224 patients with FFA were identified, with female (214, 95.5%) predominance and a mean age of 61.9 years (range, 27-90 years). Most patients presented with both scalp and eyebrow involvement (144, 64.3%), and 88 (39.3%) patients had total eyebrow loss. Patients with eyebrow involvement typically presented with preceding or concurrent symptoms of pruritus or pain at areas of involvement (98, 68.1%). Among patients with eyebrow involvement who pursued treatment at our institution (n = 111), 28 (25.2%) experienced DS, 28 (25.2%) had SDP, and 55 (49.6%) had UDP. Among patients without eyebrow involvement who pursued treatment (n = 55), 17 (30.9%) experienced DS, 25 (45.5%) had SDP, and 13 (23.6%) had UDP. Eyebrow involvement was significantly associated with UDP (P = .0023). Patients with eyebrow involvement experienced longer times to disease remission, with a mean and median of 812.1 and 730 days, respectively (range, 37-2194 days). In contrast, patients without eyebrow involvement had mean and median remission times of 502.8 and 193 days, respectively (range, 57-2276 days). Patients with total eyebrow loss were more likely to pursue aggressive treatment with systemic immunosuppressants (methotrexate or mycophenolate mofetil) for refractory disease than patients who did not experience total eyebrow loss (P = .0029).

In conclusion, eyebrow involvement and the extent of eyebrow loss can be a useful prognostic factor in patients with FFA. Patients with complete eyebrow loss may be more likely to have refractory disease and seek more aggressive treatment. Limitations of this study include its retrospective design, with reliance on clinical notes, and the lack of quantitative or validated measures to evaluate disease activity and the evolution of FFA over time.

Conflicts of interest

None disclosed.