the use of dermoscopy , initially limited to pigmented lesions , has become an important tool for the diagnosis of nonpigmented skin lesions and in inflammatory and infectious diseases . here we report a case of postmenopausal frontal fibrosing alopecia ( ffa ) to confirm the role of dermoscopy in the differential diagnosis of hair and scalp disorders . ffa , first described by kossard in 1994 , is a variety of cicatricial alopecia characterized by selective involvement of the hair of the frontoparietal region of the scalp . patients present with frontotemporal hair recession and eyebrow loss . the affected scalp is uniformly pale with loss of follicular orifices and the affected hair margin shows perifollicular erythema [ 3 , 4 ] . dermoscopy shows absence of follicular openings , perifollicular scale , and a variable degree of perifollicular erythema . typical histopathological findings are prominent perifollicular fibrosis and lymphocytic inflammation in a lichenoid pattern around the infundibular isthmus and bulge portions of the follicles . there is a reduction in the number of hair follicles and replacement by fibrous tracts . these findings are indistinguishable from those of lichen planopilaris , and ffa is therefore considered to be a distinct frontal variant of lichen planopilaris [ 6 , 7 ] . a 50-year - old woman presented with frontotemporal recession and partial loss of eyebrows for one year . she had previously been given the diagnosis of androgenetic alopecia and she was treated with topical minoxidil , 2 - 5% twice daily , without improvement . the patient spontaneously discontinued the treatment after 3 weeks , about 7 months prior to our visit . on presentation she had been taking ramipril ( 5 mg orally every day ) for her hypertension since the age of 47 years . clinical examination showed frontotemporal recession with uniformly pale skin and loss of follicular orifices where the recession had occurred ( fig . 1a , b ) there was perifollicular erythema at the hair margin and there was also partial loss and erythema of the eyebrows . laboratory investigations included a full blood count , which was normal , and hormone studies : follicle stimulating hormone , luteinizing hormone , testosterone , thyroid stimulating hormone , which were consistent with postmenopausal levels . anamnestic data , with no history of hairdressing associated with traction of scalp hair ruled out the possibility of a traction alopecia . dermoscopic examination was performed and showed absence of follicular openings , perifollicular scale , and a feeble perifollicular erythema ( fig . a 4-mm scalp punch biopsy from the frontal hairline , at the margin within the hair - bearing area was performed . histopathology showed some mild chronic lymphocytic inflammatory infiltrate around the infundibular and the isthmus and around the small vessels ; a reduction in the number of hair follicles and replacement by fibrous tracts were also evident ( fig . the patient was treated with a topical steroid ( betamethasone dipropionate lotion once a day for 6 months ) . from the 1-month follow up visit , a treatment with oral hydroxychloroquine was added ( 200 mg twice a day , for 6 months ) . the perifollicular erythema at the temporal hair margin was still present but there had been no progression of the frontotemporal recession 3 months since the completion of treatment . in patients who present with alopecia of the scalp margin , dermoscopy can be very useful , as the differential diagnosis between traction alopecia , alopecia areata , ffa and cicatricial marginal alopecia ( cma ) may be difficult   ( table 1 ) . in our case , there was absence of yellow dots and dystrophic hairs , the most relevant dermoscopic findings of alopecia areata . this was confirmed by the absence of miniaturized hairs , white dots and fractured hair shafts at dermoscopic examination . dermoscopic findings of cma recently described by goldberg , including low hair density and loss of follicular ostia , with thinned shafts of the remaining hairs , were present . however , usually cma presents with hair loss limited to all the periphery of the scalp , including frontal , temporal and occipital margins . in our case , hair loss involved selectively the frontoparietal region . moreover , in the case that we report , perifollicular scale and a variable degree of perifollicular erythema were also evident at dermoscopy supporting the diagnosis of ffa . in our case histopathological findings with the presence of a conspicuous inflammatory infiltrate and of many vellus - like follicles completely excluded the possibility of a cma . the etiology of ffa is yet unknown , but most cases of ffa reported are in postmenopausal women , supporting the idea that hormonal changes may play a role in the etiology [ 3 , 4 , 11 , 12 ] . ffa may represent a variety of lichen planopilaris with selective involvement of certain androgen - dependent areas . the affected follicles may also have typical biologic markers that could explain the clinical and histologic features found in the disease . the fact that ffa is becoming increasingly common may also suggest that environmental factors could be involved in etiology . it is not possible to restart hair growth where follicles have been destroyed , and the aim of treatment must be to arrest hair loss . continuance of recession is not inevitable and in most women it appears that the disease eventually stabilizes . we report our case not only for the rarity of the disease , but because it demonstrates that dermoscopy could improve diagnostic accuracy of hair and scalp disorders .
frontal fibrosing alopecia ( ffa ) is more common in postmenopausal women , but it can occur in younger women . 
 some authors consider ffa to be a distinct frontal variant of lichen planopilaris . from a clinical point of view , this relatively uncommon condition is characterized by progressive frontotemporal recession due to inflammatory destruction of hair follicles . 
 dermoscopy can be very useful , as the differential diagnosis between traction alopecia , alopecia areata , ffa and cicatricial marginal alopecia may be difficult . 
 it is not clear whether or not treatment alters the natural history of the disease - the disease stabilized with time in most of the patients with or without continuing treatment . 
 here we report a case of a 50-year - old woman with ffa and discuss the relevance of dermoscopy in the differential diagnosis of this disease .