A 40-year-old woman presents with progressive hair loss forming an inverted triangular area at the frontoparietal hairline, sparing the frontal hairline itself. On trichoscopy, peripilar casts and follicular yellow dots are absent, but perifollicular erythema and scale are present. Biopsy shows a lichenoid infiltrate at the infundibulo-isthmic region with fibrous tracts replacing follicles. What is the diagnosis?

• A Lichen planopilaris / Frontal fibrosing alopecia (Kossard's syndrome) ✓
• B Female pattern hair loss (androgenetic alopecia)
• C Discoid lupus erythematosus affecting the scalp
• D Alopecia areata (ophiasis pattern)

Explanation

Frontal fibrosing alopecia (FFA, Kossard's syndrome) is a variant of lichen planopilaris characterised by progressive recession of the frontoparietal hairline in a band-like pattern, with preservation of the frontal hairline (band-like recession behind the frontal hairline). Trichoscopy shows absence of follicular ostia (scarring), perifollicular erythema, and tubular perifollicular scale. Histopathology reveals a lichenoid lymphocytic infiltrate targeting the isthmus and infundibulum with concentric fibrosis replacing follicles — the hallmark of primary lymphocytic cicatricial alopecia. It is distinct from alopecia areata (non-scarring, yellow dots, exclamation-mark hairs).

Reference: Neena Khanna Illustrated Synopsis of Dermatology & STD, 6th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.