frontal fibrosing alopecia ( ffa ) is a scarring alopecia characterized by progressive recession of the frontotemporal hairline .
current treatment is aimed at stopping progression , and the combination of dutasteride and pimecrolimus is the most effective therapy .
side effects associated with dutasteride are erectile dysfunction as well as breast tenderness and enlargement , while pimecrolimus produces a burning sensation .
we present a 57-year - old postmenopausal female with a 3-year history of a scarring alopecic plaque in her frontotemporal region .
biopsy confirmed the diagnosis of ffa , and she was started on dutasteride 0.5 mg p.o . q.d .
eight months after initiating treatment , she showed hyperpigmentation on her metacarpophalangeal and interphalangeal joints , as well as on the cheeks and on the chin ; dutasteride and pimecrolimus were discontinued .
after 5 months of follow - up , her hyperpigmentation improved by 80% only by using photoprotection .
because of the variable clinical course of ffa , treatment is focused on halting its progression .
several therapeutic agents have been evaluated and the combination of dutasteride and pimecrolimus has shown a high response rate . there is no reported evidence of hyperpigmentation associated with this combination .
frontal fibrosing alopecia ( ffa ) is a scarring alopecia that affects postmenopausal women and is considered a clinical variant of lichen planopilaris .
currently , there is no treatment of choice and because of the scarring nature , the aim is to stop progression .
studies have shown that the combination of dutasteride and pimecrolimus is by far the most effective therapy for this condition , and even hair regrowth has been reported [ 2 , 3 ] .
we present a 57-year - old postmenopausal female with a 3-year history of scarring alopecic plaques on both her frontotemporal regions , which she developed after an upper third face lift with aptos threads .
skin biopsy revealed the presence of a perifollicular lymphocytic infiltrate and lamellar fibrosis , a decrease of hair follicles and apoptotic cells in the external root sheath , therefore confirming the diagnosis of ffa ( fig .
q.d . at the fifth month of follow - up , we added topical pimecrolimus 1% b.i.d . at this point ,
eight months after the treatment was started , the patient presented hyperchromic macules in the metacarpophalangeal and interphalangeal joints of both hands as well as on the cheeks and chin ( fig .
five months after the treatment was discontinued , the patient showed an 80% improvement of her hyperpigmented lesions ( fig .
ffa was described in 1994 by kossard in postmenopausal women , but it can also affect premenopausal women and males . it is considered a clinical variant of lichen planopilaris ; histologically , both entities show a lymphocytic infiltrate and fibrosis between the follicular epithelium and the dermis , involving the upper mid - portion of the follicle , but ffa shows less inflammatory infiltrate than lichen planopilaris .
the pathogenesis is unknown , but a t - cell - mediated inflammatory reaction with the destruction of stem cells and hormonal changes as well as increased levels of androgens are thought to play an important role .
several therapeutic agents have been evaluated and topical and systemic corticosteroids have been the most commonly used agents ; with a high risk of relapse upon discontinuation , other treatments have been studied , e.g. antimalarials , mycophenolate mofetil , doxycycline , and topical minoxidil with variable results . treatments with 5-reductase inhibitors have shown good results supporting the role of androgens in the pathogenesis of ffa .
dutasteride is a 5-reductase inhibitor , it is 3 times more potent than finasteride at inhibiting type ii enzyme and 100 times more potent at inhibiting type i enzyme , making it a leading option in treating ffa .
pimecrolimus , a topical calcineurin inhibitor that blocks t - cell activation and cytokine production , has been used effectively in combination with dutasteride .
reported side effects associated with dutasteride and finasteride use are erectile dysfunction as well as breast tenderness and enlargement [ 7 , 8 ] .
for finasteride , there are reports of cutaneous vasculitis , drug - related folliculitis , erythema annulare centrifugum , solitary fixed drug eruption , urticarial rash and acute generalized exanthematous pustulosis ; the last one occurred 3 months after it was initiated .
for pimecrolimus , the reported adverse effects are a burning sensation and pruritus , and there is one report of induced lentiginosis on the application site of this drug ; however , in this case , the hyperpigmentation did not appear at the sites of application of pimecrolimus .
there is no reported evidence of hyperpigmentation associated with this combination or with the use of dutasteride .
another described cause of hyperpigmentation in the presence of alopecia is the cronkhite - canada syndrome .
it is a rare syndrome involving the skin and the gastrointestinal tract , showing hyperpigmentation , alopecia , onychodystrophy , diarrhea , hamartomatous polyposis and weight loss [ 11 , 12 ] .
the alopecia in these patients is a non - scarring alopecia , with telogen hair follicles without miniaturization or atrophy of the hair follicle and absence of inflammation , which can start in patches and then become total ; the hyperpigmentation is observed diffusely in the upper extremities .
it shows onychodystrophy which includes a thinning of the nail plate , onycholysis and onychomadesis . in our patient 's case , this diagnosis is discarded because she does not have gastrointestinal symptoms , she has a scarring alopecia , and the hyperpigmentation occurred mainly on her face .
because of the variable clinical course of ffa , treatment is focused on halting its progression .
several therapeutic agents have been evaluated ; the combination of dutasteride and pimecrolimus has shown a high response rate .
this case is of particular interest because the patient developed hyperpigmentation following the use of dutasteride and a remission after its discontinuation .
there is still no clear evidence that points to dutasteride as the sole precipitating agent ; therefore , more studies are required to further evaluate this association .
 introductionfrontal fibrosing alopecia ( ffa ) is a scarring alopecia characterized by progressive recession of the frontotemporal hairline . 
 current treatment is aimed at stopping progression , and the combination of dutasteride and pimecrolimus is the most effective therapy . 
 side effects associated with dutasteride are erectile dysfunction as well as breast tenderness and enlargement , while pimecrolimus produces a burning sensation.case reportwe present a 57-year - old postmenopausal female with a 3-year history of a scarring alopecic plaque in her frontotemporal region . 
 biopsy confirmed the diagnosis of ffa , and she was started on dutasteride 0.5 mg p.o . q.d . 
 , and later , topical pimecrolimus 1% b.i.d 
 . was added . 
 eight months after initiating treatment , she showed hyperpigmentation on her metacarpophalangeal and interphalangeal joints , as well as on the cheeks and on the chin ; dutasteride and pimecrolimus were discontinued . 
 after 5 months of follow - up , her hyperpigmentation improved by 80% only by using photoprotection.conclusionbecause of the variable clinical course of ffa , treatment is focused on halting its progression . 
 several therapeutic agents have been evaluated and the combination of dutasteride and pimecrolimus has shown a high response rate . there is no reported evidence of hyperpigmentation associated with this combination . 
Introduction
Case Report
Conclusion
Introduction
Case Report
Discussion
Conclusion
Disclosure Statement