Journal Scan / Case Study · January 15, 2021 Occipital Fibrosing Alopecia International Journal of Dermatology

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• The authors report a series of 14 cases of women with frontal fibrosing alopecia (FFA) limited to the occipital scalp, known as occipital fibrosing alopecia (OFA). The diagnosis of OFA was made clinically with the assistance of trichoscopy but was also confirmed with confocal microscopy (in 9 patients) and on pathology specimens. Interestingly, 9 patients presented for excessive hair shedding and were unaware of the occipital alopecia, which was diagnosed during clinical examination.

• Although occipital involvement with FFA has been previously reported in up to one-third of cases, it generally occurs along with the typical frontoparietal pattern. This represents the first series of patients in whom occipital involvement represented the only scalp involvement in FFA. The authors urge clinicians to be aware of this variation in presentation, as the rapid rise in FFA incidence may mean that this pattern will be seen more frequently in the future.

– Caroline K. Crabtree, MD

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Paradi Mirmirani MD

Frontal fibrosing alopecia (FFA) was first described in 1994 in 6 post-menopausal women who presented with band-like scarring alopecia along the fontal hairline and loss of eyebrows. Since the initial description, this condition has been seen with increasing frequency worldwide.

Over the years, the clinical manifestations of FFA have expanded beyond just the frontal hairline and eyebrows. It is now recognized that hair loss may also occur along the temporal and occipital hairline (in up to 32% of cases), as well as the eyelashes, beard, and body. Facial papules are another manifestation that indicate inflammation of vellus hairs. This report of 14 women highlights the novel finding that occipital hair loss may be the first and only manifestation of scarring alopecia. 

The takeaway is for clinicians to have a high index of suspicion and be aware of this pattern in order to identify occipital fibrosing alopecia (OFA) in its early stages. A careful history along with trichoscopy and biopsy can be useful in distinguishing OFA from alopecia areata or traction alopecia. Although the paper does not delve into treatment, as the pathologic findings of OFA are the same as FFA, my approach to therapy would be the same.

Interestingly, the authors propose that depilation of the occipital hairline or styling practices may be a contributing factor in some women. This would fit with the prevailing hypothesis that the pathogenesis of FFA involves environmental insults that may lead to pilosebaceous unit dysfunction, collapse of immune privilege, and a lichenoid immune response in predisposed individuals. Thus, it may be helpful to ask about, and eliminate, any potential triggers.

Abstract 

Frontal fibrosing alopecia (FFA) classically results in a band‐like scarring alopecia involving the frontotemporal hairline and eyebrows.1-4 Diagnosis is confirmed by trichoscopy showing the absence of vellus hairs and peripilar casts and pathology showing scarring alopecia with a lichenoid infiltrate. Occipital involvement has been described in up to 32% of cases; however, it usually occurs in association with frontoparietal scarring.5 We report here a case series of 14 women with FFA limited to the occipital scalp.

International Journal of Dermatology

Occipital Fibrosing Alopecia

Int. J. Dermatol 2020 Dec 20;[EPub Ahead of Print], MA Martinez-Velasco, B Burroway, C Thompson, T Silyuk, A Tosti 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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