Context: Frontal fibrosing alopecia (FFA) is a primary cicatricial alopecia characterized by progressive recession of frontal, and often temporoparietal, hairline mainly in postmenopausal women. Currently, there are no guidelines or proposed evidence-based treatment for FFA. Aims: The aim of this study was to retrospectively evaluate the effect and safety of intralesional triamcinolone acetonide injections (ITAIs) either as monotherapy or as concomitant treatment in the management of hairline recession in FFA. Subjects and Methods: All patients with FFA, who visited our specialist hair clinic from July 2012 to October 2016 and were treated with ITAI either as monotherapy or as concomitant treatment, were enrolled in our study. Measurements were performed from five different points on the scalp. The analysis of data included demographics, associated symptoms, clinical and dermoscopic findings, comorbidities, family history of FFA, concomitant medication, treatment outcome, and recording of adverse events. Statistical Analysis: Statistical analysis was performed using the Statistical Package for the Social Sciences, version 22.0. Results: A total of 40 patients, all females were enrolled in our study. The mean age of the patients was 65.88 ± 8.18 whereas the mean age of the diagnosis was 61.24 ± 7.4. A total of 39 patients were treated with a combination of treatments, including ITAI, and only one with ITAI as monotherapy. There was a halting of the progress of the disease, and no significant adverse events were noted, apart from mild pain. Conclusions: A halting in the progression of FFA was achieved, with unremarkable adverse events. ITAI could serve as an effective and safe option for the treatment of FFA, although difficult to assess it as monotherapy. Further randomized controlled trials are needed to evaluate its efficacy and safety as the sole treatment in the management of FFA.

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Introduction: Hair loss is a common and distressing clinical complaint in the dermatology clinics. Common causes of hair loss in children include alopecia areata, tinea capitis, traction alopecia, and trichotillomania. Newly, trichoscopy allows differential diagnosis of hair loss in most cases and allows visualization of hair shafts and scalps without the need of removing hair. Objective: The main objective is to compare the different trichoscopic features of common causes of patchy hair in children loss including tinea capitis, alopecia areata, traction alopecia, and trichotillomania. Patients and Methods: This study included 134 patients, 63 patients with tinea capitis, 38 patients with alopecia areata, 18 patients with traction alopecia, and 15 patients with trichotillomania. The diagnostic tools for the diagnosis of hair loss problem included a detailed history, evaluation of the child's hair and scalp, fungal scrapping, and trichoscopy. Results: Tinea capitis was the most common, and the trichoscopic features were comma-shaped hairs, corkscrew hairs, short broken hairs, and interrupted hairs. While in alopecia areata patients, the most specific features were yellow dots and black dots, microexclamation mark, hair shafts with variable thickness, and vellus hairs, with uncommon features included: monilethrix, coiled, zigzag, and tulip hairs. Trichoscopy of trichotillomania showed hair with fraying of ends, breakage at different lengths, short and coiled hairs, and amorphous hair residues. The trichoscopic features of traction alopecia were similar to those of trichotillomania. However, flame hairs and coiled hairs were less common. Conclusions: Trichoscopy is a noninvasive method of examining hair and scalp. It allows differential diagnosis of hair loss in most cases.

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Valproate is a drug used in the treatment of various seizure disorders, bipolar disorder, migraine prophylaxis, and off label in many indications by various specialists. The common adverse drug reactions reported on valproate administration are tremor, weight gain, gastrointestinal disturbances, liver dysfunction, metabolic acidosis, thrombocytopenia, and hair loss. An internet search with keywords “valproate” and “hair” was done on Google Search and PubMed for articles related to the topic. Recognition of cosmetically significant side effects on hair is necessary and neglect of which might result in poor compliance. Valproate-induced hair loss is diffused, nonscarring, and dose related. Other hair-related adverse events are curling of hair, graying, dirty appearance, and changes in texture. In contrast to oral ingestions causing hair loss, experiments with topical valproic acid have shown some initial evidence on hair regeneration. This makes valproate's effects on hair interesting and understanding it's effects on hair is very much essential in clinical practice.

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Frontal fibrosing alopecia (FFA) represents a distinctive condition with a marginal scarring alopecia along the frontal and temporal hairline. Since its original description, the condition has been recognized to represent a more generalized than localized process, with extension beyond the frontotemporal hairline to include the parieto-occipital hairline and involve peculiar facial papules as evidence of facial vellus hair involvement and loss of peripheral body hair. Finally, the association of FFA with oral lichen planus, nail involvement, and concomitant lichen planopilaris (LPP) points to a close relationship to lichen planus. The Koebner phenomenon or isomorphic reaction has been described in lichen planus, LPP, and ultimately FFA, with face-lift procedures and hair restoration surgery having been implicated as the culprits in the latter. We report the first case of FFA in whom LPP developed at the sites of wig attachments, providing the evidence for Koebner phenomenon. Therefore, wigs are to be included to the list of procedures for hair restoration at risk of eliciting an isomorphic reaction in patients with FFA. Ultimately, the association of Koebner phenomenon with LPP-type lesions in FFA may provide further insight into the underlying pathology and nosology of the condition.

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We report a patient with frontal fibrosing alopecia (FFA), in whom autologous hair transplantation was successfully performed despite evidence of active disease. Since the underlying pathology of FFA is usually lichen planopilaris, reservations, and caveats have been expressed with respect to the risk of köbnerization phenomena following hair transplantation surgery. An important question that arises is how the lichenoid tissue reaction pattern is generated around the hair follicles in FFA. Follicles with some form of damage or malfunction might express cytokine profiles that attract inflammatory cells to assist in damage repair or in the initiation of apoptosis-mediated organ deletion. Alternatively, an as yet unknown antigenic stimulus from the damaged or malfunctioning hair follicle might initiate a lichenoid tissue reaction in the immunogenetically susceptible individual. Therefore, it might be expected that the transplantation of whole healthy hair follicles might less give rise to an inflammatory reaction than the disease itself, as revealed in our case report of successful hair transplantation in FFA.

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Woolly hair nevus is a rarely acquired disorder of the scalp hair with well-circumscribed patch of curly and unruly hairs which are smaller in diameter than normal surrounding hair. We report a case of progressively evolving multiple woolly hair nevi in a 10-year-old child. Trichoscopy of unruly hairs showed abnormal kinking of hair shafts. Varying diameters of a single hair shaft, damaged cuticle, and trichorrhexis nodosa-like features were observed on hair microscopy. Histopathology showed abnormal bending of hair follicle above the hair bulb and irregularities of inner root sheath near the bulb at the bending. Most of the reported cases of woolly hair nevi had one or two stable patches, but this case presented with four patches which were progressively evolving.

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Lichen planopilaris (LPP) is an inflammatory hair disorder that is characterized by scarring hair loss, mostly affecting the vertex and parietal areas of the scalp. Frontal fibrosing alopecia (FFA) is considered a particular form of LPP, primarily affecting the hair follicles in the frontotemporal area of the scalp, with the hairline recession and eyebrow loss. There are case reports of FFA with concomitant involvement of facial vellus, characterized by roughening of the facial skin. We report five cases of facial vellus hair involvement in LPP, in the absence of other sites of disease activity. To the best of our knowledge, ours is the first report of LPP affecting the facial vellus hairs in the absence of FFA.

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Trichoscopy is the term coined for the use of dermatoscope for the evaluation of hair and scalp. Dermatologists involved in the management of hair and scalp disorders have discovered dermatoscope to be useful in their daily clinical practice, and expert studies suggest that dermoscopy may improve diagnostic capability beyond simple clinical inspection. Therefore, trichoscopy has gained popularity as a tool in the differential diagnosis of hair and scalp disorders. Despite the enthusiasm emerging with its establishment as a valuable dermatologic tool, caution is warranted not to elevate trichoscopy to something like a fetish status. As a diagnostic procedure, trichoscopy remains to be understood as representing an integral part of a comprehensive dermatological examination. Furthermore, trichoscopy represents an integral part of surface or epiluminescence microscopy of the skin or dermoscopy. It seems that the dermatoscope for the evaluation of the hair and scalp picks up from the culture of a stethoscope within internal medicine, in terms of being a time-tested, sophisticated, hand-held diagnostic medical instrument conferring an uncontested dignity in the hands of a physician attending hair and scalp disorders.

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Since Quinquaud's original report of folliculitis decalvans (FD), further clinical variants have been described on the basis of common histopathological and microbiological findings. Histopathology reveals a neutrophilic primary scarring alopecia, and microbiological studies invariably reveal pathogenic strains of Staphylococcus aureus. The presence of thickening of lesional skin in FD has been previously described. We report a new presentation of FD, clinically mimicking linear circumscribed scleroderma of the scalp. Overlapping features of the scarring alopecias may blur the distinction between different conditions that ultimately share the common final pathway of replacement of follicle by fibrous tissue. Therefore, a careful patient history, clinical examination including dermoscopy, microbiological studies, and a scalp biopsy for histopathology, and immunofluorescence studies are prerequisites to an accurate diagnosis and appropriate treatment of the respective condition. The case is presented to illustrate the clinical variability in presentation of FD and to underline the necessity of performing a biopsy for an accurate diagnosis in the scarring alopecias.

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