Frontal Fibrosing Alopecia in Patients of Color: Diagnosis, Trichoscopy, Pigmentation, and Treatment

Conclusions

• Frontal fibrosing alopecia in darker skin patients often has more facial pigmentation and itch, but less obvious perifollicular scale and erythema, so it can be easier to miss clinically.
• Patients of color with FFA may have coexisting hair-loss or autoimmune conditions such as CCCA, lupus, or alopecia areata, so clinicians should broaden the differential when evaluating them.
• FFA in darker skin can be misdiagnosed as traction alopecia because the clinical appearance may overlap substantially.
• Trichoscopy and serial photography are essential for detecting disease activity and monitoring progression because clinical examination alone may underestimate inflammation.
• Treating and counseling on pigmentation is a major part of care in darker skin patients with FFA, and improvement can be documented over time with consistent follow-up and sun protection.
• Aggressive and sustained treatment can slow progression and improve outcomes even in patients who initially appear to have severe or recalcitrant disease.
• Physical sun protection and visible-light avoidance are especially important in patients of color because light exposure can worsen pigmentation changes.
• A practical treatment approach for FFA in darker skin often combines anti-inflammatory therapy with agents such as hydroxychloroquine, calcineurin inhibitors, 5-alpha reductase inhibitors, and additional therapies for more severe disease.
• Hair restoration procedures can be considered in carefully selected patients once disease is sufficiently controlled, though long-term durability may be limited.
• Overall, successful management of FFA in darker skin requires a different diagnostic mindset, closer imaging follow-up, and attention to both inflammation and pigmentation.