BH04 A hair-raising complication: de novo frontal fibrosing alopecia after transplantation

Abstract

We present two cases of men with early-onset androgenetic alopecia in their 30s, having undergone hair transplantation abroad. Prior to hair transplantation, neither reported any scalp symptoms of discomfort or rashes. Following transplantation, both developed inflammation and burning localized to the frontal hairline with associated hair-margin retraction. No inflammation or hair loss was reported from elsewhere on the scalp or body. Clinical examination demonstrated typical clinical features of frontal fibrosing alopecia (FFA), including perifollicular inflammation and scaling along the frontotemporal hair margins. Biopsies demonstrated perifollicular lichenoid lymphocytic infiltration around the infundibulum and isthmus at sites of active disease, supporting a diagnosis of FFA. FFA is a primary cicatricial alopecia of unclear aetiology. Immune dysregulation and autoimmune-­mediated follicular damage involving T lymphocytes are postulated mechanisms. Koebnerization is well recognized in cutaneous lichen planus, and we propose that trauma from hair transplantation may play a role in triggering de novo FFA. Cosmetic procedures, including hair transplantation, are increasingly common, while failed transplants are considered rare and are not always investigated or reviewed by hair specialists. Donovan described a case series of 17 patients who developed lichen planopilaris following hair transplantation. Similarly, Chiang et al. reported seven cases of de novo FFA or lichen planopilaris after hair transplantation, as well as three cases following facelift surgery. They suggested surgically induced koebnerization, postoperative autoimmune activation, and inflammatory follicular collapse with altered follicular response as potential mechanisms. This case adds to the growing literature supporting hair transplantation as a trigger for de novo FFA, an association of increasing relevance as more UK patients pursue cosmetic hair procedures and dermatologists encounter such presentations. Awareness may improve recognition, counselling, surveillance, diagnosis and management in such individuals.