LAUSR

DEAR EDITOR, We thank the authors for their comments regarding the Frontal Fibrosing Alopecia Severity Index (FFASI). Our intention in developing FFASI was to provide an objective assessment of the primary feature of frontal fibrosing alopecia (FFA), namely hairline alopecia. However, we included scoring of known associated features to allow prospective study of prognostic implications in relation to disease severity and treatment stratification. When FFASI was devised and validated (2013–2014), pigmentary abnormalities had not been described in FFA case series, and data on only two cohorts of black patients with FFA had been published. The first described no pigmentary abnormalities. The second cohort of 44 African cases described 24 cases associated with lichen planus pigmentosus (LPPigm) and 20 without pigmentary abnormalities. However, these series included no control group to inform background frequency of LPPigm. Thus, during FFASI development, association of LPPigm with FFA was not well established. However, we wish FFASI to be comprehensive and flexible. Pragmatically, ad hoc additions to the ‘Additional features’ table would capture the expanding disease spectrum. Alternatively, LPPigm could be scored within the ‘cutaneous lichen planus (LP)/LP variants’ subsection. However, if a more detailed assessment of pigmentation were necessary, particularly if this were a primary patient concern, we would argue that inclusion of an additional scoring system within FFASI would render it unwieldy and would encourage the authors to consider development of an LPPigm score. We recognize traction alopecia (TA) is common in black patients and may coexist with FFA and other types of alopecia, making diagnosis and assessment more challenging. However, there is already an existing TA scoring system and to avoid increasing FFASI complexity, we suggest that in cases where traction is confirmed and can be distinguished from FFA, the TA scoring system should be used. However, it could be argued that, irrespective of the relative contributions of additional factors, for those with confirmed FFA, recession should be scored using FFASI. We agree that FFA is often asymptomatic; however, while histology may be helpful diagnostically, we would argue that findings from a small skin sample may not be representative of inflammation globally and would not be a practical means of assessing ongoing disease activity. We concur that FFA assessment methods should be applicable to all but would reiterate our position that, based on available evidence, alopecia bandwidth should remain the primary means of assessing FFA.