Differential diagnoses include lichen androgenetic alopecia (AGA), alopecia areata, chronic cutaneous lupus, familial high frontal hairline, and traction alopecia. AGA usually spares the frontal hairline, and it is not associated with scarring, perifollicular erythema, or loss of eyebrows. The histopathologic findings reveal miniaturization of follicles and nonspecific superficial perivascular inflammation [22]. The sudden onset of progressive hair loss in the scalp margin and eyebrows may lead to a wrong diagnosis of alopecia areata (AA). The lack of scarring changes and the clinical presentation of AA are important features to take in consideration. Chronic cutaneous lupus may result in broken hairs, patchy frontal alopecia, and scarring. In these cases, the scalp often shows gross scarring and hyperkeratinization with mottled hyperpigmentation and hypopigmentation. Biopsy specimens with positive immunofluorescence from areas of alopecia in chronic cutaneous lupus erythematosus are important to rule out this condition. A familial high frontal hairline may be present in some women. It usually has an early age of onset and is not associated with scarring and loss of eyebrows, and there is no evidence of perifollicular erythema [10]. Prolonged tension on the hair root from certain hairstyles leads to traction alopecia (TA), which can over time result in irreversible scarring alopecia. This condition is frequently observed among some groups (e.g., African American women) as a result of cultural hair care practices [23]. TA may produce hair loss localized to the frontal hairline associated with a ragged border and broken hairs of uneven lengths. Biopsy specimens show no significant lymphocytic inflammation, contrasting with FFA. Dermoscopy can be very useful in the diagnosis of the disease. Dermoscopy shows absence of follicular openings, perifollicular scale, and a variable degree of perifollicular erythema [24].

Treatments that have been used for FFA include topical and systemic steroids, topical retinoids, oral isotretinoin, topical minoxidil, hydroxychloroquine, and finasteride. In most cases the disease is stabilized with time, and it is not possible to determine whether the disease stabilization is the result of the treatment or a part of the natural history of the disease. Local treatment is generally used in conjunction with systemic therapy or to patients who respond well to systemic treatment as a maintenance therapy. Fernandes et al. conducted a study that included 11 patients with FFA treated with different drugs depending on the stage of the disease. No significant improvement was observed in the majority of cases, except in one patient with a rapidly and recent (less than a year) regressing disease who received intralesional corticosteroids on the frontal hairline and oral hydroxychloroquine 400 mg per day for 12 months. In this case the initial biopsy specimen revealed a predominance of inflammatory changes. After a mean follow-up of 30 months, progression of the condition stopped in ten patients (90.9 %) [14]. This study suggests that early anti-inflammatory therapy could have some benefits in the recession of the disease in accordance with the study of Moreno-Raminez et al. [6].

The study of Samrao et al. included 36 adults with FFA, treated with hydroxychloroquine, doxycycline, and mycophenolate mofetil. Hydroxychloroquine and mycophenolate were initiated in patients with FFA when biopsy specimen showed a moderate to dense inflammatory infiltrate. Doxycycline was given when the infiltrate was sparse. The study revealed that hydroxychloroquine is significantly effective in reducing signs and symptoms of FFA after both 6 and 12 months of treatment. The lack of a significant reduction in signs and symptoms between 6 and 12 months indicates that the maximal benefits of hydroxychloroquine are evident within the first 6 months of use [3]. This study is in accordance with the study conducted by Chiang et al. which demonstrated response to treatment with hydroxychloroquine in 40 patients with LPP, including 11 patients with FFA. The data showed a statistically significant reduction in LPPAI at 6 months with continued reduction in LPPAI scores at 12 months [17].

Racz et al. conducted a literature search in order to find all primary studies on the treatment of FFA and LPP trying to determine the effectiveness of available options for FFA and LPP and to identify promising treatment options for future studies. According to their study, there is currently no effective treatment of FFA. Comparing all the systemic treatments, oral 5-alpha-reductase inhibitors, which were provided more often, seem to be the most effective treatment resulting in good clinical response in 45 % of the patients, possibly affecting the accompanying androgenic alopecia. Hydroxychloroquine resulted in good clinical response in 30 % of the 29 treated patients. Topical corticosteroids are ineffective in FFA, and the remaining treatments were all reported in less than ten patients. There is still an argument whether cyclosporine A could be a good candidate for future studies on the treatment of FFA. Ladizinsky et al. performed a retrospective review of 19 patients with FFA seen at Duke University. A number of treatments, including topical and intralesional steroids, antibiotics, and immunomodulators, were used with disappointing results in most patients. Moreover, stabilization of hair loss was seen in 7 of 10 (70 %) patients treated with dutasteride (2 in combination with doxycycline and 1 in combination with topical tacrolimus and topical class I steroid), in 1 of 3 (33 %) patients treated with finasteride, in 2 of 4 (50 %) patients on hydroxychloroquine, in 1 of 3 (33 %) on methotrexate, and in 1 of 2 on minocycline (in combination with topical tacrolimus). However, the majority of patients on dutasteride experienced disease stabilization, but no therapy was associated with significant hair regrowth [11]. MacDonald et al. conducted a review of 60 patients with FFA treated with several different modalities, none consistently effective. According to their study, potent topical corticosteroids and calcineurin inhibitors reduced inflammation but without clear benefit in slowing the alopecia. The most frequently used systemic medication, hydroxychloroquine, was without consistent benefit, and the number of patients treated with other modalities (tetracycline, intralesional triamcinolone, and UVB) precludes any conclusion regarding efficacy [1]. At the end, another study conducted by Tan et al. is in agreement with previous reports showing that it is not clear whether treatment with topical and systemic steroids, topical retinoids, oral isotretinoin, topical minoxidil, hydroxychloroquine and finasteride stops the progression of the disease or the stabilization of FFA is part of the natural history of the disease [7].