Fibrosing Alopecia in a Pattern Distribution (FAPD)
Overview
Hair follicle destroys do not grow back, so the sooner it is diagnosed, the more hair can be preserved.It affects the top and crown of the scalp, the same areas involved in male and female pattern hair loss and the two can occur at the same time.
Aurora Dermatology’s experienced dermatologists specialise in diagnosing and managing it.
A specialist diagnosis means you get treatment that targets the inflammation, to prevent further thinning.
What is Fibrosing Alopecia in a Pattern Distribution (FAPD)?
The immune system targets the hair follicles along the top and crown of the scalp, causing inflammation that gradually replaces follicles with scar tissue.
FAPD has clinical and histopathological features of both Lichen planopilaris (LPP) and androgenetic alopecia (AGA), which is why a dermatology consult is important for a correct diagnosis.
The condition was first reported by Zinkernagel and Trueb in 2000.
Mild to moderate dysesthesias have been reported in this condition – in other words, unpleasant sensations of the scalp without an obvious cause, including itch and pain.
The condition mostly affects middle-aged women or older women, but also men.
The hair pull test, which involves a gentle tug on a small bunch of hairs to see how many come out, is negative in most cases of FAPD.
When should I see a dermatologist for FAPD?
Early warning signs of FAPD include:
- Thinning on top of the scalp over the crown and central scalp, often with progressively widening part
Scalp itch, tenderness (also known as scalp dysesthesia), sometimes worse when brushing hair. - Scale, redness or flaking around individual hairs
- Hair loss treatment that isn’t working as expected and thinning progresses
- In some people, there may be overlapping signs of frontal fibrosing alopecia (FFA), which is a close cousin, but not quite the same.
If you have noticed one or more of these signs, one of our dermatologists can assess the cause with a quick scalp examination, and if needed a biopsy.
How does Aurora Dermatology diagnose FAPD?
Our diagnosis involves
01 – Consultation
Your symptoms, how the thinning has changed, past treatments and family history
02 – Trichcoscopy
A painless, magnified look at the scalp to spot inflammation and scarring
03 – Scalp biopsy
Often recommended to confirm FAPD and separate it from pattern hair loss alone
04 – Baseline and follow-up
Standardised photos and symptom scores to track how the treatment is working
Because FAPD combines inflammation with pattern thinning, our care targets both issues specifically. Plans are reviewed at regular follow ups.
What is the cause of FAPD?
What are the clinical features of FAPD?
It affects the androgen-dependent areas of the scalp and anterior hairline is usually preserved.
Three distinct patterns have been described: uniform hair thinning from the frontal scalp to the crown (most common form), frontal accentuation (described as the ‘Christmas tree pattern’ in Female Pattern Hair Loss (FPHL) which means that if you look down at the top of the head with the hair parted down the middle, the part is widest at the front and gets narrower towards the crown.
There is also vertex accentuation, or thinning most noticeable at the crown or the top-back of the head.
Clinically, FAPD can resemble Androgenetic Alopecia (AGA), but the presence of inflammation and scarring features on trichoscopy (scalp dermoscopy).
This involves the use of a special magnifying device for the scalp which helps distinguish FAPD from non-scarring pattern hair loss.
Unlike lichen planopilaris, (LPP), In FAPD existence of vellus hair (fine, short, light coloured hairs) and hair loss in pattern are some of its distinguishing features.
Scalp symptoms are often absent; when present they often include mild dysesthesia, pain, burning sensation, and/or pruritus (itching).
Eyebrow, face, or body hair involvement are uncommon in FAPD, as opposed to frontal fibrosing alopecia (FFA).
What are the trichoscopy (scalp dermoscopy) features of FAPD?
The dermoscopic features of FAPD resemble AGA in some respects such as hairs of different thicknesses, and more follicles growing in a single hair instead of two or three.
LPP like features include perifollicular hyperkeratosis or scale around the base of each hair, or redness around each hair (perifollicular erythema).
There may also be a loss of follicular ostia, which is the disappearance of the tiny openings that hairs grow from, which is also sign of scarring.
AGA like features include hair shaft diameter variability, vellus hairs, increased single-hair follicular units.
For doctors, additional reported clinical features include: hyperpigmented perifollicular halo, honeycomb pigmented network, small, white scattered scars, milky-red areas, and discordant anisotrichosis.
What are prominent features of histopathology in FAPD?
There is no single histopathological feature specific to FAPD.
The histopathology of FAPD typically shows features of both LPP and AGA, including interface dermatitis, peri-infundibular or peri-isthmic lymphocytic infiltrate, concentric perifollicular lamellar fibrosis (scarring).
There may also be reduced or absent sebaceous glands, follicular scars, along with hair follicular, (miniaturisation) where hairs become shorter and thinner over time.
Apart from scarring, perifollicular inflammation and perifollicular fibrosis can be seen in AGA and seborrhoeic dermatitis (SD).
What is the differential diagnosis of FAPD?
How is the diagnosis of FAPD made?
When diagnosing FAPD, your Aurora Dermatology doctor will combine what they see when examining your scalp, what a magnified look at the scalp (or trichoscopy) indicates, and will also take a very small skin biopsy. If FAPD is suspected, it’s much better to treat early and preserve hair rather than wait for hair loss to get worse.
What is the treatment of FAPD?
Treatment options include: Anti-inflammatory creams Lotions, scalp injections or tablets to calm inflammation Treatments to slow pattern thinning and support hair growth.
Cosmetic coverage such as camouflage, wigs, or scalp micropigmentation can be offered.
Your dermatologist will discuss which options suit you.
What is the outlook for FAPD?
FAPD is a slowly progressive scarring alopecia. Delays in diagnosis and treatment can lead to permanent hair loss. The goal of treatment is to prevent disease progression and preserve the remaining hair.
What is the outlook for FAPD?
FAPD is a slowly progressive scarring alopecia. Delays in diagnosis and treatment can lead to permanent hair loss. The goal of treatment is to prevent disease progression and preserve the remaining hair.
References
Jerjen R, Pinczewski J, Sinclair R, Bhoyrul B. Clinicopathological characteristics and treatment outcomes of fibrosing alopecia in a pattern distribution: a retrospective cohort study. J Eur Acad Dermatol Venereol. 2021;35(12):2440-2447. doi:10.1111/jdv.17604.
Kinoshita-Ise M, Fukuyama M, Ohyama M. Distinctive age distribution and hair loss pattern putatively highlighting uniqueness of Japanese cases of fibrosing alopecia in a pattern distribution. J Dermatol. 2022;49(1):106-117. doi:10.1111/1346-8138.16155.
Tang GT, et al. Clinicopathological features and treatment outcomes of fibrosing alopecia in a pattern
distribution: a multicentre cohort study. Clin Exp Dermatol. 2026;51(3):411-417. doi:10.1093/ced/llaf444.
Teixeira MS, et al. Fibrosing alopecia in a pattern distribution in African-descent and Hispanic female patients.
Skin Appendage Disord. 2019;5:211-215.
Werner B, et al. Understanding fibrosing alopecia in a pattern distribution: a retrospective study with
histological challenges in the diagnosis of diffuse central alopecia. Arch Dermatol Res. 2025;317:506.
doi:10.1007/s00403-025-04014-3
Triyangkulsri K, Srisuwanwattana P, Sriphojanart T, Suchonwanit P. Fibrosing Alopecia in a Pattern
Distribution: A Case Report and Literature Review. Case Rep Dermatol. 2019;11(3):297-302.
doi:10.1159/000503681.
Wu R, Li Y, Wang L, Yang Z, Liu Q, Yang D. Tofacitinib for fibrosing alopecia in a pattern distribution. Indian J
Dermatol Venereol Leprol. 2025;91(S2):S145-S147. doi:10.25259/IJDVL_655_2024.
Svigos K, Yin L, Shaw K, Gutierrez D, Peterson E, Lo Sicco K, Shapiro J. Use of platelet-rich plasma in lichen
planopilaris and its variants: A retrospective case series demonstrating treatment tolerability without
koebnerization. J Am Acad Dermatol. 2020;83(5):1506-1509. doi:10.1016/j.jaad.2020.06.026.
Gómez-Zubiaur A, Valenzuela C, Andrés-Lencina JJ, Rodríguez-Villa A, Ricart JM. Algorithm proposal for
hair transplantation in fibrosing alopecia pattern distribution. J Cosmet Dermatol. 2022;21(11):5543-5545.
doi:10.1111/jocd.15124.
