Ilana S. Rosman, MD

Dermatology is one of the least diverse medical specialties with only 3% of dermatologists being Black and 4% Latinx.¹ Leading dermatology organizations have called for specialty-wide efforts to improve diversity, with a particular focus on the resident selection process.^2,3 Medical students who are underrepresented in medicine (UIM)(ie, those who identify as Black, Latinx, Native American, or Pacific Islander) face many potential barriers in applying to dermatology programs, including financial limitations, lack of support and mentorship, and less exposure to the specialty.^1,2,4 The COVID-19 pandemic introduced additional challenges in the residency application process with limitations on clinical, research, and volunteer experiences; decreased opportunities for in-person mentorship and away rotations; and a shift to virtual recruitment. Although there has been increased emphasis on recruiting diverse candidates to dermatology, the COVID-19 pandemic may have exacerbated existing barriers for UIM applicants.

We surveyed dermatology residency program directors (PDs) and applicants to evaluate how UIM students approach and fare in the dermatology residency application process as well as the effects of COVID-19 on the most recent application cycle. Herein, we report the results of our surveys with a focus on racial differences in the application process.

Methods

We administered 2 anonymous online surveys—one to 115 PDs through the Association of Professors of Dermatology (APD) email listserve and another to applicants who participated in the 2020-2021 dermatology residency application cycle through the Dermatology Interest Group Association (DIGA) listserve. The surveys were distributed from March 29 through May 23, 2021. There was no way to determine the number of dermatology applicants on the DIGA listserve. The surveys were reviewed and approved by the University of Southern California (Los Angeles, California) institutional review board (approval #UP-21-00118).

Participants were not required to answer every survey question; response rates varied by question. Survey responses with less than 10% completion were excluded from analysis. Data were collected, analyzed, and stored using Qualtrics, a secure online survey platform. The test of equal or given proportions in R studio was used to determine statistically significant differences between variables (P<.05 indicated statistical significance).

Results

The PD survey received 79 complete responses (83.5% complete responses, 73.8% response rate) and the applicant survey received 232 complete responses (83.6% complete responses).

Applicant Characteristics—Applicant characteristics are provided in the eTable; 13.2% and 8.4% of participants were Black and Latinx (including those who identify as Hispanic/Latino), respectively. Only 0.8% of respondents identified as American Indian or Alaskan Native and were excluded from the analysis due to the limited sample size. Those who identified as White, Asian, multiple races, or other and those who preferred not to answer were considered non-UIM participants.

Differences in family background were observed in our cohort, with UIM candidates more likely to have experienced disadvantages, defined as being the first in their family to attend college/graduate school, growing up in a rural area, being a first-generation immigrant, or qualifying as low income. Underrepresented in medicine applicants also were less likely to have a dermatology program at their medical school (both Black and Latinx) and to have been elected to honor societies such as Alpha Omega Alpha and the Gold Humanism Honor Society (Black only).

Underrepresented in medicine applicants were more likely to complete a research gap year (eTable). Most applicants who took research years did so to improve their chances of matching, regardless of their race/ethnicity. For those who did not complete a research year, Black applicants (46.7%) were more likely to base that decision on financial limitations compared to non-UIMs (18.6%, P<.0001). Interestingly, in the PD survey, only 4.5% of respondents considered completion of a research year extremely or very important when compiling rank lists.

Application Process and Match Outcomes—The Table highlights differences in how UIM applicants approached the application process. Black but not Latinx applicants were less likely to be first-time applicants to dermatology compared to non-UIM applicants. Black applicants (8.3%) were significantly less likely to apply to more than 100 programs compared to non-UIM applicants (29.5%, P=.0002). Underrepresented in medicine applicants received greater numbers of interviews despite applying to fewer programs overall.

There also were differences in how UIM candidates approached their rank lists, with Black and Latinx applicants prioritizing diversity of patient populations and program faculty as well as program missions and values (Figure).

In our cohort, UIM candidates were more likely than non-UIM to match, and Black applicants were most likely to match at one of their top 3 choices (Table). In the PD survey, 77.6% of PDs considered contribution to diversity an important factor when compiling their rank lists.

Comment

Applicant Background—Dermatology is a competitive specialty with a challenging application process² that has been further complicated by the COVID-19 pandemic. Our study elucidated how the 2020-2021 application cycle affected UIM dermatology applicants. Prior studies have found that UIM medical students were more likely to come from lower socioeconomic backgrounds; financial constraints pose a major barrier for UIM and low-income students interested in dermatology.^4-6 We found this to be true in our cohort, as Black and Latinx applicants were significantly more likely to come from disadvantaged backgrounds (P<.000008 and P=.006, respectively). Additionally, we found that Black applicants were more likely than any other group to indicate financial concerns as their primary reason for not taking a research gap year. 

Although most applicants who completed a research year did so to increase their chances of matching, a higher percentage of UIMs took research years compared to non-UIM applicants. This finding could indicate greater anxiety about matching among UIM applicants vs their non-UIM counterparts. Black students have faced discrimination in clinical grading,⁷ have perceived racial discrimination in residency interviews,^8,9 and have shown to be less likely to be elected to medical school honor societies.¹⁰ We found that UIM applicants were more likely to pursue a research year compared to other applicants,¹¹ possibly because they felt additional pressure to enhance their applications or because UIM candidates were less likely to have a home dermatology program. Expansion of mentorship programs, visiting student electives, and grants for UIMs may alleviate the need for these candidates to complete a research year and reduce disparities in the application process.

Factors Influencing Rank Lists for Applicants—In our cohort, UIMs were significantly more likely to rank diversity of patients (P<.0001 for Black applicants and P=.04 for Latinx applicants) and faculty (P<.001 for Black applicants and P<.001 for Latinx applicants) as important factors in choosing a residency program. Historically, dermatology has been disproportionately White in its physician workforce and patient population.^1,12 Students with lower incomes or who identify as minorities cite the lack of diversity in dermatology as a considerable barrier to pursuing a career in the specialty.^4,5 Service learning, pipeline programs aimed at early exposure to dermatology, and increased access to care for diverse patient populations are important measures to improve diversity in the dermatology workforce.^13-15 Residency programs should consider how to incorporate these aspects into didactic and clinical curricula to better recruit diverse candidates to the field.

Equity in the Application Process—We found that Black applicants were more likely than non-UIM applicants to be reapplicants to dermatology; however, Black applicants in our study also were more likely to receive more interview invites, match into dermatology, and match into one of their top 3 programs. These findings are interesting, particularly given concerns about equity in the application process. It is possible that Black applicants who overcome barriers to applying to dermatology ultimately are more successful applicants. Recently, there has been an increased focus in the field on diversifying dermatology, which was further intensified last year.^2,3 Indicative of this shift, our PD survey showed that most programs reported that applicants’ contributions to diversity were important factors in the application process. Additionally, an emphasis by PDs on a holistic review of applications coupled with direct advocacy for increased representation may have contributed to the increased match rates for UIM applicants reported in our survey.

Latinx Applicants—Our study showed differences in how Latinx candidates fared in the application process; although Latinx applicants were more likely than their non-Latinx counterparts to match into dermatology, they were less likely than non-Latinx applicants to match into one of their top 3 programs. Given that Latinx encompasses ethnicity, not race, there may be a difference in how intentional focus on and advocacy for increasing diversity in dermatology affected different UIM applicant groups. Both race and ethnicity are social constructs rather than scientific categorizations; thus, it is difficult in survey studies such as ours to capture the intersectionality present across and between groups. Lastly, it is possible that the respondents to our applicant survey are not representative of the full cohort of UIM applicants.

Study Limitations—A major limitation of our study was that we did not have a method of reaching all dermatology applicants. Although our study shows promising results suggestive of increased diversity in the last application cycle, release of the National Resident Matching Program results from 2020-2021 with racially stratified data will be imperative to assess equity in the match process for all specialties and to confirm the generalizability of our results.

Dermatology is one of the least diverse medical specialties with only 3% of dermatologists being Black and 4% Latinx.¹ Leading dermatology organizations have called for specialty-wide efforts to improve diversity, with a particular focus on the resident selection process.^2,3 Medical students who are underrepresented in medicine (UIM)(ie, those who identify as Black, Latinx, Native American, or Pacific Islander) face many potential barriers in applying to dermatology programs, including financial limitations, lack of support and mentorship, and less exposure to the specialty.^1,2,4 The COVID-19 pandemic introduced additional challenges in the residency application process with limitations on clinical, research, and volunteer experiences; decreased opportunities for in-person mentorship and away rotations; and a shift to virtual recruitment. Although there has been increased emphasis on recruiting diverse candidates to dermatology, the COVID-19 pandemic may have exacerbated existing barriers for UIM applicants.

We surveyed dermatology residency program directors (PDs) and applicants to evaluate how UIM students approach and fare in the dermatology residency application process as well as the effects of COVID-19 on the most recent application cycle. Herein, we report the results of our surveys with a focus on racial differences in the application process.

Methods

We administered 2 anonymous online surveys—one to 115 PDs through the Association of Professors of Dermatology (APD) email listserve and another to applicants who participated in the 2020-2021 dermatology residency application cycle through the Dermatology Interest Group Association (DIGA) listserve. The surveys were distributed from March 29 through May 23, 2021. There was no way to determine the number of dermatology applicants on the DIGA listserve. The surveys were reviewed and approved by the University of Southern California (Los Angeles, California) institutional review board (approval #UP-21-00118).

Participants were not required to answer every survey question; response rates varied by question. Survey responses with less than 10% completion were excluded from analysis. Data were collected, analyzed, and stored using Qualtrics, a secure online survey platform. The test of equal or given proportions in R studio was used to determine statistically significant differences between variables (P<.05 indicated statistical significance).

Results

The PD survey received 79 complete responses (83.5% complete responses, 73.8% response rate) and the applicant survey received 232 complete responses (83.6% complete responses).

Applicant Characteristics—Applicant characteristics are provided in the eTable; 13.2% and 8.4% of participants were Black and Latinx (including those who identify as Hispanic/Latino), respectively. Only 0.8% of respondents identified as American Indian or Alaskan Native and were excluded from the analysis due to the limited sample size. Those who identified as White, Asian, multiple races, or other and those who preferred not to answer were considered non-UIM participants.

Differences in family background were observed in our cohort, with UIM candidates more likely to have experienced disadvantages, defined as being the first in their family to attend college/graduate school, growing up in a rural area, being a first-generation immigrant, or qualifying as low income. Underrepresented in medicine applicants also were less likely to have a dermatology program at their medical school (both Black and Latinx) and to have been elected to honor societies such as Alpha Omega Alpha and the Gold Humanism Honor Society (Black only).

Underrepresented in medicine applicants were more likely to complete a research gap year (eTable). Most applicants who took research years did so to improve their chances of matching, regardless of their race/ethnicity. For those who did not complete a research year, Black applicants (46.7%) were more likely to base that decision on financial limitations compared to non-UIMs (18.6%, P<.0001). Interestingly, in the PD survey, only 4.5% of respondents considered completion of a research year extremely or very important when compiling rank lists.

Application Process and Match Outcomes—The Table highlights differences in how UIM applicants approached the application process. Black but not Latinx applicants were less likely to be first-time applicants to dermatology compared to non-UIM applicants. Black applicants (8.3%) were significantly less likely to apply to more than 100 programs compared to non-UIM applicants (29.5%, P=.0002). Underrepresented in medicine applicants received greater numbers of interviews despite applying to fewer programs overall.

There also were differences in how UIM candidates approached their rank lists, with Black and Latinx applicants prioritizing diversity of patient populations and program faculty as well as program missions and values (Figure).

In our cohort, UIM candidates were more likely than non-UIM to match, and Black applicants were most likely to match at one of their top 3 choices (Table). In the PD survey, 77.6% of PDs considered contribution to diversity an important factor when compiling their rank lists.

Comment

Applicant Background—Dermatology is a competitive specialty with a challenging application process² that has been further complicated by the COVID-19 pandemic. Our study elucidated how the 2020-2021 application cycle affected UIM dermatology applicants. Prior studies have found that UIM medical students were more likely to come from lower socioeconomic backgrounds; financial constraints pose a major barrier for UIM and low-income students interested in dermatology.^4-6 We found this to be true in our cohort, as Black and Latinx applicants were significantly more likely to come from disadvantaged backgrounds (P<.000008 and P=.006, respectively). Additionally, we found that Black applicants were more likely than any other group to indicate financial concerns as their primary reason for not taking a research gap year. 

Although most applicants who completed a research year did so to increase their chances of matching, a higher percentage of UIMs took research years compared to non-UIM applicants. This finding could indicate greater anxiety about matching among UIM applicants vs their non-UIM counterparts. Black students have faced discrimination in clinical grading,⁷ have perceived racial discrimination in residency interviews,^8,9 and have shown to be less likely to be elected to medical school honor societies.¹⁰ We found that UIM applicants were more likely to pursue a research year compared to other applicants,¹¹ possibly because they felt additional pressure to enhance their applications or because UIM candidates were less likely to have a home dermatology program. Expansion of mentorship programs, visiting student electives, and grants for UIMs may alleviate the need for these candidates to complete a research year and reduce disparities in the application process.

Factors Influencing Rank Lists for Applicants—In our cohort, UIMs were significantly more likely to rank diversity of patients (P<.0001 for Black applicants and P=.04 for Latinx applicants) and faculty (P<.001 for Black applicants and P<.001 for Latinx applicants) as important factors in choosing a residency program. Historically, dermatology has been disproportionately White in its physician workforce and patient population.^1,12 Students with lower incomes or who identify as minorities cite the lack of diversity in dermatology as a considerable barrier to pursuing a career in the specialty.^4,5 Service learning, pipeline programs aimed at early exposure to dermatology, and increased access to care for diverse patient populations are important measures to improve diversity in the dermatology workforce.^13-15 Residency programs should consider how to incorporate these aspects into didactic and clinical curricula to better recruit diverse candidates to the field.

Equity in the Application Process—We found that Black applicants were more likely than non-UIM applicants to be reapplicants to dermatology; however, Black applicants in our study also were more likely to receive more interview invites, match into dermatology, and match into one of their top 3 programs. These findings are interesting, particularly given concerns about equity in the application process. It is possible that Black applicants who overcome barriers to applying to dermatology ultimately are more successful applicants. Recently, there has been an increased focus in the field on diversifying dermatology, which was further intensified last year.^2,3 Indicative of this shift, our PD survey showed that most programs reported that applicants’ contributions to diversity were important factors in the application process. Additionally, an emphasis by PDs on a holistic review of applications coupled with direct advocacy for increased representation may have contributed to the increased match rates for UIM applicants reported in our survey.

Latinx Applicants—Our study showed differences in how Latinx candidates fared in the application process; although Latinx applicants were more likely than their non-Latinx counterparts to match into dermatology, they were less likely than non-Latinx applicants to match into one of their top 3 programs. Given that Latinx encompasses ethnicity, not race, there may be a difference in how intentional focus on and advocacy for increasing diversity in dermatology affected different UIM applicant groups. Both race and ethnicity are social constructs rather than scientific categorizations; thus, it is difficult in survey studies such as ours to capture the intersectionality present across and between groups. Lastly, it is possible that the respondents to our applicant survey are not representative of the full cohort of UIM applicants.

Study Limitations—A major limitation of our study was that we did not have a method of reaching all dermatology applicants. Although our study shows promising results suggestive of increased diversity in the last application cycle, release of the National Resident Matching Program results from 2020-2021 with racially stratified data will be imperative to assess equity in the match process for all specialties and to confirm the generalizability of our results.

Dermatology is one of the least diverse medical specialties with only 3% of dermatologists being Black and 4% Latinx.¹ Leading dermatology organizations have called for specialty-wide efforts to improve diversity, with a particular focus on the resident selection process.^2,3 Medical students who are underrepresented in medicine (UIM)(ie, those who identify as Black, Latinx, Native American, or Pacific Islander) face many potential barriers in applying to dermatology programs, including financial limitations, lack of support and mentorship, and less exposure to the specialty.^1,2,4 The COVID-19 pandemic introduced additional challenges in the residency application process with limitations on clinical, research, and volunteer experiences; decreased opportunities for in-person mentorship and away rotations; and a shift to virtual recruitment. Although there has been increased emphasis on recruiting diverse candidates to dermatology, the COVID-19 pandemic may have exacerbated existing barriers for UIM applicants.

We surveyed dermatology residency program directors (PDs) and applicants to evaluate how UIM students approach and fare in the dermatology residency application process as well as the effects of COVID-19 on the most recent application cycle. Herein, we report the results of our surveys with a focus on racial differences in the application process.

Methods

We administered 2 anonymous online surveys—one to 115 PDs through the Association of Professors of Dermatology (APD) email listserve and another to applicants who participated in the 2020-2021 dermatology residency application cycle through the Dermatology Interest Group Association (DIGA) listserve. The surveys were distributed from March 29 through May 23, 2021. There was no way to determine the number of dermatology applicants on the DIGA listserve. The surveys were reviewed and approved by the University of Southern California (Los Angeles, California) institutional review board (approval #UP-21-00118).

Participants were not required to answer every survey question; response rates varied by question. Survey responses with less than 10% completion were excluded from analysis. Data were collected, analyzed, and stored using Qualtrics, a secure online survey platform. The test of equal or given proportions in R studio was used to determine statistically significant differences between variables (P<.05 indicated statistical significance).

Results

The PD survey received 79 complete responses (83.5% complete responses, 73.8% response rate) and the applicant survey received 232 complete responses (83.6% complete responses).

Applicant Characteristics—Applicant characteristics are provided in the eTable; 13.2% and 8.4% of participants were Black and Latinx (including those who identify as Hispanic/Latino), respectively. Only 0.8% of respondents identified as American Indian or Alaskan Native and were excluded from the analysis due to the limited sample size. Those who identified as White, Asian, multiple races, or other and those who preferred not to answer were considered non-UIM participants.

Differences in family background were observed in our cohort, with UIM candidates more likely to have experienced disadvantages, defined as being the first in their family to attend college/graduate school, growing up in a rural area, being a first-generation immigrant, or qualifying as low income. Underrepresented in medicine applicants also were less likely to have a dermatology program at their medical school (both Black and Latinx) and to have been elected to honor societies such as Alpha Omega Alpha and the Gold Humanism Honor Society (Black only).

Underrepresented in medicine applicants were more likely to complete a research gap year (eTable). Most applicants who took research years did so to improve their chances of matching, regardless of their race/ethnicity. For those who did not complete a research year, Black applicants (46.7%) were more likely to base that decision on financial limitations compared to non-UIMs (18.6%, P<.0001). Interestingly, in the PD survey, only 4.5% of respondents considered completion of a research year extremely or very important when compiling rank lists.

Application Process and Match Outcomes—The Table highlights differences in how UIM applicants approached the application process. Black but not Latinx applicants were less likely to be first-time applicants to dermatology compared to non-UIM applicants. Black applicants (8.3%) were significantly less likely to apply to more than 100 programs compared to non-UIM applicants (29.5%, P=.0002). Underrepresented in medicine applicants received greater numbers of interviews despite applying to fewer programs overall.

There also were differences in how UIM candidates approached their rank lists, with Black and Latinx applicants prioritizing diversity of patient populations and program faculty as well as program missions and values (Figure).

In our cohort, UIM candidates were more likely than non-UIM to match, and Black applicants were most likely to match at one of their top 3 choices (Table). In the PD survey, 77.6% of PDs considered contribution to diversity an important factor when compiling their rank lists.

Comment

Applicant Background—Dermatology is a competitive specialty with a challenging application process² that has been further complicated by the COVID-19 pandemic. Our study elucidated how the 2020-2021 application cycle affected UIM dermatology applicants. Prior studies have found that UIM medical students were more likely to come from lower socioeconomic backgrounds; financial constraints pose a major barrier for UIM and low-income students interested in dermatology.^4-6 We found this to be true in our cohort, as Black and Latinx applicants were significantly more likely to come from disadvantaged backgrounds (P<.000008 and P=.006, respectively). Additionally, we found that Black applicants were more likely than any other group to indicate financial concerns as their primary reason for not taking a research gap year. 

Although most applicants who completed a research year did so to increase their chances of matching, a higher percentage of UIMs took research years compared to non-UIM applicants. This finding could indicate greater anxiety about matching among UIM applicants vs their non-UIM counterparts. Black students have faced discrimination in clinical grading,⁷ have perceived racial discrimination in residency interviews,^8,9 and have shown to be less likely to be elected to medical school honor societies.¹⁰ We found that UIM applicants were more likely to pursue a research year compared to other applicants,¹¹ possibly because they felt additional pressure to enhance their applications or because UIM candidates were less likely to have a home dermatology program. Expansion of mentorship programs, visiting student electives, and grants for UIMs may alleviate the need for these candidates to complete a research year and reduce disparities in the application process.

Factors Influencing Rank Lists for Applicants—In our cohort, UIMs were significantly more likely to rank diversity of patients (P<.0001 for Black applicants and P=.04 for Latinx applicants) and faculty (P<.001 for Black applicants and P<.001 for Latinx applicants) as important factors in choosing a residency program. Historically, dermatology has been disproportionately White in its physician workforce and patient population.^1,12 Students with lower incomes or who identify as minorities cite the lack of diversity in dermatology as a considerable barrier to pursuing a career in the specialty.^4,5 Service learning, pipeline programs aimed at early exposure to dermatology, and increased access to care for diverse patient populations are important measures to improve diversity in the dermatology workforce.^13-15 Residency programs should consider how to incorporate these aspects into didactic and clinical curricula to better recruit diverse candidates to the field.

Equity in the Application Process—We found that Black applicants were more likely than non-UIM applicants to be reapplicants to dermatology; however, Black applicants in our study also were more likely to receive more interview invites, match into dermatology, and match into one of their top 3 programs. These findings are interesting, particularly given concerns about equity in the application process. It is possible that Black applicants who overcome barriers to applying to dermatology ultimately are more successful applicants. Recently, there has been an increased focus in the field on diversifying dermatology, which was further intensified last year.^2,3 Indicative of this shift, our PD survey showed that most programs reported that applicants’ contributions to diversity were important factors in the application process. Additionally, an emphasis by PDs on a holistic review of applications coupled with direct advocacy for increased representation may have contributed to the increased match rates for UIM applicants reported in our survey.

Latinx Applicants—Our study showed differences in how Latinx candidates fared in the application process; although Latinx applicants were more likely than their non-Latinx counterparts to match into dermatology, they were less likely than non-Latinx applicants to match into one of their top 3 programs. Given that Latinx encompasses ethnicity, not race, there may be a difference in how intentional focus on and advocacy for increasing diversity in dermatology affected different UIM applicant groups. Both race and ethnicity are social constructs rather than scientific categorizations; thus, it is difficult in survey studies such as ours to capture the intersectionality present across and between groups. Lastly, it is possible that the respondents to our applicant survey are not representative of the full cohort of UIM applicants.

Study Limitations—A major limitation of our study was that we did not have a method of reaching all dermatology applicants. Although our study shows promising results suggestive of increased diversity in the last application cycle, release of the National Resident Matching Program results from 2020-2021 with racially stratified data will be imperative to assess equity in the match process for all specialties and to confirm the generalizability of our results.

Amid increasing numbers of applications, decreasing match rates, and ongoing lack of diversity in the dermatology trainee workforce, the COVID-19 pandemic introduced additional challenges to the dermatology residency application process and laid bare systemic inequities and inherent problems that must be addressed. Historically, dermatology applicants have excelled in academic metrics, such as US Medical Licensing Examination (USMLE) scores and nomination to the Alpha Omega Alpha honor society. As biases associated with these academic metrics are being elucidated, they have in turn become less available. With the upcoming change in USMLE Step 1 reporting to pass/fail only, as well as the elimination of Alpha Omega Alpha nomination for students, clinical grades, and/or class ranks at many medical schools, other elements of the application, such as volunteer experiences and research publications, may be weighed more heavily in the selection process. This may serve to exacerbate the application arms race, characterized by a steady rise in volunteer experiences, research publications, and research gap years that has already begun and likely will continue, particularly among dermatology applicants.

These issues are not unique to dermatology and are occurring across all medical specialties to varying degrees. The monetary and opportunity costs of the application process have become astronomical for both applicants and faculty. Faculty are overburdened with administrative duties related to resident recruitment and advising, and students are experiencing heightened match-related anxiety earlier and more acutely. These factors may contribute to burnout among trainees and faculty and may have deleterious effects on medical education. It is clear that transformative work must be pursued to ensure an equitable and sustainable residency application process moving forward. In this column, we review the notable work being done within dermatology and across specialties to reform the residency application process.

Coalition Recommendations

In August 2021, the Coalition for Physician Accountability (CoPA) released recommendations for comprehensive improvement of the undergraduate medical education (UME) to graduate medical education transition, which includes residency application. Of the 9 principal themes addressed, 2 focus on the residency application process: (1) equitable mission-driven application review, and (2) optimization of the application, interview, and selection processes, which relates to application volume as well as interview offers and formats.¹

In the area of application review, CoPA recommends replacing all letters of recommendation with structured evaluative letters as a universal tool in the application process.¹ These letters would include specialty-specific questions based on core competencies and would be completed by an evaluator who directly observed the student. Additionally, the group recommends revising the content and structure of the medical student performance evaluation to improve access to longitudinal assessment data about students. Ideally, developing UME competency outcomes to apply across learners would decrease reliance on traditional but potentially problematic application elements, such as licensing examination scores, clinical grades, and narrative evaluations.¹

To optimize residency application processes, CoPA recommends exploring innovative approaches to reduce application volume and maximize applicants interviewing and matching at programs where mutual interest is high.¹ Suggestions to address these issues include preference signaling, application caps, and/or additional rounds of application or matching. Standardization of the interview process also is recommended to improve equity, minimize educational disruption, and improve applicant well-being. Suggestions include the use of common interview offer and scheduling platforms, policies to govern interview offers and scheduling timelines, interview caps, and ongoing study of the impact of virtual interviews.¹

Residency Application Innovations Implemented by Other Specialties

A number of specialties have developed innovations in the residency application process to improve equity and fairness as well as optimize applicant-program fit. Emergency medicine created a now widely adopted, specialty-specific standardized letter of evaluation (SLOE).² It compares applicants across a number of measures that include personal qualities, clinical skills, and a global assessment. The SLOE is designed to assess and compare applicants across institutions rather than provide recommendations. The emergency medicine SLOE also provides useful information about the letter writer, including duration and depth of interaction with the applicant and distribution of rankings of prior applicants.²

In 2019, obstetrics and gynecology launched a standardized application and interview process, which set a specialty-wide application deadline, limited interview invitations to the number of interview positions available, encouraged coordinated release of interview offers, and allowed applicants 72 hours to respond to invitations.³ These measures were implemented to improve fairness, transparency, and applicant well-being, as well as to promote equitable distribution of interviews. Data following this launch suggested that universal offer dates reduced excessive interviewing among competitive applicants.³

Last year, otolaryngology implemented a process known as preference signaling in which applicants were able to signal up to 5 preferred programs at the time of application. A signal allowed applicants to demonstrate interest in specific programs and could be used by programs during their application review process. Most applicants opted to submit signals, and programs received 0 to 71 signals (mean, 22).⁴ Almost all programs received at least 1 signal. The rate of receiving an interview was significantly higher for signaled programs (58%) compared to nonsignaled programs (14%)(P<.001), indicating that preference signaling may be beneficial for both programs and applicants for interview selection.⁴

Residency Application Innovations Implemented by Dermatology

Over the last 2 application cycles, dermatology has implemented several innovations to the residency application process. Initial work included release of guidelines for residency programs to conduct holistic application review,⁵ recommendations for website updates to share program-specific information with prospective trainees,⁶ and informational webinars and statements to update dermatology applicants about changes to the process and to answer application-related questions.^7-9

In 2020, dermatology initiated a coordinated interview invitation release in which interview offers were released on prespecified dates and applicants were given 48 hours prior to scheduling. Approximately 50% of residency programs participated in the first year, yet nearly all programs released on 1 of 2 universal dates in the current cycle. In a recent survey of dermatology applicants, nearly 90% supported coordinated release.¹⁰ Several other specialties also have incorporated universal release dates into their processes.

For the 2021-2022 application cycle, dermatology—along with internal medicine and general surgery—participated in the Association of American Medical Colleges’ pilot supplemental Electronic Residency Application Service (ERAS) application.¹¹ The pilot was designed as a first step to updating the ERAS content by allowing students to share more information about their extracurricular, research, and clinical activities, as well as geographic and program preferences to optimize applicant-program fit. Preference signaling, similar to the otolaryngology process, was included in the supplemental application, with dermatology applicants choosing up to 3 preferred programs to signal, excluding their home programs and any programs where they completed in-person away rotations. Preliminary data suggest that the vast majority of dermatology programs and applicants participated in the supplemental application.¹² Ongoing analysis of survey data from applicants, advisors, and program directors will help inform future directions. Dermatology has been an integral partner in the development, implementation, and evaluation of this pilot.

Proposed Innovations to the Application Process

Given the challenges of the current application process, there has been a long list of proposed innovations to ameliorate applicant, advisor, and program concerns.¹³ Many of these approaches are intended to respond to increasing costs to programs and applicants as well as the lack of equity in the process. Application caps and an early result acceptance program have both been proposed to address the ever-increasing volume of applications.^14,15 Neither of these proposals has been adopted by a specialty yet, but obstetrics and gynecology stakeholders have shown broad support for an early result acceptance program, signaling a possible future pilot.¹⁶

Interview caps also have been proposed to promote more equitable distribution of interview positions.¹⁷ Ophthalmology implemented this approach in the 2021-2022 application cycle, with applicants limited to a maximum of 18 interviews.¹⁸ Data from this pilot will help determine the effect of interview caps as well as the optimal limit, which will vary by specialty.

Changes to the application content itself could better facilitate holistic review and optimize applicant-program fit. This is the principle driving the pilot supplemental ERAS application, but it also has been addressed in other specialties. Ophthalmology replaced the traditional personal statement with a shorter autobiographical statement as well as 2 short personal essay questions. Plastic surgery designed a common supplemental application, currently in its second iteration, that highlights specialty-specific information from applicants to promote holistic review and eventually reduce application costs.¹⁹

The reforms introduced and proposed by dermatology and other specialties represent initial steps to address the issues inherent to the current residency application process. Providing faculty with better tools to holistically assess applicants during the review process and increasing transparency between programs and applicants should help optimize applicant-program fit and increase diversity in the dermatology workforce. Streamlining the application process to allow students to highlight their unique qualities in a user-friendly format as well as addressing potential inequities in interview distribution and access to the application process hopefully will contribute to better outcomes for both programs and applicants. However, many of these steps are likely to create additional administrative burdens on program faculty and are unlikely to allay student fears about matching.

The underlying issue for many specialties, and particularly for dermatology, is that demand far outstrips supply. With stable numbers of residency positions and an ever-increasing number of applicants, the match rate will continue to decrease, leading to increased anxiety among those interested in pursuing dermatology. Although USMLE Step 1 scores have been shown to have racial bias²⁰ and there are no data correlating scores with clinical performance, the elimination of a scoring system may affect the number of applicants entering dermatology with downstream effects on match rates. Heightened anxiety places increased pressure on students to choose a specialty earlier in their training and impacts the activities they pursue during medical school. Overemphasis on specialty choice and the match process can lead to higher rates of burnout among students and trainees, as students may focus on activities designed to increase their chances of matching at the expense of pursuing activities that could lead to greater engagement and passion in their careers—a key protective factor against burnout.

The goal of the residency application process is to optimize fit between candidates and programs by aligning goals, values, and learning environment. Students and programs working together as honest brokers can lead to transformative change in the process, freeing both parties to highlight their unique qualities and contributions. Programs benefit from optimal fit by being able to hone their particular mission and recruit and retain residents and faculty engaged in that mission. Residents will thrive in programs that support their learning and career goals and will ultimately be better positioned to meaningfully contribute to their chosen field in whatever capacity they choose.

Acknowledgments—The views presented in this column reflect those of the 9 elected members of the Association of Professors of Dermatology Residency Program Directors Section steering committee, all of whom are program directors at their institutions (listed in parentheses): Ammar Ahmed, MD (The University of Texas at Austin, Austin, Texas); Yolanda Helfrich, MD (University of Michigan, Ann Arbor, Michigan); Jo-Ann M. Latkowksi, MD (New York University, New York); Kiran Motaparthi, MD (University of Florida, Gainesville, Florida); Adena E. Rosenblatt, MD, PhD (The University of Chicago, Chicago, Illinois); Ilana S. Rosman, MD (Washington University, St. Louis, Missouri); Travis Vandergriff, MD (University of Texas Southwestern, Dallas, Texas); Diane Whitaker-Worth, MD (University of Connecticut, Farmington, Connecticut); Scott Worswick, MD (University of Southern California, Los Angeles, California).

Amid increasing numbers of applications, decreasing match rates, and ongoing lack of diversity in the dermatology trainee workforce, the COVID-19 pandemic introduced additional challenges to the dermatology residency application process and laid bare systemic inequities and inherent problems that must be addressed. Historically, dermatology applicants have excelled in academic metrics, such as US Medical Licensing Examination (USMLE) scores and nomination to the Alpha Omega Alpha honor society. As biases associated with these academic metrics are being elucidated, they have in turn become less available. With the upcoming change in USMLE Step 1 reporting to pass/fail only, as well as the elimination of Alpha Omega Alpha nomination for students, clinical grades, and/or class ranks at many medical schools, other elements of the application, such as volunteer experiences and research publications, may be weighed more heavily in the selection process. This may serve to exacerbate the application arms race, characterized by a steady rise in volunteer experiences, research publications, and research gap years that has already begun and likely will continue, particularly among dermatology applicants.

These issues are not unique to dermatology and are occurring across all medical specialties to varying degrees. The monetary and opportunity costs of the application process have become astronomical for both applicants and faculty. Faculty are overburdened with administrative duties related to resident recruitment and advising, and students are experiencing heightened match-related anxiety earlier and more acutely. These factors may contribute to burnout among trainees and faculty and may have deleterious effects on medical education. It is clear that transformative work must be pursued to ensure an equitable and sustainable residency application process moving forward. In this column, we review the notable work being done within dermatology and across specialties to reform the residency application process.

Coalition Recommendations

In August 2021, the Coalition for Physician Accountability (CoPA) released recommendations for comprehensive improvement of the undergraduate medical education (UME) to graduate medical education transition, which includes residency application. Of the 9 principal themes addressed, 2 focus on the residency application process: (1) equitable mission-driven application review, and (2) optimization of the application, interview, and selection processes, which relates to application volume as well as interview offers and formats.¹

In the area of application review, CoPA recommends replacing all letters of recommendation with structured evaluative letters as a universal tool in the application process.¹ These letters would include specialty-specific questions based on core competencies and would be completed by an evaluator who directly observed the student. Additionally, the group recommends revising the content and structure of the medical student performance evaluation to improve access to longitudinal assessment data about students. Ideally, developing UME competency outcomes to apply across learners would decrease reliance on traditional but potentially problematic application elements, such as licensing examination scores, clinical grades, and narrative evaluations.¹

To optimize residency application processes, CoPA recommends exploring innovative approaches to reduce application volume and maximize applicants interviewing and matching at programs where mutual interest is high.¹ Suggestions to address these issues include preference signaling, application caps, and/or additional rounds of application or matching. Standardization of the interview process also is recommended to improve equity, minimize educational disruption, and improve applicant well-being. Suggestions include the use of common interview offer and scheduling platforms, policies to govern interview offers and scheduling timelines, interview caps, and ongoing study of the impact of virtual interviews.¹

Residency Application Innovations Implemented by Other Specialties

A number of specialties have developed innovations in the residency application process to improve equity and fairness as well as optimize applicant-program fit. Emergency medicine created a now widely adopted, specialty-specific standardized letter of evaluation (SLOE).² It compares applicants across a number of measures that include personal qualities, clinical skills, and a global assessment. The SLOE is designed to assess and compare applicants across institutions rather than provide recommendations. The emergency medicine SLOE also provides useful information about the letter writer, including duration and depth of interaction with the applicant and distribution of rankings of prior applicants.²

In 2019, obstetrics and gynecology launched a standardized application and interview process, which set a specialty-wide application deadline, limited interview invitations to the number of interview positions available, encouraged coordinated release of interview offers, and allowed applicants 72 hours to respond to invitations.³ These measures were implemented to improve fairness, transparency, and applicant well-being, as well as to promote equitable distribution of interviews. Data following this launch suggested that universal offer dates reduced excessive interviewing among competitive applicants.³

Last year, otolaryngology implemented a process known as preference signaling in which applicants were able to signal up to 5 preferred programs at the time of application. A signal allowed applicants to demonstrate interest in specific programs and could be used by programs during their application review process. Most applicants opted to submit signals, and programs received 0 to 71 signals (mean, 22).⁴ Almost all programs received at least 1 signal. The rate of receiving an interview was significantly higher for signaled programs (58%) compared to nonsignaled programs (14%)(P<.001), indicating that preference signaling may be beneficial for both programs and applicants for interview selection.⁴

Residency Application Innovations Implemented by Dermatology

Over the last 2 application cycles, dermatology has implemented several innovations to the residency application process. Initial work included release of guidelines for residency programs to conduct holistic application review,⁵ recommendations for website updates to share program-specific information with prospective trainees,⁶ and informational webinars and statements to update dermatology applicants about changes to the process and to answer application-related questions.^7-9

In 2020, dermatology initiated a coordinated interview invitation release in which interview offers were released on prespecified dates and applicants were given 48 hours prior to scheduling. Approximately 50% of residency programs participated in the first year, yet nearly all programs released on 1 of 2 universal dates in the current cycle. In a recent survey of dermatology applicants, nearly 90% supported coordinated release.¹⁰ Several other specialties also have incorporated universal release dates into their processes.

For the 2021-2022 application cycle, dermatology—along with internal medicine and general surgery—participated in the Association of American Medical Colleges’ pilot supplemental Electronic Residency Application Service (ERAS) application.¹¹ The pilot was designed as a first step to updating the ERAS content by allowing students to share more information about their extracurricular, research, and clinical activities, as well as geographic and program preferences to optimize applicant-program fit. Preference signaling, similar to the otolaryngology process, was included in the supplemental application, with dermatology applicants choosing up to 3 preferred programs to signal, excluding their home programs and any programs where they completed in-person away rotations. Preliminary data suggest that the vast majority of dermatology programs and applicants participated in the supplemental application.¹² Ongoing analysis of survey data from applicants, advisors, and program directors will help inform future directions. Dermatology has been an integral partner in the development, implementation, and evaluation of this pilot.

Proposed Innovations to the Application Process

Given the challenges of the current application process, there has been a long list of proposed innovations to ameliorate applicant, advisor, and program concerns.¹³ Many of these approaches are intended to respond to increasing costs to programs and applicants as well as the lack of equity in the process. Application caps and an early result acceptance program have both been proposed to address the ever-increasing volume of applications.^14,15 Neither of these proposals has been adopted by a specialty yet, but obstetrics and gynecology stakeholders have shown broad support for an early result acceptance program, signaling a possible future pilot.¹⁶

Interview caps also have been proposed to promote more equitable distribution of interview positions.¹⁷ Ophthalmology implemented this approach in the 2021-2022 application cycle, with applicants limited to a maximum of 18 interviews.¹⁸ Data from this pilot will help determine the effect of interview caps as well as the optimal limit, which will vary by specialty.

Changes to the application content itself could better facilitate holistic review and optimize applicant-program fit. This is the principle driving the pilot supplemental ERAS application, but it also has been addressed in other specialties. Ophthalmology replaced the traditional personal statement with a shorter autobiographical statement as well as 2 short personal essay questions. Plastic surgery designed a common supplemental application, currently in its second iteration, that highlights specialty-specific information from applicants to promote holistic review and eventually reduce application costs.¹⁹

The reforms introduced and proposed by dermatology and other specialties represent initial steps to address the issues inherent to the current residency application process. Providing faculty with better tools to holistically assess applicants during the review process and increasing transparency between programs and applicants should help optimize applicant-program fit and increase diversity in the dermatology workforce. Streamlining the application process to allow students to highlight their unique qualities in a user-friendly format as well as addressing potential inequities in interview distribution and access to the application process hopefully will contribute to better outcomes for both programs and applicants. However, many of these steps are likely to create additional administrative burdens on program faculty and are unlikely to allay student fears about matching.

The underlying issue for many specialties, and particularly for dermatology, is that demand far outstrips supply. With stable numbers of residency positions and an ever-increasing number of applicants, the match rate will continue to decrease, leading to increased anxiety among those interested in pursuing dermatology. Although USMLE Step 1 scores have been shown to have racial bias²⁰ and there are no data correlating scores with clinical performance, the elimination of a scoring system may affect the number of applicants entering dermatology with downstream effects on match rates. Heightened anxiety places increased pressure on students to choose a specialty earlier in their training and impacts the activities they pursue during medical school. Overemphasis on specialty choice and the match process can lead to higher rates of burnout among students and trainees, as students may focus on activities designed to increase their chances of matching at the expense of pursuing activities that could lead to greater engagement and passion in their careers—a key protective factor against burnout.

The goal of the residency application process is to optimize fit between candidates and programs by aligning goals, values, and learning environment. Students and programs working together as honest brokers can lead to transformative change in the process, freeing both parties to highlight their unique qualities and contributions. Programs benefit from optimal fit by being able to hone their particular mission and recruit and retain residents and faculty engaged in that mission. Residents will thrive in programs that support their learning and career goals and will ultimately be better positioned to meaningfully contribute to their chosen field in whatever capacity they choose.

Acknowledgments—The views presented in this column reflect those of the 9 elected members of the Association of Professors of Dermatology Residency Program Directors Section steering committee, all of whom are program directors at their institutions (listed in parentheses): Ammar Ahmed, MD (The University of Texas at Austin, Austin, Texas); Yolanda Helfrich, MD (University of Michigan, Ann Arbor, Michigan); Jo-Ann M. Latkowksi, MD (New York University, New York); Kiran Motaparthi, MD (University of Florida, Gainesville, Florida); Adena E. Rosenblatt, MD, PhD (The University of Chicago, Chicago, Illinois); Ilana S. Rosman, MD (Washington University, St. Louis, Missouri); Travis Vandergriff, MD (University of Texas Southwestern, Dallas, Texas); Diane Whitaker-Worth, MD (University of Connecticut, Farmington, Connecticut); Scott Worswick, MD (University of Southern California, Los Angeles, California).

Amid increasing numbers of applications, decreasing match rates, and ongoing lack of diversity in the dermatology trainee workforce, the COVID-19 pandemic introduced additional challenges to the dermatology residency application process and laid bare systemic inequities and inherent problems that must be addressed. Historically, dermatology applicants have excelled in academic metrics, such as US Medical Licensing Examination (USMLE) scores and nomination to the Alpha Omega Alpha honor society. As biases associated with these academic metrics are being elucidated, they have in turn become less available. With the upcoming change in USMLE Step 1 reporting to pass/fail only, as well as the elimination of Alpha Omega Alpha nomination for students, clinical grades, and/or class ranks at many medical schools, other elements of the application, such as volunteer experiences and research publications, may be weighed more heavily in the selection process. This may serve to exacerbate the application arms race, characterized by a steady rise in volunteer experiences, research publications, and research gap years that has already begun and likely will continue, particularly among dermatology applicants.

These issues are not unique to dermatology and are occurring across all medical specialties to varying degrees. The monetary and opportunity costs of the application process have become astronomical for both applicants and faculty. Faculty are overburdened with administrative duties related to resident recruitment and advising, and students are experiencing heightened match-related anxiety earlier and more acutely. These factors may contribute to burnout among trainees and faculty and may have deleterious effects on medical education. It is clear that transformative work must be pursued to ensure an equitable and sustainable residency application process moving forward. In this column, we review the notable work being done within dermatology and across specialties to reform the residency application process.

Coalition Recommendations

In August 2021, the Coalition for Physician Accountability (CoPA) released recommendations for comprehensive improvement of the undergraduate medical education (UME) to graduate medical education transition, which includes residency application. Of the 9 principal themes addressed, 2 focus on the residency application process: (1) equitable mission-driven application review, and (2) optimization of the application, interview, and selection processes, which relates to application volume as well as interview offers and formats.¹

In the area of application review, CoPA recommends replacing all letters of recommendation with structured evaluative letters as a universal tool in the application process.¹ These letters would include specialty-specific questions based on core competencies and would be completed by an evaluator who directly observed the student. Additionally, the group recommends revising the content and structure of the medical student performance evaluation to improve access to longitudinal assessment data about students. Ideally, developing UME competency outcomes to apply across learners would decrease reliance on traditional but potentially problematic application elements, such as licensing examination scores, clinical grades, and narrative evaluations.¹

To optimize residency application processes, CoPA recommends exploring innovative approaches to reduce application volume and maximize applicants interviewing and matching at programs where mutual interest is high.¹ Suggestions to address these issues include preference signaling, application caps, and/or additional rounds of application or matching. Standardization of the interview process also is recommended to improve equity, minimize educational disruption, and improve applicant well-being. Suggestions include the use of common interview offer and scheduling platforms, policies to govern interview offers and scheduling timelines, interview caps, and ongoing study of the impact of virtual interviews.¹

Residency Application Innovations Implemented by Other Specialties

A number of specialties have developed innovations in the residency application process to improve equity and fairness as well as optimize applicant-program fit. Emergency medicine created a now widely adopted, specialty-specific standardized letter of evaluation (SLOE).² It compares applicants across a number of measures that include personal qualities, clinical skills, and a global assessment. The SLOE is designed to assess and compare applicants across institutions rather than provide recommendations. The emergency medicine SLOE also provides useful information about the letter writer, including duration and depth of interaction with the applicant and distribution of rankings of prior applicants.²

In 2019, obstetrics and gynecology launched a standardized application and interview process, which set a specialty-wide application deadline, limited interview invitations to the number of interview positions available, encouraged coordinated release of interview offers, and allowed applicants 72 hours to respond to invitations.³ These measures were implemented to improve fairness, transparency, and applicant well-being, as well as to promote equitable distribution of interviews. Data following this launch suggested that universal offer dates reduced excessive interviewing among competitive applicants.³

Last year, otolaryngology implemented a process known as preference signaling in which applicants were able to signal up to 5 preferred programs at the time of application. A signal allowed applicants to demonstrate interest in specific programs and could be used by programs during their application review process. Most applicants opted to submit signals, and programs received 0 to 71 signals (mean, 22).⁴ Almost all programs received at least 1 signal. The rate of receiving an interview was significantly higher for signaled programs (58%) compared to nonsignaled programs (14%)(P<.001), indicating that preference signaling may be beneficial for both programs and applicants for interview selection.⁴

Residency Application Innovations Implemented by Dermatology

Over the last 2 application cycles, dermatology has implemented several innovations to the residency application process. Initial work included release of guidelines for residency programs to conduct holistic application review,⁵ recommendations for website updates to share program-specific information with prospective trainees,⁶ and informational webinars and statements to update dermatology applicants about changes to the process and to answer application-related questions.^7-9

In 2020, dermatology initiated a coordinated interview invitation release in which interview offers were released on prespecified dates and applicants were given 48 hours prior to scheduling. Approximately 50% of residency programs participated in the first year, yet nearly all programs released on 1 of 2 universal dates in the current cycle. In a recent survey of dermatology applicants, nearly 90% supported coordinated release.¹⁰ Several other specialties also have incorporated universal release dates into their processes.

For the 2021-2022 application cycle, dermatology—along with internal medicine and general surgery—participated in the Association of American Medical Colleges’ pilot supplemental Electronic Residency Application Service (ERAS) application.¹¹ The pilot was designed as a first step to updating the ERAS content by allowing students to share more information about their extracurricular, research, and clinical activities, as well as geographic and program preferences to optimize applicant-program fit. Preference signaling, similar to the otolaryngology process, was included in the supplemental application, with dermatology applicants choosing up to 3 preferred programs to signal, excluding their home programs and any programs where they completed in-person away rotations. Preliminary data suggest that the vast majority of dermatology programs and applicants participated in the supplemental application.¹² Ongoing analysis of survey data from applicants, advisors, and program directors will help inform future directions. Dermatology has been an integral partner in the development, implementation, and evaluation of this pilot.

Proposed Innovations to the Application Process

Given the challenges of the current application process, there has been a long list of proposed innovations to ameliorate applicant, advisor, and program concerns.¹³ Many of these approaches are intended to respond to increasing costs to programs and applicants as well as the lack of equity in the process. Application caps and an early result acceptance program have both been proposed to address the ever-increasing volume of applications.^14,15 Neither of these proposals has been adopted by a specialty yet, but obstetrics and gynecology stakeholders have shown broad support for an early result acceptance program, signaling a possible future pilot.¹⁶

Interview caps also have been proposed to promote more equitable distribution of interview positions.¹⁷ Ophthalmology implemented this approach in the 2021-2022 application cycle, with applicants limited to a maximum of 18 interviews.¹⁸ Data from this pilot will help determine the effect of interview caps as well as the optimal limit, which will vary by specialty.

Changes to the application content itself could better facilitate holistic review and optimize applicant-program fit. This is the principle driving the pilot supplemental ERAS application, but it also has been addressed in other specialties. Ophthalmology replaced the traditional personal statement with a shorter autobiographical statement as well as 2 short personal essay questions. Plastic surgery designed a common supplemental application, currently in its second iteration, that highlights specialty-specific information from applicants to promote holistic review and eventually reduce application costs.¹⁹

The reforms introduced and proposed by dermatology and other specialties represent initial steps to address the issues inherent to the current residency application process. Providing faculty with better tools to holistically assess applicants during the review process and increasing transparency between programs and applicants should help optimize applicant-program fit and increase diversity in the dermatology workforce. Streamlining the application process to allow students to highlight their unique qualities in a user-friendly format as well as addressing potential inequities in interview distribution and access to the application process hopefully will contribute to better outcomes for both programs and applicants. However, many of these steps are likely to create additional administrative burdens on program faculty and are unlikely to allay student fears about matching.

The underlying issue for many specialties, and particularly for dermatology, is that demand far outstrips supply. With stable numbers of residency positions and an ever-increasing number of applicants, the match rate will continue to decrease, leading to increased anxiety among those interested in pursuing dermatology. Although USMLE Step 1 scores have been shown to have racial bias²⁰ and there are no data correlating scores with clinical performance, the elimination of a scoring system may affect the number of applicants entering dermatology with downstream effects on match rates. Heightened anxiety places increased pressure on students to choose a specialty earlier in their training and impacts the activities they pursue during medical school. Overemphasis on specialty choice and the match process can lead to higher rates of burnout among students and trainees, as students may focus on activities designed to increase their chances of matching at the expense of pursuing activities that could lead to greater engagement and passion in their careers—a key protective factor against burnout.

The goal of the residency application process is to optimize fit between candidates and programs by aligning goals, values, and learning environment. Students and programs working together as honest brokers can lead to transformative change in the process, freeing both parties to highlight their unique qualities and contributions. Programs benefit from optimal fit by being able to hone their particular mission and recruit and retain residents and faculty engaged in that mission. Residents will thrive in programs that support their learning and career goals and will ultimately be better positioned to meaningfully contribute to their chosen field in whatever capacity they choose.

Acknowledgments—The views presented in this column reflect those of the 9 elected members of the Association of Professors of Dermatology Residency Program Directors Section steering committee, all of whom are program directors at their institutions (listed in parentheses): Ammar Ahmed, MD (The University of Texas at Austin, Austin, Texas); Yolanda Helfrich, MD (University of Michigan, Ann Arbor, Michigan); Jo-Ann M. Latkowksi, MD (New York University, New York); Kiran Motaparthi, MD (University of Florida, Gainesville, Florida); Adena E. Rosenblatt, MD, PhD (The University of Chicago, Chicago, Illinois); Ilana S. Rosman, MD (Washington University, St. Louis, Missouri); Travis Vandergriff, MD (University of Texas Southwestern, Dallas, Texas); Diane Whitaker-Worth, MD (University of Connecticut, Farmington, Connecticut); Scott Worswick, MD (University of Southern California, Los Angeles, California).

Frontal fibrosing alopecia (FFA) is a form of lymphocytic cicatricial alopecia that presents as frontotemporal hairline recession, typically in postmenopausal women.¹ The condition is considered to be a variant of lichen planopilaris (LPP) due to its similar histologic appearance.² Loss of eyebrow^1-11 and body^5-11 hair also is commonly present in FFA, and histologic findings are identical to those for hair loss on the scalp,^8,9 suggesting that FFA may be a form of generalized alopecia.

The pathogenesis of FFA is unknown, but several etiologies have been postulated. Some suggest that as a variant of LPP, FFA is a hair-specific autoimmune disorder characterized by a T cell–mediated immune reaction against epithelial hair follicle stem cells, leading to fibrosis and depletion of hair regeneration potential.¹² In support of this theory, FFA has been associated with other autoimmune diseases including hypothyroidism,^6,8,13-16 mucocutaneous lichen planus,^8,15,17 vitiligo,^15,18 Sjögren syndrome,¹⁹ and lichen sclerosus et atrophicus.^15,20 Another hypothesis suggests that the proandrogenic state in postmenopausal women may be related to the disease process.¹ This hypothesis is supported by the reported success of antiandrogen therapy with 5α-reductase inhibitors (5α-RIs) in stabilizing FFA.^3-5,7 Finally, genetic^16,21 and environmental factors related to smoking and socioeconomic status⁵ also have been postulated to be risk factors for FFA. A variety of treatments have shown varying success, including topical and intralesional corticosteroids, hydroxychloroquine, immunomodulators, antibiotics, and 5α-RIs.^{1,3-6,8,15,17,22} However, FFA is considered to be relatively difficult to treat and commonly progresses regardless of treatment before spontaneously stabilizing.^2-4,6,8,10

Since its discovery in 1994,¹ FFA has become increasingly prevalent, comprising 17% of new referrals for hair loss in one study (N=57).⁶ Although growing recognition of the condition likely plays a role in its increasing presentation, other unidentified factors may contribute to its expanding incidence. In this report, we describe the demographics, clinical features, and disease progression of 29 cases of FFA treated within our division using a series of surveys and chart reviews.

Methods

Upon receiving approval for the project from the institutional review board, we identified 29 patients who met the criteria for diagnosis of FFA through a chart review of all patients being treated for hair loss by clinics within the Washington University Division of Dermatology (St. Louis, Missouri). Diagnostic criteria for FFA included scarring alopecia in the frontotemporal distribution with associated perifollicular erythema or papules and, if performed, a scalp biopsy of the involved area of alopecia showing lymphocytic cicatricial alopecia, compatible with LPP. The diagnosis was confirmed by biopsy in 18 patients (62%), while the remainder of the diagnoses were made clinically. Most biopsy specimens were diagnosed by board-certified dermatopathologists at Washington University, with the remainder diagnosed by outside pathologists if the patient was initially diagnosed at another institution.

Patients meeting criteria for FFA were mailed a study consent form, as well as a 2-page survey to assess demographics, clinical features of hair loss, medical histories, social and family histories, and treatments utilized. After receiving consent from patients, survey results were collected and summarized. If there was any need for clarification of answers, follow-up questions were conducted via email prior to any data analysis that was performed.

For analysis of treatment response, patients were asked what treatments they had utilized and about the progression of their hair loss. Patients reporting stabilization of hair loss or hair regrowth were classified as treatment responsive. Patients who underwent multiple treatments were included in the analyses for each of those treatments. Physician records for treatment response were not correlated with patient responses due to inconsistent documentation, care received outside of our medical system, and prolonged or loss to follow-up. Physician-reported data were only used to identify qualifying patients and their biopsy results, as described above.

Results

Patient Demographic
Between October 2013 and May 2014, 29 patients with FFA were recruited into the study. Patients were diagnosed between January 2006 and December 2013. There were 28 female patients (97%) and 1 male patient (3%). The average age of disease onset was 55.4 years (range, 29–75 years). Twenty-five patients (86%) self-identified as non-Hispanic white, 3 patients (10%) as Asian, and 1 patient (3%) as black. Patients also appeared to be a more affluent group than the general St. Louis County population, with a median household income between $75,000 and $100,000. In comparison, the median household income reported in St. Louis County from 2008 to 2012 was $58,485.²³ The patient population was primarily composed of nonsmokers, with 22 (76%) patients who had never smoked, 6 (21%) who were present smokers, and 1 (3%) smoked in the past. These results were comparable to the reported number of female smokers in Missouri.²⁴

Clinicopathologic Features
The clinical features of FFA are described in Table 1. All patients had frontotemporal recession of the hairline with some degree of scarring and perifollicular erythema (Figure 1). Most patients also reported hair loss at other sites, including 25 patients (86%) with eyebrow hair loss, 18 (62%) with limb hair loss, 11 (38%) with axillary hair loss, 11 (38%) with pubic hair loss, and 1 (3%) with eyelash hair loss. Patients also frequently reported inflammatory symptoms, including 19 patients (66%) with itching, 18 (62%) with redness, 3 (10%) with pain, 2 (7%) with papular lesions, and 1 (3%) with sores and erosions on the skin. Regarding progression of hair loss over time, 16 patients (55%) reported stabilization of hair loss, 11 (38%) reported progressive hair loss, and 2 (7%) reported some hair regrowth. Thirteen patients (45%) identified some inciting event that they believed to have triggered the disease. Ten patients (35%) identified stress as the inciting event, and 5 patients (17%) specifically referred to health-related stressors, including hip-replacement surgery, new diagnoses of systemic diseases, starting new medications, and stopping hormone replacement therapy. Furthermore, 2 (7%) patients reported exposure to chemicals and pesticides as suspected triggers.

Table 2 describes the comorbidities of all 29 patients. A history of autoimmune disease was prominent, found in 16 patients (55%). Thirteen patients (45%) reported thyroid disease, including 10 patients (35%) with hypothyroidism. Additionally, 8 patients (28%) had a history of mucocutaneous lichen planus, 2 (7%) of psoriasis/psoriatic arthritis, 1 (3%) of vitiligo, 1 (3%) of systemic lupus erythematosus, 1 (3%) of iritis, 1 (3%) of Sjögren syndrome, and 1 (3%) of ulcerative colitis. Six patients (21%) also reported a history of breast cancer.

A dental history was obtained in 24 patients. All 24 patients reported having some dental implant or filling placed. Twenty-four patients (100%) had a history of metal amalgam implants, 8 (33%) had gold alloy implants, 4 (17%) had composite resin implants, and 3 (13%) had porcelain implants. Two patients had metal amalgam implants that had since been replaced by nonmetal implants. Both patients reported no change in their clinical conditions with removal of the metal implants. Six of 8 patients (75%) with mucocutaneous lichen planus reported having dental implants. Of them, all 6 patients (100%) reported having metal amalgam implants, and 3 patients (50%) additionally reported having gold alloy implants.

Treatments
On average, patients were treated with 3 different therapies for FFA (range, 0–14). The treatments utilized are listed in Table 3, and responses to treatments are summarized in Table 4. Topical steroids were the most popular treatment modality and were used by 21 patients (72%). Approximately half of those patients reported treatment response with stabilization of hair loss or regrowth (n=11; 52%). Hydroxychloroquine was the second most commonly used modality (16 patients [55%]), with 10 of those patients (63%) reporting treatment response. Intralesional steroids were used in 11 patients (38%), with a treatment response in 36% (4/11) of those patients. Topical pimecrolimus and tacrolimus were used by 6 patients (21%), with 5 of those patients (83%) reporting treatment response. UVB excimer laser therapy was used on 3 patients (10%) with 100% treatment response.

Comment

Frontal fibrosing alopecia is a form of cicatricial alopecia considered to be a clinical subset of LPP. Although the pathogeneses of both diseases are poorly understood, LPP is the better-studied model and is generally considered to be an autoimmune disease specific to the hair follicle, involving a cell-mediated inflammatory response to epithelial hair follicle stem cells.¹² In support of this hypothesis, FFA and LPP have been frequently associated with autoimmune diseases, particularly with hypothyroidism.^6,13-15 We found that 55% of our patients had a history of autoimmune disease, including 35% with hypothyroidism, 28% with mucocutaneous lichen planus, 7% with psoriasis, 3% with vitiligo, 3% with systemic lupus erythematosus, 3% with iritis, 3% with Sjögren syndrome, and 3% with ulcerative colitis. The link between FFA and hypothyroidism has been the best studied, with a large study by Atanskova Mesinkovska et al¹⁴ finding that 34% of 166 patients with LPP and FFA have some kind of thyroid disease and 29% have hypothyroidism. Frontal fibrosing alopecia also has been associated with mucocutaneous lichen planus,^8,15,17 vitiligo,^15,18 Sjögren syndrome,¹⁹ and lichen sclerosus et atrophicus^15,19 in other studies, but the current study also identifies less frequently reported associations between FFA and psoriasis, iritis, and ulcerative colitis.

Although FFA has been classically described to affect postmenopausal women, recent studies have consistently identified that premenopausal women^4-6,8,16,17 and men^14,16 also can be affected by the condition. In our patient cohort, there was 1 male patient (3%), and a substantial number of the female patients were premenopausal (19%) and menopausal (19%) at the time of disease onset. Most of the patients studied were white; Asian and black patients were a consistent minority across FFA studies,^5,13-16,25 highlighting the importance of screening for FFA in all demographics.

In our study, FFA patients also appeared to be more affluent than the general population and were predominantly nonsmokers (76%). These statistics are consistent with the United Kingdom population studied by MacDonald et al,⁶ which demonstrated a higher socioeconomic status and higher incidence of nonsmoking in their cases of FFA. Another large retrospective study of FFA patients in Spain found that 87% of their FFA cases (N=355) were nonsmokers, though they did not note a difference from the general unaffected population.¹⁵ In our study, we replicated these trends, finding an above average affluence level and a high but not statistically significant incidence of nonsmokers. Although it is not clear how socioeconomic status or smoking factors into the pathology of FFA, these studies may show a general trend in the environmental demographics of the disease.

Clinically, patients with FFA typically present with hair loss of the scalp as well as other sites. The eyebrows are the most common site to be affected outside of the scalp, affecting 86% of our patients, whereas eyelashes are the least commonly affected, presenting in only 3% of our patients. Body hair loss also is common, with almost two-thirds of our cohort reporting hair loss on the limbs and more than one-third reporting loss of axillary and pubic hair. These findings are consistent with those of other studies.^3-6,8,13,15 Eyelash loss, body hair loss, and facial papules have been found to be associated with more severe forms of FFA,¹⁵ though we did not investigate these forms in our study. Inflammatory symptoms are common, with pruritus affecting 66% of our patients and pain affecting 10% of patients, consistent with the published literature.^3,13,15,17

Multiple studies have shown that female FFA patients have a higher incidence of hysterectomies in their medical history.^5,8,15 This observation has been used to further support the hypothesis that a change in sex hormone balance may trigger the initial onset of disease.^5,8,15 A considerable number of the female patients in our study had also undergone hysterectomies (29%). Only 2 patients (7%) underwent premature surgical menopause through bilateral removal of the ovaries, and neither of these patients had abnormally early onset of FFA (age at onset, 52 and 65 years). Many patients in our study also reported a history of pharmacologic manipulation of sex hormones with hormone replacement therapy (43%) and oral contraceptive use (43%). However, patients with FFA have not been identified to have abnormal hormone levels compared to unaffected postmenopausal women.¹ Additionally, the disease does not exclusively affect androgen-dependent hair, as indicated by the high prevalence of eyebrow hair loss. We hypothesize that the link between increased prevalence of hysterectomy and FFA is not due to hormonal changes but rather from the stresses related to the hysterectomy or associated conditions that required the surgery. In our study, 35% of patients identified stress as the inciting event prior to their onset of hair loss, with 17% specifically referring to health-related stress such as surgery or new diagnoses as the cause. Although this pattern is purely observational, it is valuable to consider that stress could contribute to the initial onset of FFA as with alopecia areata.²⁶

A dental history was obtained in 24 patients to explore the possibility of FFA as a manifestation of contact allergy secondary to exposure to metal dental implants. Contact allergies to metal amalgam and gold alloy dental implants/fillings frequently have been described as presenting as oral lichen planus in the literature.^27-34 Given the histologic overlap between oral lichen planus and LPP/FFA, it is worth exploring the possibility that LPP and FFA are other manifestations of contact allergic response. In our study, 100% of the patients who provided a dental history had metal amalgam implants and 33% had gold alloy implants. It is an interesting observation, but it should be noted that none of the patients in our study had undergone patch testing for contact allergies to the metals in their dental implants, and further studies are required to explore this hypothesis.

Frontal fibrosing alopecia is a difficult condition to treat. In our study, patients tried an average of 3 different treatments, the most common being topical steroids (72%), hydroxychloroquine (55%), and intralesional steroids (38%). 5α-reductase isozymes were rarely utilized for patients in this study. Treatment response was noted in most patients using topical steroids, hydroxychloroquine, topical calcineurin inhibitors, and excimer laser therapy. Intralesional steroids also were efficacious in about 36% of patients treated. Little to no treatment response was reported in patients using doxycycline, minocycline, and topical minoxidil.

A PubMed search of articles indexed for MEDLINE using the terms randomized control trial and frontal fibrosing alopecia yielded no randomized controlled trials that have been performed to demonstrate the most efficacious treatments of FFA. However, one systematic review of 114 patients found 5α-RIs, antimalarials, and intralesional corticosteroids to yield the best responses in treating FFA.²² Another large, multicenter, retrospective study of 355 patients also demonstrated that 5α-RIs and intralesional corticosteroids minimized hair loss most effectively across treatment modalities.¹⁵ One treatment that was not discussed in either study but was utilized in ours was the UVB excimer laser, which has been demonstrated to induce T-cell apoptosis and decrease inflammation in psoriasis but has been infrequently studied in the use of FFA or LPP. In one study of 13 patients with LPP, excimer laser treatment was successful in reducing inflammatory symptoms and improving hair loss.³⁵ Our results reaffirm that laser therapy could be considered more frequently as a treatment of FFA.

This study is subject to several limitations. The study size was comprised of a relatively small number of patients with the condition. Additionally, only one-third of patients contacted agreed to participate in the study, and therefore the responses received may not be completely representative of all FFA patients. With a retrospective study, there is potential for recall bias in the data that are collected. Physician chart correlation to patient responses could not be reliably performed due to inconsistent documentation, care received outside our medical system, and prolonged or loss to follow-up. Another concern is that not all diagnoses of FFA in this study were biopsy confirmed. In one patient with systemic lupus erythematous who declined biopsy, it cannot be confirmed that her etiology of scarring alopecia was FFA rather than discoid lupus erythematous. Finally, because patients were treated with multiple medications, often concurrently, it was difficult to parse out which medications were efficacious and which were not. Despite these limitations, the findings in the study add to the growing literature about a rare but increasingly prevalent presentation.

Conclusion

Frontal fibrosing alopecia is a condition that predominantly affects white postmenopausal women but should not be overlooked in other demographics; higher socioeconomic status and nonsmoking are consistent with cases of FFA worldwide. Alopecia frequently involves other body hair, particularly the eyebrows, and is commonly associated with pruritus and pain. Many patients can identify an inciting event, usually stress, a health crisis, or new external exposures that they believe to have triggered the event. Consistent with data about LPP, FFA is frequently associated with autoimmune conditions, particularly hypothyroidism. A substantial portion of patients with FFA have had metal amalgam or gold alloy dental implants placed, though no patch testing was done to confirm that these patients have a contact allergy to these metals. Treatment for the condition is difficult, but topical and intralesional steroids, hydroxychloroquine, calcineurin inhibitors, and excimer laser therapy are efficacious in a large proportion of patients. Nevertheless, further research through prospective randomized trials is necessary to determine the best treatment modalities for FFA. Frontal fibrosing alopecia is a scarring form of hair loss that causes substantial emotional distress; therefore, it is critical to continue to investigate its etiology and treatments to improve patient care.

Frontal fibrosing alopecia (FFA) is a form of lymphocytic cicatricial alopecia that presents as frontotemporal hairline recession, typically in postmenopausal women.¹ The condition is considered to be a variant of lichen planopilaris (LPP) due to its similar histologic appearance.² Loss of eyebrow^1-11 and body^5-11 hair also is commonly present in FFA, and histologic findings are identical to those for hair loss on the scalp,^8,9 suggesting that FFA may be a form of generalized alopecia.

The pathogenesis of FFA is unknown, but several etiologies have been postulated. Some suggest that as a variant of LPP, FFA is a hair-specific autoimmune disorder characterized by a T cell–mediated immune reaction against epithelial hair follicle stem cells, leading to fibrosis and depletion of hair regeneration potential.¹² In support of this theory, FFA has been associated with other autoimmune diseases including hypothyroidism,^6,8,13-16 mucocutaneous lichen planus,^8,15,17 vitiligo,^15,18 Sjögren syndrome,¹⁹ and lichen sclerosus et atrophicus.^15,20 Another hypothesis suggests that the proandrogenic state in postmenopausal women may be related to the disease process.¹ This hypothesis is supported by the reported success of antiandrogen therapy with 5α-reductase inhibitors (5α-RIs) in stabilizing FFA.^3-5,7 Finally, genetic^16,21 and environmental factors related to smoking and socioeconomic status⁵ also have been postulated to be risk factors for FFA. A variety of treatments have shown varying success, including topical and intralesional corticosteroids, hydroxychloroquine, immunomodulators, antibiotics, and 5α-RIs.^{1,3-6,8,15,17,22} However, FFA is considered to be relatively difficult to treat and commonly progresses regardless of treatment before spontaneously stabilizing.^2-4,6,8,10

Since its discovery in 1994,¹ FFA has become increasingly prevalent, comprising 17% of new referrals for hair loss in one study (N=57).⁶ Although growing recognition of the condition likely plays a role in its increasing presentation, other unidentified factors may contribute to its expanding incidence. In this report, we describe the demographics, clinical features, and disease progression of 29 cases of FFA treated within our division using a series of surveys and chart reviews.

Methods

Upon receiving approval for the project from the institutional review board, we identified 29 patients who met the criteria for diagnosis of FFA through a chart review of all patients being treated for hair loss by clinics within the Washington University Division of Dermatology (St. Louis, Missouri). Diagnostic criteria for FFA included scarring alopecia in the frontotemporal distribution with associated perifollicular erythema or papules and, if performed, a scalp biopsy of the involved area of alopecia showing lymphocytic cicatricial alopecia, compatible with LPP. The diagnosis was confirmed by biopsy in 18 patients (62%), while the remainder of the diagnoses were made clinically. Most biopsy specimens were diagnosed by board-certified dermatopathologists at Washington University, with the remainder diagnosed by outside pathologists if the patient was initially diagnosed at another institution.

Patients meeting criteria for FFA were mailed a study consent form, as well as a 2-page survey to assess demographics, clinical features of hair loss, medical histories, social and family histories, and treatments utilized. After receiving consent from patients, survey results were collected and summarized. If there was any need for clarification of answers, follow-up questions were conducted via email prior to any data analysis that was performed.

For analysis of treatment response, patients were asked what treatments they had utilized and about the progression of their hair loss. Patients reporting stabilization of hair loss or hair regrowth were classified as treatment responsive. Patients who underwent multiple treatments were included in the analyses for each of those treatments. Physician records for treatment response were not correlated with patient responses due to inconsistent documentation, care received outside of our medical system, and prolonged or loss to follow-up. Physician-reported data were only used to identify qualifying patients and their biopsy results, as described above.

Results

Patient Demographic
Between October 2013 and May 2014, 29 patients with FFA were recruited into the study. Patients were diagnosed between January 2006 and December 2013. There were 28 female patients (97%) and 1 male patient (3%). The average age of disease onset was 55.4 years (range, 29–75 years). Twenty-five patients (86%) self-identified as non-Hispanic white, 3 patients (10%) as Asian, and 1 patient (3%) as black. Patients also appeared to be a more affluent group than the general St. Louis County population, with a median household income between $75,000 and $100,000. In comparison, the median household income reported in St. Louis County from 2008 to 2012 was $58,485.²³ The patient population was primarily composed of nonsmokers, with 22 (76%) patients who had never smoked, 6 (21%) who were present smokers, and 1 (3%) smoked in the past. These results were comparable to the reported number of female smokers in Missouri.²⁴

Clinicopathologic Features
The clinical features of FFA are described in Table 1. All patients had frontotemporal recession of the hairline with some degree of scarring and perifollicular erythema (Figure 1). Most patients also reported hair loss at other sites, including 25 patients (86%) with eyebrow hair loss, 18 (62%) with limb hair loss, 11 (38%) with axillary hair loss, 11 (38%) with pubic hair loss, and 1 (3%) with eyelash hair loss. Patients also frequently reported inflammatory symptoms, including 19 patients (66%) with itching, 18 (62%) with redness, 3 (10%) with pain, 2 (7%) with papular lesions, and 1 (3%) with sores and erosions on the skin. Regarding progression of hair loss over time, 16 patients (55%) reported stabilization of hair loss, 11 (38%) reported progressive hair loss, and 2 (7%) reported some hair regrowth. Thirteen patients (45%) identified some inciting event that they believed to have triggered the disease. Ten patients (35%) identified stress as the inciting event, and 5 patients (17%) specifically referred to health-related stressors, including hip-replacement surgery, new diagnoses of systemic diseases, starting new medications, and stopping hormone replacement therapy. Furthermore, 2 (7%) patients reported exposure to chemicals and pesticides as suspected triggers.

Table 2 describes the comorbidities of all 29 patients. A history of autoimmune disease was prominent, found in 16 patients (55%). Thirteen patients (45%) reported thyroid disease, including 10 patients (35%) with hypothyroidism. Additionally, 8 patients (28%) had a history of mucocutaneous lichen planus, 2 (7%) of psoriasis/psoriatic arthritis, 1 (3%) of vitiligo, 1 (3%) of systemic lupus erythematosus, 1 (3%) of iritis, 1 (3%) of Sjögren syndrome, and 1 (3%) of ulcerative colitis. Six patients (21%) also reported a history of breast cancer.

A dental history was obtained in 24 patients. All 24 patients reported having some dental implant or filling placed. Twenty-four patients (100%) had a history of metal amalgam implants, 8 (33%) had gold alloy implants, 4 (17%) had composite resin implants, and 3 (13%) had porcelain implants. Two patients had metal amalgam implants that had since been replaced by nonmetal implants. Both patients reported no change in their clinical conditions with removal of the metal implants. Six of 8 patients (75%) with mucocutaneous lichen planus reported having dental implants. Of them, all 6 patients (100%) reported having metal amalgam implants, and 3 patients (50%) additionally reported having gold alloy implants.

Treatments
On average, patients were treated with 3 different therapies for FFA (range, 0–14). The treatments utilized are listed in Table 3, and responses to treatments are summarized in Table 4. Topical steroids were the most popular treatment modality and were used by 21 patients (72%). Approximately half of those patients reported treatment response with stabilization of hair loss or regrowth (n=11; 52%). Hydroxychloroquine was the second most commonly used modality (16 patients [55%]), with 10 of those patients (63%) reporting treatment response. Intralesional steroids were used in 11 patients (38%), with a treatment response in 36% (4/11) of those patients. Topical pimecrolimus and tacrolimus were used by 6 patients (21%), with 5 of those patients (83%) reporting treatment response. UVB excimer laser therapy was used on 3 patients (10%) with 100% treatment response.

Comment

Frontal fibrosing alopecia is a form of cicatricial alopecia considered to be a clinical subset of LPP. Although the pathogeneses of both diseases are poorly understood, LPP is the better-studied model and is generally considered to be an autoimmune disease specific to the hair follicle, involving a cell-mediated inflammatory response to epithelial hair follicle stem cells.¹² In support of this hypothesis, FFA and LPP have been frequently associated with autoimmune diseases, particularly with hypothyroidism.^6,13-15 We found that 55% of our patients had a history of autoimmune disease, including 35% with hypothyroidism, 28% with mucocutaneous lichen planus, 7% with psoriasis, 3% with vitiligo, 3% with systemic lupus erythematosus, 3% with iritis, 3% with Sjögren syndrome, and 3% with ulcerative colitis. The link between FFA and hypothyroidism has been the best studied, with a large study by Atanskova Mesinkovska et al¹⁴ finding that 34% of 166 patients with LPP and FFA have some kind of thyroid disease and 29% have hypothyroidism. Frontal fibrosing alopecia also has been associated with mucocutaneous lichen planus,^8,15,17 vitiligo,^15,18 Sjögren syndrome,¹⁹ and lichen sclerosus et atrophicus^15,19 in other studies, but the current study also identifies less frequently reported associations between FFA and psoriasis, iritis, and ulcerative colitis.

Although FFA has been classically described to affect postmenopausal women, recent studies have consistently identified that premenopausal women^4-6,8,16,17 and men^14,16 also can be affected by the condition. In our patient cohort, there was 1 male patient (3%), and a substantial number of the female patients were premenopausal (19%) and menopausal (19%) at the time of disease onset. Most of the patients studied were white; Asian and black patients were a consistent minority across FFA studies,^5,13-16,25 highlighting the importance of screening for FFA in all demographics.

In our study, FFA patients also appeared to be more affluent than the general population and were predominantly nonsmokers (76%). These statistics are consistent with the United Kingdom population studied by MacDonald et al,⁶ which demonstrated a higher socioeconomic status and higher incidence of nonsmoking in their cases of FFA. Another large retrospective study of FFA patients in Spain found that 87% of their FFA cases (N=355) were nonsmokers, though they did not note a difference from the general unaffected population.¹⁵ In our study, we replicated these trends, finding an above average affluence level and a high but not statistically significant incidence of nonsmokers. Although it is not clear how socioeconomic status or smoking factors into the pathology of FFA, these studies may show a general trend in the environmental demographics of the disease.

Clinically, patients with FFA typically present with hair loss of the scalp as well as other sites. The eyebrows are the most common site to be affected outside of the scalp, affecting 86% of our patients, whereas eyelashes are the least commonly affected, presenting in only 3% of our patients. Body hair loss also is common, with almost two-thirds of our cohort reporting hair loss on the limbs and more than one-third reporting loss of axillary and pubic hair. These findings are consistent with those of other studies.^3-6,8,13,15 Eyelash loss, body hair loss, and facial papules have been found to be associated with more severe forms of FFA,¹⁵ though we did not investigate these forms in our study. Inflammatory symptoms are common, with pruritus affecting 66% of our patients and pain affecting 10% of patients, consistent with the published literature.^3,13,15,17

Multiple studies have shown that female FFA patients have a higher incidence of hysterectomies in their medical history.^5,8,15 This observation has been used to further support the hypothesis that a change in sex hormone balance may trigger the initial onset of disease.^5,8,15 A considerable number of the female patients in our study had also undergone hysterectomies (29%). Only 2 patients (7%) underwent premature surgical menopause through bilateral removal of the ovaries, and neither of these patients had abnormally early onset of FFA (age at onset, 52 and 65 years). Many patients in our study also reported a history of pharmacologic manipulation of sex hormones with hormone replacement therapy (43%) and oral contraceptive use (43%). However, patients with FFA have not been identified to have abnormal hormone levels compared to unaffected postmenopausal women.¹ Additionally, the disease does not exclusively affect androgen-dependent hair, as indicated by the high prevalence of eyebrow hair loss. We hypothesize that the link between increased prevalence of hysterectomy and FFA is not due to hormonal changes but rather from the stresses related to the hysterectomy or associated conditions that required the surgery. In our study, 35% of patients identified stress as the inciting event prior to their onset of hair loss, with 17% specifically referring to health-related stress such as surgery or new diagnoses as the cause. Although this pattern is purely observational, it is valuable to consider that stress could contribute to the initial onset of FFA as with alopecia areata.²⁶

A dental history was obtained in 24 patients to explore the possibility of FFA as a manifestation of contact allergy secondary to exposure to metal dental implants. Contact allergies to metal amalgam and gold alloy dental implants/fillings frequently have been described as presenting as oral lichen planus in the literature.^27-34 Given the histologic overlap between oral lichen planus and LPP/FFA, it is worth exploring the possibility that LPP and FFA are other manifestations of contact allergic response. In our study, 100% of the patients who provided a dental history had metal amalgam implants and 33% had gold alloy implants. It is an interesting observation, but it should be noted that none of the patients in our study had undergone patch testing for contact allergies to the metals in their dental implants, and further studies are required to explore this hypothesis.

Frontal fibrosing alopecia is a difficult condition to treat. In our study, patients tried an average of 3 different treatments, the most common being topical steroids (72%), hydroxychloroquine (55%), and intralesional steroids (38%). 5α-reductase isozymes were rarely utilized for patients in this study. Treatment response was noted in most patients using topical steroids, hydroxychloroquine, topical calcineurin inhibitors, and excimer laser therapy. Intralesional steroids also were efficacious in about 36% of patients treated. Little to no treatment response was reported in patients using doxycycline, minocycline, and topical minoxidil.

A PubMed search of articles indexed for MEDLINE using the terms randomized control trial and frontal fibrosing alopecia yielded no randomized controlled trials that have been performed to demonstrate the most efficacious treatments of FFA. However, one systematic review of 114 patients found 5α-RIs, antimalarials, and intralesional corticosteroids to yield the best responses in treating FFA.²² Another large, multicenter, retrospective study of 355 patients also demonstrated that 5α-RIs and intralesional corticosteroids minimized hair loss most effectively across treatment modalities.¹⁵ One treatment that was not discussed in either study but was utilized in ours was the UVB excimer laser, which has been demonstrated to induce T-cell apoptosis and decrease inflammation in psoriasis but has been infrequently studied in the use of FFA or LPP. In one study of 13 patients with LPP, excimer laser treatment was successful in reducing inflammatory symptoms and improving hair loss.³⁵ Our results reaffirm that laser therapy could be considered more frequently as a treatment of FFA.

This study is subject to several limitations. The study size was comprised of a relatively small number of patients with the condition. Additionally, only one-third of patients contacted agreed to participate in the study, and therefore the responses received may not be completely representative of all FFA patients. With a retrospective study, there is potential for recall bias in the data that are collected. Physician chart correlation to patient responses could not be reliably performed due to inconsistent documentation, care received outside our medical system, and prolonged or loss to follow-up. Another concern is that not all diagnoses of FFA in this study were biopsy confirmed. In one patient with systemic lupus erythematous who declined biopsy, it cannot be confirmed that her etiology of scarring alopecia was FFA rather than discoid lupus erythematous. Finally, because patients were treated with multiple medications, often concurrently, it was difficult to parse out which medications were efficacious and which were not. Despite these limitations, the findings in the study add to the growing literature about a rare but increasingly prevalent presentation.

Conclusion

Frontal fibrosing alopecia is a condition that predominantly affects white postmenopausal women but should not be overlooked in other demographics; higher socioeconomic status and nonsmoking are consistent with cases of FFA worldwide. Alopecia frequently involves other body hair, particularly the eyebrows, and is commonly associated with pruritus and pain. Many patients can identify an inciting event, usually stress, a health crisis, or new external exposures that they believe to have triggered the event. Consistent with data about LPP, FFA is frequently associated with autoimmune conditions, particularly hypothyroidism. A substantial portion of patients with FFA have had metal amalgam or gold alloy dental implants placed, though no patch testing was done to confirm that these patients have a contact allergy to these metals. Treatment for the condition is difficult, but topical and intralesional steroids, hydroxychloroquine, calcineurin inhibitors, and excimer laser therapy are efficacious in a large proportion of patients. Nevertheless, further research through prospective randomized trials is necessary to determine the best treatment modalities for FFA. Frontal fibrosing alopecia is a scarring form of hair loss that causes substantial emotional distress; therefore, it is critical to continue to investigate its etiology and treatments to improve patient care.

Frontal fibrosing alopecia (FFA) is a form of lymphocytic cicatricial alopecia that presents as frontotemporal hairline recession, typically in postmenopausal women.¹ The condition is considered to be a variant of lichen planopilaris (LPP) due to its similar histologic appearance.² Loss of eyebrow^1-11 and body^5-11 hair also is commonly present in FFA, and histologic findings are identical to those for hair loss on the scalp,^8,9 suggesting that FFA may be a form of generalized alopecia.

The pathogenesis of FFA is unknown, but several etiologies have been postulated. Some suggest that as a variant of LPP, FFA is a hair-specific autoimmune disorder characterized by a T cell–mediated immune reaction against epithelial hair follicle stem cells, leading to fibrosis and depletion of hair regeneration potential.¹² In support of this theory, FFA has been associated with other autoimmune diseases including hypothyroidism,^6,8,13-16 mucocutaneous lichen planus,^8,15,17 vitiligo,^15,18 Sjögren syndrome,¹⁹ and lichen sclerosus et atrophicus.^15,20 Another hypothesis suggests that the proandrogenic state in postmenopausal women may be related to the disease process.¹ This hypothesis is supported by the reported success of antiandrogen therapy with 5α-reductase inhibitors (5α-RIs) in stabilizing FFA.^3-5,7 Finally, genetic^16,21 and environmental factors related to smoking and socioeconomic status⁵ also have been postulated to be risk factors for FFA. A variety of treatments have shown varying success, including topical and intralesional corticosteroids, hydroxychloroquine, immunomodulators, antibiotics, and 5α-RIs.^{1,3-6,8,15,17,22} However, FFA is considered to be relatively difficult to treat and commonly progresses regardless of treatment before spontaneously stabilizing.^2-4,6,8,10

Since its discovery in 1994,¹ FFA has become increasingly prevalent, comprising 17% of new referrals for hair loss in one study (N=57).⁶ Although growing recognition of the condition likely plays a role in its increasing presentation, other unidentified factors may contribute to its expanding incidence. In this report, we describe the demographics, clinical features, and disease progression of 29 cases of FFA treated within our division using a series of surveys and chart reviews.

Methods

Upon receiving approval for the project from the institutional review board, we identified 29 patients who met the criteria for diagnosis of FFA through a chart review of all patients being treated for hair loss by clinics within the Washington University Division of Dermatology (St. Louis, Missouri). Diagnostic criteria for FFA included scarring alopecia in the frontotemporal distribution with associated perifollicular erythema or papules and, if performed, a scalp biopsy of the involved area of alopecia showing lymphocytic cicatricial alopecia, compatible with LPP. The diagnosis was confirmed by biopsy in 18 patients (62%), while the remainder of the diagnoses were made clinically. Most biopsy specimens were diagnosed by board-certified dermatopathologists at Washington University, with the remainder diagnosed by outside pathologists if the patient was initially diagnosed at another institution.

Patients meeting criteria for FFA were mailed a study consent form, as well as a 2-page survey to assess demographics, clinical features of hair loss, medical histories, social and family histories, and treatments utilized. After receiving consent from patients, survey results were collected and summarized. If there was any need for clarification of answers, follow-up questions were conducted via email prior to any data analysis that was performed.

For analysis of treatment response, patients were asked what treatments they had utilized and about the progression of their hair loss. Patients reporting stabilization of hair loss or hair regrowth were classified as treatment responsive. Patients who underwent multiple treatments were included in the analyses for each of those treatments. Physician records for treatment response were not correlated with patient responses due to inconsistent documentation, care received outside of our medical system, and prolonged or loss to follow-up. Physician-reported data were only used to identify qualifying patients and their biopsy results, as described above.

Results

Patient Demographic
Between October 2013 and May 2014, 29 patients with FFA were recruited into the study. Patients were diagnosed between January 2006 and December 2013. There were 28 female patients (97%) and 1 male patient (3%). The average age of disease onset was 55.4 years (range, 29–75 years). Twenty-five patients (86%) self-identified as non-Hispanic white, 3 patients (10%) as Asian, and 1 patient (3%) as black. Patients also appeared to be a more affluent group than the general St. Louis County population, with a median household income between $75,000 and $100,000. In comparison, the median household income reported in St. Louis County from 2008 to 2012 was $58,485.²³ The patient population was primarily composed of nonsmokers, with 22 (76%) patients who had never smoked, 6 (21%) who were present smokers, and 1 (3%) smoked in the past. These results were comparable to the reported number of female smokers in Missouri.²⁴

Clinicopathologic Features
The clinical features of FFA are described in Table 1. All patients had frontotemporal recession of the hairline with some degree of scarring and perifollicular erythema (Figure 1). Most patients also reported hair loss at other sites, including 25 patients (86%) with eyebrow hair loss, 18 (62%) with limb hair loss, 11 (38%) with axillary hair loss, 11 (38%) with pubic hair loss, and 1 (3%) with eyelash hair loss. Patients also frequently reported inflammatory symptoms, including 19 patients (66%) with itching, 18 (62%) with redness, 3 (10%) with pain, 2 (7%) with papular lesions, and 1 (3%) with sores and erosions on the skin. Regarding progression of hair loss over time, 16 patients (55%) reported stabilization of hair loss, 11 (38%) reported progressive hair loss, and 2 (7%) reported some hair regrowth. Thirteen patients (45%) identified some inciting event that they believed to have triggered the disease. Ten patients (35%) identified stress as the inciting event, and 5 patients (17%) specifically referred to health-related stressors, including hip-replacement surgery, new diagnoses of systemic diseases, starting new medications, and stopping hormone replacement therapy. Furthermore, 2 (7%) patients reported exposure to chemicals and pesticides as suspected triggers.

Table 2 describes the comorbidities of all 29 patients. A history of autoimmune disease was prominent, found in 16 patients (55%). Thirteen patients (45%) reported thyroid disease, including 10 patients (35%) with hypothyroidism. Additionally, 8 patients (28%) had a history of mucocutaneous lichen planus, 2 (7%) of psoriasis/psoriatic arthritis, 1 (3%) of vitiligo, 1 (3%) of systemic lupus erythematosus, 1 (3%) of iritis, 1 (3%) of Sjögren syndrome, and 1 (3%) of ulcerative colitis. Six patients (21%) also reported a history of breast cancer.

A dental history was obtained in 24 patients. All 24 patients reported having some dental implant or filling placed. Twenty-four patients (100%) had a history of metal amalgam implants, 8 (33%) had gold alloy implants, 4 (17%) had composite resin implants, and 3 (13%) had porcelain implants. Two patients had metal amalgam implants that had since been replaced by nonmetal implants. Both patients reported no change in their clinical conditions with removal of the metal implants. Six of 8 patients (75%) with mucocutaneous lichen planus reported having dental implants. Of them, all 6 patients (100%) reported having metal amalgam implants, and 3 patients (50%) additionally reported having gold alloy implants.

Treatments
On average, patients were treated with 3 different therapies for FFA (range, 0–14). The treatments utilized are listed in Table 3, and responses to treatments are summarized in Table 4. Topical steroids were the most popular treatment modality and were used by 21 patients (72%). Approximately half of those patients reported treatment response with stabilization of hair loss or regrowth (n=11; 52%). Hydroxychloroquine was the second most commonly used modality (16 patients [55%]), with 10 of those patients (63%) reporting treatment response. Intralesional steroids were used in 11 patients (38%), with a treatment response in 36% (4/11) of those patients. Topical pimecrolimus and tacrolimus were used by 6 patients (21%), with 5 of those patients (83%) reporting treatment response. UVB excimer laser therapy was used on 3 patients (10%) with 100% treatment response.

Comment

Frontal fibrosing alopecia is a form of cicatricial alopecia considered to be a clinical subset of LPP. Although the pathogeneses of both diseases are poorly understood, LPP is the better-studied model and is generally considered to be an autoimmune disease specific to the hair follicle, involving a cell-mediated inflammatory response to epithelial hair follicle stem cells.¹² In support of this hypothesis, FFA and LPP have been frequently associated with autoimmune diseases, particularly with hypothyroidism.^6,13-15 We found that 55% of our patients had a history of autoimmune disease, including 35% with hypothyroidism, 28% with mucocutaneous lichen planus, 7% with psoriasis, 3% with vitiligo, 3% with systemic lupus erythematosus, 3% with iritis, 3% with Sjögren syndrome, and 3% with ulcerative colitis. The link between FFA and hypothyroidism has been the best studied, with a large study by Atanskova Mesinkovska et al¹⁴ finding that 34% of 166 patients with LPP and FFA have some kind of thyroid disease and 29% have hypothyroidism. Frontal fibrosing alopecia also has been associated with mucocutaneous lichen planus,^8,15,17 vitiligo,^15,18 Sjögren syndrome,¹⁹ and lichen sclerosus et atrophicus^15,19 in other studies, but the current study also identifies less frequently reported associations between FFA and psoriasis, iritis, and ulcerative colitis.

Although FFA has been classically described to affect postmenopausal women, recent studies have consistently identified that premenopausal women^4-6,8,16,17 and men^14,16 also can be affected by the condition. In our patient cohort, there was 1 male patient (3%), and a substantial number of the female patients were premenopausal (19%) and menopausal (19%) at the time of disease onset. Most of the patients studied were white; Asian and black patients were a consistent minority across FFA studies,^5,13-16,25 highlighting the importance of screening for FFA in all demographics.

In our study, FFA patients also appeared to be more affluent than the general population and were predominantly nonsmokers (76%). These statistics are consistent with the United Kingdom population studied by MacDonald et al,⁶ which demonstrated a higher socioeconomic status and higher incidence of nonsmoking in their cases of FFA. Another large retrospective study of FFA patients in Spain found that 87% of their FFA cases (N=355) were nonsmokers, though they did not note a difference from the general unaffected population.¹⁵ In our study, we replicated these trends, finding an above average affluence level and a high but not statistically significant incidence of nonsmokers. Although it is not clear how socioeconomic status or smoking factors into the pathology of FFA, these studies may show a general trend in the environmental demographics of the disease.

Clinically, patients with FFA typically present with hair loss of the scalp as well as other sites. The eyebrows are the most common site to be affected outside of the scalp, affecting 86% of our patients, whereas eyelashes are the least commonly affected, presenting in only 3% of our patients. Body hair loss also is common, with almost two-thirds of our cohort reporting hair loss on the limbs and more than one-third reporting loss of axillary and pubic hair. These findings are consistent with those of other studies.^3-6,8,13,15 Eyelash loss, body hair loss, and facial papules have been found to be associated with more severe forms of FFA,¹⁵ though we did not investigate these forms in our study. Inflammatory symptoms are common, with pruritus affecting 66% of our patients and pain affecting 10% of patients, consistent with the published literature.^3,13,15,17

Multiple studies have shown that female FFA patients have a higher incidence of hysterectomies in their medical history.^5,8,15 This observation has been used to further support the hypothesis that a change in sex hormone balance may trigger the initial onset of disease.^5,8,15 A considerable number of the female patients in our study had also undergone hysterectomies (29%). Only 2 patients (7%) underwent premature surgical menopause through bilateral removal of the ovaries, and neither of these patients had abnormally early onset of FFA (age at onset, 52 and 65 years). Many patients in our study also reported a history of pharmacologic manipulation of sex hormones with hormone replacement therapy (43%) and oral contraceptive use (43%). However, patients with FFA have not been identified to have abnormal hormone levels compared to unaffected postmenopausal women.¹ Additionally, the disease does not exclusively affect androgen-dependent hair, as indicated by the high prevalence of eyebrow hair loss. We hypothesize that the link between increased prevalence of hysterectomy and FFA is not due to hormonal changes but rather from the stresses related to the hysterectomy or associated conditions that required the surgery. In our study, 35% of patients identified stress as the inciting event prior to their onset of hair loss, with 17% specifically referring to health-related stress such as surgery or new diagnoses as the cause. Although this pattern is purely observational, it is valuable to consider that stress could contribute to the initial onset of FFA as with alopecia areata.²⁶

A dental history was obtained in 24 patients to explore the possibility of FFA as a manifestation of contact allergy secondary to exposure to metal dental implants. Contact allergies to metal amalgam and gold alloy dental implants/fillings frequently have been described as presenting as oral lichen planus in the literature.^27-34 Given the histologic overlap between oral lichen planus and LPP/FFA, it is worth exploring the possibility that LPP and FFA are other manifestations of contact allergic response. In our study, 100% of the patients who provided a dental history had metal amalgam implants and 33% had gold alloy implants. It is an interesting observation, but it should be noted that none of the patients in our study had undergone patch testing for contact allergies to the metals in their dental implants, and further studies are required to explore this hypothesis.

Frontal fibrosing alopecia is a difficult condition to treat. In our study, patients tried an average of 3 different treatments, the most common being topical steroids (72%), hydroxychloroquine (55%), and intralesional steroids (38%). 5α-reductase isozymes were rarely utilized for patients in this study. Treatment response was noted in most patients using topical steroids, hydroxychloroquine, topical calcineurin inhibitors, and excimer laser therapy. Intralesional steroids also were efficacious in about 36% of patients treated. Little to no treatment response was reported in patients using doxycycline, minocycline, and topical minoxidil.

A PubMed search of articles indexed for MEDLINE using the terms randomized control trial and frontal fibrosing alopecia yielded no randomized controlled trials that have been performed to demonstrate the most efficacious treatments of FFA. However, one systematic review of 114 patients found 5α-RIs, antimalarials, and intralesional corticosteroids to yield the best responses in treating FFA.²² Another large, multicenter, retrospective study of 355 patients also demonstrated that 5α-RIs and intralesional corticosteroids minimized hair loss most effectively across treatment modalities.¹⁵ One treatment that was not discussed in either study but was utilized in ours was the UVB excimer laser, which has been demonstrated to induce T-cell apoptosis and decrease inflammation in psoriasis but has been infrequently studied in the use of FFA or LPP. In one study of 13 patients with LPP, excimer laser treatment was successful in reducing inflammatory symptoms and improving hair loss.³⁵ Our results reaffirm that laser therapy could be considered more frequently as a treatment of FFA.

This study is subject to several limitations. The study size was comprised of a relatively small number of patients with the condition. Additionally, only one-third of patients contacted agreed to participate in the study, and therefore the responses received may not be completely representative of all FFA patients. With a retrospective study, there is potential for recall bias in the data that are collected. Physician chart correlation to patient responses could not be reliably performed due to inconsistent documentation, care received outside our medical system, and prolonged or loss to follow-up. Another concern is that not all diagnoses of FFA in this study were biopsy confirmed. In one patient with systemic lupus erythematous who declined biopsy, it cannot be confirmed that her etiology of scarring alopecia was FFA rather than discoid lupus erythematous. Finally, because patients were treated with multiple medications, often concurrently, it was difficult to parse out which medications were efficacious and which were not. Despite these limitations, the findings in the study add to the growing literature about a rare but increasingly prevalent presentation.

Conclusion

Frontal fibrosing alopecia is a condition that predominantly affects white postmenopausal women but should not be overlooked in other demographics; higher socioeconomic status and nonsmoking are consistent with cases of FFA worldwide. Alopecia frequently involves other body hair, particularly the eyebrows, and is commonly associated with pruritus and pain. Many patients can identify an inciting event, usually stress, a health crisis, or new external exposures that they believe to have triggered the event. Consistent with data about LPP, FFA is frequently associated with autoimmune conditions, particularly hypothyroidism. A substantial portion of patients with FFA have had metal amalgam or gold alloy dental implants placed, though no patch testing was done to confirm that these patients have a contact allergy to these metals. Treatment for the condition is difficult, but topical and intralesional steroids, hydroxychloroquine, calcineurin inhibitors, and excimer laser therapy are efficacious in a large proportion of patients. Nevertheless, further research through prospective randomized trials is necessary to determine the best treatment modalities for FFA. Frontal fibrosing alopecia is a scarring form of hair loss that causes substantial emotional distress; therefore, it is critical to continue to investigate its etiology and treatments to improve patient care.