Hairlines through history: Frontal fibrosing alopecia over 500 years?

Frontal fibrosing alopecia (FFA) was first described in 1994 by Kossard who noted a scarring, frontotemporal hair loss pattern in six postmenopausal women.1 Reports suggest the incidence may be increasing.2 We examined historical female portraits looking for evidence of FFA. This study aimed to establish the frequency of FFA in a historical population and to examine whether there was a trend in frontal hairline height with time. All female portraits displayed at the National Portrait Gallery and The National Gallery in London, UK were included. Portraits where the face was angled, or the subject wore a headdress, hat or fringe obscuring the hairline were excluded. For each portrait, the subject, artist and year were recorded. Measurements of the forehead height from the frontal hairline to the mid-pupillary level (A) and from the chin to frontal hairline height (B) were taken (centimetres) as illustrated in Figure 1. A ratio of A/B was calculated, so a higher ratio indicated a higher hairline. Portraits with an A/B ratio in the upper quartile were reviewed by two Consultant Dermatologists for high hairlines, temporal hair loss, eyebrow loss and evidence of FFA. Linear regression was used to evaluate for differences in the forehead A/B ratio over time. This retrospective cohort study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. 120 consecutive female portraits were eligible and analysed. Portraits dated from 1170 CE (AD) to 2012 with a median of 1676 CE. The A/B ratio ranged from 0.300 to 0.527 with a median of 0.4145. Portraits in the upper quartile had an A/B ratio of 0.438 or more. Nine portraits (7.5%) were thought likely to have FFA (Figure 2), with the earliest case dated as 1455 CE. Features observed included pathologically high hairlines, temporal hair loss and eyebrow thinning or loss. There was a significant linear trend (Figure 3), with the forehead A/B ratio decreasing over time (r2 = 0.0972, p = 0.0005), so later portraits had less evidence of frontal hair loss. The prevalence of possible FFA in the historical population appeared greater than that reported in recent UK epidemiological studies, and there are multiple possible explanations for this.3 Portrait subjects were often affluent individuals of white ethnicity and Fitzpatrick type I/II skin. Recent literature suggests these may be risk factors for FFA.2 Furthermore, fashion trends for high hairlines and artistic licence in portrait proportions may have influenced results.4 In the 16th century, Queen Elizabeth I pioneered the removal of eyebrows and hair from the hairline and so shaved foreheads and heavily plucked eyebrows were common practice.5 Curiosa Arcana, a publication in 1711 by Nicholas Lemery, a French apothecary, later provided a recipe for cat faeces, vinegar and egg shells for hair removal. Traction alopecia secondary to heavy headdress or tightly pulled hairstyles may have influenced results.6 Technical limitations exist, whereby the portraits did not enable visualization of the whole scalp making differentiation from other diagnoses difficult such as ophiasis pattern alopecia areata and androgenetic alopecia. Assessment of the subjects' age was challenging, which may limit this study, given FFA is typically seen in postmenopausal women. Validation of this technique is required and, furthermore, could be repeated in other countries. This historical study found hairlines may have moved forward over the past millennium. The rising prevalence of FFA in recent literature could be explained by increasing recognition and health-seeking behaviours, or possibly increasing use of unidentified topical triggers in sunscreens and cosmetics. Recent studies have provided insight into FFA as a genetically predisposed immuno-inflammatory disorder, associated with the HLA-B*07:02 allele.7 Other reported associations include an ageing population, sunscreen application and early menopause.2, 8 Difficulty in assessing hairlines using two-dimensional (2D) images only is a limitation. We could not utilize the Frontal Fibrosing Alopecia Severity Index (FFASI), which has proven intraobserver concordance.9 However, this study also identified a method to screen for possible FFA in patient 2D images using the forehead A/B ratio. Further validation of this technique is required. In conclusion, the medium of art and history has provided evidence of hairlines in female portraits moving forward with time which we hypothesize may give insights into the natural history of FFA. Permission for reproduction of the portraits has been kindly granted by National Portrait Gallery and The National Gallery in London, UK. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. None. The data that support the findings of this study are available from the corresponding author upon reasonable request.