From a surgical standpoint - A comment on: “Bilateral temporal triangle alopecia mimicking male pattern alopecia in an adult female: a case report and review of the literature”

Funding: None
Conflict of interest: None
Submitted on: 07/28/2025
Final decision: 09/03/2025
How to cite this article: Rezende HD, Rodrigues RAC, Alérico ALS, Melo IPV, Dinato SLM. From a surgical standpoint - A comment on: “Bilateral temporal triangle alopecia mimicking male pattern alopecia in an adult female: a case report and review of the literature.” Surg Cosmet Dermatol. 2025;17:e20250502.

Abstract

Temporal triangular alopecia (TTA) is a rare condition frequently mistaken for androgenetic alopecia or other hair disorders. We comment on the recent case reported by Lucca et al., emphasizing the importance of histopathological confirmation in suspected cases to avoid misdiagnosis and unnecessary treatments. Although valuable, trichoscopy may not reliably distinguish TTA from conditions such as alopecia areata, trichotillomania, or frontal fibrosing alopecia in advanced stages. Surgical correction remains the treatment of choice for confirmed TTA, but caution is warranted when considering hair transplantation in other forms of alopecia, as outcomes and safety may be compromised in the absence of diagnostic certainty.

Keywords: Alopecia; Transplantation; Pathology, Clinical; Surgery, Plastic

To the Editor

We read with great interest the case report by Lucca et al. describing bilateral temporal triangular alopecia (TTA) in an adult woman, a rare condition that is frequently mistaken for androgenetic alopecia or other causes of hair loss. Their report underscores the diagnostic challenges posed by this entity and highlights the importance of a thorough evaluation.

We would like to expand the discussion by emphasizing the need for histopathological confirmation in suspected cases and careful consideration of the role of hair transplantation in true TTA compared with its differential diagnoses. While trichoscopy is undoubtedly a valuable diagnostic tool, its limitations must be acknowledged. It relies on physician expertise, and several forms of alopecia, particularly in chronic or advanced stages, may present with inconspicuous or very subtle trichoscopic findings.¹ This can make it difficult to distinguish TTA from other conditions such as late-stage alopecia areata unilocularis and trichotillomania, which have different therapeutic approaches and prognoses. Delaying histological confirmation may lead to unnecessary or even harmful interventions in such cases.

The case reported by the authors illustrates the potential consequences of these diagnostic pitfalls. A patient with alopecia areata involving the frontal hairline would most likely undergo intralesional corticosteroid injections in an area that is highly innervated, painful, and cosmetically sensitive, making the inherent risk of cutaneous atrophy particularly concerning. Patients with patchy frontal fibrosing alopecia (FFA) would likely undergo systemic therapies such as hydroxychloroquine or doxycycline, which have their own adverse effects. A misdiagnosis of trichotillomania may expose patients to unwarranted psychotherapeutic or pharmacological interventions, including antipsychotics. Even a misdiagnosis of androgenetic alopecia would likely expose the patient to chronic use of topical and/or oral minoxidil and 5-α-reductase inhibitors, as could have occurred in the case reported by Lucca et al.²

Although surgical correction remains the treatment of choice for confirmed TTA,³ the role of hair transplantation in other forms of alopecia should be approached with caution. Proceeding with transplantation without diagnostic certainty may compromise both clinical outcomes and patient safety.

In alopecia areata, for example, surgical approaches on chronic lesions, even after prolonged disease stability, have proven risky. Civas et al. reported the case of a 24-year-old man undergoing eyebrow hair transplantation for therapy-resistant alopecia areata who experienced disease reactivation and complete graft loss after 5 years.⁴ Similarly, as emphasized by Robert True in his recommendations for surgical candidacy, patients with active trichotillomania are not suitable candidates for hair restoration procedures, as compulsive hair pulling can destroy both native and transplanted follicles, resulting in unsatisfactory outcomes and unnecessary costs.⁵ Lastly, although surgical treatment has been tried for FFA, this approach remains cautious, as graft survival rates are generally lower than in unaffected individuals and results tend to be more limited.⁵

Beyond the risk of unnecessary clinical interventions and their potential adverse effects, it should be stressed that while congenital triangular alopecia is most effectively treated with hair transplantation, diagnosis confirmation through histopathology remains essential. Misdiagnosis involving other differential conditions exposes patients to ineffective or risky treatments and may also lead to irreversible aesthetic and psychological distress. By reinforcing the diagnostic value of biopsy and clarifying the role of surgical interventions, we aim to promote safer and more effective management of patients with TTA and other uncommon forms of alopecia.

AUTHOR’S CONTRIBUTION:

Hudson Dutra Rezende
ORCID: 0000-0002-7039-790X
Approval of the final version of the manuscript, Conception and design of the study, Preparation and writing of the manuscript, Critical review of the literature, Critical revision of the manuscript.
Renata Almeida Chaebub Rodrigues
ORCID: 0009-0009-9084-2036
Preparation and writing of the manuscript, Critical review of the literature, Critical revision of the manuscript.
Ana Lígia Scotti Alérico
ORCID: 0000-0002-8709-8607
Approval of the final version of the manuscript, Preparation and writing of the manuscript, Critical review of the literature.
Ingrid Palloma Vieira de Melo
ORCID: 0009-0003-4693-567X
Approval of the final version of the manuscript, Preparation and writing of the manuscript, Critical review of the literature.
Sandra Lopes Mattos e Dinato
ORCID: 0000-0002-8025-1517
Approval of the final version of the manuscript, Preparation and writing of the manuscript, Critical review of the literature.

REFERENCES:

1. Katoulis AC, Liakou AI, Bozi E, Alevizou A, Rigopoulos D. Temporal triangular alopecia: clinical, trichoscopic, and histopathological features. Skin App Dis. 2019;5(4):230–5.

2. Lucca MB, Ferreira LO, Boff AL, Vettorato R. Alopecia triangular temporal bilateral simulando alopecia androgenética de padrão masculino em mulher adulta: relato de caso e revisão da literatura. Surg Cosmet Dermatol. 2025;17:e20250380.

3. Bang CY, Byun JW, Kang MJ, Yang BH, Song HJ, Shin J, et al. Successful treatment of temporal triangular alopecia with topical minoxidil. Ann Dermatol. 2013;25(3):387–8.

4. Civas E, Aksoy B, Ozer F, Eski M. Long-term result of hair transplantation for therapy- resistant alopecia areata of eyebrows. Indian J Dermatol Venereol Leprol. 2017;83(5):618–9.

5. True RH. Is every patient of hair loss a candidate for hair transplant? Deciding surgical candidacy in pattern hair loss. Indian J Plast Surg. 2021;54(4):435–40.