Clinics in Dermatology (2012) 30, 548–552
DERMATOLOGIC DISQUISITIONS AND OTHER ESSAYS
Edited by Philip R. Cohen, MD
Frontal pseudoalopecia in history:
Part 1—Fashionable forms
Angel Fernandez-Flores MD, PhD ⁎
Department of Pathology, Hospital El Bierzo, Medicos Sin Fronteras 7, 24411 Ponferrada, Spain
Introduction
The progressive recession of the frontal hairline is a
common phenomenon in postmenopausal women. It is
considered a variant of androgenic alopecia, being related to
androgenic hormones; however, postmenopausal frontal
fibrosing alopecia is another form of frontal alopecia that is
not related to virilization. It was described in 1994, and its
pathogenesis is not totally understood. 1,2 Frontal fibrosing
alopecia shows frontal and parietal hairline recession with
frontal alopecia. At the frontal line, the skin is pale without
erythema. There is also thinning of the eyebrows. This type
of alopecia is perceived with great concern by patients, who
consider it antiaesthetic and a source of stress. This feeling
has always not been the rule in history.
I shall examine two historical periods in which the
absence of hair from the frontal areas was acquired because it
had aesthetic (it was considered “beautiful”) or social and
political (obedience to the emperor) value.
In Western cultures, this was common during the Middle
Ages, when women voluntarily plucked the hair from the
frontal area to look more attractive. This topic is covered in
the current report. In Asia, particularly in China during the
1600s, Manchu invaders imposed the style of a shaved
frontal area upon the population as a rule of obedience,
which will be commented in a future report (Part 2).
⁎ Corresponding author. Tel.: 0034-987-423-732; fax: 0034-987-459-
102.
E-mail address: gpyauflowerlion@terra.es.
0738-081X/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.clindermatol.2011.08.003
Hairstyle in the Middle Ages
Removing frontal hair as a fashionable practice became
common for noble women in Europe in the 1400s. 3 Only
very young girls and hairstyles accompanying a few
exceptional regal costumes were free from this tradition. 4
According to some, one of the main reasons why this
habit became so popular was the style of the headdresses. As
they became more and more ornate and exaggerated, it was
decided that nothing should distract attention from it, so that
women removed the hair from their foreheads and back of
their necks. 5 This was accomplished by plucking, rubbing it
off with a sharp pumice stone, or by using a cream made of
water and quicklime, which had a burning effect. 3 Younger
women used tweezers to pluck their eyebrows. 6 The result
was a wide bare forehead, often ornamented with a frontlet. 4
Plucking the hair became commonplace, and it was not
unusual for a woman to do it in public with the aid of a small
mirror or a piece of polished metal, just as we might expect
to see a woman powdering her nose or adding lipstick in
public. 5 This trend was also accompanied by eyelash
trimming and eyebrow plucking. 3
The fashion lasted at least for the entire 15th century,
although by the latter decades, it was slowly giving way to a
trend of letting the hair hang loosely down the back. 4
Frontal plucking of the hair in art
Medieval art offers a clear reflection of the fashion of
plucking the hair at the frontal line, and previous
Frontal pseudoalopecia in history
Fig. 1 Portrait of Battista Sforza and Federico da Montefeltro, by Piero della Francesca, 1472.
dermatologic reports have mentioned the bald frontal areas
displayed in medieval paintings. For instance, Serrano-
Falcón and Serrano-Ortega discussed the Portrait of the
Fig. 2 Girl Reading a Letter at an Open Window, by Johannes
Vermeer, circa 1658.
549
Duchesse of Urbino, by Piero della Francesca, on display in
room 7 of the Gallery of the Uffizi in Florence 7 (Figure 1).
The authors hypothesize that the Duchesse suffered from
fibrosing frontal alopecia, despite her young age. As
justification, they explain that instances of the condition
occurring before menopause have been reported. 8-10
In 1983, Dotz 11 published a report on Jan Vermeer
paintings, remarking that models in several of the works
showed marked frontal alopecia (Figure 2). Dotz offered
several hypotheses for this phenomenon, suggesting
Fig. 3 Portrait of a Young Girl, by Petrus Christus, 1470.
550 A. Fernandez-Flores

Fig. 4 Portrait of a Noblewoman, Probably Isabella of Portugal

(1397-1472), Netherlandish painter, mid-15th century.

Fig. 6 Portrait of a Man and Woman at a Casement, by Filippo

postpartum telogen effluvium, a chronic circumferential
pressure on the scalp caused by tight headdresses, and
ophiasis. His most plausible suggestion concerns the
curious cosmetic practices of the period. He specifically
describes how “it was common habit among women in
northern Europe to pluck and shave hair from the frontal
hairline and from the eyebrows to give the appearance of a
round and high brow.” 11
Lippi, 1440.
An examination of the paintings in this period shows how
common this phenomenon was, leading to the conclusion
that the art reflects what must have been the fashion of the era
rather than an epidemic of alopecia.

Fig. 7 Portrait of a Lady, by Benedetto Ghirlandaio

Fig. 5 Portrait of Simonetta Vespucci, by Piero di Cosimo, 1480. (15th century).
Frontal pseudoalopecia in history 551

Fig. 8 Portrait of a Princess of the House of Este, by

Vittore Pisano.

The Flemish School is one of the most prolific in

portraying such phenomenon. Examples include Portrait of
a Young Girl by Petrus Christus in 1470 (Figure 3), and
Portrait of a Noblewoman, Probably Isabella of Portugal
(Figure 4).

Fig. 10 Saint George, by Bernat Martorell.

Fig. 9 Madonna Surrounded by Seraphim and Cherubim, by

Frances Jean Fouquet. Fig. 11 Virgin of the “Consellers,” by Lluis Dalmau.
552
Painters from Southern Europe feature similar hairstyles.
The recession of the frontal line of the hair is well displayed
in the Portrait of Simonetta Vespucci, by the Italian painter
Piero di Cosimo (Figure 5). In the Portrait of a Man and
Woman at a Casement by Filippo Lippi, this phenomenon
can be observed in a side view of the model (Figure 6). A
more extreme example is shown in the Portrait of a Lady, by
Benedetto Ghirlandaio. Although the model partially covers
the frontal area of her scalp with a veil, it is not enough to
completely conceal the bald areas (Figure 7). Even very
young women took part in this practice, as can be seen in the
Portrait of a Princess of the House of Este, by Vittore Pisano,
in which the model, a teenager, preserves only the back part
of her hair, tied in the fashion of a ribbon (Figure 8).
Although this was in style in the culture, the trend is
present even in religious art, probably due to the hairstyle
of the models. The Virgin Mary in Madonna Surrounded
by Seraphim and Cherubim, by the French painter Frances
Jean Fouquet, displays frontal baldness (Figure 9). The
Catalan painter, Bernat Martorell, painted his Saint George
with the Virgin bearing a frontal alopecic area (Figure 10).
In the Virgin of the “Consellers”, by Lluis Dalmau, many
women, including the Virgin, display typical frontal
baldness (Figure 11).
Conclusions
Evidence proves that aesthetic tendencies in the culture
can determine how certain dermatologic diseases are
perceived. Some forms of alopecia, which would be seen
with great concern by the women affected, could have been
viewed in the Middle Ages as something not only acceptable,
but also as an aesthetic blessing. In a way, this demonstrates
that what is considered “abnormal” or “pathologic” in
medicine can be influenced by many other nonmedical
fields through history.
Acknowledgement
I would like to thank Dr. Joyce Lee, from the National
Skin Centre of Singapore, who, at a coffee break during the
31st symposium of the International Society of Dermato-
pathology in Barcelona (2010), reminded me that this hair
fashion had also been typical of Chinese opera singers
representing the story of the Qing Dynasty. She also sent me
A. Fernandez-Flores
valuable information on the Chinese history of the Queue,
and helped me to source additional bibliographical resources
on the subject.
References
1. Kossard S, Lee MS, Wilkinson B. Postmenopausal frontal fibrosing
alopecia: a frontal variant of lichen planopilaris. J Am Acad Dermatol
1997;36:59-66.
2. Camacho Martínez F, García-Hernández MJ, Mazuecos Blanca J.
Postmenopausal frontal fibrosing alopecia. Br J Dermatol 1999;140:
1181-2.
3. Elliot L. Beauty. In: Elliot L, editor. Clothing in the Middle Ages.
Ontario. Canada: Crabtree Publishing Company; 2004. p. 29-31.
4. Houston MG. Civilian dress of the fifteenth century. In: Houston MG,
editor. Medieval costume in England and France. New York. Inc: Dover
publications; 1996. p. 159-98.
5. Brooke I. English costume of the latter Middle Ages (the 14th-15th
centuries). In: Brooke I, editor. English costume from the early Middle
Ages through the sixteenth century. New York: Dover Publications Inc;
2000. p. 91-178.
6. Mortimer I. What to wear. In: Mortimer I, editor. The time traveller's
guide to Medieval England. London: Vintage Books; 2009. p. 117.
7. Serrano-Falcón C, Serrano-Ortega S. ¿Tenía la Duquesa de Urbino una
alopecia frontal fibrosante? Actas Dermosifiliogr 2008;99:737-8.
8. Vaisse V, Matard B, Assouly P, Jouannique C, Reygagne P. Alopécie
fibrosante frontale post ménopausique: 20 cas. Ann Dermatol Venereol
2003;130:607-10.
9. Jumez N, Bessis D, Guillot B. L'alopecie fibrosante frontale n'est pas
toujours pot-menopausique. Ann Dermatol Venereol 2005;132:263.
10. Moreno-Ramírez D, Ferrándiz L, Camacho FM. Alopecia frontal
fibrosante: valoración diagnóstica y terapeútica. Actas Dermosifiliogr
2007;98:594-602.
11. Dotz W. Jan Vermeer and his alopecic models. Am J Dermatopathol
1983;5:245-8.
Angel Fernandez-Flores, MD, PhD studied Medicine in the University
Autónoma of Madrid, where he graduated in 1992. He trained as a
histopathologist in the Fundación Jiménez Díaz of Madrid. In 2003, he
obtained his PhD in the University Autónoma of Madrid. He has been Head
of the Service of Cellular Pathology of Clinica Ponferrada since 1997.
Currently, he is a Consultant Histopathologist in the Hospital El Bierzo,
Ponferrada, Spain. He is member of the Spanish Society of Anatomic
Pathology, of the Club of the European School of Oncology, of the
European Academy of Dermatology and Venereology and of the
International Society of Dermatopathology. He is the editor of the book
New Research in Cutaneous Lymphomas, published in 2007. He has
published more than 70 reports indexed in PubMed. He is also the author of
the chapter “Keratoacanthoma Versus Epidermoid Carcinoma: An Updated
Interpretation” in the book Skin Cancer: New Research.
Please submit contributions to this section to Philip R. Cohen, MD.
E-mail address: mitehead@aol.com.