Scarring alopecias Pt. 1: Frontal fibrosing alopecia

Frontal fibrosing alopecia (FFA) is a rare condition that mostly affects post-menopausal women. The average age of onset is about 56 years, with cases occurring as young as 21 years.(1) FFA was first described in 1994 as a type of scarring alopecia, which destroys hair follicles and subsequently replaces them with scar tissue.(2) FFA is considered a type of lichen planopilaris (an inflammatory condition that causes patchy hair loss on the scalp) but others consider it as a new disease.(3) FFA presents as a receding hairline at the front and sides of the scalp that may progress above and beyond the ears.(4) The hair loss can be sudden and proceed rapidly or can occur slowly and subtly.(4) FFA has also been reported to stabilize spontaneously over time.(5) One of the most typical and earliest signs of FFA is a loss of eyebrow hair;(3) however, it may also be associated with a loss of body hair.(4)

The cause of FFA is currently unknown. There may be complex factors influencing whether or not someone develops FFA, such as genetics, immune response, and hormones. There are some studies showing familial cases of FFA.(3) Other studies have found that FFA is associated with autoimmune conditions such as lupus erythematous, vitiligo, and rheumatoid arthritis.(4) Another possibility is that FFA is caused by a decrease in estrogen levels after menopause or after a hysterectomy.(1)

There is very little research examining possible treatments for FFA and the research that exists has many limitations. Based on a review of all treatments reportedly used for FFA, Harries and Messenger concluded that intralesional triamcinolone acetonide 20mg/mL (a corticosteroid) given every three months to the frontal hairline may be the most effective treatment available to date.(6) However, no randomized controlled trials have been conducted yet. Other treatment regimens that have been given to patients with FFA include: finasteride, dutasteride, minoxidil, corticosteroids (topical, systemic), hydroxychloroquine, tetracycline, topical retinoid, ketoconazole shampoo, and biotin.(5) Few papers have reported attempts at hair transplantation for FFA, with results suggesting that the transplanted hairs may do well initially but may disappear 2-4 years after the transplant.(7)  Treatment for FFA and scarring alopecias focus on stopping hair loss progression and alleviating disease symptoms. Treatments cannot regenerate hair from scarred areas.(7)

Article by: M.A. MacLeod, MSc., Mediprobe Research Inc.

References

1. Vañó-Galván S, Molina-Ruiz AM, Serrano-Falcón C, Arias-Santiago S, Rodrigues-Barata AR, Garnacho-Saucedo G, et al. Frontal fibrosing alopecia: A multicenter review of 355 patients. J Am Acad Dermatol. 2014 Apr;70(4):670–8.
2. Kossard S. Postmenopausal frontal fibrosing alopecia. Scarring alopecia in a pattern distribution. Arch Dermatol. 1994 Jun;130(6):770–4.
3. Navarro-Belmonte MR, Navarro-López V, Ramírez-Boscà A, Martínez-Andrés MA, Molina-Gil C, González-Nebreda M, et al. Case series of familial frontal fibrosing alopecia and a review of the literature. J Cosmet Dermatol. 2015 Mar;14(1):64–9.
4. Banka N, Mubki T, Bunagan MJK, McElwee K, Shapiro J. Frontal fibrosing alopecia: a retrospective clinical review of 62 patients with treatment outcome and long-term follow-up. Int J Dermatol. 2014 Nov;53(11):1324–30.
5. Rácz E, Gho C, Moorman PW, Noordhoek Hegt V, Neumann H a. M. Treatment of frontal fibrosing alopecia and lichen planopilaris: a systematic review. J Eur Acad Dermatol Venereol JEADV. 2013 Dec;27(12):1461–70.
6. Harries MJ, Messenger A. Treatment of frontal fibrosing alopecia and lichen planopilaris. J Eur Acad Dermatol Venereol JEADV. 2014 Oct;28(10):1404–5.
7. Jiménez F, Poblet E. Is hair transplantation indicated in frontal fibrosing alopecia? The results of test grafting in three patients. Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 2013 Jul;39(7):1115–8.

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