FRONTAL FIBROSING ALOPECIA

By Gary M. White, MD

Frontal fibrosing alopecia Note the band of complete alopecia anteriorly and the diminished eyebrows in a postmenopausal woman.


Frontal fibrosing alopecia (FFA) is a scarring alopecia that prefers the anterior hairline of women.

Clinical

Progressive recession of the frontal hairline in a postmenopausal woman associated with perifollicular erythema is characteristic. The alopecia is concentrated in the front, but may extend to the lateral margins. Complete or extensive loss of the eyebrows is common.

Multiple, facial, flesh-colored to whitish papules have been reported in FFA. They appear as multiple, grouped, noninflammatory follicular papules, most often inside the temporal area, and may be described as "roughness" by the patient. Histologic examination shows hypertrophic sebaceous glands with no associated vellus hair follicle. It is hypothesized that the FFA destroys the vellus hair follicle, but the sebaceous gland remains. Low dose isotretinoin 10 mg every other day greatly reduced the appearance of the bumps [JAAD 2017;77;764].

In one study [JAAD April 2014], 97% of patients were women and most were postmenopausal with an average age of onset of 59. Both hysterectomy and early menopause were associated. Facial papules, depression of frontal veins, the presence of glabellar red dots, loss of body hair and trichodynia may occur.

The coexistence of FFA and lichen planus pigmentosus has been reported [JAAD 2014;71;e26–e27]. Patients tend to be middle-aged women of darker skin. In addition to the FFA, there is progressive development of gray-brown macules on the face and neck in a photo-distribution.

Hypopigmentation of the forehead is associated and may be better appreciated with Wood's light examination. This hypopigmentation is associated with fewer epidermal melanocytes [JAAD 2017;76;1184].

FFA does occur in men [JAAD 2017;77;683]. Loss of sideburns and facial hair is seen in men.

Differential diagnosis

Chronic marginal traction alopecia may be difficult to distinguish. A biopsy may be necessary.

Treatment

No therapy has been proven to alter the course of the disease. Stabilization or prevention of progression is usually the goal. It is a little hard to know what to recommend with regard to topical, leave-on cosmetic products and in particular sunscreens. Given the above cited studies on the association, should patients be counseled to minimize or completely avoid topical cosmetic products in the affected areas? Hopefully, more studies in the future will address this. As noted above, low dose isotretinoin can minimize the appearance of the facial papules.

Treatments listed below may be considered.

Steroids

Clobetasol plus or minus IL triamcinolone 10 mg/cc monthly for 3 months.

Antiandrogens

Finasteride (2.5-5 mg/d) and dutasteride (0.5 mg/wk) improved 47% and 44% of the treated patients, respectively [JAAD April 2014]. For this therapy, there seems to be a 50/50 chance of improvement and a low side effect profile.

Second Line

Minocycline 100 mg bid or hydroxychloroquine 200 mg BID.

Third line

Tacrolimus, mycophenolate, dapsone or azathioprine.

Pioglitazone Treatment of FFA and LPP

Additional Pictures

Note the receding hairline and the prominence of blood vessels. Frontal fibrosing alopecia

Alopecia of the eyebrows.
Frontal fibrosing alopecia showing alopecia of the eyebrows Frontal fibrosing alopecia showing alopecia of the eyebrows

Frontal Fibrosing Alopecia Frontal Fibrosing Alopecia

References

FFA and lichen planus pigmentosus JAAD 2014;71;e26–e27

The fringe sign is a marker for traction alopecia, but it may also occur in FFA as shown in this article. BJD 2015;173;1327–1347

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