Frontal Fibrosing Alopecia – a review and a practical guide for clinicians

Abstract

Despite a significant increase in reported cases of frontal fibrosing alopecia (FFA) in literature, discussion about the possible role of environmental factors, instruction for diagnosis and guideline for treatment, are limited. The review aims to provide a detailed synthesis of this condition that could be used by clinicians in their practise. Whether single-centre or multicentre, studies of more than 60 cases less than 5 years old were mainly taken into consideration. Results obtained were that FFA affects mainly postmenopausal Caucasian women; the most common comorbidities are hyperlipidaemia, arterial hypertension, osteoporosis, hypothyroidism, depression, alongside dermatological disorders such as atopic dermatitis, rosacea, seborrheic dermatitis and androgenetic alopecia. Autoimmune, genetic, hormonal (e.g. estrogen deficiency, pregnancy, lactation, HRT and raloxifene) and environmental (e.g. daily use of facial sunscreens and less frequent use of hair dyes and shampoo) hypotheses were proposed for pathogenesis, as well as association with various predisposing factors (patient's health-social profile, disease's history and comorbidities). Clinical presentation of FFA can be divided into 3 specific patterns, each with a different prognosis. Diagnosis is usually made clinically with the use of trichoscopy; however, scalp biopsy remains the gold standard. The condition is regarded as a variant of lichen planopilaris (LPP) due to the similarity of the prominent histopathological findings, but the clinical image is distinct and therapeutic options vary. 5α-reductase inhibitors, intralesional steroids, and hydroxychloroquine provide the highest level of evidence for the treatment of FFA. The conclusion is that a better understanding of the disease is crucial for proper disease management.

Refractory alopecia areata with single hairs imitating frontal fibrosing alopecia: a prospective observational study

“…Trichoscopy shows the presence of residual isolated terminal hairs and the absence of vellus hairs. Perifollicular erythema with perifollicular scaling due to follicular hyperkeratosis are important features 15,16 …”

The Frontal Fibrosing Alopecia Treatment Dilemma

“…The main aims of treatment are to ameliorate symptoms and to suppress disease progression [7,24,45]. A positive response is manifested as stabilization, i.e., cessation of hairline regression, or improvement, i.e., hair regrowth; a negative response is considered as progressive hairline recession [4].…”

“…FFA treatment commonly consists of combined therapy, involving topical and systemic treatments [45,48]. Selected therapeutic options are presented in Table 5.…”

A review of isotretinoin in the treatment of frontal fibrosing alopecia

“…The etiology of FFA remains unknown, but different factors such as autoimmunity, genetics, hormones, and environmental factors seem to be involved 8 . A familial basis is seen in roughly 80% of cases, and genetic associations have been noted in many articles 8,9 …”

“…8 A familial basis is seen in roughly 80% of cases, and genetic associations have been noted in many articles. 8,9 Although the pathogenesis of FFA is still unclear, some studies have shown a decreased expression of cytokeratin 15, a marker of epithelial stem cells, located in the region of the hair follicles. 10 In a study conducted by Harries et al an increase in MHC class I and II molecules, β-2-microglobulin, and interferon γ were detected in areas of alopecia in patients with FFA.…”