<p>Frontal fibrosing alopecia: efficacy of treatment modalities</p>

Abstract

Frontal fibrosing alopecia (FFA) is a primary cicatricial alopecia characterized by loss of follicular stem cells, fibrosis, and a receding frontotemporal hairline, with frequent loss of eyebrows, and less commonly, body hair involvement. Diagnosis is clinical and the disease most often affects postmenopausal women. Treatment is difficult with the goal of disease stabilization rather than hair regrowth due to the scarring nature of FFA. To date, there are no randomized controlled trials evaluating efficacy of treatments. Therefore, much of our knowledge is based on small retrospective studies. In this review, we highlight the various and most current treatment options for FFA, including 5-α-reductase inhibitors, intralesional steroids, hydroxychloroquine, topical steroids, topical calcineurin inhibitors, systemic retinoids, pioglitazone, oral antibiotics, minoxidil, excimer laser, and hair transplantation. Currently, 5-α-reductase inhibitors, intralesional steroids, and hydroxychloroquine have the highest level of evidence for treating FFA, while the remaining therapies have variable results and require further data to draw definitive conclusions.

<p>Optimal Management of Frontal Fibrosing Alopecia: A Practical Guide</p>

“…Intralesional corticosteroids (ILCs) are often considered part of the mainstay of treatment for FFA, as they suppress the inflammatory process, which in turn decreases T-cellmediated destruction of follicular stem cells. 33,40,41 Current evidence supports ILCs as part of first-line treatment for FFA. Vañó-Galván and colleagues reported an overall positive clinical response rate of 83% in patients with FFA who received ILCs' injections every 3 to 6 months, with an average of eight injections in total.…”

“…32 In order to decrease the risk of ASE, one proposal has been to alternate tCS with another topical therapy, such as tCI. 33 If Topical Calcineurin Inhibitors tCI include pimecrolimus and tacrolimus, which exert immunomodulatory and anti-inflammatory effects through blockage of calcineurin phosphate and subsequent downstream decreases in cytokine production and T cell activation. 33,34 tCI may help treat FFA, as one of the postulated pathophysiologic mechanisms of FFA is T-cellmediated destruction of follicular stem cells.…”

“…33 If Topical Calcineurin Inhibitors tCI include pimecrolimus and tacrolimus, which exert immunomodulatory and anti-inflammatory effects through blockage of calcineurin phosphate and subsequent downstream decreases in cytokine production and T cell activation. 33,34 tCI may help treat FFA, as one of the postulated pathophysiologic mechanisms of FFA is T-cellmediated destruction of follicular stem cells. 33 In their paper on FFA treatment options, Fertig and Tosti detail that tCI are part of their favored course of combination treatment, noting that they treat a large number of FFA patients and have had the best results using combination medical therapy with tCI, oral finasteride, hydroxychloroquine, and excimer laser.…”

“… 32 In order to decrease the risk of ASE, one proposal has been to alternate tCS with another topical therapy, such as tCI. 33 …”

Frontal fibrosing alopecia shows robust T helper 1 and Janus kinase 3 skewing

“…As FFA predominantly affects postmenopausal women, 9,10 there have been attempts to use antiandrogen treatments, with limited clinical response. 11,12 Intralesional corticosteroids may achieve some disease stabilization, with associated adverse effects such as pain and skin atrophy, 13,14 and topical corticosteroids are often not effective. 15 Most studies evaluated FFA alongside lichen planopilaris (LPP), a condition considered to have similar histopathological changes.…”