Treatment of frontal fibrosing alopecia and lichen planopilaris: a systematic review

Abstract

Frontal fibrosing alopecia (FFA) is a primary lymphocytic cicatricial alopecia with characteristic clinical pattern of progressive frontotemporal hairline recession, perifollicular erythema and hyperkeratosis and symptoms of itch and burning, occurring mainly in post-menopausal women. FFA is considered a subtype of lichen planopilaris (LPP), based on their identical histopathology. Currently, no evidence-based treatment is available for FFA. Our aim was to determine the effectiveness of available treatment options for FFA, and to identify promising treatment options for future studies. For this, literature search was conducted to find all primary studies on the treatment of FFA and LPP. From the primary studies, data were subtracted and analysed. No randomized controlled trials were found, and one controlled trial. Treatment of 114 patients is described in the literature. They received 10 different regimes, of which oral 5-alpha-reductase inhibitors were provided most often, resulting in good clinical response in 45% of them. Hydroxychloroquine resulted in good clinical response in 30% of the 29 treated patients. Topical corticosteroid preparations are ineffective in FFA. The remaining treatments were all reported in less than 10 patients. For the treatment of LPP, topical corticosteroid preparations are the first line of treatment, followed by oral cyclosporine and systemic corticosteroids, although they are characterized by a high relapse rate. Summarizing, there is currently no effective treatment of FFA, the most effective being oral 5-alpha-reductase inhibitors that possibly affect the accompanying androgenetic alopecia. We argue that oral cyclosporine A might be a good candidate for future studies on the treatment of FFA.

Examination of Clinical and Demographic Characteristics of 14 Cases with Frontal Fibrosing Alopecia

“…half of the cases (42%) using systemic steroid. In some studies, daily administration of oral prednisolone of 25-50 mg in short term was reported to be more beneficial (26). Steroids were found to be less efficacious in FFA than LPP.…”

“…FFA progresses slowly and the progression stops spontaneously over time, therefore, organizing the treatment and assessing the treatment response may be difficult (2)(3)(4). As the alopecia is cicatricial, the aim should be stopping the progression of the disease, preventing more alopecia and decreasing the symptoms (2,26). Also, there is no clear consensus on how to assess the efficacy of FFA treatment.…”

“…Most authors considered the steroid treatment as first-line therapy. Intermediate to strong potent topical steroids cannot stop the progression of alopecia in most cases (26). Intralesional steroid administration given in 3-4 weeks intervals was reported to be effective in the early stages of the disease, especially in clinical and histological inflammation stages (3,4).…”

“…Also, there is no clear consensus on how to assess the efficacy of FFA treatment. There is no effective option of treatment (3,4,26). In the literature, preferred treatment options mostly include the use of corticosteroids alone or combined with other medications (26).…”

“…There is no effective option of treatment (3,4,26). In the literature, preferred treatment options mostly include the use of corticosteroids alone or combined with other medications (26). Steroids may be administered via topical, intralesional or systemic routes.…”