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Frontal Fibrosing Alopecia: Causes, Symptoms & Treatments

Frontal Fibrosing Alopecia (FFA) is a form of scarring or cicatricial alopecia that mainly affects women. In 83-95% of women, Frontal Fibrosing Alopecia usually begins after menopause between 55-63-years-old [1]. FFA causes permanent hair loss from the frontotemporal or front and sides of your scalp hair margin and other body parts, like the eyebrows and eyelashes [1].

FFA may be caused by genetic, hormonal, immune, and environmental factors, however, the exact cause is unknown [2]. There is no cure for FFA, but there are several medical treatment options available that can slow the progression of this type of scarring hair loss.  

In this article, we will explore FFA in detail, covering what causes it, common symptoms of FFA, how FFA is diagnosed, and how it is treated.

Table of Contents

What is Frontal Fibrosing Alopecia?

Frontal Fibrosing Alopecia is a type of alopecia (hair loss) characterised by a band-like receding hairline [2]. FFA is a special form of a disease called lichen planopilaris ­– a common type of scarring hair loss.

In Frontal Fibrosing Alopecia, scientists believe that inflammatory cells from the immune system infiltrate and destroy the stem cells found in the bulge of the epithelial hair follicles, affecting their ability to regenerate and produce hair. The loss of the regenerative potential of the hair follicle causes fibrosis (or scarring) and permanent hair loss [2]. 

Informational graphic showing how immune cells infiltrate and damage hair follicle bulges
Immune cells infiltrate and damage the hair follicle bulge and cause the loss of its regenerative potential (HF) [1].

FFA is one of the most common causes of cicatricial (scarring) alopecia globally, and since it was first described in 1994, cases have been increasing [3]. 

What causes Frontal Fibrosing Alopecia? 

Even though cases of Frontal Fibrosing Alopecia are on the rise, the exact cause of FFA is still unknown. However, genetic, hormonal, autoimmune, inflammatory, and environmental conditions may contribute to FFA development [1].  

Since Frontal Fibrosing Alopecia predominantly affects postmenopausal women, it is commonly associated with androgenetic alopecia (female pattern hair loss), and is responsive to 5-alpha-reductase inhibitors (anti-androgens). Researchers have suggested that hormones could play a role in FFA [4]. However, Frontal Fibrosing Alopecia happens in people with normal hormonal balances. Furthermore, hormone replacement therapy does not affect the disease [2].

Early menopause could contribute to the premature development of FFA or increase the risk of developing Frontal Fibrosing Alopecia [1]. Autoimmunity is thought to play a role in FFA as immune cells can attack the hair follicles, causing damage. Up to 30% of patients with FFA have an autoimmune disorder such as lupus, hypothyroidism, or psoriasis [5]. 

Similarly, genetic factors may lead to Frontal Fibrosing Alopecia, as it often affects several people in the same family; 8% of FFA cases are familial. However, studies have shown that it is not hereditary [6]. 

Environmental factors such as facial products, environmental toxins, viral infections, surgery, or stress may play a role in developing FFA [1]. Studies have shown that using certain leave-on cosmetics, including facial sunscreens, hair care products, and hair dyes may contain ingredients that trigger and increase the incidence of FFA in genetically susceptible individuals [4,6].

Who is at risk for Frontal Fibrosing Alopecia?

FFA used to be called Postmenopausal Frontal Fibrosing Alopecia because it mainly affects women after menopause [1]. However, some cases have been seen in premenopausal women and also in men [2].

FFA rarely affects men, and when it does, it seems to be due to genetic factors [2]. The average age of onset of diagnosis is 55 years old, and most patients are older than 60 years old when they are diagnosed [6].

Women of African descent often show symptoms earlier, and it is associated with traction alopecia, which is common in this group due to certain hairstyles [2].

What are the symptoms of Frontal Fibrosing Alopecia?

FFA can cause hair loss anywhere hair grows, including the scalp, face, arms, legs, and even the pubic area. The main symptom of FFA is cicatricial frontotemporal hair loss along the frontal hairline and sides of the hairline [2].

In addition, in the early stages of FFA, before frontotemporal hair loss, people may experience perifollicular erythema (redness around the hair follicle) and scaling. In some cases, there may be thinning of the lateral parts of the eyebrows or loss of hair on the arms and legs [6]. 

Perifollicular erythema and scaling

Perifollicular erythema and scaling [7].

Frontal Fibrosing Alopecia: Causes, Symptoms & Treatments, Wimpole Clinic

Hair loss from eyebvrows [4]

In the later stages of the disease, there is a clear difference between the affected area, where the skin is pale, scarred, and shiny due to the lack of hair follicles and the rest of the forehead, which looks normal [2]. 

Women with diagnosed frontal fibrosing alopecia at different stages; premenopausal 30-year-old woman (a), postmenopausal 63-77-year-old women with frontotemporal recession and eyebrow loss (b-d)
Women with diagnosed frontal fibrosing alopecia at different stages; premenopausal 30-year-old woman (a), postmenopausal 63-77-year-old women with frontotemporal recession and eyebrow loss (b-d) [8].
Frontal Fibrosing Alopecia: Causes, Symptoms & Treatments, Wimpole Clinic
Frontal Fibrosing Alopecia in a male with loss of sideburns and frontotemporal scarring alopecia with lonely hairs [9].

There can sometimes be isolated hairs in the affected area and sometimes erythema or perifollicular papules [2]. Most women with FFA lose 80-90% of their eyebrows as well. Other symptoms of FFA include:

  •     Itchiness and pain
  •     Facial papules or raised bumps
  •     Facial veins of the forehead
  •     Hyperpigmentation or darkening of the face and neck
  •     Rosacea-like rash

How is Frontal Fibrosing Alopecia diagnosed?

Doctors or trichologists usually diagnose FFA by performing an oral history to ask you about your symptoms and when you started experiencing hair loss. This will then be followed by a medical examination of your eyebrows, hairline, and scalp [2]. Sometimes a skin biopsy is needed. This scalp biopsy involves removing small samples of affected skin whilst under local anaesthetic to study them under a microscope.

Other tests, such as a gentle hair pull test may be done to rule out other hair loss conditions like traction alopecia or androgenic alopecia

What is the treatment for Frontal Fibrosing Alopecia?

There is currently no cure for FFA, but there are treatments available that slow the progression of the disease. Unfortunately, there is very little evidence for the efficacy of Frontal Fibrosing Alopecia treatments, and sometimes, the condition stops on its own. The most common treatments include:

  • Topical calcineurin inhibitor ointments to reduce inflammation.
  • Topical minoxidil. This is a popular hair loss treatment that has been shown to be effective for hair growth when combined with finasteride.
  • Corticosteroids may be injected or applied topically to the scalp to reduce inflammation.
  • Tetracycline antibiotics (e.g. doxycycline or lymecycline) reduce inflammation.
  • Hydroxychloroquine. This is an anti-malarial tablet that reduces itchiness and pain in the early stages in patients with FFA.
  • Mycophenolate mofetil. This is an immunosuppressant that can prevent inflammation around the hair follicles.
  • 5-alpha-reductase inhibitors (such as finasteride and dutasteride). These are anti-androgen medicines that prevent further hair loss.
Frontal fibrosing alopecia
Frontal Fibrosing Alopecia in a 52-year-old woman; before transplant (a), one year after treatment with 85% survival of transplanted grafts (b), and four years after transplant with 50% survival of transplanted grafts and clinical worsening of FFA [10].

Other alternative options include hair transplantation once the condition has been stable for many years, and laser regrowth therapy which may be effective in reducing symptoms in patients with active disease [6]. However, hair transplants may not be suitable for everyone, because there may be reactivation of FFA, and hair transplant grafts may fall out.

Individuals with Frontal Fibrosing Alopecia may be told to be gentle with the skin on their face whilst cleansing and opt for a fragrance-free cleanser. Additionally, it is important to avoid hair-styling tools that generate heat and tight hairstyles (ex. tight ponytails) that can promote hair loss.

Discuss your treatment plan with your hair loss consultant to find out if you’re eligible for a hair transplant at the Wimpole Clinic or to speak about alternative options.

Living with Frontal Fibrosing Alopecia

 Although FFA cannot be cured, people with Frontal Fibrosing Alopecia go on to live very fulfilling lives. It is important to stick with your treatment plan as it can delay the progression of FFA and permanent hair loss. Always speak to your trichologist or doctor before trying natural remedies or if you have any side effects.

If you’re self-conscious about having FFA, hair extensions and wigs are good options, as they boost confidence. You may also want to join a support group for people with alopecia as these groups give added emotional support and may even help spread awareness of the condition with events and programs for Alopecia Awareness Month.

Book a free consultation at the Wimpole Clinic to diagnose your hair loss, and find the right medical therapy to restore your hair.

Frontal Fibrosing Alopecia: Causes, Symptoms & Treatments, Wimpole Clinic

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