Frontal fibrosing alopecia (FFA) is a form of scarring or cicatricial alopecia that mainly affects women. In 83-95% of women, FFA usually begins after menopause between 55-63-years-old . FFA causes permanent hair loss from the frontotemporal or front and sides of your scalp and other body parts, like the eyebrows and eyelashes .
FFA may be caused by genetic, hormonal, immune, and environmental factors, however, the exact cause is unknown . There is no cure for FFA, but there are several treatment options available that can slow the progression of 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.
What is Frontal Fibrosing Alopecia?
Frontal fibrosing alopecia (FFA) is a type of alopecia characterised by a band-like receding hairline . FFA is a special form of a disease called lichen planopilaris – a common type of scarring alopecia. In frontal fibrosing alopecia, scientists believe that inflammatory immune cells 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 .
Immune cells infiltrate and damage the hair follicle bulge and cause the loss of its regenerative potential (HF) .
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 .
What causes Frontal Fibrosing Alopecia?
Even though cases of FFA are on the rise, the exact cause of FFA is still unknown. However, genetic, hormonal, autoimmune, inflammatory, and environmental factors may contribute to FFA development .
Because FFA predominantly affects postmenopausal women, is commonly associated with androgenetic alopecia, and is responsive to 5-alpha-reductase inhibitors (anti-androgens), researchers have suggested that hormones could play a role in FFA . However, FFA happens in people with normal hormonal balances, and hormone replacement therapy does not affect the disease . Early menopause could contribute to the premature development of FFA or increase the risk of developing FFA .
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 .
Similarly, genetic factors may lead to FFA, 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 .
Environmental factors such as facial products, environmental toxins, viral infections, surgery or stress may play a role in developing FFA . 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 might have Frontal Fibrosing Alopecia?
FFA used to be called postmenopausal frontal fibrosing alopecia, because it mainly affects women after menopause . However, some cases have been seen in premenopausal women and also in men . FFA rarely affects men, and when it does, it seems to be due to genetic factors . The average age of onset of diagnosis is 55 years old, and most patients are older than 60 years old when they are diagnosed . Black women often show symptoms earlier, and it is associated with traction alopecia, which is common in this group due to certain hairstyles .
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 front and sides of the hairline . 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 .
Perifollicular erythema and scaling .
Hair loss from eyebvrows 
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 .
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) .
Frontal fibrosing alopecia in a male with loss of sideburns and frontotemporal scarring alopecia with lonely hairs .
There can sometimes be isolated hairs in the affected area and sometimes erythema or perifollicular papules . 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 having hair loss, followed by a medical examination of your eyebrows, hairline, and scalp . Sometimes a skin biopsy is needed, which 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 conditions like traction alopecia or androgenic alopecia.
Treatments 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 FFA treatments, and sometimes, the condition stops on its own. The most common treatments include:
- Topical calcineurin inhibitor ointments reduce inflammation.
- Topical minoxidil is a popular hair loss treatment which has been shown to be effective 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 is an anti-malarial tablet that reduces itchiness and pain in the early stages in patients with FFA.
- Mycophenolate mofetil is an immunosuppressant that can prevent inflammation around the hair follicles.
- 5-alpha-reductase inhibitors (finasteride and dutasteride) are anti-androgen that prevent further hair loss.
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 .
Other alternative options include hair transplantation once the condition has been stable for many years and laser therapy which may be effective in reducing symptoms in patients with active disease . 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 FFA may be told to be gentle with the skin on their face whilst cleansing and opt for a fragrance-free cleanser, and avoid hair-styling tools that generate heat and tight hairstyles 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 FFA 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.
Book a free consultation at the Wimpole Clinic to diagnose your hair loss, and find the right treatment path to restore your hair.
- Frontal Fibrosing Alopecia: A Review
- Frontal Fibrosing Alopecia
- Guidelines for clinical trials of frontal fibrosing alopecia: consensus recommendations from the International FFA Cooperative Group (IFFACG)
- Frontal Fibrosing Alopecia: An Update on Pathogenesis, Diagnosis, and Treatment
- Examining the autoimmune aspects of frontal fibrosing alopecia
- Frontal fibrosing alopecia: a disease that remains enigmatic
- Platelet‐rich plasma for treatment resistant frontal fibrosing alopecia: A case report
- Frontal fibrosing alopecia: A multicenter review of 355 patients
- Frontal fibrosing alopecia among men: A clinicopathologic study of 7 cases.
- Hair transplant in frontal fibrosing alopecia: A multicenter review of 51 patients
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