Frontal fibrosing alopecia

Author: Dr Darshan Singh MBChB, Registrar, Department of Dermatology, Waikato Hospital, Hamilton, New Zealand, 2001. Updated by Adjunct A/Prof Amanda Oakley, Dermatologist, Waikato Hospital, Hamilton, New Zealand. May 2018.


What is frontal fibrosing alopecia?

Frontal fibrosing alopecia describes hair loss and scarring in the frontal region of the scalp. It was first described in a group of Australian women in 1994 [1].

Who gets frontal fibrosing alopecia?

Frontal fibrosing alopecia usually affects post-menopausal women over the age of 50. It is uncommon in younger women and in men.

The incidence is reported to be increasing in white-skinned women, and it is uncommon in women with dark skin. One study has reported that the disorder may be more common in women that use facial cosmetics, particularly sunscreens [2].

What is the cause of frontal fibrosing alopecia?

The exact cause of frontal fibrosing alopecia is unknown. It is thought to be due to disturbed immune response to some component of the intermediate-sized and vellus scalp hair follicles. Genetic, hormonal and environmental factors may be involved. The role of cosmetics, sun exposure, and sunscreens has been questioned [2].

Frontal fibrosing alopecia is considered a variant of lichen planopilaris

What are the clinical features of frontal fibrosing alopecia?

Frontal fibrosing alopecia is characterised by usually symmetrical band of hair loss on the front and sides of the scalp, and loss of eyebrows. The edge may appear moth-eaten, and single "lonely" hairs may persist in the bald areas.

The skin in the affected area usually looks normal but may be pale, shiny or mildly scarred, without visible follicular openings. At the margins of the bald areas, close inspection or dermatoscopy shows redness and scaling around hair follicles.

In some cases, there are skin coloured or yellowish follicular papules located on the forehead and temples [3]. Some women with frontal fibrosing alopecia also have female pattern hair loss.

Trichoscopy reveals absent follicles, white dots, tubular perifollicular scale and perifollicular erythema.

Fibrosing alopecia

How is the diagnosis of frontal fibrosing alopecia made?

The clinical features of frontal fibrosing alopecia are characteristic. A skin biopsy examination in the laboratory may help to make or confirm the diagnosis. The newly affected hair follicles are surrounded by a lichenoid pattern of inflammation associated with scarring. The histopathological features are identical to those of lichen planopilaris.

Biopsy of skin papules may show a lichenoid pattern of inflammation, fibrosing alopecia, or sebaceous gland hyperplasia.

What is the outlook for frontal fibrosing alopecia?

Usually frontal fibrosing alopecia is slowly progressive. In a few patients it stabilises after a few years. Hair regrowth has been reported in some patients.

What is the treatment of frontal fibrosing alopecia?

There is no effective treatment available for frontal fibrosing alopecia as yet. A short course of oral steroids, anti-inflammatory antibiotics such as tetracyclines, or antimalarial tablets may benefit patients who have a rapid onset of hair loss. The 5-alpha reductase inhibitors finasteride and dutasteride have been reported to stop further hair loss in some women.

Since 2009, there have been several reports of the use of the antidiabetic agent pioglitazone (off-label) for the treatment of frontal fibrosing alopecia. Its efficacy has varied. In one report, 3 out of 4 treated patients had reduced symptoms, inflammation, and disease progression. Side effects include ankle swelling and weight gain [4].

Sun protective measures include wearing a broad brimmed hat and avoiding exposure to direct sun.

 

Related Information

References

  1. Kossard S. Postmenopausal frontal fibrosing alopecia. Scarring alopecia in a pattern distribution. Arch Dermatol. 1994 Jun;130(6):770-4. Erratum in: Arch Dermatol 1994 Nov;130(11):1407. PubMed PMID: 8002649. Journal.
  2. Aldoori N, Dobson K, Holden CR et al. Frontal fibrosing alopecia: possible association with leave‐on facial skin care products and sunscreens; a questionnaire study. Br J Dermatol 2016; 175:762–67. Journal.
  3. Pirmez, Rodrigo et al. Histopathology of facial papules in frontal fibrosing alopecia and therapeutic response to oral isotretinoin. Journal of the American Academy of Dermatology , Volume 78 , Issue 2 , e45. Journal.
  4. Mesinkovska, Natasha Atanaskova et al. The use of oral pioglitazone in the treatment of lichen planopilaris. J Am Acad Dermatol 2015; 72:355–356

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