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]. It is a localised form of lichen planopilaris.

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.

What is the cause of frontal fibrosing alopecia?

The exact cause of frontal fibrosing alopecia is unknown. There is a disturbed immune response to some component of the intermediate-sized and vellus scalp hair follicles. Genetic, hormonal and environmental factors may be involved. Contact allergy or photocontact allergy to cosmetics, hair dye, and sunscreens have been suggested as possible causative factors [2,3].

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 a 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 [4]. Some women with frontal fibrosing alopecia also have female pattern hair loss.

Trichoscopy reveals absent follicles, white dots, tubular perifollicular scale and perifollicular erythema. In skin that tans easily, perifollicular pigmentation may be observed.

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 five alpha-reductase inhibitors finasteride and dutasteride have been reported to stop further hair loss in some women but has not been confirmed by controlled studies.

The use of the antidiabetic agent pioglitazone (off-label) for the treatment of frontal fibrosing alopecia was reported to reduce symptoms, inflammation, and progression of frontal fibrosing alopecia [5] but its use has not been supported by further investigations [6]. Side effects include ankle swelling and weight gain. 

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

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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. Kumaran MS, Razmi T M, Vinay K, Parsad D. Clinical, dermoscopic, and trichoscopic analysis of frontal fibrosing alopecia associated with acquired
    dermal macular hyperpigmentation: A cross sectional observational case-control study. J Am Acad Dermatol. 2018 Sep;79(3):588-591. doi: 10.1016/j.jaad.2018.03.001. Epub 2018 Mar 12. PubMed PMID: 29544741.
  4. 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.
  5. Mesinkovska, Natasha Atanaskova et al. The use of oral pioglitazone in the treatment of lichen planopilaris. J Am Acad Dermatol 2015; 72:355–356
  6. Tziotzios C, Brier T, Lee JYW, Saito R, Hsu CK, Bhargava K, Stefanato CM, Fenton DA, McGrath JA. Lichen planus and lichenoid dermatoses: Conventional and emerging therapeutic strategies. J Am Acad Dermatol. 2018 Nov;79(5):807-818. doi: 10.1016/j.jaad.2018.02.013. Review. PubMed PMID: 30318137. PubMed.

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