The Frontal Fibrosing Alopecia Treatment Dilemma

Abstract

Frontal fibrosing alopecia (FFA) is a type of cicatricial alopecia predominantly observed in postmenopausal women, with the incidence rising since its initial description in 1994. The exact etiopathogenesis of the disease has not been completely elucidated. FFA is characterized by an inflammatory process affecting the hair follicles of the fronto-temporal hairline, leading to its gradual recession. Eyebrows, particularly the lateral parts, may also be affected. Early diagnosis and an implementation of effective therapy to limit the inflammatory process are crucial in halting disease progression. Various treatment possibilities have been reported, including anti-inflammatory and immunosuppressive agents, as well as 5-alpha-reductase inhibitors, retinoids, and antimalarial agents. The use of phototherapy and surgical procedures has also been described. However, most available data have been obtained retrospectively, frequently consisting of descriptions of case reports or small case series, and not from randomized controlled trials. In addition, the etiopathogenesis of FFA remains unclear and its course unpredictable, occasionally being linked with spontaneous stabilization. Hence, no precise guidelines exist regarding treatment modalities. Therefore, the aims of this study were to provide a comprehensive review of the efficacy of existing therapeutic modalities for FFA and to highlight novel therapeutic options.

Keywords: FFA; FFA management; FFA treatment; cicatricial alopecia; frontal fibrosing alopecia; frontal hairline recession; inflammatory scalp disease.

Figure 1

FFA; regression of fronto-temporal lines, pale skin in contrast with normal, photoaged skin, lateral eyebrow loss (A,B). Perifollicular hyperkeratosis, perifollicular erythema, and a lack of follicular units (C). Extravasated hemorrhages due to reduced erythema and perifollicular hyperkeratosis as a result of long-term topical corticosteroid use (D).

Figure 2

Clinical patterns of FFA presentation. Type I, “linear pattern”: a band of uniform frontal hairline recession. Type II, “diffuse pattern”: a diffuse or zigzag band-like alopecia of the frontal hairline with loss of hair density behind the hairline. Type III, “pseudo fringe-sign pattern” (original authors’ sketch).