What is Frontal Fibrosing Alopecia?
Frontal fibrosing alopecia is a specific type of hair loss, discovered by Kossarden in 1994. This condition generally causes hair loss in a band-like pattern around the forehead and temples. Signs of inflammation around the hair follicles are often observable at the edge of the area where hair loss occurs. This condition can also result in hair loss on the eyebrows, and less commonly, the underarms, pubic area, face, and other places with hair on the body.
If examined under a microscope, it can be seen that there is an infiltration of lymphocytes, a type of white blood cell, around the parts of the hair follicle called the isthmus and infundibulum. This is typically paired with a decrease in the number of hair follicles, which are replaced by scarring tissue. Frontal fibrosing alopecia is a particular type of lichen planopilaris, which usually affects the front area of the scalp in women, more commonly after menopause.
This condition has been recently identified in humans and there have been new reports of this condition occurring among family members. Check out the image of Frontal Fibrosing Alopecia for more illustration.
What Causes Frontal Fibrosing Alopecia?
We’re still not completely sure what causes this disease. However, there have been more and more cases where it runs in families, which means that genes might be involved. Certain environmental elements like pollution in animal-sourced food, medications, exposure to the sun, sunscreens, and viral infections may set off the disease in patients who are already genetically at risk.
Risk Factors and Frequency for Frontal Fibrosing Alopecia
Frontal fibrosing alopecia, a form of hair loss, is becoming more prevalent in Europe, the United States, and Japan. This condition primarily impacts women after they’ve gone through menopause, usually around the age of 60. Nevertheless, it’s not exclusive to postmenopausal women; there have been cases in women before menopause, and even in men, though these are less frequent. It’s interesting to note that men tend to be affected mainly due to genetic reasons. Among African women, if frontal fibrosing alopecia coincides with traction alopecia – another form of hair loss caused by tension on the hair – the disease can worsen. On the other hand, Japanese women typically experience milder forms compared to their European counterparts.
Signs and Symptoms of Frontal Fibrosing Alopecia
Frontal fibrosing alopecia is a hair condition that makes the hairline recede from the forehead. It mostly affects the frontal line of the scalp but can also spread to the areas in front of and behind the ears. Advanced stages of the disease have noticeable differences between the hairless area and the rest of the forehead. The area without hair becomes pale, whereas the rest of the forehead darkens due to sun damage. The hairline looks unusual as all hair follicles disappear, but some solitary hairs might still be seen in the affected areas. During certain stages of the disease, the affected areas might be red or have small bumps.
There are cases where hair loss spreads to the back or side of the head and forms circular patterns. During the active stages of the disease, a test that consists of gently pulling on hair strands might result positively, indicating hair loss even when there’s no visible inflammation. Unlike other hair conditions, itchiness is rare, and discomfort or pain is usually absent. Loss of eyebrows, either partially or entirely, affects the majority of patients with frontal fibrosing alopecia. This can sometimes precede hair loss from the forehead. Apart from the hair on the head and eyebrows, this condition can also affect hair in armpits, the pubic area, limbs, and eyelashes. This makes it similar to the Graham–Little-Piccardi–Lassueur syndrome, which is a combination of different types of hair loss.
Testing for Frontal Fibrosing Alopecia
In someone who has a hair loss condition known as frontal fibrosing alopecia, certain signs can be observed through a skin examination technique known as dermoscopy. These signs include:
* The disappearance of hair follicle openings and minor flaking around the hair follicles
* Notable thickening of the skin around the hair follicles, which is more visible without wetting the skin (immersion)
* Redness around the hair follicles, which can be more easily seen with a type of dermoscopy where the instrument does not touch the skin
* The disappearance of the hair follicle openings, a feature which can be hard to spot [18]
It’s particularly important to examine the hairline at the front of the scalp, especially in the early stages of the condition.
Treatment Options for Frontal Fibrosing Alopecia
Frontal fibrosing alopecia, a type of hair loss, can be challenging to treat effectively. It’s important to approach treatment with caution as this condition can sometimes resolve on its own. Since no established standard exists for measuring treatment success, doctors often evaluate hair loss by counting hairs, taking photos, or measuring the area of hair loss.
The use of strong local corticosteroids, which reduce swelling and the body’s immune response, doesn’t typically stop hair loss in most cases. But there have been some instances where it stabilized the condition, especially when used alongside minoxidil, a medication commonly used for hair growth. Injecting triamcinolone acetonide, a type of corticosteroid, directly into the affected area has shown improvement in around 60% of patients, but there’s a risk it could worsen skin thinning. These injections are more effective on the eyebrows where 80% of the patients reported partial or full regrowth.
Minoxidil alone usually doesn’t work, unless the patient also has a common type of hair loss known as androgenic alopecia. Antimalarial medications like hydroxychloroquine and chloroquine have not been proven effective in many cases either, despite some reports of improvements.
Two drugs that inhibit an enzyme called 5-alpha reductase, finasteride and dutasteride, tend to show the most promising results. For instance, four out of eight patients saw their condition stabilize after taking finasteride and using topical minoxidil for 18 months. One patient also experienced stabilization after using dutasteride and a topical medicine called pimecrolimus. While worthwhile, these treatments can lead to a misleading impression of improvement if the patient also has androgenic alopecia, because they also help with this kind of hair loss.
Other treatments such as topical tacrolimus, oral ciclosporin and mycophenolate mofetil have shown some effectiveness, but they possess high recurrence rates and potential side effects. While some doctors see potential in using ciclosporin for future treatment, there’s no indication that hormone replacement therapy would be beneficial for this condition. Frontal fibrosing alopecia can sometimes stabilize on its own.
A hair transplant could be a viable option for some patients with frontal fibrosing alopecia due to the slow progress of this condition. However, more than half of the transplanted hair disappeared in the first three years for three patients who were monitored in a study. Active disease signs were observed in the remaining grafts. Therefore, doctors might recommend hair grafting to patients whose disease has stabilized, preferring to test the procedure first and monitoring the patient for three years minimum.
What else can Frontal Fibrosing Alopecia be?
Androgenic alopecia, commonly known as male pattern baldness, typically impacts the front edge of the hairline. However, some hair continues to grow in this area. Unlike some other types of hair loss, there’s no scarring or inflammation around the hair follicles. The eyebrows are usually unaffected. If a biopsy is carried out, the results will usually show very small, shrunken hair follicles.
It can sometimes be difficult to tell the difference between the onset of frontal fibrosing alopecia, which affects the eyebrows and the back of the head, and a condition called alopecia areata. In the early phases, there’s no noticeable scarring in either case. However, using a dermoscopy (a type of skin examination) can be useful. It might show distinctive signs of alopecia areata, like hair that’s shaped like an exclamation mark, tiny black or yellow dots, and spiral-shaped hair.
Another condition, chronic lupus erythematosus, may cause a swath of hard, scar tissue to develop at the front of the scalp. But unlike frontal fibrosing alopecia, it doesn’t result in a change in skin color, hardened skin, or a widespread skin inflammation. Some women have a naturally high hairline, which starts at birth and isn’t associated with scarring, inflammation around the hair follicles or changes in their eyebrows. This can help doctors to make the correct diagnosis.
Traction alopecia, which is particularly common in women, involves hair loss as a result of tension or pulling on the hair. The continued presence of hair at the front of the scalp usually suggests this diagnosis. Another strong indicator of traction alopecia is the detection of moving hair follicles along the area affected by tension.
What to expect with Frontal Fibrosing Alopecia
Alopecia is a condition that can result in hair loss, sometimes affecting up to half of the scalp – a condition commonly referred to as ‘crown alopecia’. It’s important to note that the pace at which this disease progresses can differ greatly from one person to the next. Without treatment, hair can fall out at a rate that varies from 0.2 to 2 cm per year or, on average, 0.9 mm per month. The extent of hair loss you might experience before the condition stabilizes varies and can be hard to predict.
Possible Complications When Diagnosed with Frontal Fibrosing Alopecia
Frontal fibrosing alopecia, a condition that leads to hair loss, creates issues that go past just being a cosmetic problem. It can cause significant mental distress due to visible hair loss and possible permanent scarring. In addition, there could be other effects on the face and eyes such as loss of eyebrows, redness around the eyes and a condition in which the eyelid is pulled away from the eyeball called cicatricial ectropion. Some people have even reported hair loss on their beard. Dealing with this condition often requires a team of healthcare professionals including skin specialists (dermatologists), hormone specialists (endocrinologists), and sometimes eye doctors (ophthalmologists) to manage the varying effects of the disease.
Common Symptoms:
- Visible hair loss
- Permanent scarring
- Loss of eyebrows
- Redness around the eyes
- Condition in which the eyelid is pulled away from the eyeball (cicatricial ectropion)
- Beard hair loss
Team of Healthcare Professionals:
- Skin specialists (dermatologists)
- Hormone specialists (endocrinologists)
- Eye doctors (ophthalmologists)
Preventing Frontal Fibrosing Alopecia
Managing Frontal Fibrosing Alopecia, a type of hair loss, can be difficult due to its ongoing progression and the limited treatment options available. Therefore, it’s crucial to make sure that patients fully understand the nature of this condition, which can include possible complications and the treatments that are available. Providing this information can help patients to have a realistic view of the situation and follow their treatment more closely.
A key part of managing this condition is to catch it early, which can help to slow down its progression and prevent any permanent scarring. Patients can also benefit from learning about the things that can make the condition worse, like exposure to the sun or certain skincare products. This information can help patients make choices in their day-to-day life that can lessen the impact of the disease. Doctors may recommend patients to get regular check-ups with a skin doctor (dermatologist) and to get any new hair loss or changes to the hair at the front of their head or eyebrows checked out immediately.
Working together, patients and their doctors can make decisions that help to manage the disease more effectively and improve the patient’s quality of life.
