Frontal fibrosing alopecia (“scarring alopecia”) is a hair loss condition that affects women aged 45-65. This is a permanent hair loss condition, commonly affecting the frontal hairline. Once this condition has been diagnosed, several treatment modalities are available for patients.
Contents
Overview
- Frontal fibrosing alopecia is a hair loss condition that predominantly affects women aged 45-65. This form of scarring alopecia usually affects postmenopausal women. This condition is different to female pattern hair loss.
- This permanent hair loss condition is caused by several factors, including genetics, hormones, and the environment. Frontal fibrosing alopecia is characterised by hair loss in the temples and hairline, often accompanied by redness, inflammation, and scarring on the skin.
- There is no cure for frontal fibrosing alopecia. However, several treatments can help manage the condition. These include steroids, immunosuppressants, topical hair treatments, and DHT blockers.
What is Frontal Fibrosing Alopecia?
Frontal fibrosing alopecia, or “scarring alopecia”, is a hair loss condition that affects postmenopausal women (aged 50 to 65). Women with this condition will experience hair loss in the hairline and temple regions. Fibrosing alopecia can also cause eyebrow loss, as well.
Scientific research shows frontal fibrosing alopecia is caused by “lichen planopilaris”, a rare autoimmune disease. This condition causes inflammation and scarring in hair follicles, leading to permanent hair loss.
While there’s no cure for frontal fibrosing alopecia, several treatment options are available for people suffering from this condition. Treatments include anti-inflammatory medications (steroids, hydroxychloroquine), 5-alpha reductase inhibitors (finasteride, dutasteride), and hair transplants (FUE, DHI, FUT).
What are the Symptoms of Frontal Fibrosing Alopecia?
Symptoms of frontal fibrosing alopecia can vary from person to person. People with this autoimmune condition usually experience common symptoms, most notably a receding hairline and eyebrow loss.
A receding hairline is when a person experiences hair loss in the temples and frontal area of the hairline. This forms a distinct “m-shape” in the hairline. As this symptom worsens, the recession becomes more pronounced.
Many sufferers of frontal fibrosing alopecia also experience hair loss on the eyebrows and eyelashes. This symptom is usually visible before a person experiences a receding hairline.
Secondary symptoms to watch out for are:
- Redness or inflammation of the hair follicles – this indicates that a person may be experiencing an immune system flare-up.
- Itching or burning sensations in the frontal scalp region – when a person suffers from frontal fibrosing alopecia, their scalp may feel itchy.
- A smooth & shiny scalp in the affected area – this symptom indicates a person may have experienced scarring hair loss, where hair follicles are permanently damaged.
What are the Causes of Frontal Fibrosing Alopecia?
Frontal fibrosing alopecia is believed to be caused by genetic, autoimmune, and environmental factors. Although the exact cause is unclear, these aforementioned factors are likely to play a role in frontal fibrosing alopecia.
The leading explanation for frontal fibrosing alopecia is that the condition is caused by an autoimmune disease called lichen planopilaris [1]. This is where the body’s immune system mistakenly attacks its own hair follicles, leading to inflammation and scarring.
Recent scientific research has identified some genetic factors that may contribute to a person’s susceptibility to developing frontal fibrosing alopecia [2]. This condition appears to have a genetic component as it is common in people with a family history of autoimmune diseases. As such, genetic predisposition to lichen planopilaris or lichen planus pigmentosus may increase your chances of developing frontal fibrosing alopecia.
Of course, hormonal changes may also play an important role in developing frontal fibrosing alopecia. This condition predominantly affects postmenopausal women, which has led researchers to believe that hormonal changes occurring during menopause might play a role in triggering or worsening the disease.
During menopause, oestrogen and progesterone levels decline, affecting how a woman’s hair follicles function. With these hormonal changes, there may be an increase in the relative effect of androgens (male hormones), which can impact hair growth and hair follicle health. Some researchers suspect that these hormonal shifts may make hair follicles more susceptible to immune attack, which is characteristic of frontal fibrosing alopecia [2].
How is Frontal Fibrosing Alopecia Diagnosed?
Frontal fibrosing alopecia is diagnosed by using clinical examination, a medical history, and (if required) a skin biopsy to assess the condition. Traditionally, conditions like frontal fibrosing alopecia are unlikely to be diagnosed by a hair transplant clinic. A dermatologist is usually required to diagnose this condition.
A dermatologist will begin by examining the affected areas of the scalp, particularly the frontal hairline, temples, and other potentially affected areas like the eyebrows and eyelashes. This distinctive pattern of hair loss, characterised by receding hair loss and scarring alopecia, provides strong clues toward a diagnosis.
To confirm the diagnosis, a scalp biopsy is usually performed. This is where a small sample of scalp tissue is removed. This sample is examined under a microscope to detect the typical signs of frontal fibrosing alopecia, such as inflammation around hair follicles, fibrosis (scarring), and reduction or loss of sebaceous (oil) glands, which confirm the diagnosis.
Who is Typically Affected by Frontal Fibrosing Alopecia?
Frontal fibrosing alopecia typically affects post-menopausal women between the ages of 45 and 65. This is primarily due to the hormonal changes induced by the menopause. Rare cases have been recorded in younger women and some men.
Postmenopausal frontal fibrosing alopecia is the most prevalent form of the condition. In women, the condition occurs in a patterned fashion, causing hair loss in the temples and thinning across the frontal hairline.
In men, frontal fibrosing alopecia shows a different pattern distribution. Hair loss in men is usually more varied, often affecting the beard and facial hair. Temple recession in men is usually indicative of a condition called male pattern baldness (androgenic alopecia).
What Treatment Options Are Available for Patients With Frontal Fibrosing Alopecia?
Many treatments are available for patients suffering from frontal fibrosing alopecia. Treatment recommendations depend on several factors, such as: the severity of the condition, the level of scarring on the hairline, the condition of a person’s donor area, and age.
As frontal fibrosing alopecia is associated with autoimmune diseases, medications such as steroids, anti-inflammatories, and immunosuppressants are often prescribed by doctors. These treatments tackle the body’s immune response to autoimmune flare-ups by combating inflammation and dry/itchy skin.
Several hair loss medications would also be suitable for patients suffering from frontal fibrosing alopecia. These include, but are not limited to topical treatments (minoxidil, azelaic acid, etc), DHT-blockers (finasteride, dutasteride, etc), and also hair transplant surgeries.
Minoxidil For Frontal Fibrosing Alopecia
A topical treatment like minoxidil promotes hair growth by providing hair follicles with the nutrients needed to survive. Minoxidil, or “rogaine”, is a vasodilator usually applied as a topical foam. This makes blood vessels expand, allowing hair follicle roots to receive more blood flow.
Patients suffering from frontal fibrosing alopecia would apply minoxidil to their hairline and temples twice a day, massaging the foam until it is fully absorbed by the skin. This ensures the affected hair follicles keep receiving oxygen and nutrients, reducing the chances of further hair loss.
Although clinical research shows minoxidil to be slightly less effective at treating hair loss symptoms than stronger medications, it does have several benefits for patients with FFA. Minoxidil is a suitable treatment for women. You can buy minoxidil over the counter of any supermarket or pharmacy. Finally, it is a relatively cheap treatment, when compared to finasteride, laser therapy, and hair transplants.
DHT Blockers For Frontal Fibrosing Alopecia
One of the most studied hair loss treatments is called 5 alpha-reductase inhibitors. This is the technical term we give to DHT blockers like finasteride and dutasteride. These medications prevent the hair follicle from binding to the hormone DHT, limiting the amount of hair loss.
Although DHT blockers are a powerful and effective treatment, they are not recommended for all patients. Research shows finasteride may not be suitable for use in younger women as it affects fertility. However, the medication is safe for men and postmenopausal women.
If you’re thinking about finasteride as a treatment for postmenopausal frontal fibrosing alopecia, book a free consultation with us, Harley Street Hair Transplant Clinics, to assess your options!
Hair Transplant For Frontal Fibrosing Alopecia
If you’re looking to reverse signs of frontal fibrosing alopecia, then a hair transplant can sometimes be an option. However, eligibility for surgery is dependent on several factors. Hair transplants and scarring alopecia are fraught with difficulty.
The first problem is that frontal fibrosing alopecia is associated with autoimmune diseases. If the condition continues to flare up, this can affect the results of a hair transplant. As such, patients must show that their condition has been under control for a long period.
Scarring hair loss can also reduce the efficacy of a hair transplant. As the skin in the recipient area may be damaged, this can lower the graft uptake rate. If a person’s skin is too scarred, then surgery may be ruled out by a hair transplant surgeon.
The success of a surgical approach varies and depends on the patient, stabilisation of the disease, and management of any remaining inflammation before and after the procedure. Patients considering this option often need to continue using anti-inflammatory treatments, like topical steroids or immunosuppressive agents, to reduce the risk of further follicle damage.
References
- Ramirez-Marin, H. (2022) ‘Examining the Autoimmune aspects of frontal fibrosing alopecia’, Expert Review of Clinical Immunology, 18(11), pp.1091-1094.
- Tziotzios, C. (2019) ‘Genome-wide association study in frontal fibrosing alopecia identifies four susceptibility loci including HLA-B*07:02′, Nature Communications, 10(1150), https://pmc.ncbi.nlm.nih.gov/articles/PMC6408457/ [accessed: 30/10/2024].
- Roman, A. (2024) ‘Frontal Fibrosing Alopecia and Reproductive Health: Assessing the Role of Sex Hormones in Disease Development’, Journal of Personalised Medicine, 14(1), https://pmc.ncbi.nlm.nih.gov/articles/PMC10817300/ [accessed: 30/10/2024].
