Frontal fibrosing alopecia

Author: Dr Darshan Singh MBChB, Registrar, Department of Dermatology, Waikato Hospital, Hamilton, New Zealand. Updated in January 2015 by A/Prof Amanda Oakley, Dermatologist, Waikato Hospital, Hamilton, New Zealand.

Frontal fibrosing alopecia describes hair loss and scarring in the frontal region of the scalp.

What are its features?

Frontal fibrosing alopecia usually affects post-menopausal women over the age of 50. It 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 shows redness and scaling around hair follicles.

Some women with frontal fibrosing alopecia also have female pattern hair loss.

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

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. The onset after menopause suggests there may be a hormonal component.

Frontal fibrosing alopecia is considered a variant of lichen planopilaris.

Skin biopsy findings

A skin biopsy examination in the laboratory helps in making 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.

Course and prognosis

Usually frontal fibrosing alopecia is slowly progressive. In a few patients it stabilises after a few years.

Treatment of frontal fibrosing alopecia

There is no effective treatment available 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(1), 3 out of 4 treated patients had reduced symptoms, inflammation, and disease progression. Side effects include ankle swelling and weight gain.

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