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Frontal fibrosing alopecia

FRONTAL FIBROSING ALOPECIA

What are the aims of this leaflet?

This leaflet has been written to help you understand more about frontal fibrosing alopecia. It tells you what frontal fibrosing alopecia (FFA) is, what causes it, what can be done about it and where you can get more information.

What is frontal fibrosing alopecia?

Frontal fibrosing alopecia is a form of scarring hair loss affecting the hair margin on the front of the scalp. This happens due to inflammation and destruction of the hair follicles. There may also be hair loss from the scalp near the ears and from the eyebrows. Sometimes hair loss can also occur from other parts of the body, but this is less common. FFA occurs mostly in white postmenopausal women but can occur in premenopausal women, men, and people of other ethnicities. Frontal fibrosing alopecia is thought to be a variant of another condition called lichen planopilaris.

What causes frontal fibrosing alopecia?

The cause of frontal fibrosing alopecia is unknown. We know that cells, called lymphocytes, that are part of the body’s immune system attack the hair follicles. It is not understood why it particularly affects the front of the scalp. It is thought that genetics, overactivity of the body’s immune system and, possibly, hormones play a role.

Is frontal fibrosing alopecia hereditary?

Frontal fibrosing alopecia is not an inherited condition, although occasionally it has been reported to affect a number of people in the same family.

What are the symptoms of frontal fibrosing alopecia?

Frontal fibrosing alopecia may cause no symptoms at all or may cause an itchy, painful or burning sensation in a band across the frontal hairline. Many people find the experience of hair loss to be distressing. 

What does frontal fibrosing alopecia look like?

Frontal fibrosing alopecia causes the frontal hairline to progressively recede over time. The rate of hair loss tends to vary from person to person. There can be some redness and flaky skin around individual hairs.  Once a hair has fallen out, it will not re-grow in this area. The skin left behind may appear slightly paler and smoother than the rest of the skin on the forehead. In addition some patients may have loss of hairs from eyebrows and other parts of the body.

How is frontal fibrosing alopecia diagnosed?

A skin biopsy may be performed to confirm the diagnosis. It involves taking a small piece of skin from the scalp under local anaesthetic, which is then examined under a microscope. A small scar is left at the site of the biopsy.

Can frontal fibrosing alopecia be cured?

There are treatments that help to slow down or halt further hair loss in some people. Unfortunately, there is no treatment that cures frontal fibrosing alopecia. Once hair loss that has already taken place it cannot be reversed. Often the condition does become inactive over time.

How can frontal fibrosing alopecia be treated?

There are a number of treatments that are used for frontal fibrosing alopecia. Unfortunately, their success is variable and some people cannot find a treatment that is effective for them.

Treatments include:

  • Topical corticosteroids. Potent steroid gels, lotions or creams applied to the skin on the front of the scalp can be helpful. They may also be used alongside other treatments as they may not slow hair line recession on their own.
  • Topical Tacrolimus. An ointment or cream that acts by suppressing the immune system and calming the inflammation where it is applied.
  • Intralesional steroids. Injections of steroid into the skin on the front of the scalp can be used. This helps to settle the inflammation and slow or halt the progression of hair line recession. This treatment may need to be repeated.
  • Antibiotics e.g. tetracycline, doxycycline. Thesemedicines are chiefly used to help reduce inflammation and not for their antibiotic action. They can help to relieve the symptoms and redness of the scalp.
  • Hydroxychloroquine. This may help frontal fibrosing alopecia become inactive in some people. It will usually require a trial of 4-6 months. It is uncertain how this drug works in this condition. It carries a small risk of damage to your eyesight and annual eye tests are required.
  • Immunomodulatory drugs e.g. mycophenolate mofetil. These can help to dampen down the immune system and prevent the inflammation around the hair follicles. In some people it can slow or halt hair loss.
  • Antiandrogen treatments e.g. oral finasteride and dutasteride. These treatments work by maintaining levels of testosterone (a hormone naturally found in men and women) in the hair follicles. Reduced levels of testosterone have been associated with a different type of hair loss called female/male pattern alopecia. This may occur with frontal fibrosing alopecia also contributing to hair loss. Treatment with antiandrogens may be of benefit where the two conditions occur together.

What if I need a wig?

Some individuals with alopecia will prefer to wear a wig. These can either be bought privately, or obtained through the NHS on a consultant’s prescription (a financial contribution is usually required in England). Your local hospital orthotic (surgical appliances) department will be able to advise you on the range of hairpieces available on the NHS. They can recommend local suppliers who are sensitive to the needs of people with alopecia.

What can I do?

  • You may find that joining a patient support group (see below) and meeting other people with alopecia will make it easier for you to adjust to your condition.
  • A few people with longer hair find hair extensions help camouflage the problem. Some hairdressers become expert at this. It is important to avoid too much tension on any hair when this is done. This is because this could cause hair loss, called traction alopecia.
  • Eyebrow pencils and eyebrow tattoos can help some people with problems in these areas.

Where can I get more information?

Web links to detailed leaflets:

https://bhns.org.uk/

www.dermnetnz.org/hair-nails-sweat/frontal-fibrosing-alopecia.html

www.pcds.org.uk/clinical-guidance/lichen-planus-follicular-lichen-planus

www.alopeciaonline.org.uk

Links to patient support groups:

Alopecia UK
Tel: 0800 101 7025
Web:www.alopecia.org.uk
E-mail: info@alopecia.org.uk

Information about entitlement to free wigs is given in NHS leaflet HC11.

For details of source materials used please contact the Clinical Standards Unit (clinicalstandards@bad.org.uk).

This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists: individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor.

This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel

BRITISH ASSOCIATION OF DERMATOLOGISTS
PATIENT INFORMATION LEAFLET
PRODUCED JULY 2015
UPDATED JULY 2018

REVIEW DATE JULY 2021

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Frontal fibrosing alopecia

Frontal fibrosing alopecia is a form of scarring hair loss affecting the hair margin on the front of the scalp. This happens due to inflammation and destruction of the hair follicles. There may also be hair loss from the scalp near the ears and from the eyebrows. Sometimes hair loss can also occur from other parts of the body, but this is less common. FFA occurs mostly in white postmenopausal women but can occur in premenopausal women, men, and people of other ethnicities. Frontal fibrosing alopecia is thought to be a variant of another condition called lichen planopilaris.

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