Frontal Fibrosing Alopecia – Treatment, Symptoms & Causes

Hair loss can be a mentally challenging experience attributed to different causes. It is especially difficult for women, as hair is a precious symbol of beauty for them.

One such cause of hair loss in women is Frontal Fibrosing Alopecia. In this article, we will explore its causes and risk factors, signs & symptoms, assessment and treatment.

What Is Frontal Fibrosing Alopecia?

Frontal Fibrosing Alopecia is hair loss that starts at the front and sides of the scalp and is associated with some skin changes. Unfortunately, once it starts it progressively gets worse and has no cure.

In order to understand this condition, let’s break down the name:

• • Frontal means area on the front of scalp
  • Fibrosing means thickening of the skin
  • Alopecia means hair loss

Frontal Fibrosing Alopecia – Who Is At Risk?

This type of hair loss usually affects women, mostly after menopause. While it commonly occurs in women over 50, it can also affect younger women in their 20s. African women can develop this condition in their 40s too.

Frontal alopecia is considerably less common, but it is increasingly being reported in men of all ages.

Some risk factors putting women at higher chances of getting frontal baldness are as follows:

• Positive family history
• Rosacea (Skin condition)
• Type 2 diabetes
• Thyroid disease

Though the exact cause is unknown, but researchers have speculations about a few causes such as:

• Autoimmune Conditions such as lichen planus; in these conditions, the body immune system starts attacking its own cells.
• Genetics – This condition can run in families.
• Hormones – Hormones may play a role towards this as it usually develops after women hit their menopause.
• Surgery Or Procedures – e.g., hair transplants or facelifts.
• Environmental Triggers – Sun exposure, viral skin infections, sunscreens, pollutants, medications etc.

What Are The Symptoms Of Frontal Fibrosing Alopecia?

Hair loss, the most prominent feature of this condition, starts along the front and sides of the hairline. Gradually, skin involvement becomes noticeable, with changes including:

• Pale
• Thickened
• Shiny
• Hyperpigmentation
• Itchy skin
• Large veins on forehead
• Small bumps near the hairline

Apart from hair loss on the head, other areas may be affected, such as the eyebrows. Some reports show that 80-90% people may experience eyebrow loss when experiencing this condition.

Less commonly hair loss can also occur on the arms, legs, eyelashes, face, underarms or even pubic region.

It can start with subtle signs that, if diagnosed timely, can prevent progression.

• Early Stage: Receding hairline on front with redness and scaling around hair follicles.
• Hair Loss With Inflammation: Prominent hair loss on sides of head with increased redness, itching, burning or abnormal sensations on scalp.
• Scarring: Smooth shiny areas appear as scars on areas of hair loss.
• Latent Stage: No active inflammation or hair loss.

Your doctor, usually a dermatologist, will take a detailed history of your hair loss, including how and when it started, its progression and affected areas. They will also ask about other medical conditions, family history and medications you use.

Apart from this, they will examine your hair loss pattern and skin changes and may take a skin sample for biopsy.

• Local Anesthesia: Numbs the area from where skin samples will be taken to reduce the blood flow and make the procedure pain free.
• Collecting Skin Sample: One or more pieces of adequate size skin are removed from the numb area.
• Microscopy: The skin sample is visualized under the microscope to determine the changes in skin layers and hair follicles, which help to diagnose the condition.

Frontal Fibrosing Alopecia – Diagnostic Criteria

For diagnosis, either 2 major criteria or 1 major with 2 minor criterias are required.

Major Criteria

• • • Hair loss on characteristic sites such as the front and sides of the scalp without keratotic papules on the body.
    • Loss of eyebrow hair with scarring.

Minor Criteria

• • • Redness around hair follicles or single hair seen under microscope.
    • Characteristic histology seen on biopsy;
      • • Sebaceous glands hyperplasia
        • Lichenoid inflammation
        • Hair Loss with scarring
    • Similar signs on other sites of the body.
    • Papules on face without inflammation.
    • Pain or itching at sites involved.

Sadly, there is no cure for this type of hair loss, yet doctors may prescribe you medications to slow its progression. These may include:

1. Antibiotics: They help in reducing infection and inflammation of the skin.
2. Steroids: Usually injected on the scalp or as a cream for a localized effect.
3. Finasteride: Taken as a pill to prevent hair loss caused by hormonal imbalance.
4. Hydroxychloroquine: For reducing itching and pain.
5. Minoxidil: As a topical cream to prevent progression of hair loss.
6. Tacrolimus Or Mycophenolate Mofetil: Immunosuppressive drugs to control inflammation and slow hair loss.

In addition, the psychological trauma of losing hair can be dealt with counselling and cosmetic interventions such as hair transplant, laser therapy, wig, hairpieces, hats or even makeup to cover eyebrows.

Frequently Asked Questions

Why am I losing hair on the sides of my head?

If you’re a postmenopausal woman experiencing hair loss on the sides of your head, you may have frontal fibrosing alopecia. This can lead to receding hairline owing to multiple causes.

Does hair grow back after frontal fibrosing alopecia?

Unfortunately, hair loss due to frontal fibrosing alopecia is permanent and hair does not grow back. There are treatments which can slow down the progression but it can not start new hair growth.

What autoimmune disease causes frontal fibrosing alopecia?

Frontal Fibrosing Alopecia is linked to autoimmune conditions. People with other autoimmune conditions such as lichen planus, rosacea, lupus, thyroid conditions such as Hashimoto thyroiditis, rheumatoid arthritis and diabetes are more likely to develop it.

What can be mistaken for frontal fibrosing alopecia?

Hair loss can be caused by multiple reasons and so it can be difficult to appreciate the exact cause. Therefore, frontal fibrosing alopecia can be mistaken for traction alopecia (due to pulling on the scalp) or hereditary baldness (which is more common in men).