Frontal Fibrosing Alopecia: Everything You Need To Know

Scarring or cicatricial alopecia can cause intense emotional distress. There are different types of scarring alopecia, and the causes of most of them are not well-understood. Frontal fibrosing alopecia (FFA) is one example of this. It can end up making you feel sad and hopeless. The scarring can be a permanent reminder of what you had to endure. 

All in all, this condition can have a significant impact on your overall quality of life. While FFA can be quite challenging and complicated, there are still some things you can do to make the best of your situation. Awareness of this type of hair loss can also help ensure that you get early treatment, which can limit the damaging effects of frontal fibrosing alopecia. 

What Is Frontal Fibrosing Alopecia? 

Frontal fibrosing alopecia (FFA) is a type of patterned scarring alopecia that permanently damages the hair follicle, replacing it with scar tissue. Mainly, it affects the hairline, but it can also occur on the sides and back of the head. According to DermNet NZ, FFA can make the hairline recede by 1.8-2.6 cm on the scalp. But this condition is not just limited to the scalp. It can also cause eyelash and eyebrow hair loss. Additionally, it can cause body hair loss. 

Frontal fibrosing alopecia was first described in 1994 by Australian pathologist Steven Kossard. According to him, it was a type of lichen planopilaris, but it is widely debated as there are differences between the two conditions. Interestingly, the prevalence of this condition has been increasing since the 90s. It is not exactly understood why. Some say that it’s a result of wearing sunscreen, but others strongly argue against it. 

This type of hair loss more commonly affects postmenopausal women around the age of 56. However, it can also occur in premenopausal women and men (usually affects the beard and sideburns) of all ages and ethnicities. Since it progresses quite slowly, it can take a couple of years or more for a person to even notice that they’re experiencing frontal hair loss. 

What Are The Risk Factors For Frontal Fibrosing Alopecia? 

There are certain risk factors that may be responsible for frontal fibrosing alopecia. These are as follows:  

  • Hormone replacement therapy 
  • Autoimmune conditions (lupus and rheumatoid arthritis) 
  • Fragrance allergy 
  • Rosacea 
  • Face soap and moisturisers 
  • Sunscreen 
  • Makeup 
  • Psychological stress 
  • Hair dyes 

Thyroid disorders can also cause it. And that condition itself causes thyroid hair loss.

The presence of titanium dioxide nanoparticles in the formulation of body products (some mentioned above) may cause this type of hair loss.

Frontal fibrosing alopecia has also been found to coexist with other types of alopecia, such as androgenetic alopecia and alopecia areata. However, it cannot be said if one is responsible for the other. 

What Causes Frontal Fibrosing Alopecia? 

The exact cause of frontal fibrosing alopecia isn’t known, but it’s believed to occur due to a combination of genetic, hormonal and environmental factors. Some people who have FFA also have a family history of this condition. It has also been reported in identical twins, which indicates a genetic basis. 

However, the fact that it affects post-menopausal women quite commonly points towards the involvement of hormones. The problem is, according to the NHS, when blood tests are done, there are no abnormalities in the levels of hormones. So, again, it’s not that well-understood. 

And as mentioned above, some environmental factors can also trigger it. But there’s an additional explanation, which is that FFA is an autoimmune condition. That means that the body’s immune cells are targeting the hair follicles on the scalp, destroying them. But why is it the front of the scalp that’s most commonly affected? More research is needed. 

What Are The Symptoms of FFA? 

If you have frontal fibrosing alopecia, it may have the following signs and symptoms: 

  • Progressive hair loss at the front (it moves backwards) 
  • Loss of eyebrow/eyelash hair
  • Body hair loss  
  • Scarring 
  • Pain 
  • Itchiness 
  • Red, scaly skin around the hair follicle
  • Hypopigmentation or hyperpigmentation 
  • Burning sensation on the scalp (trichodynia
  • Skin-coloured papules on the face 
  • Lonely hair signs (isolated terminal hair) 
  • Pale, smooth, & shiny-looking bald areas 

According to a study published in the British Journal of Dermatology, the kind of symptoms that more commonly appear can differ between males and females. It notes that androgenetic alopecia, body hair loss, and facial papules in FFA are more likely to occur in males. Low sex hormones may also be responsible for frontal fibrosing alopecia in males. It is also possible for FFA to be asymptomatic. 

How Is FFA Diagnosed? 

To diagnose frontal fibrosing alopecia, your doctor will begin with a physical exam. The colour of the skin on the scalp may be lighter than that on the forehead. There will also be scarring, while the skin will appear shiny with no visible hair follicles. 

The doctor may also perform a pull test to see how much hair falls out. Most commonly though a biopsy is done. In this, a small piece of skin tissue will be removed from the scalp so it can be closely examined in a lab. This will help rule out other similar types of hair loss and confirm the diagnosis for FFA. 

Does Frontal Fibrosing Alopecia Cause Permanent Hair Loss? 

Unfortunately, hair loss caused by frontal fibrosing alopecia is permanent. Once the scar tissue forms in place of the follicle, no hair growth will take place from there. The rate of hair loss can vary between people, but it usually takes years; it cannot be predicted. Eventually, though, it stops all of a sudden and goes into remission. 

According to a study published in the Mayo Clinic Proceedings, on average, it can take 1.8 years to reach the point of remission. Before that, some treatments can help protect your hair. 

How To Treat Frontal Fibrosing Alopecia? 

Currently, there is no cure for frontal fibrosing alopecia, but it may be possible to manage its symptoms through various medications. Usually, topical steroids are prescribed, but if the target area is small steroids may be injected instead. Other than that, topical Calcineurin Inhibitors (TCIs) are also prescribed for settling down the inflammation resulting from FFA. Orally, the following kind of drugs are usually given: 

  • Antibiotics 
  • Steroids 
  • Hydroxychloroquine
  • Immunosuppressants

Minoxidil and finasteride are also prescribed for hair loss but it needs to be monitored very strictly. However, here, you should know that the success rates of these treatments vary. Some people try a combination of them and they don’t work out. In that case, they simply try to wait it out. In any case, if you have any symptoms of this condition, you should seek treatment as quickly as possible. 

Is Hair Transplant Possible In Frontal Fibrosing Alopecia? 

Frontal fibrosing alopecia patients can undergo hair transplantation. It is only possible after the condition has been in remission for a few years. It is important to know, however, that the success rate of the surgery may be lower than usual.

A review published in the Journal of the American Academy of Dermatology reported 51 patients who had a hair transplant 12 months after FFA stabilised. The graft survival rate was 87% in the first year but dropped to 41% after 5 years. Although still, at the 5-year-mark, 82% of patients were satisfied with their hair transplant.

If you’re planning to have a hair transplant with FFA, make sure to discuss the graft survival rate with your surgeon, along with other risks and complications. If a transplant surgery is not possible, you can consider scalp micropigmentation instead. 

How To Care For Your Hair With Frontal Fibrosing Alopecia? 

FFA itself is very damaging, but you should make sure to not harm your hair in any other way. For that, you can consider doing the following: 

  • Wear loose hairstyles as tight hairstyles can cause traction alopecia which will exacerbate your hair loss. 
  • Do not use heat styling products like curlers, straighteners and dryers excessively. That’s because heat can stimulate inflammation which can worsen your condition. 
  • Be gentle with your hair and discuss with your doctor the kind of hair/skin products that you can use. 

Concluding Remarks 

Frontal fibrosing alopecia is a type of scarring alopecia which is not exactly well-understood. A band-like pattern of hair loss is commonly seen along the scalp’s front. And it can leave permanent scars from which no hair growth will take place. 

To manage its symptoms, it’s important to seek early treatment so that FFA doesn’t cause extensive damage. However, unfortunately, sometimes, even different treatments don’t work. In that case, you can consider wearing a wig, hat, or scarf. A hair tattoo can also camouflage the bald area. And lastly, you can get a hair transplant, but make sure to discuss the success rate of the surgery with your doctor. It can vary between patients.

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