What is the initial treatment approach for frontal alopecia?

Initial Treatment Approach for Frontal Alopecia

For frontal fibrosing alopecia (FFA), the initial treatment approach should include 5-α-reductase inhibitors, intralesional corticosteroids, or hydroxychloroquine, as these have the highest level of evidence for disease stabilization. 1

Understanding Frontal Alopecia

Frontal alopecia can refer to different conditions, with frontal fibrosing alopecia (FFA) being the most common specific entity. FFA is a cicatricial (scarring) alopecia characterized by:

• Progressive recession of the frontotemporal hairline
• Band-like pattern of hair loss
• Perifollicular erythema
• Lighter skin in the affected area compared to the forehead
• Frequent loss of eyebrows
• "Lonely hair" sign (isolated terminal hairs within areas of hair loss)

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Clinical examination: Look for band-like recession of frontotemporal hairline, perifollicular erythema, and eyebrow loss 2
• Trichoscopy: Essential for all hair diseases to identify specific patterns 3
• Scalp biopsy: May be necessary in unclear cases, though clinical diagnosis is often sufficient 2

Treatment Algorithm for Frontal Fibrosing Alopecia

First-line options (choose based on patient factors):

1. 5-α-reductase inhibitors:

   • Finasteride (1-2.5mg daily) or dutasteride (0.5mg daily)
   • Highest level of evidence for disease stabilization 1
   • More suitable for postmenopausal women (most common demographic)

2. Intralesional corticosteroids:

   • Triamcinolone acetonide (5-10mg/mL) injected into active inflammatory areas
   • Particularly effective for controlling inflammation and symptoms 4
   • Administer at 4-6 week intervals

3. Hydroxychloroquine:

   • 200-400mg daily
   • May take 6-12 months to show effectiveness 2
   • Monitor for ocular toxicity with regular ophthalmologic exams

Adjunctive treatments:

• Topical treatments:

  • Minoxidil 5% solution/foam (daily application)
  • Topical corticosteroids for symptomatic relief of pruritus
  • Topical calcineurin inhibitors (tacrolimus, pimecrolimus)

• For refractory cases:

  • Methotrexate (15-25mg weekly) 2
  • Systemic retinoids (acitretin)
  • Pioglitazone

Treatment Goals and Expectations

It's crucial to understand that:

• The goal of treatment is disease stabilization rather than hair regrowth due to the scarring nature of FFA 1
• Treatment response should be assessed by:
  • Reduction in perifollicular erythema (marker of active disease)
  • Cessation of progressive hairline recession
  • Improvement in symptoms (pruritus, burning)

Common Pitfalls and Caveats

• Delayed treatment response: Most treatments require 6-12 months before efficacy can be properly assessed
• Spontaneous stabilization: The variable course of FFA can lead to overestimation of treatment effects 2
• Psychological impact: Hair loss significantly impacts quality of life and may cause anxiety and depression 5
• Treatment adherence: Complex regimens may lead to poor compliance; consider simplifying when possible
• Eyebrow restoration: Consider permanent makeup/microblading for eyebrow loss as this rarely responds to medical treatment

Monitoring

• Photographic documentation at baseline and follow-up visits (every 3-6 months)
• Use of validated assessment tools like the Frontal Fibrosing Alopecia Severity Score 2
• Particular attention to perifollicular erythema, which correlates with disease activity 2

Remember that FFA is a chronic condition requiring long-term management and patient education about realistic expectations is essential for treatment success.