What is the treatment for frontal fibrosing alopecia?

Treatment of Frontal Fibrosing Alopecia

Intralesional corticosteroid injections are the first-line treatment for frontal fibrosing alopecia, with triamcinolone acetonide showing the highest efficacy for halting disease progression. 1

Understanding Frontal Fibrosing Alopecia (FFA)

Frontal fibrosing alopecia is a primary cicatricial (scarring) alopecia characterized by:

• Progressive recession of the frontotemporal hairline
• Frequent loss of eyebrows (in 81% of patients)
• Perifollicular erythema (73% of patients)
• Perifollicular hyperkeratosis (31% of patients)
• Predominantly affects postmenopausal women
• Can cause symptoms like itching, pain, or burning sensations in 65% of patients

Treatment Algorithm for FFA

First-Line Treatments:

1. Intralesional corticosteroids

   • Medication: Triamcinolone acetonide (5-10 mg/mL)
   • Administration: Injected just beneath the dermis in the upper subcutis
   • Dosage: 0.05-0.1 mL per injection site
   • Efficacy: 97% of patients achieve symptom reduction and hairline stabilization 1
   • Follow-up: 31% of patients may achieve remission lasting 6 months to 6 years

2. 5-α-reductase inhibitors

   • Options: Finasteride (2.5 mg daily) or dutasteride
   • Best for: Patients with concurrent androgenetic alopecia
   • Note: Limited evidence for effectiveness when used alone 2, 3

Second-Line Treatments:

1. Hydroxychloroquine

   • Mechanism: Anti-inflammatory effects
   • Evidence level: Moderate, but less than intralesional steroids 2

2. Topical treatments

   • Topical corticosteroids: Clobetasol propionate 0.05% solution daily
   • Topical calcineurin inhibitors (tacrolimus, pimecrolimus)
   • Topical minoxidil 5%
   • Note: Limited evidence of efficacy when used alone 4, 3

Third-Line/Alternative Treatments:

1. Systemic retinoids

   • Limited evidence of efficacy 4

2. Pioglitazone

   • Emerging treatment with limited data 4

3. Oral antibiotics

   • Limited evidence of efficacy 5

Important Clinical Considerations

• Treatment goals: Disease stabilization rather than hair regrowth due to the scarring nature of FFA 2
• Evidence limitations: No randomized controlled trials evaluating treatment efficacy; knowledge based on small retrospective studies 2, 5
• Disease activity assessment: Before initiating treatment, determine if the disease is active or stable, as 13 of 18 patients in one study presented with stable disease 3
• Treatment duration: Long-term treatment is often necessary as FFA is a chronic condition 4

Common Pitfalls and Caveats

1. Expecting hair regrowth: Due to the scarring nature of FFA, the primary goal is to halt progression rather than regrow hair. Setting realistic expectations with patients is crucial.

2. Delayed treatment: Early intervention with intralesional corticosteroids is key to halting disease progression before permanent scarring occurs 1.

3. Misdiagnosis: FFA can be confused with other forms of alopecia. A skin biopsy may be necessary to confirm diagnosis in unclear cases.

4. Inadequate follow-up: Regular monitoring is essential as FFA can have periods of activity and remission.

5. Ignoring associated conditions: FFA may be associated with autoimmune connective tissue diseases in 14% of patients 1.

6. Treatment abandonment: Patients should be counseled that treatment response may be slow and that continued therapy is often necessary even when improvement is not immediately visible.