How to manage frontal fibrosing alopecia?

Management of Frontal Fibrosing Alopecia

The most effective treatment approach for frontal fibrosing alopecia (FFA) includes 5-α-reductase inhibitors (finasteride or dutasteride) combined with intralesional corticosteroids as first-line therapy, with the goal of disease stabilization rather than hair regrowth due to the scarring nature of the condition. 1

First-Line Treatment Options

5-α-Reductase Inhibitors

• Oral finasteride (2.5 mg/day) or dutasteride (0.5 mg/day) show the highest efficacy rates (88% response rate) 2
• These medications help stabilize disease progression by reducing inflammation
• Treatment duration is typically long-term as discontinuation may lead to disease recurrence
• Important to counsel patients about potential side effects including sexual dysfunction

Intralesional Corticosteroids

• Triamcinolone acetonide (5-10 mg/mL) injected into active inflammatory areas 2
• Injections should be administered just beneath the dermis in the upper subcutis
• Treatment sessions typically every 4-6 weeks
• Most suitable for treating limited areas with active inflammation
• Skin atrophy is a common side effect at injection sites

Second-Line Treatment Options

Hydroxychloroquine

• Oral hydroxychloroquine (200-400 mg daily) may be effective in some patients
• Typically requires 6-12 months to determine efficacy
• Regular ophthalmologic monitoring is required for long-term use

Topical Treatments

• Superpotent topical corticosteroids (e.g., clobetasol 0.05% solution) applied once daily 3
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) may reduce inflammation
• Topical minoxidil 5% can be used as an adjunct therapy, particularly in cases with concurrent androgenetic alopecia

Clinical Patterns and Prognosis

FFA can be classified into three clinical patterns with different prognoses 4:

• Pattern I (Linear): Most common (48.8%), moderate prognosis
• Pattern II (Diffuse): 45% of cases, worst prognosis
• Pattern III (Double line): 6.2% of cases, best prognosis

Treatment Monitoring and Expectations

• Take baseline photographs before starting treatment
• Evaluate treatment response at 3,6, and 12 months with standardized photographs
• Success is defined as stabilization of hair loss rather than regrowth
• Treatment may need to be continued long-term to maintain stabilization
• Counsel patients that complete hair regrowth is unlikely due to the scarring nature of the disease

Important Considerations

• FFA primarily affects postmenopausal Caucasian women (mean age of presentation: 64 years) 5
• Eyebrow loss occurs in approximately 73% of patients and may be the initial presenting symptom 5
• Body hair loss can occur in 25% of cases 5
• The prevalence of FFA appears to be increasing over the past decade 5
• Hair transplantation should be considered only after disease has been stable for at least 1-2 years, with understanding that grafted hairs may still be affected by the disease process

Treatment Algorithm

1. Confirm diagnosis (clinical assessment, dermoscopy, biopsy if needed)
2. Assess disease activity and pattern
3. Start with combination of oral 5-α-reductase inhibitor and intralesional corticosteroids for active areas
4. Add topical treatments (corticosteroids, calcineurin inhibitors) for daily home use
5. Consider hydroxychloroquine if inadequate response after 6 months
6. Monitor every 3 months with clinical photographs
7. Adjust treatment based on disease activity and side effects

The goal of treatment is disease stabilization rather than hair regrowth, and patients should be counseled accordingly about realistic expectations.