Management of Frontal Fibrosing Alopecia
There is no established consensus or standard treatment regimen for frontal fibrosing alopecia (FFA), but the strongest evidence supports using 5-α-reductase inhibitors and intralesional corticosteroids as first-line therapies, with the primary goal being disease stabilization rather than hair regrowth due to the permanent scarring nature of this condition. 1, 2, 3
Critical Understanding of FFA
FFA is a primary lymphocytic cicatricial (scarring) alopecia considered a clinical variant of lichen planopilaris, characterized by progressive recession of the frontal, temporal, or frontotemporal hairline with frequent eyebrow loss. 1, 2 The disease results in permanent hair loss due to destruction of follicular stem cells and fibrosis, making early intervention critical before irreversible damage occurs. 1, 3
Important caveat: The natural course of FFA is highly variable—hairline recession may stabilize spontaneously regardless of treatment, making it difficult to assess true treatment efficacy in the absence of randomized controlled trials. 3 However, early treatment is still strongly encouraged in active disease because hair loss is presumed permanent and intervention could modify the disease course. 3
Evidence-Based Treatment Algorithm
First-Line Therapies (Highest Level of Evidence)
5-α-Reductase Inhibitors should be considered as a primary treatment option, with 88% (158/180 patients) showing positive response in arresting or slowing hair loss across multiple studies. 3 These agents (finasteride or dutasteride) have the strongest evidence base alongside intralesional steroids. 2, 3
Intralesional Corticosteroids are equally supported as first-line therapy, with 88% (181/204 patients) demonstrating ability to slow or arrest disease progression. 3 This represents the most commonly used therapy with consistently positive treatment responses. 3
Hydroxychloroquine has the third-highest level of evidence and should be considered as part of initial management, particularly when combined with other first-line agents. 2, 4
Second-Line and Adjunctive Therapies
Topical calcineurin inhibitors (tacrolimus, pimecrolimus) have clinical evidence supporting their use and may be added to the regimen. 2, 4
Pioglitazone (a peroxisome proliferator-activated receptor gamma agonist) has been reported as beneficial and can be considered when first-line therapies are insufficient. 2, 4
Oral antibiotics (particularly tetracyclines for anti-inflammatory effects) have variable results but may provide benefit in some patients. 2
Topical corticosteroids can be used as adjunctive therapy, though evidence is less robust than for intralesional formulations. 2, 3
Therapies with Limited or Negative Evidence
Oral prednisone should generally be avoided as it was seldom used and only temporarily delayed rapid hair loss without providing sustained benefit. 3
Minoxidil has variable results and insufficient data to draw definitive conclusions about efficacy in FFA. 2
Systemic retinoids have been evaluated but require further data to establish clear benefit. 2, 4
Practical Clinical Approach
Start with combination therapy using a 5-α-reductase inhibitor (finasteride 1-5 mg daily or dutasteride 0.5 mg daily) plus intralesional triamcinolone acetonide (5-10 mg/mL) injected into the affected hairline every 4-6 weeks. 2, 3 Add hydroxychloroquine (200-400 mg daily) to this regimen for enhanced disease control. 2, 4
Monitor disease activity by assessing symptoms of active inflammation: pruritus, trichodynia (scalp pain), facial papules, and progressive hairline recession. 1 The goal is disease stabilization—stopping further recession—rather than hair regrowth, as the scarring nature of FFA makes regrowth unlikely. 2, 3
If first-line combination therapy fails to stabilize disease after 6-12 months, add topical calcineurin inhibitors or consider pioglitazone. 2, 4
Critical Pitfalls to Avoid
Do not delay treatment while waiting for spontaneous stabilization, as hair loss is permanent and early intervention offers the best chance to preserve remaining hair. 1, 3
Do not rely on oral corticosteroids for long-term management, as they provide only temporary benefit and carry significant systemic side effects. 3
Do not promise hair regrowth to patients—set realistic expectations that treatment aims to stop progression, not reverse existing scarring alopecia. 2, 3
Recognize that no randomized controlled trials exist for FFA treatment, so all recommendations are based on case series and retrospective cohort studies. 1, 2, 3, 5 This means treatment decisions must be individualized based on disease activity, patient tolerance, and response to therapy.
Emerging and Investigational Options
Potential future therapies requiring clinical trial evaluation include: Janus kinase inhibitors, phototherapy, dehydroepiandrosterone, sirolimus, cetirizine, and rituximab. 4 Hair transplantation has been attempted but results are variable and should only be considered after disease has been stable for at least 1-2 years. 2, 3