What is the recommended diagnostic work‑up and first‑line treatment for frontal fibrosing alopecia in post‑menopausal women?

Frontal Fibrosing Alopecia: Diagnostic Work-up and First-Line Treatment

Clinical Diagnosis

Frontal fibrosing alopecia (FFA) is diagnosed clinically in postmenopausal women presenting with progressive frontotemporal hairline recession appearing as a scarring hairless band, often with eyebrow loss, and confirmation requires scalp biopsy showing perifollicular lymphocytic infiltrate with fibrosis. 1, 2

Key Diagnostic Features to Identify

• Hairline pattern: Progressive frontotemporal recession with a characteristic scarring hairless band, follicular hyperkeratosis, and variable perifollicular erythema 1, 3
• Associated findings: Eyebrow loss occurs in 73% of cases, body hair loss in 25%, and eyelash loss in 3% 3
• Dermoscopy findings: Look for perifollicular erythema and follicular hyperkeratosis indicating active inflammation 4, 3
• Histopathology: Scalp biopsy demonstrates perifollicular lymphocytic infiltrate with fibrosis, confirming the diagnosis 1, 2

Essential Laboratory Work-up

The diagnostic work-up should exclude other causes of hair loss and identify treatable contributing factors:

• Thyroid function: TSH and free T4 to rule out thyroid disease 5
• Nutritional assessment: Serum ferritin (iron stores), vitamin D, and zinc levels 5
• Hormonal evaluation: Consider testosterone and SHBG if signs of androgen excess are present 5

A common pitfall is ordering excessive autoimmune panels, which are not routinely indicated when clinical and histopathologic findings confirm FFA. 5

First-Line Treatment Strategy

The primary goal of FFA treatment is disease stabilization rather than hair regrowth due to the scarring nature of the condition, and the combination of oral 5-α-reductase inhibitors with hydroxychloroquine represents the highest level of evidence for first-line therapy. 6, 4

Recommended Treatment Algorithm

Step 1: Initiate combination systemic therapy

• Oral finasteride (5-α-reductase inhibitor) combined with hydroxychloroquine shows optimal results for disease stabilization 6, 4
• These agents have the highest level of evidence among available FFA treatments 6

Step 2: Add topical anti-inflammatory therapy for active disease

• Superpotent topical corticosteroids should be applied to areas with perifollicular erythema indicating active inflammation 2, 3
• Topical calcineurin inhibitors (tacrolimus) can be used in conjunction with systemic therapy, particularly in early inflammatory stages 4, 2

Step 3: Consider intralesional corticosteroids for localized active areas

• Intralesional triamcinolone acetate may reduce inflammation in areas with active perifollicular erythema 6, 3

Step 4: Add excimer laser for persistent inflammation

• Excimer laser therapy can be beneficial in patients with signs of active inflammation despite other treatments 4

Critical Treatment Principles

• Early intervention is essential: Treatment must begin promptly to prevent definitive scarring and permanent hair loss, as FFA causes irreversible follicular stem cell loss 4, 2
• Realistic expectations: Patients must understand that treatment aims to arrest progression, not restore lost hair, because the scarring nature of FFA causes permanent follicular destruction 6, 4
• Monitor for stabilization: Treatment efficacy is measured by halting hairline recession and reducing perifollicular erythema, not by hair regrowth 6, 2

Address Nutritional Deficiencies Concurrently

• Vitamin D supplementation if levels <20 ng/mL, as deficiency correlates with hair loss severity 7
• Iron/ferritin supplementation when ferritin is low 7
• Zinc supplementation when serum zinc levels are deficient 7

Important Caveats

No randomized controlled trials exist for FFA treatment, so all recommendations are based on retrospective studies and clinical experience. 6, 3

• FFA generally shows poor response to treatment overall, with uncertain efficacy even for the most commonly used therapies 3
• The disease may resolve spontaneously after several years in some cases 2
• Treatment should focus on the early inflammatory phase (frontal effluvium with perifollicular erythema) when immunomodulators are most likely to arrest progression 2
• Avoid biotin supplementation as it interferes with thyroid function test results 7
• Address psychological impact: Hair loss causes significant emotional distress in women, warranting referral for anxiety or depression when present 7