Hair loss types: Frontal fibrosing alopecia diagnosis and treatment

Frontal fibrosing alopecia (FFA) can cause permanent hair loss. If you begin treatment early, you may prevent FFA from progressing, which can help you keep the hair you have. Dermatologists call this "stabilization."

Here’s what’s involved in diagnosing and treating FFA.

How do dermatologists diagnose frontal fibrosing alopecia?

To find out if you have this type of hair loss, your dermatologist will:

• Examine your hairline, scalp, and eyebrows closely

• Ask how long you’ve noticed the hair loss

• Ask about symptoms like itch and pain and whether you have hair loss on any other part of your body

• Talk with you about your health, medical conditions, and medications

If your dermatologist suspects that you have FFA, you may need a scalp biopsy. It’s a procedure that sounds scarier than it is.

Your dermatologist can perform this procedure during an office visit while you remain awake. To perform a scalp biopsy, your dermatologist will numb part of your scalp and remove a small bit of tissue from your scalp. This allows a doctor to look at the tissue under a microscope to see what type (or types) of hair loss you have.

Some people with FFA develop more than one type of hair loss. For example, a woman with FFA may also have female-pattern hair loss. The latter causes thinning of the hair on the scalp. The first sign is often a widened part.

In a study that looked at FFA in Black women, researchers found that many of the patients also had traction alopecia. This is a type of hair loss that develops when the hair is pulled tightly in the same way for a long time. Hairstyling practices like wearing tight braids or a tight ponytail can cause traction alopecia.

All of these types of hair loss can often be diagnosed with a scalp biopsy.

Some people who have FFA develop small, raised spots on their face that look like pimples. If you have these bumps on your face, your dermatologist may remove one. This will also be examined under a microscope. Doing so can help provide you with an accurate diagnosis.

If the exam and biopsy results indicate that you have FFA, your dermatologist will recommend treatment.

How do dermatologists treat frontal fibrosing alopecia?

If you have FFA, treatment can:

• Stop the hair loss from progressing, which can prevent more permanent hair loss

• Relieve symptoms like itch and pain

Your dermatologist will customize the treatment plan to fit your needs. Most treatment plans use a combination of therapies, as this tends to give patients the best outcome.

A treatment plan for FFA may include one or more of the following.

Note: The findings from small studies are shown below. It’s important to keep in mind that the number of people in these studies is small, so more research is needed to confirm these findings.

Finasteride or dutasteride: Studies show that including one of these medications in the treatment plan can prevent further hair loss. In one study, taking either of these medications prevented further hair loss in every patient with FFA. Nearly half of the patients in this study also saw a bit of hair regrowth.

If this medication is part of your treatment plan, you would take one pill every day. To continue getting results, you must continue taking the medication every day.

Before prescribing finasteride or dutasteride, your dermatologist will want to know more about your health and current medications.

Corticosteroids: To reduce the inflammation caused by FFA, your dermatologist may inject this medication into your scalp. For some patients, dermatologists prescribe a corticosteroid that can be applied at home.

FFA can cause loss of eyebrows, as shown here

Some patients have regrown their eyebrows after having injections of corticosteroids.

In one study, 10 out of 11 patients who had lost their eyebrows saw some regrowth after being treated with injections of corticosteroids. A few patients saw regrowth of their eyebrows at three months. Ten of the 11 patients had some regrowth within six months of starting the injections.

All of these patients who had eyebrow loss were also taking other medication to treat their FFA.

Hydroxychloroquine: This medication may reduce symptoms like itch and pain in patients who have FFA. If you have early-stage FFA, this medication may also help regrow some hair.

In studies, the results that people see from taking hydroxychloroquine vary. In one small study of 54 patients taking this medication, the results were as follows:

• 8 patients had some hair regrowth

• 32 patients stabilized, meaning they didn’t lose any more hair

• 12 patients saw their hair loss worsen

Other studies have found similar results. This medication works for some, but not all, patients.

If this medication is part of your treatment plan, you would take a pill once daily.

While this medication helps some people, one possible side effect of taking this medication is hair loss. Other possible effects include nausea, dizziness, vomiting, and loss of appetite.

Laser therapy: This treatment may reduce swelling and itch on the scalp caused by FFA. It’s a newer treatment option, so more studies are needed.

Here’s what happened in one very small study of 13 patients who had FAA. They were treated with an excimer laser twice weekly, and all patients had noticeably less inflammation on their scalp. Ten patients also had hair regrowth. Once the laser therapy stopped, only two patients kept the hair they regrew.

If this is an option, you may go to your dermatologist’s office or a treatment center for laser therapy.

Minoxidil: This is a popular hair loss treatment. It’s available without a prescription as a medication that you apply to your scalp. Some patients receive a prescription for minoxidil pills.

While minoxidil is a popular hair loss treatment, using only minoxidil is unlikely to stop FFA from worsening

When used along with other FFA treatment, minoxidil may improve your overall results.

There have been reports of patients who have FFA seeing results when they take finasteride (described above) daily and apply minoxidil to their scalp twice a day. This combination takes time to work. Of eight patients who followed this treatment plan, half had no further hair loss after following this treatment plan for between 12 and 18 months.

To continue seeing results, you must continue to take a daily pill and apply minoxidil. If you stop, hair loss returns.

Other treatment options: Your treatment plan may include medication or therapy other than those listed above.Treatment varies with your needs and where you have hair loss.

While it has yet to be proven, some studies suggest that your personal care products can affect FFA. For this reason, your dermatologist may recommend certain skin and hair care products.

Is there a frontal fibrosing alopecia diet?

What you eat and drink affects your general health. For this reason, dermatologists have been studying what role diet may have on FFA. To date, these studies have not found that any foods can help stop FFA or regrow hair.

Your dermatologist may also recommend self-care tips. When used along with treatment, self-care can improve your overall results.

To see the self-care tips that dermatologists recommend, go to: Frontal fibrosing alopecia: Self-care.

Images
Image 1: Used with permission of DermNet NZ
Image 2: Getty Images

References
Danesh M, Murase JE. “Increasing utility of finasteride for frontal fibrosing alopecia.” J Am Acad Dermatol. 2015;72(6):e157.

Gamret AC, Potluri VS, et al. “Frontal fibrosing alopecia: Efficacy of treatment modalities.” Int J Womens Health. 2019 Apr 29;11:273-85.

Ho A, Shapiro J. “Medical therapy for frontal fibrosing alopecia: A review and clinical approach.” J Am Acad Dermatol. 2019;81:568-80.

Imhof R, Tolkachjov SN. “Optimal management of frontal fibrosing alopecia: A practical guide.” Clin Cosmet Investig Dermatol. 2020;13:897-910.

Pham CT, Romero K, et al. “The role of diet as an adjuvant treatment in scarring and nonscarring alopecia.” Skin Appendage Disord. 2020;6:88-96.

Sperling LC, Sinclair RD, et al. “Alopecias.” In: Bolognia JL, et al. Dermatology. (fourth edition). Mosby Elsevier, China, 2018: 1178-9.

Strazzulla LC, Avila L, et al. “Prognosis, treatment, and disease outcomes in frontal fibrosing alopecia: A retrospective review of 92 cases.” J Am Acad Dermatol. 2018;78(1):203-5.

Vañó-Galván S, Molina-Ruiz AM, et al. “Frontal fibrosing alopecia: A multicenter review of 355 patients.” J Am Acad Dermatol. 2014;70(4):670-8.

Written by:
Paula Ludmann, MS

Reviewed by:
Shani Francis, MD, MBA, FAAD
William W. Kwan, MD, FAAD

Last updated: 8/3/22

All content solely developed by the American Academy of Dermatology

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