| FRONTAL FIBROSING ALOPECIA |
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 WHAT IS FRONTAL FIBROSING ALOPECIA?
Frontal fibrosing alopecia is a hair disorder in which the hair at the front hairline gradually falls out. Frontal fibrosing alopecia progresses slowly. It often starts with the eyebrows falling out. At some point, it becomes apparent that the hair along the front hairline has fallen out, as a strip of skin appears that is lighter in color and shows no signs of sun damage. Frontal fibrosing alopecia occurs almost exclusively in women and usually only starts from the age of around 50-60, after the menopause. It is considered to be a variant of the hair disease
lichen planopilaris.
WHAT IS THE CAUSE OF FRONTAL FIBROSING ALOPECIA?
The cause is unknown. A hormonal factor is likely to play a role, as it occurs almost exclusively in postmenopausal women (women who have reached an age where they no longer menstruate). There is also an abnormal reaction of the immune system. Cells of the immune system attack the hair follicles for no apparent reason. An inflammatory reaction develops around the hair follicles, damaging them and causing the hair to fall out. This inflammatory reaction ultimately leads to the loss of all hair follicles, leaving only scar tissue. The hair does not grow back.
WHAT ARE THE SYMPTOMS?
In frontal fibrosing alopecia, the hair along the front hairline and at the temples falls out at a slow pace, causing the hairline to gradually recede. This reveals a strip of skin that is lighter in color than the rest of the forehead, with little pigment and no sun damage. This is because this area of skin was always protected from sunlight by the hair. Sometimes there is a single hair left in this area, known as a 'lonely hair'. The eyebrows can also fall out, often starting at the outer edges.
The skin around the hairline may itch or feel burning. Small reddish-brown bumps and flakes may also be seen around the hairs. At a later stage, scarring of the hair follicles occurs. Eventually, completely bald patches develop, in which no hair follicle openings are visible. The speed at which this process occurs varies from person to person, and its course is unpredictable.
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Some women with frontal fibrosing alopecia also have very small skin-colored bumps on the skin of the face, on the forehead, at the temples, or on the cheeks. This is somewhat rarer and is called "facial papules in frontal fibrosing alopecia."
Patients with the related condition
lichen planopilaris sometimes also have abnormalities of the skin, mucous membranes, or nails (lichen planus), but in frontal fibrosing alopecia, abnormalities elsewhere on the body are rarely or never seen.
HOW IS THE DIAGNOSIS MADE?
The diagnosis is made based on the clinical picture, on how it looks. The dermatologist can usually make the diagnosis by carefully examining the skin around the hair follicles with a dermatoscope, a magnifying glass with special lighting. If the picture is not entirely clear, it may be necessary to take a
skin biopsy, in which a small piece of skin is removed under local anesthesia and sent to the pathology laboratory.
HOW CAN FRONTAL FIBROSING ALOPECIA BE TREATED?
Frontal fibrosing alopecia is difficult to treat. Once hair follicles have been lost and scarring has occurred, this is irreversible. Treatments are aimed at preventing or slowing down further hair loss and reducing itching and burning. Frontal fibrosing alopecia is treated with anti-inflammatory drugs. These can be lotions or creams applied to the scalp (local therapy), but they can also be tablets or capsules that must be taken orally (systemic therapy). Local and systemic treatments can also be combined.
Local therapy
Treatment usually starts with local corticosteroid lotions for the scalp, such as Topicorte lotion, Betnelan lotion, Diprosone lotion, Elocon lotion, Locoid scalp lotion, Dermovate lotion, Clarelux foam, or Clobex shampoo. An alternative is tacrolimus ointment or pimecrolimus cream. These products do not contain corticosteroids, but they are slightly less potent and the base is not as suitable for the scalp. There are pharmacies in the Netherlands that can make tacrolimus lotion, but it is not covered by insurance.
Systemic therapy
If local treatment is insufficiently effective, or if there is rapid spread, systemic anti-inflammatory therapy in the form of tablets or capsules can also be used. The drugs most commonly used for frontal fibrosing alopecia are hydroxychloroquine (Plaquenil), methotrexate, and cyclosporine. Sometimes mycophenolate mofetil, acitretin, or anti-inflammatory antibiotics such as doxycycline and minocycline are also used. Prednisone is also effective, but is not suitable for long-term use due to its side effects. Hormone therapy with finasteride or dutasteride is also an option (only for postmenopausal women).
WHAT IS THE OUTLOOK?
Frontal fibrosing alopecia is a difficult-to-treat hair condition with a variable course. Hair loss can be stabilized or slowed down with anti-inflammatory medication. It may also spontaneously subside over time. Unfortunately, it can always return. No new hair growth will return in the areas where scarring has occurred.
WHAT CAN YOU DO YOURSELF?
There is nothing you can do yourself to influence the course of frontal fibrosing alopecia. If large bald patches have developed, one option is to purchase a wig or hairpiece. Whether this is covered by your health insurance depends on your health insurance policy and the package you have taken out. Authorization is often required, which your dermatologist can fill out for you. It is also possible to have a hair transplant performed at a private clinic. These types of transplants are very labor-intensive and therefore expensive (approximately
€ 4.000 - € 8.000 per session), and they are not covered by health insurance.
PATIENT ASSOCIATION
There is a patient association for people with lichen planus:
www.lichenplanus.nl. You can also contact them with questions about frontal fibrosing alopecia.
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