WHAT IS FRONTAL FIBROSING ALOPECIA?Frontal fibrosing alopecia is a hair disease in which the hairs along the front hairline gradually fall out. Frontal fibrosing alopecia progresses slowly, often starting with eyebrow loss. Eventually, the hair loss along the front hairline becomes visible as a lighter strip of skin that shows no signs of sun damage. Frontal fibrosing alopecia occurs almost exclusively in women and usually begins around the age of 50 or 60, after menopause. It is considered a variant of the hair disease lichen planopilaris .WHAT CAUSES FRONTAL FIBROSING ALOPECIA?The cause is unknown. Hormonal factors likely play a role, as it occurs almost exclusively in postmenopausal women (women who have reached an age where they no longer have periods). An abnormal immune system response is also involved. Immune cells attack the hair follicles for no apparent reason. An inflammatory reaction develops around the hair follicles, damaging them and causing hair loss. This inflammatory response ultimately destroys all the hair follicles, leaving only scar tissue. The hair does not grow back.WHAT ARE THE PHENOMENA?In frontal fibrosing alopecia, the hairs along the front hairline and at the temples gradually fall out, causing the hairline to shift upward. This creates 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 has always been protected from sunlight by the hair. Sometimes a single hair remains in this area, a condition called "lonely hairs." The eyebrows can also fall out, often starting at the outer edges.
The skin around the hairline may itch or feel like it's burning. Small reddish-brown bumps and flakes may also be visible around the hairs. Scarring of the hair follicles develops later on. Eventually, completely bald patches develop, with no visible follicle openings. The speed at which this process progresses varies from person to person, and the course is unpredictable.
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| frontal fibrosing alopecia |
frontal fibrosing alopecia |
frontal fibrosing alopecia |
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| lonely hairs |
dandruff around hair |
dandruff around hair |
Some women with frontal fibrosing alopecia also have very small, skin-colored bumps on their face, forehead, temples, or 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 with frontal fibrosing alopecia, abnormalities elsewhere on the body are rarely, if ever, seen.HOW IS THE DIAGNOSIS MADE?The diagnosis is based on the clinical picture, i.e., its appearance. 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 image is not entirely clear, a skin biopsy may be necessary . A small piece of skin is then 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 follicle loss with scarring has occurred, it is irreversible. Treatments are aimed at preventing or slowing further hair loss and reducing itching and burning. Frontal fibrosing alopecia is treated with anti-inflammatory medications. These can be lotions or creams applied to the scalp ( topical therapy ), or tablets or capsules taken orally ( systemic therapy ). Topical and systemic treatments can also be combined.
Topical therapy:
Usually, topical 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, are used. Tacrolimus ointment or pimecrolimus cream are alternatives. These products do not contain corticosteroids, but they are somewhat weaker and the base is not as suitable for the scalp. Some pharmacies in the Netherlands can produce tacrolimus lotion, but this is not covered by insurance.
Systemic therapy:
If local treatment is insufficiently effective, or if the condition progresses rapidly, systemic anti-inflammatory therapy (AST) in the form of tablets or capsules can also be used. The most commonly used medications for frontal fibrosing alopecia are hydroxychloroquine (Plaquenil), methotrexate, and cyclosporine. Sometimes also micophenolate mofetil, acitretin, or anti-inflammatory antibiotics such as doxycycline and minocycline are used. Prednisone is also effective, but due to its side effects, it is not suitable for long-term use. Hormonal therapy with finasteride or dutasteride is also an option (only for postmenopausal women).WHAT ARE THE OUTLOOK?Frontal fibrosing alopecia is a difficult-to-treat hair condition with a variable course. The hair loss can be stabilized or slowed with anti-inflammatory medication. It can also subside spontaneously over time. Unfortunately, it can always recur. New hair growth will not occur in the areas where scarring has occurred.WHAT CAN YOU STILL DO YOURSELF?There are no actions you can take to influence the progression of frontal fibrosing alopecia. If large bald patches have developed, purchasing a wig or hairpiece is an option. Whether this is covered depends on your health insurance and the package you have. Authorization is often required, which your dermatologist can complete for you. It is also possible to have a hair transplant performed in 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 ASSOCIATIONThere's a patient association for people with lichen planus: www.lichenplanus.nl . You can also contact them with questions about frontal fibrosing alopecia. |
