What is FFA?
Frontal fibrosing alopecia (FFA) causes loss of hair, predominantly over the frontal area of the scalp (fringe and sideburns) as well as the eyebrows. It was originally described in 1994 but since then the incidence of FFA has increased a hundred-fold. It is thought to be a variant of lichen planus.
Who gets FFA?
FFA usually affects post-menopausal women over the age of 50. It can however occur in both pre-menopausal women (15%) and men (5%).
Why do I have FFA?
The cause of FFA is unknown but several factors have been implicated. Some of these factors include
1. Immune
a. A disturbed immune response to hair follicles
b. It has been postulated that FFA may be an autoimmune disorder due to its association with thyroid disease
2. Hormone
a. It is still uncertain how hormones contribute to FFA but as it occurs predominantly in post- menopausal
women, hormone triggers have been postulated. Oestrogen decline or androgen (male hormone) incline
could be possible factors.
b. Thyroid dysfunction is noted in approximately 10% of patients
c. Many women with FFA have associated age related hair loss (known as female pattern of hair loss).
3. Genetic
a. FFA has been reported in families and a number of genes associations have been identified in research
studies.
4. Environmental
As FFA has only been reported in recent times and due to the increasing incidence, environmental triggers
have been questioned. These include:
a. Sunscreen chemicals (sunscreen/ make up/ hair products, moisturizers, day creams)
b. Fragrances c. Sun exposure- most patients are fair skinned Caucasians and this disorder occurs in sun
exposed scalp
5. Lipid (fat) metabolism
a. A build up of toxic fats in the sebaceous glands associated with hair follicles may cause an inflammatory
response associated with hair loss
What are the symptoms of FFA?
Most patients will have noted a change in
the volume of hair over the frontal hairline, some may notice that their fringe is less thick, others may have
intense burning or itch over the affected area and some will only be alerted to the problem by their
hairdresser, friend or family member.
What does FFA look like?
The typical finding with FFA is a band of hair loss extending from one ear across the frontal hairline to the other ear. The hairline recession may not be uniform and there are often a few stranded (‘lonely’) hairs left in the band of loss. Hair loss can also extend behind the ears and can extend to the nape of the neck. Around the remaining hairs on the hairline, redness or scale may be seen and firm rough bumps may be felt. The skin that is exposed by the hair loss is smooth, shiny, thin and pale. Most patients will have eyebrow loss that can precede the scalp changes by many years. A third of sufferers can have hair loss at other body sites and some patients can have lichen planus affecting other areas of the scalp. Occasionally the face can be involved with small skin-coloured bumps often on the forehead. Rarely small red dots can be found on the area between the eyebrows.
How is FFA diagnosed?
The diagnosis of FFA is usually made by clinical examination. Examination of the affected area with a dermatoscope (a handheld instrument used by a dermatologist) can be helpful too. Occasionally a skin biopsy is needed to assist in making the diagnosis.
How will my FFA be treated?
FFA usually progresses slowly and seems to stabilise over a few years. Unfortunately once the hair has been lost, the stem cells disappear and the hair is unable to regrow. The main aims of treatment are to prevent the hairline from receding further (decrease inflammation) and to help thicken up the remaining hairs to conceal the areas of loss. There is no one treatment that works for every patient. Treatment will also be tailored to address specific areas like the eyebrows and facial bumps.
What else can I do other than medication?
It is advisable to avoid applying sunscreen/ SPF products directly to the anterior hairline as this may aggravate the condition. Sun protection with a wide brimmed hat and direct sun avoidance, is recommended. Once the disorder has settled and been inactive for 1-2 years, surgical intervention can be considered in consultation with our hair transplant surgeon. We also offer the services and consultation in the Sinclair Scalp and Hair Salon to discuss hair styling and camouflage in a non threatening, relaxing and safe environment.
• Decrease inflammation on hairline
— Topical treatments - steroid lotions and ointments as well as tacrolimus ointment can be used
— Cortisone Injections directly into the advancing edge of hair loss can reduce inflammation and slow
progression-
— Tablets Cortisone, Antibiotics, Antimalarials and Anti- inflammatory medications such as cyclosporin and
methotrexate have all been used to treat FFA.
• Increase hair growth
— Minoxidil lotion, foam and tablets as well as stemoxidine ampoules can all improve hair density over the
unaffected scalp.
— Anti-androgens such as spironolactone and dutasteride are also commonly used in FFA to improve the hair
density on the adjacent scalp.