Frontal Fibrosing Alopecia (FFA) progresses slowly, which makes early diagnosis of the disease challenging.

A standardized guideline for Frontal Fibrosing Alopecia treatment has yet to be established.

The treatment aims to inhibit the disease’s progression and limit the related side effects.

According to a study published in The Journal of American Academy of Dermatology, 33.3% of women between the ages 61 and 70 suffer from Frontal Fibrosing Alopecia (FFA) with an odds ratio of 3.38.

Most patients in these studies and reports were treated with a combination of therapies.

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

Topical treatments

Topical treatments involve medications that are supposed to be applied to the affected body part.

They are the foundation of dermatological treatment and have many advantages, which include the following:

  • Ease of use
  • Relatively low risk of systemic side effects
  • Application geared toward the patient

Topical Corticosteroids

Topical Corticosteroids often form a part of the first-line therapy for Frontal Fibrosing Alopecia treatment.

In the early stages of FFA, when there is itchiness, topical application of Corticosteroids is often considered a rational approach.

Long-term usage of Corticosteroids may cause adverse side effects, such as skin atrophy and spider veins.

To decrease the risk of these side effects, topical Calcineurin Inhibitors (tCI) have been suggested to be alternated with topical Corticosteroids.

Topical Calcineurin Inhibitors

Topical Calcineurin Inhibitor ointment for frontal fibrosing alopecia treatment
Topical Calcineurin Inhibitors for FFA treatment

A paper by Fertig and Tosti stated topical Calcineurin Inhibitors as their favored combination treatment. 

They have experienced the best outcomes when receiving medical treatment in combination with the following:

  • Topical Calcineurin Inhibitors
  • Oral Finasteride
  • Hydroxychloroquine
  • Excimer laser

Minoxidil

Minoxidil has been used to treat pattern baldness for a long time

It is known to reduce the rate of follicle miniaturization.

Topical Minoxidil as a standalone treatment might not be effective in Frontal Fibrosing Alopecia treatment. 

But it helps increase the hair volume when prescribed as a part of a combination treatment.

Intralesional Corticosteroids

Intralesional Corticosteroids appear as one of the most promising therapies in treating FFA.

The treatment involves injecting the affected area with intralesional Triamcinolone Acetonide (TAC).

A review observed a response rate on both scalp and eyebrows. It included 89% of patients treated with 4-5 injections each month at a concentration of 2.5 mg/mL.

For eyebrows, intralesional TAC 10 mg/mL with 0.125mL per eyebrow has shown to be beneficial with a low risk of atrophy.

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Oral Anti-Inflammatory Agents

Nonsteroidal anti-inflammatory drugs (NSAIDs) work like corticosteroids. 

They block the production of chemicals in the body that causes inflammation.

Some such anti-inflammatory medications are:

Hydroxychloroquine

It is an antimalarial drug with anti-inflammatory properties. 

A study by Ho A and Shapiro demonstrated that individuals with FFA who received Hydroxychloroquine in combination therapy had favorable results.

One of the rare side effects of prolonged use of Hydroxychloroquine includes retinopathy. 

The American Academy of Ophthalmology recommends these patients receive baseline eye examination and annual screening after using the medication for five years.

They also recommend quitting the medication when experiencing vision loss.

Oral Tetracyclines

Oral tetracyclines to treat FFA
Oral Tetracyclines can help in FFA treatment

Due to their anti-inflammatory properties, Tetracycline antibiotics have been used in treating FFA.

These include Doxycycline and Minocycline. 

A retrospective review by Mayo Clinic and another report by Banka et al. stated the efficacy of oral tetracyclines in disease stabilization.

Its side effects might include the following:

  • Nausea
  • Lightheadedness
  • Esophagitis
  • Photosensitivity
  • Skin eruption, and
  • Infection

These adverse side effects might limit their use.

5?-Reductase Inhibitors

The same research by Ho A and Shapiro found 5?-RIs as the most beneficial for Frontal Fibrosing Alopecia treatment. 

Salts such as Finasteride and Dutasteride are the 5?-RIs studied in this research.

They inhibit the conversion of Testosterone into DHT, thereby reducing hair loss.

A trial of 5?-RIs could be considered for patients with early signs of FFA.

It is, however, to note that 5?-RIs are category X drugs.

It means that it can not be prescribed for those pregnant or planning pregnancy.

Peroxisome Proliferator-Activated Receptor ? (PPAR-?) Agonists

PPAR-?, such as Pioglitazone, is conventionally used to manage type 2 diabetes mellitus.

It is also a proposed Lichen Planopilaris (LPP) and Frontal Fibrosing Alopecia treatment.

However, some studies show positive responses of LPP patients towards Pioglitazone; its efficacy for treating FFA still needs to be established.

Systemic Immunosuppressant Agents

Systemic Immunosuppressant Agents to treat FFA
Systemic Immunosuppressant Agents

Immunosuppressants such as Methotrexate and Mycophenolate Mofetil have been tested in FFA patients to show positive results.

However, more studies with a larger sample are needed before establishing any conclusions about the efficacy of the two.

There are some studies evaluating oral Prednisone for treating FFA. Kossard et al. reported slowed hair loss in half the participants with rapidly progressive hair loss.

Ho and Shapiro suggested treating FFA patients with an oral Prednisone dose of 40 mg daily. 

They tapered it down by 5 mg per week for eight weeks. It was also suggested to follow it up with maintenance therapy.

All this was meant for patients with rapid progression of the disorder.

Other Systemic Therapies

Systemic therapies include treatment using substances that reach and affect the cells in the body by traveling along the bloodstream.

Some such examples that have been studied to treat FFA include the following:

Oral Retinoids

Retinoids like oral Isotretinoin have traditionally been used to treat acne.

But oral retinoids have also been used to treat LPP. 

Based on this, systemic retinoids have been proposed to treat FFA patients since FFA is a variant of LPP. 

In a study by Rakowska et al., 76% of the patients treated with Isotretinoin achieved disease stabilization. 

Additionally, 72% did not experience any disease progression.

In another study by Babahosseini and others, systemic retinoids, when given in combination with 

5?-RIs were the most effective treatment option for that study.

Platelet-Rich Plasma (PRP)

Ozcan et al. have reported on using PRP to treat resistant FFA.

But there need to be more well-designed studies to prove the efficacy of PRP for FFA.

Low-level lasers

Light treatments are another option to treat FFA. It could be used alone or as an adjunct therapy.

Note:
As a general suggestion, hair restoration surgery should be attempted after at least 1-2 years of disease stabilization.

Some of the low-level laser treatment options are:

Excimer laser

Excimer laser (UVB 308 nm) has been used to suppress inflammation visible in patients with FFA and/or LPP as:

  • Pruritus
  • Erythema
  • Pain
  • Hyperkeratosis 

In a survey, patients received an average of three different treatments for hair loss. One of the most effective treatments for limiting hair loss was excimer laser light.

But unfortunately, there needs to be more studies to establish the efficacy of this treatment for FFA with certainty.

Light-Emitting Diodes

LED-based photobiomodulation therapy is a rapidly expanding therapeutic method.

It has a wide range of dermatologic indications.

It has recently been suggested as potentially beneficial for scarring Alopecia.

There has been limited evidence regarding the use of this therapy for FFA treatment.

But a pilot study reported a reduction in the symptoms and an improvement in the outcome.

The therapy was considered safe and well-tolerated by most patients.

Extensive studies with larger sample sizes and a control group are required to evaluate the long-term effects of this therapy.

Hair transplantation

Medical treatment for FFA patients can help to stabilize the condition and stop further hair loss. 

But old scar tissue may hinder new hair growth and leave patients with patches of irreversible Alopecia.

In a multicenter review of 51 patients with FFA, the mean graft survival rate dropped from 87% after two years to 41% after five years among those who received hair transplants.

The authors thus concluded that despite high patient satisfaction, the hair transplant results were temporary.

Also, patients need to be carefully monitored post-transplant for relapses. 

Monitoring is essential to protect transplanted hair and prevent disease progression.

Warning
The treatments for FFA work best when taken in combination instead of monotherapy.
You should, therefore, consult your doctor to know the best treatment options for you. 

Takeaway

Frontal fibrosing Alopecia (FFA) is more common than ever.

Its early diagnosis and prompt treatment are essential to avoid chronic scarring and hair loss.

But a variety of treatment options are available to manage this condition.

Literature on treatment modalities majorly consists of cohort studies and case reports.

Their main goal is to lessen inflammation and stop the progression of the disease.

The efficacy of each of the treatments may vary for every individual. 

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