Frontal Fibrosing Alopecia
Frontal fibrosing alopecia is a type of scarring or definitive hair loss, in which an autoimmune inflammatory process occurs, generated by the individual itself that attacks and destroys follicular units irreversibly, causing scarring on the scalp.
The origin of this disease is still unknown, however, to this day it is believed that there is not a single responsible mechanism, but that the inflammatory process that finally destroys follicular units is generated by the combination of a series of factors.
These factors can be grouped into 4 blocks: hormonal factors, genetic factors, autoimmune factors and environmental factors. The fact that the disease appears mainly in women of ages close to menopause (before and after), as well as the use of drugs that have a hormone action mechanism for their treatment justify this hormonal influence as one of the pillars of its origin. The fact that numerous cases have been described with the same type of alopecia affecting members of the same family (especially mothers and daughters) supports certain genetic involvement. The possible association of this disease to other autoimmune diseases such as hypothyroidism, makes us believe that immunity plays a relevant role. Finally, the last hypothesis, the influence of an environmental factor, which could explain the large increase in the number of cases of the disease in recent years.
It has not been possible to definitively clarify which of these environmental factors can trigger the appearance of frontal fibrosing alopecia. There are numerous studies launched in recent years to try to clarify this point, and therefore justify this growing increase in diagnoses.
Some studies have come to controversial conclusions in this regard, such as the potential relationship with the application of sunscreen or anti-ageing creams, but these are not sufficiently conclusive or solid results to be able to take a specific approach in this regard and for the time being it is not enough to recommend the NON-USE of these products. Hopefully, we will be able to shed light on this pillar of causes of frontal fibrosing alopecia in the near future, and our work is focused on developing new projects that study this field.
Once we are able to recognize what this alopecia is like clinically, its symptoms or associated signs, we have shed light on its relevance because of its increasing growth in recent years, and we have talked about the 4 pillars of its origin, it is important to know that it must be diagnosed early and appropriate treatment must be applied.
Clinically, this type of alopecia features a regression in the scalp implantation line, with hair growing further back, leaving an increasingly larger forehead both in the central and lateral areas. The hair grows further forward, as if it were a hairband.
In many cases, the first symptom of this type of hair loss, which precedes, on many occasions, even by years, the hairband progression of the hair line, is the progressive loss of the eyebrows. Other data we frequently detect in these patients is redness in the cheeks, injuries to both temples forming a kind of edging or relief or a more marked depression in the central blood vessels of the forehead.
The starting point for a correct alopecia diagnosis should always be a dermatologist who is an expert in trichology.
Early diagnosis is essential, given that it will affect the progression and the course of hair loss. If the inflammatory process that attacks and destroys hair follicles is controlled, this hair loss and scar formation will be prevented.
In addition to the correct guided medical record and the trichological examination, a trichoscopy must be performed; digitalized trichoscopy is the tool with the greatest diagnostic value at present.
In addition to allowing a more precise diagnosis, it helps to monitor the patient. For frontal fibrosing alopecia, it will provide a count of hair shafts per square centimetre and their average diameter, among others, which objectively demonstrates the patient's initial condition and improvement with the treatments prescribed.
For scarring alopecia, it also allows us to more precisely quantify the degree of inflammation and the process' activity in each area of the scalp. Sometimes, a biopsy may also be needed to establish a definitive diagnosis.
Treatment is based on controlling both mechanisms that cause it, on the one hand the hormone factor and on the other the inflammatory factor. Our goal will be to slow down the progression so that hairband that is making the forehead wider and losing hair will remain stable. We will use drugs from these two groups with topical application (directly in the form of gels or creams on the scalp), mesotherapy (infiltrations on the affected area) or orally. The use of one method or the other and the different combinations of anti-inflammatory drugs and hormone modulators must be individualized for each patient and also according to the progression and activity of the disease. In the same patient, the treatment will be modified as required by the disease's activity, being more aggressive during periods in which signs of more severe inflammatory process are identified.
New advances in knowledge on the causes of frontal fibrosing alopecia are expected in the coming years. With current knowledge it is important that when faced with warning signs, easily recognizable with the clinical signs offered, to consult a dermatologist specialized in trichology to make a correct and early diagnosis, allowing the early start of an individualized treatment that will be modulated according to the disease's progression. In addition, trichoscopic examination will help determine the degree of inflammation at any time and complementary analytical studies will rule out potential associations with other autoimmune diseases.