Frontal fibrosing alopecia: a review of 60 cases

Background: Frontal fibrosing alopecia (FFA) is a variant of lichen planopilaris primarily affecting postmenopausal women, with a predilection for the frontotemporal hairline.

Objectives: We sought to examine possible causal associations and review the clinical features, natural history, and response to treatment of patients with FFA attending a specialist hair clinic.

Methods: This was a case note review of 60 patients with FFA.

Results: The number of patients with FFA seen has increased over the last decade. All were Caucasian women, with significantly above-average affluence scores and were less likely to be smokers. The mean age at presentation was 64 years and average disease duration was 3.4 years (range: 6 months-30 years). Three patients were premenopausal. All patients had frontotemporal involvement, with follicular hyperkeratosis, scarring, and variable perifollicular erythema. Several patients had more unusual patterns: 8 had extensive parietal involvement, 4 had occipital involvement, 1 had asymmetric frontal involvement, and 5 had typical FFA associated with diffuse scalp lichen planopilaris. Eyebrow loss was documented in 73%, eyelash loss in 3%, and body hair loss in 25%. Almost all patients had been treated with superpotent topical steroids. Other treatments included topical calcineurin inhibitors; intralesional triamcinolone acetate; phototherapy; hydroxychloroquine; lymecycline; and prednisolone. Although some treatments may reduce inflammation, their efficacy in controlling the progress of the alopecia was uncertain.

Limitations: This is a retrospective review.

Conclusions: FFA is a clinically distinctive condition, the prevalence of which appears to be increasing. It has a generally poor response to treatment. The origin remains uncertain.