Optimal Management of Frontal Fibrosing Alopecia: A Practical Guide

Figures & data

Table 1 FFA Diagnostic Criteria

FFA Diagnostic Criteria: Requires 2 Major Criteria, or 1 Major and 2 Minor Criteria
Major criteria:
1. Cicatricial alopecia of the frontal, temporal, or frontotemporal scalp on examination, in the absence of follicular keratotic papules on the body
2. Diffuse bilateral eyebrow cicatricial alopecia
Minor criteria:
1. Perifollicular erythema, perifollicular hyperkeratosis, or solitary hairs on physical or trichoscopic examination in a field of frontal/frontotemporal cicatricial alopecia
2. Histopathologic features of cicatricial alopecia in the pattern of FFA or LPP on biopsy – Peri-infundibular and peri-isthmal lymphocytic inflammation, interface changes at the infundibular-isthmal epithelium, peri-infundibular and peri-isthmal fibrosis, increased hair in the catagen and telogen phases, and polytrichia.
3. Involvement (hair loss, perifollicular erythema, or perifollicular hyperkeratosis) of additional FFA sites: occipital area, facial hair, sideburns, or body hair
4. Noninflammatory facial papules
5. Preceding or concurrent symptoms, such as pruritus or pain, at areas of involvement

Note: Reproduced from Tolkachjov SN, Chaudhry HM, Imhof RL, Camilleri MJ, Torgerson RR. Reply to: “Updated diagnostic criteria for frontalfibrosing alopecia”. J Am Acad Dermatol. 2018;78(1):e23–e24. Copyright (2018), with permission from Elsevier.¹⁵

Abbreviations: FFA, frontal fibrosing alopecia; LPP, lichen planopilaris.

Figure 1 FFA treatment algorithm.

Notes: *If pre-menopausal may consider HCQ or doxycycline over finasteride and dutasteride. If 5α-RI or oral retinoids are used, effective contraceptive measures are mandatory. Data from Ho A, Shapiro J.²³ The unique side-effect profile, patient characteristics and pregnancy status, and potential for laboratory monitoring should be considered for each medication suggested.

Abbreviations: 5α-RI, 5-α-reductase-inhibitors (dutasteride 0.5 mg/d or finasteride 1–5 mg/d); Doxy, doxycycline (100 mg bid); FFA, frontal fibrosing alopecia; HCQ, hydroxychloroquine (150–400 mg/d); IL-TAC, intralesional triamcinolone acetonide; MMF, mycophenolate mofetil (0.5–1 g bid); MTX, methotrexate (15–25 mg/wk); PRP, platelet-rich plasma; tCS, topical corticosteroids; tCI, topical calcineurin inhibitors.

Table 2 Summary Table of FFA Treatment Options Reported in the Literature

Treatment	Studies Reporting on Outcomes	Dosing (Ranges Reported)	Reported Side Effects/Comments
tCS	^Citation2^–^Citation4,^Citation10,Citation16,Citation25,Citation26,Citation28,Citation29	Applied twice per week – applied daily	Skin atrophy telangiectasia^Citation28,Citation30 follicular pustules, focal purpura^Citation32
IL-TAC	^Citation4,Citation11,Citation16,Citation35,Citation39,Citation40,Citation42	20 mg/mL every 3–6 months; 2.5 mg/mL every 1 month; 0.5–3 mL every 6 −8 weeks; 10 mg/mL with 0.125 mL per eyebrow
tCI	^Citation16,Citation22,Citation26,Citation28,Citation35	Tacrolimus 0.1–0.3% twice daily; pimecrolimus 1% twice daily	Erythema, scaling^Citation26
Topical minoxidil	^Citation5,Citation38,Citation39,Citation53	2–5% twice daily
HCQ	^Citation4,Citation10,Citation16,Citation21,Citation23,Citation32,Citation35,Citation39,^Citation43^–^Citation45	200–400 mg daily	Gastrointestinal upset, headache, myopathy, retinopathy (rare), notably safe in pregnancy^Citation28,Citation30
Oral tetracyclines	^Citation10,Citation11,Citation21,Citation22,Citation44	Doxycycline: 100 mg twice daily; Tetracycline: 500 mg twice daily	Category D during pregnancy, photosensitivity reactions, gastrointestinal symptoms,^Citation19 nausea, esophagitis, lightheadedness, skin eruption, and candida infection^Citation20
5α-RI	^Citation4,Citation10,Citation20,Citation28,Citation29,Citation38,Citation39,Citation42,Citation44,^Citation48^–^Citation53	Finasteride 2.5–5.0 mg daily; dutasteride 0.5 mg weekly, 3 times weekly, or daily	Category X during pregnancy,^Citation21 psychiatric and sexual side effects, potential increase in breast cancer risk^Citation30
Pioglitazone	^Citation10,Citation44,Citation55	15 mg daily	Heart failure, hypoglycemia, edema, upper respiratory tract infection, decreased bone mineral density and fractures^Citation28,Citation30
MTX	^Citation10,Citation44	Not reported	Category X during pregnancy, hepatotoxicity, nephrotoxicity, gastrointestinal disorders, pneumonitis, hematologic disorders, dermatitis and infections^Citation54 * Suggested to be reserved for patients with refractory disease^Citation21
MMF	^Citation2,Citation10,Citation21	Not reported
Oral prednisone	^Citation2	25–50 mg daily	* Suggested to be reserved for patients with rapidly progressive FFA with treatment for one week followed by taper^Citation21
Oral retinoids	^Citation20,Citation26,Citation50,^Citation59^–^Citation61	Isotretinoin: 10 mg every other day-20 mg daily; acitretin: 20 mg daily	Category X during pregnancy, adverse reproductive, neurological, and cutaneous effects^Citation30,Citation58
Naltrexone	^Citation63	3 mg daily
PRP	^Citation70	Not reported
Excimer laser	^Citation35,Citation73	Not reported
LED	^Citation73	Once per week for 10 weeks
Transplantation	^Citation53,^Citation76^–^Citation81	Not applicable	^a suggested that stabilization of disease be a pre-requisite, transplantation may fail over time^Citation30

Notes: ^aThe unique side-effect profile, patient characteristics and pregnancy status, and potential for laboratory monitoring should be considered for each medication suggested.

Abbreviations: 5α-RI, 5-α-reductase-inhibitors; HCQ, hydroxychloroquine; IL-TAC, intralesional triamcinolone acetonide; LED, light-emitting diodes; MMF, mycophenolate mofetil; MTX, methotrexate; PRP, platelet-rich plasma; tCS, topical corticosteroids; tCI, topical calcineurin inhibitors.

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