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Hair loss types: Frontal fibrosing alopecia overview
Frontal fibrosing alopecia
What is frontal fibrosing alopecia?
The medical name for hair loss is “alopecia.” Frontal fibrosing alopecia is a specific type of hair loss. It destroys the hair follicles (openings out of which hair grows), causing permanent hair loss. With an early diagnosis and medical treatment, it’s possible to stop the disease from progressing and causing further permanent hair loss.
Is frontal fibrosing alopecia contagious? No
Frontal fibrosing alopecia (FFA) tends to start slowly, often causing a thin band of balding skin that runs along the front and sides of the hairline.
FFA can also cause hair loss elsewhere on the body. Anywhere you have hair, you may notice hair loss. Many people lose some (or all) of their eyebrows. As the hair loss advances, some people lose pubic hair, underarm hair, or hair on their arms or legs. People with facial hair may notice less hair in their beard area.
FFA usually begins during menopause (have not had a period for at least one year). Most people say they’ve noticed hair loss for about two to 12 years after they start menopause. FFA can also begin earlier in life.
Frontal fibrosing alopecia (early)
This type of hair loss often looks like a receding hairline that runs along the front and sides of your head.
The first noticeable sign of FFA is often noticeable loss of eyebrow hairs. Between 80% and 95% of women diagnosed with FFA have lost some (or all) of their eyebrows.
Without medical treatment, FFA often causes permanent hair loss that covers a larger area with each passing year. That receding hairline which was once barely noticeable can become a bald band that reaches to the middle of the head — or even further back. This hair loss is permanent, so hair cannot regrow once lost.
The good news is that when caught early, medical treatment can stop further hair loss. The earlier someone gets diagnosed with FFA and starts treatment, the more effective treatment tends to be.
As FFA tends to develop slowly, it can be difficult to notice the earliest signs.
It’s also possible for FFA to cause hair loss that comes on rapidly rather than gradually. Some people develop patches of hair loss rather than a receding hairline.
You’ll find more information about the possible signs and symptoms along with pictures of FFA at: Frontal fibrosing alopecia: Signs and symptoms.
Image
Image used with permission of the Journal of the American Academy of Dermatology. (J Am Acad Dermatol 2005;52:55-60.)
References
Brandi N, Starace M, et al. “The doll hairline: A clue for the diagnosis of frontal fibrosing alopecia.” J Am Acad Dermatol. 2017;77(5):e127-8.
Imhof R, Tolkachjov SN. “Optimal management of frontal fibrosing alopecia: A practical guide.” Clin Cosmet Investig Dermatol. 2020;13:897-910.
Mirmirani P, Tosti A, et al. “Frontal fibrosing alopecia: An emerging epidemic.” Skin Appendage Disord 2019;5:90-3.
Tosti A, Piraccini BM, et al. “Frontal fibrosing alopecia in postmenopausal women.” J Am Acad Dermatol. 2005;52:55-60.
Strazzulla LC, Avila L, et al. “Prognosis, treatment, and disease outcomes in frontal fibrosing alopecia: A retrospective review of 92 cases.” [reserch letter] J Am Acad Dermatol. 2018;78:203-4.
Vano-Galvan S, Molina-Riuz AM, et al. “Frontal fibrosing alopecia: A multicenter review of 355 patients.” J Am Acad Dermatol. 2014;70:670–8.
Written by:
Paula Ludmann, MS
Reviewed by:
Shani Francis, MD, MBA, FAAD
Elena B. Hawryluk, MD, PhD, FAAD
Carrie L. Kovarik, MD, FAAD
William W. Kwan, MD, FAAD
Shari Lipner, MD, PhD, FAAD
Last updated: 8/18/21
Hair loss types: Frontal fibrosing alopecia signs and symptoms
Where does frontal fibrosing alopecia develop on the body?
This type of hair loss develops on the scalp, usually beginning as a receding hairline. The receding hairline tends to appear in the front or along the temples.
Along with losing hair on their scalp, some people see less hair on another area of their body. Frontal fibrosing alopecia (FFA) can cause noticeable hair loss anywhere hair grows.
After the scalp, the most common areas for hair loss are:
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Face (eyebrows and beard area most common)
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Arms
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Legs
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Pubic area
What are the signs and symptoms of frontal fibrosing alopecia?
Before you see noticeable hair loss, you may develop symptoms. The following explains what symptoms people may develop and shows what FFA can look like.
Itchy or painful scalp
Before seeing noticeable hair loss, many people who develop FFA remember feeling some discomfort on their scalp. Common early symptoms are itch or pain.
Rash along hairline, face, or scalp
Some people develop a rash before they see noticeable hair loss. This rash of small bumps may be red, skin-colored, or yellow. The bumps often feel scaly.
Loss of eyebrows
Many people who have FFA see noticeable eyebrow loss. You may notice thinner eyebrows or hair loss along the outer edges before you notice a receding hairline. As hair loss on the scalp progresses, some people see complete loss of their eyebrows.
Receding hairline (early)
This 30-year-old woman has noticeable hair loss, which looks like a band of lighter skin, on her forehead and temples. This is a common sign of FFA.
Hair loss spreads
With time, the hair loss grows more noticeable. Most people see the hair loss spread backward, as shown here. FFA can also cause hair loss that appears in a zigzag pattern or as balding patches.
Advanced hair loss
Without treatment, hair loss tends to spread. As FFA advances, the hairline usually moves back on the scalp as shown here.
Small, raised bumps on the face
Along with a receding hairline, some people develop small, raised bumps on their face. The pimple-like spots on this man’s face are due to FFA.
Loss of hair in beard area
While most people who develop this type of hair loss are women, men can develop FFA. In men, signs of FFA include a receding hairline, loss of eyebrows, and the patchy beard growth shown here.
Hair loss on arms, legs, or elsewhere
Aside from causing a receding hairline that tends to spread slowly, FFA can cause permanent hair loss anywhere on the body. This man developed a patch of complete hair loss on his lower arm.
A few white hairs change color
While this is rare, a few patients who have snow-white hair have noticed that some of their former natural hair color returns. This typically only happens to a few hairs, but the effect can be noticeable.
As researchers learn more about FFA, they are discovering that some people have a higher risk of developing this type of hair loss. Find out if you do, by going to: Frontal fibrosing alopecia: Causes.
Images
Images 1, 10: Getty Images
Images 2-9: Journal of the American Academy of Dermatology:
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Image 2: J Am Acad Dermatol 2017;77:683-90.
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Image 3: J Am Acad Dermatol 2005;52:55-60.
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Images 4,5: J Am Acad Dermatol 2014;70:670-8.
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Image 6: J Am Acad Dermatol 2016;75:1081-99.
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Images 7-9: J Am Acad Dermatol 2014;70:670-8.
References
Bernárdez C, Saceda-Corralo D, et al. “Beard loss in men with frontal fibrosing alopecia.” J Am Acad Dermatol. 2021;20:S0190-9622(21)00179-1. [Online ahead of print].
Brandi N, Starace M, et al. “The doll hairline: A clue for the diagnosis of frontal fibrosing alopecia.” J Am Acad Dermatol. 2017;77(5):e127-8.
Gamret AC, Potluri VS, et al. “Frontal fibrosing alopecia: Efficacy of treatment modalities.” Int J Womens Health. 2019 Apr 29;11:273-85.
Heymann WR, “Frontal fibrosing alopecia: Bewitched, bothered, and bewildered.” Dermatol World Insights & Inquires. Published 2/13/2017. Last accessed 4/30/2021.
Lis-Święty A, Brzezińska-Wcisło L. “Frontal fibrosing alopecia: a disease that remains enigmatic.” Postepy Dermatol Alergol. 2020;37(4):482-9.
Ramos PM, Anzai A, et al. “Risk factors for frontal fibrosing alopecia: A case-control study in a multiracial population.” J Am Acad Dermatol. 2021;84(3):712-8.
Strazzulla LC, Avila L, et al. “Prognosis, treatment, and disease outcomes in frontal fibrosing alopecia: A retrospective review of 92 cases.” J Am Acad Dermatol. 2018;78(1):203-5.
Tosti A, Piraccini BM, et al. “Frontal fibrosing alopecia in postmenopausal women.” J Am Acad Dermatol. 2005;52(1):55-60.
Vano-Galvan S, Molina-Riuz AM, et al. “Frontal fibrosing alopecia: A multicenter review of 355 patients.” J Am Acad Dermatol. 2014;70:670–8.
Written by:
Paula Ludmann, MS
Reviewed by:
Shani Francis, MD, MBA, FAAD Elena B. Hawryluk, MD, PhD, FAAD Carrie L. Kovarik, MD, FAAD William W. Kwan, MD, FAAD Shari Lipner, MD, PhD, FAAD
Last updated: 8/18/21
Hair loss types: Frontal fibrosing alopecia diagnosis and treatment
Frontal fibrosing alopecia (FFA) can cause permanent hair loss. If you begin treatment early, you may prevent the hair loss from progressing, which can help you keep the hair you have. Dermatologists call this “stabilization.”
Here’s what’s involved in diagnosing and treating FFA.
How do dermatologists diagnose frontal fibrosing alopecia?
To find out if you have this type of hair loss, your dermatologist will:
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Examine your hairline, scalp, and eyebrows closely
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Ask how long you’ve noticed the hair loss
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Ask about symptoms like itch and pain and whether you have hair loss on any other part of your body
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Talk with you about your health, medical conditions, and medications
If your dermatologist suspects that you have FFA, you may need a scalp biopsy. Your dermatologist can perform this procedure during an office visit while you remain awake. To perform a scalp biopsy, your dermatologist will numb part of your scalp and remove a small bit of skin.
The skin that your dermatologist removes will be examined under a microscope. This microscopic view helps to rule out other types of hair loss like traction alopecia.
Some people who have FFA develop small, raised spots on their face that look like pimples. If you have these bumps on your face, your dermatologist may remove one. This will also be examined under a microscope. Doing so can help provide you with an accurate diagnosis.
If the exam and biopsy results indicate that you have FFA, your dermatologist will recommend treatment.
How do dermatologists treat frontal fibrosing alopecia?
If you have FFA, treatment can:
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Stop the hair loss from progressing, which can prevent more permanent hair loss
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Relieve symptoms like itch and pain
Your dermatologist will customize the treatment plan to fit your needs. Most treatment plans use a combination of therapies, as this tends to give patients the best outcome.
A treatment plan for FFA may include one or more of the following:
Finasteride or dutasteride: Studies show that including one of these medications in the treatment plan can prevent further hair loss. In one study, taking either of these medications prevented further hair loss in every patient with FFA. Nearly half of the patients in this study also saw a bit of hair regrowth.
If this medication is part of your treatment plan, you would take one pill every day. To continue getting results, you must continue taking the medication every day.
Your dermatologist will want to know more about your health and current medications before prescribing finasteride or dutasteride.
Tell your dermatologist if you are pregnant or planning to become pregnant
These medications, finasteride and dutasteride, are not safe to take during pregnancy.
Corticosteroids: To reduce the inflammation caused by FFA, your dermatologist may inject this medication into your scalp. For some patients, dermatologists prescribe a corticosteroid that can be applied at home. Patients apply this medication directly to their scalp.
FFA can cause loss of eyebrows, as shown here
Some patients have regrown their eyebrows after having injections of corticosteroids.
In one study, 10 out of 11 patients who had lost their eyebrows saw some regrowth after being treated with injections of corticosteroids. A few patients saw regrowth of their eyebrows at three months. Ten of the 11 patients had some regrowth within six months of starting the injections.
All of these patients who had eyebrow loss were also taking other medication to treat their FFA.
Hydroxychloroquine: This medication may reduce symptoms like itch and pain in patients who have FFA. If you have early-stage FFA, this medication may also help regrow some hair.
In studies, the results that people see from taking hydroxychloroquine vary. In one study of 54 patients taking this medication, the results were as follows:
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8 patients had some hair regrowth
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32 patients stabilized, meaning they didn’t lose any more hair
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12 patients saw their hair loss worsen
Other studies have found similar results. This medication works for some, but not all, patients.
If this medication is part of your treatment plan, you would take a pill once daily.
While this medication helps some people, one possible side effect of taking this medication is hair loss. Other possible effects include nausea, dizziness, vomiting, and loss of appetite.
Laser therapy: This treatment may reduce swelling and itch on the scalp caused by FFA. It’s a newer treatment option, so more studies are needed. Here’s what happened in one small study of 13 patients who had FAA. They were treated with an excimer laser twice weekly, and all patients had noticeably less inflammation on their scalp. Ten patients also had hair regrowth. Once the laser therapy stopped, only two patients kept the hair they regrew.
If this is an option, you may go to your dermatologist’s office or a treatment center for laser therapy.
Minoxidil: This is a popular hair loss treatment. It’s available without a prescription as a medication that you apply to your scalp. Some patients receive a prescription for minoxidil pills.
While minoxidil is a popular hair loss treatment, using only minoxidil is unlikely to stop FFA from worsening
When used along with other FFA treatment, minoxidil may improve your overall results.
There have been reports of patients who have FFA seeing results when they take finasteride (described above) daily and apply minoxidil to their scalp twice a day. This combination takes time to work. Of eight patients who followed this treatment plan, half had no further hair loss after following this treatment plan for between 12 and 18 months.
To continue seeing results, you must continue to take a daily pill and apply minoxidil. If you stop, hair loss returns.
Other treatment options: Your treatment plan may include medication or therapy other than those listed above. Treatment varies with your needs and where you have hair loss.
While it has yet to be proven, some studies suggest that your personal care products can affect FFA. For this reason, your dermatologist may recommend certain skin and hair care products.
Your dermatologist may also recommend self-care tips. When used along with treatment, self-care can improve your overall results.
To see the self-care tips that dermatologists recommend, go to: Frontal fibrosing alopecia: Self-care.
Images
Image 1: Used with permission of DermNet NZ
Image 2: Getty Images
References
Danesh M, Murase JE. “Increasing utility of finasteride for frontal fibrosing alopecia.” J Am Acad Dermatol. 2015;72(6):e157.
Gamret AC, Potluri VS, et al. “Frontal fibrosing alopecia: Efficacy of treatment modalities.” Int J Womens Health. 2019 Apr 29;11:273-85.
Ho A, Shapiro J. “Medical therapy for frontal fibrosing alopecia: A review and clinical approach.” J Am Acad Dermatol. 2019;81:568-80.
Imhof R, Tolkachjov SN. “Optimal management of frontal fibrosing alopecia: A practical guide.” Clin Cosmet Investig Dermatol. 2020;13:897-910.
Sperling LC, Sinclair RD, et al. “Alopecias.” In: Bolognia JL, et al. Dermatology. (fourth edition). Mosby Elsevier, China, 2018: 1178-9.
Strazzulla LC, Avila L, et al. “Prognosis, treatment, and disease outcomes in frontal fibrosing alopecia: A retrospective review of 92 cases.” J Am Acad Dermatol. 2018;78(1):203-5.
Vañó-Galván S, Molina-Ruiz AM, et al. “Frontal fibrosing alopecia: A multicenter review of 355 patients.” J Am Acad Dermatol. 2014;70(4):670-8.
Written by:
Paula Ludmann, MS
Reviewed by:
Shani Francis, MD, MBA, FAAD
Elena B. Hawryluk, MD, PhD, FAAD
Carrie L. Kovarik, MD, FAAD
William W. Kwan, MD, FAAD
Shari Lipner, MD, PhD, FAAD
Last updated: 8/18/21
Hair loss types: Frontal fibrosing alopecia self-care
Are you seeing the results you want from treatment?
If not, talk with your dermatologist about your skin care routine. Changing products or how your care for your skin may improve your results.
To help their patients who have frontal fibrosing alopecia (FFA) get the best results from treatment, dermatologists recommend following these self-care tips.
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Fill your prescriptions and follow your treatment plan. FFA can cause permanent hair loss. Delaying treatment gives this hair loss time to progress, which can lead to more visible (and permanent) hair loss.
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Talk with your dermatologist before trying a quick fix or home remedy for hair loss. You’ll find plenty of home remedies and products that claim you’ll regrow your hair. Some sites selling these remedies even promise to refund your money if you don’t regrow your hair.
Dermatologists tell their patients to be wary of these products and home remedies, which can sound so appealing. If there really was a quick fix or home remedy for FFA, your dermatologist would share it with you.
Even knowing this, promises of “all-natural” and “money-back guarantee” can sound tempting. Some patients want to try one of these quick fixes before seeing a dermatologist or starting their treatment plan.
If you feel that a hair loss product or home remedy could help, talk with your dermatologist before you try it. -
Speak with your dermatologist if you are concerned about possible side effects from the medication. Dermatologists have plenty of experience treating people with the medications that they prescribe to stop further hair loss. They also understand that some patients may have concerns about taking medication to treat hair loss.
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Understand that treatment takes time to work. It’s natural to want to see results as soon as you start treatment. On average, patients begin to see results about 6 to 18 months after beginning treatment. The sooner you start treatment, the better your outcome.
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Be gentle with your skin. FFA causes inflammation. Where you have hair loss, being very gentle can avoid more inflammation. This means washing your face (and other areas) gently with your fingertips. You want to use a mild, fragrance-free cleanser in these areas.
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Reduce your use of hair-styling tools that generate heat (e.g., blow dryers and curling irons). Heat tends to speed up inflammation in the skin. Reducing your use of heated styling tools may reduce inflammation on your scalp.
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Ask your dermatologist about ways to hide noticeable hair loss. If you want to hide signs of hair loss, tell your dermatologist. A dermatologist can tell you how to camouflage hair loss in a way that gives you a natural look. You may be able to apply a powder to your scalp that hides the hair loss. With the right technique, this can look completely natural. Your dermatologist may also recommend other options for hiding hair loss.
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Consider joining a support group. Is hair loss making you feel sad or less capable? When hair loss takes an emotional toll, talking about it with others who are experiencing hair loss can help.
The Cicatricial Alopecia Research Foundation offers support groups for people who have a scarring type of hair loss like FFA. To find out more about these support groups, go to CARF: Support and meetings.
Image
Getty Images
Reference
Lis-Święty A, Brzezińska-Wcisło L. “Frontal fibrosing alopecia: a disease that remains enigmatic.” Postepy Dermatol Alergol. 2020;37(4):482-9.
Written by:
Paula Ludmann, MS
Reviewed by:
Shani Francis, MD, MBA, FAAD
Elena B. Hawryluk, MD, PhD, FAAD
Carrie L. Kovarik, MD, FAAD
William W. Kwan, MD, FAAD
Shari Lipner, MD, PhD, FAAD
Last updated: 8/18/21