Frontal Fibrosing Alopecia

What is frontal fibrosing alopecia?

Frontal fibrosing alopecia (FFA) is a condition that leads to hair loss (alopecia) at the front and sides of your scalp. FFA may also affect hair on other parts of your body, most commonly your eyebrows.

Frontal fibrosing alopecia usually worsens over time. Healthcare providers can use treatments to slow frontal fibrosing alopecia. But these treatments won’t restore any hair you’ve already lost.

Who might have frontal fibrosing alopecia?

Frontal fibrosing alopecia usually affects women and people assigned female at birth (AFAB) after menopause, most often after age 50. But women as young as age 21 can have FFA, too. Women of African descent also tend to show symptoms earlier, sometimes in their early 40s. Men, or people assigned male at birth (AMAB), rarely have this condition.

People may be at higher risk of frontal fibrosing alopecia if they have:

• A family member with FFA.
• Rosacea.
• Thyroid disease.
• Type 2 diabetes.

How common is frontal fibrosing alopecia?

Frontal fibrosing alopecia is a somewhat rare condition, but growing numbers of people around the world are getting it.

What causes frontal fibrosing alopecia?

Researchers don’t know the exact cause of frontal fibrosing alopecia. But they suspect:

• Autoimmune disease, when your immune system attacks the openings where your hair grows (hair follicles). FFA may be a type of autoimmune disease (lichen planus) that causes scarring and inflammation of the scalp (lichen planopilaris).
• Genetics, as cases of FFA are sometimes seen in families.
• Hormones, as most people with FFA are post-menopausal.
• Surgeries, such as facelifts or hair transplants.

Researchers also suspect that environmental factors may trigger FFA in people with a family history of the condition (genetic predisposition). These environmental factors may include:

• Exposure to the sun.
• Infections from viruses.
• Medications.
• Pollutants (dioxins) in food made from animals.
• Sunscreens.

What are the symptoms of frontal fibrosing alopecia?

The main symptom of frontal fibrosing alopecia is hair loss along the front and sides of your hairline. This hair loss can start slowly but worsen over time. Your skin in this area may look normal, but can also appear:

• Pale.
• Scarred.
• Shiny.

The other main FFA symptom is eyebrow loss. This symptom may happen before the hair loss on your scalp. Eyebrow loss affects between 80% and 90% of women with FFA.

Other early symptoms of FFA may include:

• Flat, dark brown or gray areas of skin on your face and neck (hyperpigmentation).
• Itchy skin (pruritus) or pain on your scalp.
• Large veins on your forehead.
• Rosacea.
• Small yellow- or skin-colored bumps that look like pimples near your hairline or on your face or scalp.

Less common symptoms of frontal fibrosing alopecia include hair loss from:

• Arms or legs.
• Eyelashes.
• Face.
• Pubic region.
• Underarms.

More rarely, people with white hair may notice a few hairs return to their original color.

How is frontal fibrosing alopecia diagnosed?

Your healthcare provider will ask about your:

• Medical history.
• Medications you take.
• Symptoms, including when you started having hair loss and on what body parts your hair loss occurred.

Your healthcare provider will do a physical examination and take a close look at your:

• Eyebrows.
• Hairline.
• Scalp.

If your healthcare provider suspects FFA, they may do a skin biopsy. During the biopsy, they’ll:

1. Numb a small area of your scalp.
2. Remove a small piece of skin.
3. Examine the skin under a microscope.

Your healthcare provider may also do other tests, including:

• Hair pull test: They’ll gently pull on your hairs to see how many come out.
• Removing a small bump on your face: They’ll examine the bump under a microscope.

These tests can help your provider rule out other conditions such as:

• Hair loss due to pulling or tension on the scalp (traction alopecia).
• Hereditary baldness (androgenic alopecia).

How is frontal fibrosing alopecia treated?

There isn’t a cure for frontal fibrosing alopecia. But treatments can help to slow its progression. Your healthcare provider may suggest a combination of medications, including:

• Antibiotics, such as doxycycline or minocycline, to reduce inflammation.
• Corticosteroids, either injected into your scalp or as a cream to use at home, can help with eyebrow hair loss.
• Finasteride (Propecia®) or dutasteride, taken as a pill to prevent more hair loss.
• Hydroxychloroquine, to reduce symptoms of itchiness and pain. Studies suggest it may also help regrow some hair if taken in early stages.
• Minoxidil, to apply to your scalp. It may help improve hair loss when taken along with another medication, such as finasteride or corticosteroids.

Other treatments may include:

• Hair grafts, which may help with hair growth after FFA progression has slowed.
• Laser therapy, to reduce itchiness and swelling.

How soon after treatment will I see results?

Depending on the treatment, you may start to see a slowing of hair loss in six to 18 months.

How can I reduce my risk of frontal fibrosing alopecia?

You can’t reduce your risk of frontal fibrosing alopecia. But the earlier you begin treatment, the better the chances of slowing the hair loss.

What can I expect if I have frontal fibrosing alopecia?

How quickly FFA develops varies from person to person. Without treatment, your hair loss may worsen over time.

Your hairline may move back on your scalp. You may also develop bald patches or hair loss in a zigzag pattern. But sometimes, hair loss stops on its own without treatment.

What is the outlook if I have frontal fibrosing alopecia?

If you have FFA, treatments usually help slow hair loss over time. But hair you’ve already lost usually doesn’t grow back.

How do I take care of myself with frontal fibrosing alopecia?

Hair loss can be very upsetting. It may affect your mental health and sense of well-being. Talking to close friends or family members or a therapist can help.

You may also want to join a support group for people with FFA. Sharing experiences with others in a similar situation can be a great source of comfort and information.

You should also try to begin treatment for FFA as early as possible. The longer you wait, the more hair loss you may see.

You can also take care of yourself by:

• Avoiding home remedies for hair loss, unless you discuss them with your healthcare provider first.
• Lessening use of heated styling tools such as curling irons and hair dryers to decrease inflammation from heat.
• Talking to your hairdresser about a style that might help hide the hair loss.
• Washing your face with gentle, fragrance-free cleansers to avoid inflammation.
• Wearing accessories such as a hat, headband or wig.

When should I see my healthcare provider?

See your healthcare provider if you have concerns about any side effects from your treatments. They may also be able to offer tips to help lessen the look of the hair loss, including options such as powders.

A note from Cleveland Clinic

Frontal fibrosing alopecia (FFA) is a condition that results in hair loss on the front and sides of your scalp. You may also have hair loss on eyebrows, eyelashes and other parts of your body. FFA mainly affects women after age 50, though men and younger people can also have this condition. Researchers don’t know the exact cause of FFA, but they believe an autoimmune reaction, genetics or hormones may play a role. Healthcare providers diagnose frontal fibrosing alopecia with a physical examination and a skin biopsy. They usually suggest a combination of medications to treat this condition. Although there isn’t a cure for FFA, early treatment can help slow its progress.