Frontal Fibrosing Alopecia: Clinical Presentations, Prognosis and Pharmacist Intervention
When patients search the Internet for “hair loss” or “alopecia,” the top results won’t mention frontal fibrosing alopecia (FFA). There’s a good reason it’s not on these lists—it’s generally considered to be rare. But these resources don’t reflect one important fact: The incidence of FFA is marked by a steady upward trend.
The lack of information about FAA makes it more important for pharmacists to be aware of the condition. Armed with this knowledge, you can facilitate a diagnosis, which means patients can get the one thing that may stop this progressive hair loss—early treatment.
Key Information About Frontal Fibrosing Alopecia
Even though there’s no epidemiological data for FFA, papers published in recent years consistently say its incidence is increasing, reported the Skin Therapy Letter in July 2016.1 As one example, records from the Alan Lyell Centre for Dermatology in Glasgow, U.K., shows that FFA represented 6 percent of all new cases in 2005, 11 percent in 2010, and was up to 28 percent in 2015. Some experts in the field are beginning to use the word “epidemic.”
Speaking at the 2014 meeting of the Pacific Dermatologic Association, Dr. Jerry Shapiro called it a “silent epidemic,” saying that he sees about seven cases daily in his Vancouver office and three to four cases a day in New York.2
FFA is a scarring type of alopecia, generically called cicatricial alopecia, that’s likely a subtype of lichen planopilaris—they share similar histological features and both are associated with autoimmune disease. Hair loss results when lymphocytic infiltrate causes inflammation, leading to scar tissue and the permanent destruction of the hair follicle. Clinical features and patient demographics include:
- About 85 percent of patients with FFA are white, postmenopausal women—remaining patients may be either sex and any ethnicity.3
- The distinctive pattern of hair loss is symmetrical and bilateral along the front hairline, causing a band of alopecia—both terminal and vellus hairs are lost.
- 80 percent of people lose part or all of their eyebrows—sometimes before the hairline recedes.
- Progressive hair loss occurs gradually in most patients.
- Erythema and papules occur in varying degrees along the new hairline.
- Skin in the band of lost hair appears pale, shiny and smooth compared to the normally aged skin on the forehead.
- Involvement of vellus facial hair may cause papules.
- Hair loss from limbs and body may also occur.
Its predominance in postmenopausal women suggests a hormonal cause. However, hormone replacement therapy doesn’t affect the disease and testing of patients with FFA fails to show high levels of androgens or hormonal abnormalities, so this theory hasn’t been substantiated.
Treatment Options for Frontal Fibrosing Alopecia
Dr. Shapiro also suggested that scarring alopecia should be considered a “trichologic emergency.” This sense of urgency comes from the fact that early treatment is the only way to stop progressive and permanent hair loss. Following a skin biopsy to identify the amount of active inflammation and the type of infiltrate, treatment may include:
- Intralesional corticosteroid injections. This is considered first-line treatment, with physicians often using triamcinolone acetonide at higher concentrations for the scalp and lower concentrations when treating eyebrows. Injections given every four to eight weeks produce a response rate of up to 60 percent—they’re only successful prior to scarring.
- Systemic corticosteroids. Prednisone 0.5 to 1 mg/kg daily used for as long as 18 months may halt disease progression, especially when inflammation is present. Unfortunately, relapse is common when therapy is discontinued.
- Antimalarials. Based on the theory that FFA is a variant of lichen planopilaris, which responds to antimalarials, some clinicians may prescribe a six-month regimen of hydroxychloroquine 200 to 400 mg daily or chloroquine diphosphate 250 mg daily.
- Antibiotics. Tetracycline 500 mg or minocycline 100 mg may treat inflammation, but their ability to control FFA is undetermined.
- Topical treatments. Topical corticosteroids to treat inflammation and calcineurin inhibitors or minoxidil to slow hair loss are often considered. Positive results are reported when all three are used together.
- 5-alpha-reductase inhibitor. Even though the hormonal basis hasn’t been proven, treatment with finasteride or dutasteride has been effective. However, some experts question these results, noting that the 5-alpha-reductase inhibitors were combined with other topical and intralesional treatments.
Tips for Pharmacist Outreach
While early treatment is vital, FFA can go undetected for years because the hair loss typically proceeds at a very slow pace. One patient only noticed when a 1/2-inch wide band of skin at her hairline got more sunburned than the rest of her face. Others won’t notice until their hairline recedes by an inch or more. Any delay in diagnosis allows time for scarring to develop and then regrowth is impossible. Pharmacists may be the first member of the community healthcare team to notice, so they shouldn’t hesitate to intervene. Keep an eye out for the following:
- Patients buying over-the-counter (OTC) products. Develop a plan to reach out to patients—especially women—buying OTC hair loss products such as Rogaine. You may develop a brochure about all types of hair loss or a handout about FFA to give patients at the checkout.
- Eyebrow loss. This is one of the key signs of FFA, so it can be used as a way to open communication. Hair loss from the outer third of the eyebrows is common, but some patients may have thinning overall or total loss of eyebrows. Try putting up a poster in the cosmetics section of the pharmacy that simply asks if they’ve noticed thinning eyebrows and how that’s a sign of progressive hair loss, then suggest talking with the pharmacist to prevent balding.
- Patients buying topical OTC skin treatments. Some patients may experience itching or burning as FFA progresses. When older women come to the checkout with skin care products, do a quick visual exam of the skin near their hairline for signs of FFA.
- Normal postmenopausal thinning vs. FFA. Target older women and offer information about the difference between natural hair loss caused by dropping levels of estrogen, which occurs all over the head, versus the distinctive pattern of FFA.
Pharmacist Intervention Facilitates Early Diagnosis
Even when women notice hair loss, they’re liable to shrug it off as a normal part of aging. When pharmacists develop a plan to identify the signs of FFA then proactively reach out, they minimize the risk of progressive balding by counseling about hair loss and encouraging women to consult a physician. Alopecia is so closely tied to self-esteem that the topic may be hard to initiate, but patients will quickly get over any embarrassment they may feel when they realize your intervention—and a subsequent early diagnosis—helps prevent hair loss.
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- “Frontal Fibrosing Alopecia,” July-August 2016, http://www.skintherapyletter.com/2016/21.4/2.html ↩
- “Early Treatment Key to Halting Progression of Cicatricial Alopecia,” September 2014, http://www.practiceupdate.com/content/early-treatment-key-to-halting-progression-of-cicatricial-alopecia/16982 ↩
- “Frontal Fibrosing Alopecia Update,” February 2015, http://www.wjgnet.com/2218-6190/full/v4/i1/33.htm ↩