Frontal Fibrosing Alopecia

Frontal fibrosing alopecia (FFA) is a form of scarring alopecia that affects the hairline on the forehead and temples. This condition is characterized by the progressive loss of hair along with the formation of fibrous tissue, which eventually leads to scarring and permanent hair loss. It is a rare condition that affects mostly postmenopausal women, but it can also affect men and premenopausal women.

Causes

It is characterized by progressive hair loss in the frontal and temporal regions, as well as eyebrows and eyelashes. The exact cause of FFA is unknown, but there are several theories and factors that have been linked to its development.

1. Androgenic factors

Androgens are male hormones that are present in both men and women. High levels of androgens can lead to hair loss, and it has been suggested that androgenic factors may play a role in the development of FFA. This is because FFA is often seen in women with elevated levels of androgens, such as those with polycystic ovary syndrome (PCOS).

2. Genetics

There is evidence to suggest that genetics may play a role in the development of FFA. A family history of FFA has been reported in some cases, and there is a higher prevalence of FFA in certain populations, such as people of Mediterranean descent. This suggests that there may be a genetic predisposition to the condition.

3. Autoimmunity

Autoimmunity is the process by which the body’s immune system attacks its own tissues. In FFA, it is believed that the hair follicles are targeted by the immune system, leading to hair loss. This theory is supported by the fact that FFA is often seen in individuals with other autoimmune diseases, such as lupus.

4. Inflammation

Inflammation has been linked to the development of FFA. Inflammation of the hair follicles can cause scarring and hair loss, and it is believed that this may contribute to the development of FFA. This theory is supported by the fact that topical and oral corticosteroids, which are anti-inflammatory drugs, are often used to treat FFA.

5. Hormonal changes

Hormonal changes, particularly the decrease in estrogen levels that occurs with menopause, have been linked to the development of FFA. Estrogen plays a role in hair growth, and a decrease in estrogen levels can lead to hair loss. This theory is supported by the fact that FFA is primarily seen in post-menopausal women.

6. Environmental factors

Environmental factors, such as exposure to chemicals, radiation, and UV light, have been linked to the development of FFA. These factors can cause inflammation and damage to the hair follicles, leading to scarring and hair loss.

7. Microorganisms

Microorganisms, such as bacteria and fungi, have been linked to the development of FFA. These microorganisms can cause inflammation and infection of the hair follicles, leading to scarring and hair loss.

8. Other factors

There are several other factors that have been linked to the development of FFA, including stress, hormonal imbalances, and nutritional deficiencies. However, the exact role of these factors in the development of FFA is not well understood.

Symptoms

The main symptoms of frontal fibrosing alopecia are:

1. Receding Hairline: One of the most noticeable symptoms of FFA is the receding hairline, which starts from the temples and progresses towards the center of the forehead, forming a distinctive “M” shape.
2. Hair Thinning: In addition to the receding hairline, people with FFA may also experience hair thinning along the hairline, which can make it easier to see the scalp.
3. Bald Patches: Some people with FFA may develop bald patches, which can be circular or oval in shape, and can be located anywhere on the scalp, but typically occur along the hairline.
4. Eyebrow Loss: FFA can also cause hair loss in the eyebrows, which can be noticeable if the eyebrows are thinning or if there are gaps between the hairs.
5. Scalp Inflammation: People with FFA may experience itching, burning, and redness on the scalp, which are symptoms of inflammation. This can be uncomfortable and can make it difficult to wear certain hairstyles.
6. Scalp Sensitivity: Some people with FFA may experience sensitivity or tenderness on the scalp, which can make it uncomfortable to wear certain hairstyles or to touch the scalp.
7. Changes in Hair Texture: People with FFA may notice changes in the texture of their hair, such as hair becoming brittle or wiry.
8. Nail Changes: People with FFA may also experience changes in their nails, such as ridges or discoloration, which can be a sign that the condition is affecting the entire body.
9. Scalp Scarring: In severe cases of FFA, scarring on the scalp may occur, which can make it difficult for new hair to grow in the affected area.
10. Systemic Symptoms: In some cases, people with FFA may experience systemic symptoms, such as fatigue, joint pain, and muscle aches, which can be a sign that the condition is affecting the entire body.

FFA is a progressive condition, which means that it will continue to get worse over time if left untreated. It is important to seek treatment as soon as possible to slow the progression of the condition and to prevent permanent hair loss.

Diagnosis

Diagnosis of FFA is based on a combination of clinical examination, patient history, and laboratory tests. The following is a list of the main diagnostic tests and procedures used to diagnose FFA:

1. Clinical Examination: A physical examination of the scalp is the first step in the diagnosis of FFA. The doctor will look for signs of hair loss, scarring, and inflammation in the frontal hairline. The skin may appear shiny, smooth, and tight, and there may be a visible loss of eyebrows and eyelashes.
2. Trichoscopy: Trichoscopy is a non-invasive diagnostic technique that uses a special device called a dermatoscope to examine the scalp. The dermatoscope provides a magnified view of the hair and scalp, allowing the doctor to see any changes in the hair follicles, such as miniaturization, inflammation, and scarring.
3. Biopsy: A biopsy is the removal of a small sample of skin for examination under a microscope. This test is used to confirm the diagnosis of FFA and to rule out other conditions that may cause hair loss, such as scarring alopecia, lupus, or lichen planopilaris.
4. Blood Tests: Blood tests may be performed to rule out other autoimmune conditions that may cause hair loss, such as lupus, thyroid disease, and iron-deficiency anemia.
5. Skin Culture: A skin culture may be performed to rule out fungal infections, such as tinea capitis, which can cause hair loss.

The following is a list of the most common laboratory tests used in the diagnosis of FFA:

1. Complete Blood Count (CBC): A CBC measures the number of red and white blood cells, as well as the number of platelets in the blood.
2. Erythrocyte Sedimentation Rate (ESR): The ESR is a test that measures the speed at which red blood cells settle to the bottom of a tube. An elevated ESR may indicate inflammation in the body.
3. C-Reactive Protein (CRP): CRP is a protein that is produced in response to inflammation. An elevated CRP level may indicate an underlying autoimmune condition.
4. Antinuclear Antibody (ANA) Test: The ANA test is used to detect the presence of antibodies that attack the body’s own tissues. A positive result may indicate an autoimmune condition, such as lupus.
5. Anti-dsDNA Antibody Test: The anti-dsDNA antibody test is used to diagnose lupus. A positive result may indicate the presence of autoantibodies that attack the body’s own DNA.
6. Antiphospholipid Antibody Test: The antiphospholipid antibody test is used to diagnose antiphospholipid syndrome, an autoimmune condition that causes blood clots.
7. Thyroid Function Tests: Thyroid function tests are used to assess the function of the thyroid gland, which regulates the body’s metabolism. An underactive thyroid gland (hypothyroidism) may cause hair loss.

In conclusion, the diagnosis of FFA requires a combination of clinical examination, patient history, and laboratory tests. The main diagnostic tests and procedures include a physical examination, trichoscopy, biopsy, blood tests,

Treatment

There are various treatments available for FFA, but none of them are considered to be a cure. The goal of treatment is to slow the progression of hair loss and improve the appearance of the affected area. Here are the main lists of treatments for FFA:

1. Topical Minoxidil

Minoxidil is a topical solution that is applied to the scalp. It is thought to stimulate hair growth by increasing blood flow to the hair follicles. Minoxidil is considered to be the most effective treatment for FFA, as it can slow down the progression of hair loss and improve the appearance of the affected area. Minoxidil is applied twice daily and it can take several months to see the results.

2. Topical Corticosteroids

Topical corticosteroids are often used to treat FFA, as they can reduce inflammation and prevent the destruction of hair follicles. Corticosteroids are applied directly to the scalp and can be used in combination with other treatments, such as minoxidil. Corticosteroids are often prescribed in low doses and are used for a short period of time.

3. Systemic Corticosteroids

Systemic corticosteroids are taken orally and work by reducing inflammation throughout the body. This type of treatment is usually used in severe cases of FFA, as it can have significant side effects. Systemic corticosteroids can be used for a short period of time, and are often prescribed in conjunction with other treatments.

4. Immunosuppressive Drugs

Immunosuppressive drugs are used to suppress the immune system, which is thought to play a role in the development of FFA. These drugs are used in severe cases of FFA, as they can have significant side effects. Some of the most commonly used immunosuppressive drugs for FFA include methotrexate, azathioprine, and cyclosporine.

5. Light Therapy

Light therapy, also known as phototherapy, is a non-invasive treatment that involves exposing the scalp to a specific type of light. This type of therapy is thought to stimulate hair growth by increasing blood flow to the hair follicles. Light therapy can be used in combination with other treatments, such as minoxidil or corticosteroids.

6. Platelet-Rich Plasma (PRP)

Platelet-rich plasma (PRP) is a treatment that involves injecting the patient’s own blood into the scalp. This treatment is thought to stimulate hair growth by promoting the growth of new blood vessels and increasing the supply of nutrients to the hair follicles. PRP is a relatively new treatment for FFA and more research is needed to determine its effectiveness.

7. Hair Transplantation

Hair transplantation is a surgical procedure that involves removing hair follicles from one area of the scalp and transplanting them to the affected area. Hair transplantation can be used to restore hair to the frontal hairline in cases of FFA, but it is not considered a cure for the condition.

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