What is frontal fibrosing alopecia?
Frontal fibrosing alopecia is a scarring form of permanent hair loss that most often affects the front and sides of the hairline. It occurs predominantly in women after the menopause, but it can also begin before menopause and can affect men. It is considered a clinical variant of lichen planopilaris, in which inflammation damages hair follicles and replaces them with scar tissue.
How does it look?
The hairline usually recedes gradually in a smooth, band-like pattern. Redness and scale may be visible around follicles at the active edge, while established areas look pale or scarred and lack follicular openings. Eyebrow loss is common and can precede scalp change. Some people also develop loss of other body hair or small facial papules. Hair already lost from a scarred area cannot regrow.
Cause and diagnosis
The exact cause is unknown. An immune reaction directed at parts of the follicle appears important, but the roles of hormones, genetics and environmental exposures remain uncertain. Diagnosis is based on the pattern, symptoms and close scalp examination, often with trichoscopy. A biopsy can support the diagnosis when the appearance is uncertain or another scarring alopecia needs to be excluded.
Treatment and outlook
Treatment aims to stop or slow active loss, not to restore destroyed follicles. Strong topical or injected corticosteroids can reduce local inflammation. A dermatologist may also consider an anti-inflammatory tetracycline, hydroxychloroquine or another systemic treatment according to activity and individual risks. Response is variable, treatment may take months to assess and medicines require appropriate monitoring.
The condition may eventually become inactive, but substantial irreversible loss can occur first. Serial measurements or photographs help show whether the hairline is still moving.
When to see a doctor
Arrange dermatology assessment for recession of the front or side hairline, eyebrow loss, redness or scale around follicles, or smooth scar-like scalp skin. Early review is important when change is progressing because suppressing inflammation may preserve follicles that have not yet been destroyed.