Autologous Hair Transplantation in Frontal Fibrosing Alopecia

Frontal Fibrosing Alopecia: A Comprehensive Guide for Cosmetic Dermatologists

Frontal fibrosing alopecia (FFA) is an inflammatory, scarring hair loss that commonly affects postmenopausal women and presents as frontal hairline recession, facial papules, loss of eyebrows, and facial hyperpigmentation. Because of the chronic, progressive nature of this disease and its important impact on aesthetic appearance, patients often consult dermatologists to improve unwanted FFA symptoms. Cosmetic practices including the use of non-ablative lasers, autologous fat injections, and oral isotretinoin can improve FFA-associated facial vein prominence, atrophic indentations, and facial papules, respectively. On the other hand, while exact etiology underlying FFA development remains unclear, some procedures including deep chemical peels and ablative laser therapies have been shown to induce facial scarring and are contraindicated in patients with FFA. In the same way, some cosmetic ingredients can possibly be a triggering or worsening factor for FFA as well. Therefore, it is essential for dermatologists to be aware of both the benefits and risks of cosmetic treatments in patients with diagnosed or suspected FFA. This comprehensive review aims to outline the key cosmetic products and procedures that may be useful in patients with FFA and those which should be considered contraindicated.

Treatment of Frontal Fibrosing Alopecia

Introduction. Frontal fibrosing alopecia (FFA) is known as a lymphocytic primary cicatricial alopecia. The main characteristic of FFA is progressive frontotemporal hairline recession. The pathogenesis of FFA is not completely understood. Destructing the stem cells of the epithelial hair follicles causes permanent hair loss and seems to be the main cause of FFA. Studies have reported significantly decreased quality of life in patients with hair loss. On the other hand, late diagnosis and treatment of FFA can decrease the success rate of the treatment. In this regard, different topical and systemic therapies have been developed to resolve the symptoms; however, only a partial response to treatment is usually achieved. We conducted a systematic review of the literature to identify the effectiveness of the available treatment modalities used for FFA patients and the related outcomes. Methods. On April 2022, we made a wide systematic computer-assisted search of PubMed and Google Scholar databases, using “frontal fibrosing alopecia” and “treatment” keywords. We scanned 1,514 articles. All the studies concerning a therapeutic regimen for FFA were included. After removing duplicate studies, 50 studies containing the therapeutic regimen of 1,478 FFA patients were included in this review. Results. The 5-alpha-reductase inhibitors (oral finasteride/dutasteride) were the most used medications (usually prescribed as a combination therapy with other medications). Topical corticosteroids were the second commonly used medication for the treatment of FFA. Systemic corticosteroids seem to be ineffective in improving FFA progression. Oral isotretinoin (or alitretinoin) had the most promising effect on improving facial papules of FFA patients with a 92% rate of facial papule improvement. Conclusion. In our review, intralesional corticosteroid injection and 5-alpha-reductase inhibitors (finasteride/dutasteride) were reported as the most effective treatment modalities. Oral isotretinoin (or alitretinoin) is considered as the most promising treatment for improving facial papules in the context of FFA. However, it had minimal effects on hair regrowth or stabilization of hairline recession in FFA patients.

Frontal fibrosing alopecia

Frontal fibrosing alopecia (FFA) is a patterned primary cicatricial alopecia that was first described in 1994. Once rare, the incidence of FFA has increased dramatically, representing the current most common cause of cicatricial alopecia worldwide. FFA typically begins in postmenopausal women with symmetrical, progressive recession of the frontotemporal hairline together with bilateral loss of the eyebrows. FFA has a distinctive clinical phenotype, which remains a challenge. The histology is identical to lichen planopilaris (LPP), but only a small number of patients have coincidental LPP, usually of the scalp. The vast majority of patients have no evidence of lichen planus elsewhere, and the symmetry and patterned nature of the hair loss are unusual for LPP. Familial cases of FFA are reported, and gene associations have been identified in population studies; however, the pathophysiology remains controversial. Without treatment, FFA is slowly progressive, and although many treatments have been prescribed, the response is often disappointing. We review the pathogenesis, epidemiology, clinical features, histology, and treatment of FFA.

Hair Transplantation for Scarring Alopecia

Hair loss can be a debilitating condition, especially for individuals who already have chronic underlying medical conditions that complicate the treatment of hair loss. This article addresses the challenges posed by scarring alopecia in hair-loss treatment and the evidence-based practices that exist for hair transplantation in scarring alopecia.

Hair Transplantation in Frontal Fibrosing Alopecia and Lichen Planopilaris: A Systematic Review

OBJECTIVE

Evolving hair transplantation (HT) techniques have offered new possibilities for hair restoration. However, the role of HT in patients with frontal fibrosing alopecia (FFA) and lichen planopilaris (LPP) remains unclear. This study aims to evaluate the outcomes and temporal relationship of HT in this population.

METHODS

A literature search of three databases was conducted. We reviewed 1) literature reporting outcomes of patients with LPP or FFA who received HT, and 2) studies reporting the development of LPP or FFA resulting from HT.

RESULTS

Thirteen articles included 42 patients that provided data for evaluation. Fifteen patients had previously been diagnosed with FFA or LPP, and the remaining 27 patients developed disease after undergoing HT. Seven patients with FFA and eight patients with LPP received HT, with a mean sustained disease remission of 2.69 years prior to HT. In total, two of seven (29%) patients with FFA and five of eight (75%) patients with LPP experienced positive HT results over a follow-up period of 8-72 months. Interestingly, 27 patients without evidence of previous disease developed FFA or LPP following HT after a median duration of 16 months.

CONCLUSIONS

HT for LPP and FFA is feasible but results may be less favorable compared to HT for other causes. Outcomes may be more favorable for LPP than FFA but this was not statistically significant and evidence is very limited. FFA and LPP can also develop following HT in patients without previous evidence of disease.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:59-66, 2021.