Frontal fibrosing alopecia (FFA) is a form of cicatricial alopecia that predominantly
affects perimenopuasal and postmenopausal women.1, 2, 3, 4 Although the precise cause
is unknown, it is currently classified as a primary lymphocytic cicatricial alopecia
that is closely related to lichen planopilaris (LPP). FFA not only causes scarring
hair loss but also frequently causes skin atrophy within the frontal hairline.5, 6
Until recently, the treatment for FFA has mirrored the treatment algorithms used for
other primary lymphocytic scarring alopecias. Topical steroids, steroid injections,
hydroxychloroquine, doxycycline, tetracycline and mycophenolate mofetil have been
the main treatments. However, in the last few years, an increasing number of reports
have suggested a beneficial role for the 5 alpha reductase inhibitory medications,
finasteride and dutasteride.4, 6, 7, 8
To date, the published studies of FFA treatment outcomes have focused on hair follicles—whether
they are lost, stabilized, or promoted to regrow. The other important feature of the
condition—cutaneous atrophy—has not received much attention. Here, I report a patient
with FFA who experienced not only marked frontal hair regrowth with the 5α-reductase
inhibitor, finasteride, but also a marked reversal of cutaneous atrophy.
A 51-year-old woman presented with a 9-year history of asymptomatic frontal hair loss
(Fig 1, A and C, before treatment). Hair loss started at age 42 in the preauricular
area and extended to the entire frontal hairline. The patient was premenopausal at
the time of first hair loss and entered menopause at age 49. Eyebrows were reduced
in density but still present. A proportion of existing hair follicles in the receded
hairline displayed perifollicular erythema and perifollicular scale. Marked atrophy
was noted along the frontal hairline, and facial veins were visible (Fig 1, A and
C). Biopsy findings confirmed the diagnosis of a lymphocytic cicatricial scarring
alopecia consistent with the clinical diagnosis of frontal fibrosing alopecia. Results
of blood work, including iron and thyroid studies, were normal. Initial treatments,
including hydroxychloroquine (6 month trial); betamethasone valerate, 0.1 % cream
(3 weeks); and tacrolimus, 0.1 % ointment (2 months), were not helpful and did not
lead to any clinical change. The patient then started finasteride, 2.5 mg daily, and
within 3 months experienced a reduction in redness and reversal of skin atrophy followed
by hair regrowth in the fronto-temporal scalp. Further improvements were noted at
1-year follow-up (Fig 1, C and D).
In addition to author's assessment and patient's assessment of hair regrowth after
finasteride treatment, clinical measurements also supported hair regrowth in the frontal
hairline. In the author's practice, changes to frontal hairline in patients with frontal
fibrosing alopecia are followed with use of clinical photography, dermoscopy, and
a series of standardized measurements. For assessing the frontal hairline, the author
draws a line (often with a crayon) from the lateral canthus to the root of the helix
(LC-RH line). For most individuals, this distance is between 6 and 7 cm. Three additional
hatch marks are then drawn perpendicular to this line at 2 cm, 4 cm, and 6 cm starting
from the lateral canthus. Four separate perpendicular measurements are then taken
from the LC-RH line to the patient's hairline: one at the lateral canthus and 3 at
2, 4, and 6 cm from the lateral canthus. For the patient in this report, these measurements
(right side) were 7.6 cm, 7.0 cm, 5.5 cm, and 3 cm before treatment and 7.5 cm, 6.5 cm,
3.5 cm, and 1.5 cm after treatment with finasteride.
Emerging evidence suggests that 5α-reductase inhibitors may be among the most effective
treatments for FFA.4, 6, 7, 8 Although these drugs are not approved by the US Food
and Drug Administration for use in women and must not be used in women of childbearing
potential, they are increasingly used off label for treatment of postmenopausal FFA.
Recent studies by Vano-Galvan et al
support the notion that partial hair regrowth may be possible for a significant proportion
of FFA patients treated with 5α-reductase inhibitors. Specifically, 52 of 111 FFA
patients (47 %) experienced hair regrowth after treatment with these drugs.
To date, hair regrowth does not appear to be a feature of any other class of drugs
besides the 5α-reductase inhibitors.
It is well recognized that atrophy is a part of the clinical presentation of FFA.
Atrophy can also be a side effect of topical steroids or steroid injections used to
treat FFA. In our patient, atrophy was present before initiation of the short course
of topical midpotency steroids; thus, atrophy cannot be attributed to use of topical
steroids. Moreover, reversal of atrophy cannot be attributed to cessation of topical
steroid therapies. The timing of improvement of both atrophy and hair regrowth strongly
favor this as an effect of finasteride therapy.
Descriptive studies and rating scales to document atrophy have not been undertaken.
Of the main published FFA studies, only a brief mention is made to the atrophy6, 9
or presence of dilated veins in women with FFA.5, 10 It is increasingly clear that
disease activity scales often applied for the closely related condition, LPP, such
as the Lichen Planopilaris Activity Index are inadequate for evaluating treatment
responses in FFA.
The Lichen Planopilaris Activity Index does not account for hair regrowth and places
significant emphasis on disease symptoms and the positive pull test, both of which
are less frequently a feature of FFA than LPP.
New activity scales are needed that take into account variables such as patient symptoms,
clinical signs (perifollciular scale and erythema), symptoms, speed of hairline advancement,
hair regrowth, and possibly changes in skin atrophy. It would be helpful in the future
to assess changes in skin atrophy before and after treatment with histology or ultrasonography.
The assessment of skin atrophy by clinical examination is an important limitation
of this study.
This case further documents the marked changes in hair regrowth that are possible
with use of 5α-reductase inhibitors and raises the possibility that reversal of cutaneous
atrophy may also be a bona fide associated treatment outcome to monitor.