Algorithmic approach to the treatment of frontal fibrosing alopecia: A systematic review

Abstract

To the Editor: Frontal fibrosing alopecia (FFA) is a lymphocytic primary cicatricial alopecia initially described by Kossard in 1994.1Vañó-Galván S. Molina-Ruiz A.M. Serrano-Falcón C. et al.Frontal fibrosing alopecia: a multicenter review of 355 patients.J Am Acad Dermatol. 2014; 70: 670-678Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar FFA most commonly affects postmenopausal women, although cases in premenopausal women and men have been described. FFA is characterized by frontotemporal hairline recession, eyebrow hair loss, and perifollicular erythema and hyperkeratosis. There is no consensus for the treatment of FFA, and current therapy is aimed at preventing the progression of hair loss. Although some consider FFA to be a variant of lichen planopilaris, there might be treatment considerations unique to FFA. The authors have conducted a systematic review of the current literature to help in the development of a treatment algorithm for patients with FFA. On January 17, 2018, we conducted a search of the PubMed database using the term “frontal fibrosing alopecia treatment.” Publications not in English and those not including specific treatment outcomes were eliminated. A total of 22 studies were included in our review and are summarized in Supplementary Table I, available via Mendeley at https://doi.org/10.17632/nkt4k79spw.1. We utilized the levels of evidence tool from the Oxford Centre for Evidence-Based Medicine to assign grades of recommendation to each study. Treatment response was most often described as disease improvement, stabilization, or progression by authors of the original articles. Treatment regimens for 816 patients were described in the 22 studies. Topical and intralesional corticosteroids are often first-line therapies due to their minimal side effect profile and were most often used in the reviewed studies. These therapies were rarely used as solitary treatments, making it difficult to gauge their efficacy. In our review, hydroxychloroquine and 5a-reductase inhibitor (5aRIs; dutasteride and finasteride) were the most effective therapies. Sixty of 83 (72%) patients treated with hydroxychloroquine and 207 of 297 (70%) patients treated with 5aRIs experienced disease stabilization and improvement. The endpoint for most studies was disease stabilization, and in this regard, hydroxychloroquine and 5aRIs performed similarly. Patients typically experienced results within 6-12 months, although some continued to see improvement up to 2 years after treatment. Systemic corticosteroids were rarely used and were limited to cases of severe inflammation. Other therapies were utilized much less frequently with variable outcomes (Supplementary Table I). Despite decreased androgen levels noted in FFA patients, 5aRIs might nevertheless be an effective treatment option for these patients.2Ranasinghe G.C. Piliang M.P. Bergfeld W.F. Prevalence of hormonal and endocrine dysfunction in patients with lichen planopilaris (LPP): a retrospective data analysis of 168 patients.J Am Acad Dermatol. 2017; 76: 314-320Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Use of 5aRIs should be limited to patients who are postmenopausal or on reliable contraception.3Donovan J.C. Finasteride-mediated hair regrowth and reversal of atrophy in a patient with frontal fibrosing alopecia.JAAD Case Rep. 2015; 1: 353-355Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Given the findings of this review, we suggest the treatment approach for FFA outlined in Fig 1. In patients with continued disease progression despite standardized therapies, special consideration should be given to emerging therapies, such as platelet-rich plasma and low-level light-emitting diodes.4Fonda-Pascual P. Moreno-Arrones O.M. Saceda-Corralo D. et al.Effectiveness of low-level laser therapy in lichen planopilaris.J Am Acad Dermatol. 2018; 78: 1020-1023Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 5Dina Y. Aguh C. Use of platelet-rich plasma in cicatricial alopecia.Dermatol Surg. 2018; : 1https://doi.org/10.1097/DSS.0000000000001635Crossref PubMed Scopus (13) Google Scholar Limitations of this study include varying doses and lengths of treatments and subjective interpretation of disease progression and stabilization. Because there is currently no global index scale for FFA, it is difficult to assess the true efficacy of treatment. In addition, in some instances it was unclear whether resolution was due to the natural history of the disease or employment of a specific therapy.1Vañó-Galván S. Molina-Ruiz A.M. Serrano-Falcón C. et al.Frontal fibrosing alopecia: a multicenter review of 355 patients.J Am Acad Dermatol. 2014; 70: 670-678Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar Moving forward, randomized controlled trials are necessary to evaluate the effectiveness of various treatments of FFA.