Over the past couple of weeks, I had two new female patients come in, ages 46 and 63, complaining of loss of hair in their hairline and eyebrows.
- Both had about one year of hair loss
- Both were not given a correct diagnosis by their dermatologist and family practitioner
I diagnosed both women with FFA or frontal fibrosing alopecia, and I wanted to share some information from recently published data that I referred to in recommending treatment for this prevalent diagnosis with my patients.
An article from the Journal of American Academy of Dermatology in 2018 reviewed 22 studies looking at the ‘algorithmic treatment approach’ of FFA in 816 patients. The endpoint of these studies was not a cure but disease stabilization.
Stabilization points of interest from 22 studies treating FFA:
- Frontline therapy is usually topical and intralesional steroids because of low side effect profile, but since they are rarely used alone, it is difficult to gauge its effectiveness.
- Two other drugs, finasteride, and hydroxychloroquine were the most effective therapies. 72% of patients using hydroxychloroquine, and 70% of patients using finasteride experiencing “disease stabilization and improvement.”
- Usually patients experienced results in 6-12 months and continued to improve up to 2 years.
- Systemic corticosteroids were not used unless there was severe inflammation.
- One of the differences between LPP and FFA is the androgen level. Even though these two entities are grouped in the same family, there are differences. In FFA the androgen level is decreased, but despite this fact a drug like finasteride may be very effective in these patients and not as effective in the LPP patients.
- The study also states that in patients with continued disease progression despite the use of standardized therapies, ‘’special consideration should be given to emerging therapies such as platelet rich plasma and LLLT.”
This review also separated treatment strategies between premenopausal, postmenopausal, and rapidly progressing disease patients, which is the first algorithm I have come across differentiating premenopausal from postmenopausal women.
- After correct diagnosis, everyone received topical and/or intralesional steroids along with topical calcineurin inhibitors. From this point the treatments diverged.
In postmenopausal women: The next step was to add finasteride 2.5-5mg/d. If there was treatment failure, then add Plaquenil 400mg/d. Again if treatment failure from this then add Isotretinoin 20mg or Acitretin 20mg per day. Again if treatment failure then add methotrexate 15-25mg weekly. At any point in the treatment progression if the disease stabilized, then topical or intralesional steroids could be used PRN along with topical calcineurin inhibitors. If all of these failed, then consider PRP and LLLT.
In premenopausal women: The study recommends after the initial steroid injections and topical calcineurin inhibitors to initial Plaquenil 400mg daily then if there is treatment failure to consider PRP and LLLT.
With rapidly progressive disease: After initiating intralesional steroids and topical calcineurin inhibitors, introduce a short course of oral corticosteroids. If the disease does not respond, then go back to the intralesional corticosteroids and topical calcineurin inhibitors.
Back to my original patients, one is premenopausal, and one is postmenopausal. We are still in the initial stages of treatment with intralesional corticosteroids and topical calcineurin inhibitors, but the difference is that I have also initiated finasteride 5mg per day in both patients. As the article states, 70% of patients across the studies using finasteride experienced disease stabilization and improvement. Also, to note, my premenopausal patient was extensively counseled about the possible side effects of finasteride, including congenital disabilities in male infants if she were to become pregnant with a male baby while taking the medication. More to follow….
An Algorithmic Approach to the Treatment of Frontal Fibrosing Alopecia-A Systematic Review
Dina, Yemisi et al.
Journal of the American Academy of Dermatology, Volume 0, Issue 0