Frontal Fibrosing Alopecia (FFA) Recent Updates

Before Initiating this goose-bump stimulating skin, disorder let’s share one sincere piece of advice that individuals affected with FFA must seek dermatological consultation in the first leisure moment. Seeking dermatological consultation is significant to prevent the skin from further damage and irritability.

What does the term FRONTAL FIBROSING ALOPECIA mean?

From a historical perspective, frontal fibrosing alopecia, also known as FFA, was first reported by Kossarden in 1994 and it is now increasing in prevalence. This medical term FRONTAL FIBROSING ALOPECIA is characterized by primary or secondary versions of cicatricial alopecia which is a scarring hair fall. The scars are produced due to perifolliculitis (inflammation of hair follicles) at the edge where hairs of the head terminate at the front temporal side.


FFA is one of the classes of LICHEN PLANOPILARIS, hence it an inflammatory condition that damages the skin and mucous membrane. Itching, redness, pain, burning sensation, irritability around the hair follicles prevail the whole situation. In FRONTAL FIBROSING ALOPECIA, corresponding alopecia of eyebrows, eyelashes, and sideburns along with the appearance of blemishes (small bumps on front-o-temporal region) and lesions in the pubic, axillary, and facial area may occur. Other features may include hypo-pigmentation of the frontal hairline and depression of veins. FFA mostly hits older women, specifically in 90% of cases the women are in the postmenopausal period. The symptoms of FFA mainly initiate in women at the age of 57 years.


What invokes/causes FFA?

Hence the efforts to probe the chief cause of FFA are continued until now in the 21st century. This disorder may occur due to genetic, environmental alterations, autoimmune responses, or hormonal imbalances.

As far as the genetic factors are concerned, research from the past few years has shown that four genes or genetic changes predispose women to FFA. These peculiar changes cause women to develop FFA, and these genes include HLA-B, CYP1B1, SEMA4B, ST3GAL1. Three of these genes if present increase the risk of FFA slightly. HLA-B is a particular genetic change that causes women of age 45 to develop FRONTAL FIBROSING ALOPECIA

Environmental insult does trigger the genetically predisposed individuals to develop FFA, and it includes the use of sunscreens, exposure to UV rays of the sun, viral infections, use of drugs, and food originated from an animal source containing dioxins.

Following hormonal imbalances in women aggravate FFA:

  • Low serum and androgens are common factors.
  • Early menopause in some history of hysterectomy
  • Thyroid dysfunction prevalent cause of FFA
  • More common in peri and postmenopausal women.

Numerous studies have been conducted to reveal the etiology of FFA, and these studies also show that individuals affected with various forms of LICHEN PLANOPILARIS also develop FFA. One of the researches prevails that 80% of people involved with FFA was previously suffered from lichen planopilaris around the body sides, 10% have oral lichen planopilaris, and 10% have vulva planopilaris. The following factors are considered as vital factors in causing FFA; Hypothyroidism, hypertension, smoking regimes, depression, anaemia, osteoporosis, vitamin D deficiency, osteopenia, obesity, etc.

According to a survey in Australia, 45% of women affected with FFA have a history of Hypothyroidism. In contrast, they found depression in 28% of patients. Females are having a history of hysterectomy, and hormonal replacement therapy also suffers from FFA.


Well! The treatment of FRONTAL FIBROSING ALOPECIA can be discussed with some drugs as a priority. Some are grouped in the 1st group and some medications in later on groups. The treatment is mapped in the following way:

1. First-line treatment:

  • Retinoid like isotretinoin, acitretin
  • Five alpha-reductase inhibitors (Finasteride/ dutasteride)
  • Steroid injection
  • Calcineurin inhibitors

2. Second-line treatment:

Tetracyclines, minoxidil, topical steroids, hydroxychloroquine

3. Third-line treatment:

  • Hair transplantation if completely stopped
  • Methotrexate, mycophenolate, lose dose of naltrexone
  • Pioglitazone

The most effective treatment for treating FRONTAL FIBROSING ALOPECIA is retinoid nowadays. The drugs included in the first line of therapy are proved to be the most appropriate drugs for FFA based on scientific evidence. Even though FFA is very similar to lichen planopilaris from a symptom perspective, but the top of medicines used for treatment in both disorders are varied.  Because in treating lichen planopilaris includes doxycycline and hydroxychloroquine while in FFA, these are retinoids.

However, the option of hair transplantation is prudent consideration while treating FFA because it may either give disastrous results in some patients or can act wonderfully in some patients. The candidates who are most suitable for hair transplantation are those in which the disorder of FFA must be terminated. One of the precautions which must be considered while having oral retinoids that pregnant women must take it carefully because it induces congenital disabilities

What Are the Diets To Be Considered For Frontal Fibrosing Alopecia?

Diet, which is the fuel of each cell of our body, also maintains our hair growth and protects our hairs from alopecia and other dermatological conditions related to hair. Hence before thriving into the important food significant to avoid FFA, you must take into consideration one more important factor which is “STRESS AND ANXIETY”. These psychological factors must be appropriately managed to allow the diet to give unusual outcomes. Following dietary regimes must be followed to avoid FFA:

  • As keratin protein is the building block of hair so protein-rich diet like beans, pulses, white and red meat, eggs must be a part of the daily diet
  • White sesame seeds are crucial in giving strength to hairs; hence they must be included in the diet. It is being employed as a natural hair loss ingredient.
  • Aloe vera- a green leafy plant containing a transparent gel-like substance do play a vital role in giving shine to hairs and also makes sebaceous glands function properly
  • As leafy vegetables contain more synthetic chemicals, therefore, fruit portions of vegetables like bitter gourd, etc. must be preferred over the green vegetable.
  • Seasoning of food must be done with freshly crushed spices instead of previously preserved ones.
  • Legumes, soy, sprouts, raisins, seafood, fish, beans, and olive oil must be added to dietary regimes to avoid FFA.

How Frontal Fibrosing Alopecia and Lupus are Connected?

After discussing FFA, it is quite more comfortable to reveal the connection between lupus and FFA. As both these disorders are having a close relationship with the immune system in most cases. The situation in which the immune system becomes wrongly signaled and is activated against its healthy body cells is termed as a disorder known as lupus erythematosus. Similar wrong activation of immune response also occurs in FRONTAL FIBROSING ALOPECIA.


The type of cutaneous lupus which occurs in FFA is discoid lupus erythematosus. It is considered as one of the chronic kinds of cutaneous immune deformity. The given disorder occurs on the cranial and facial regions causing plaques on the malar, nasal, the frontal part of the face, on the scalp, and the back of the ears. The plaques are disc or oval-shaped and flaky, and scaly skin flaps are predominated along with scarring. The treatment line for DLF is hydroxychloroquine; systemic corticosteroids like prednisone are prescribed to patients.

How the Deficiency of Vitamin D Causes Frontal Fibrosing Alopecia?

Vitamin D also is known as calciferol, is one of the crucial fat-soluble vitamins that play an essential role in absorbing calcium, magnesium, and phosphorous from various sites of the body but specifically from intestinal walls. Deficiency of vitamin d is one of the causes of FRONTAL FIBROSING ALOPECIA and also of lichen planopilaris, and this reality was revealed initially in Australia. This fact is shown in one of the researches conducted in Australia; where researchers find some facts related to sunscreens.  Because of excessive use of sunscreen in Australian people to prevent their skin from harmful sun exposure and consequently the skin cancer also suffers from a deficiency of vitamin D. The deficit in their body leads to FFA (FRONTAL FIBROSING ALOPECIA).

However, supplementing the patient with natural or synthetic vitamin D3 sources prevents osteoporosis in the postmenopausal period. L-tyrosine lessens the severity of autoimmune reactivity, and N-acetyl-cysteine to soothe down the inflammatory process and to reverse the action of radicals reduces the risk of FFA in patients and also prevents peri-folliculitis.


Autoimmune disease or disorder is termed as any fault in the function of immune cells, particularly lymphocytes, and they initiate harming their body cells instead of protecting them. The lymphocytes start engulfing the hair follicles cells. The inflammatory cells which colonize the hair follicles affected with FFA include T cells (cytotoxic, helper), B cells, and Langerhan cells. In the peri and postmenopausal period, the low level of androgens and estrogen causes autoimmune disorders to prevail in the body. Individuals having a familial background of frontal fibrosing alopecia may or may not tend to develop autoimmune reactions in their bodies.

Autoimmune reaction leading to FFA comprises of following features:

  • Systemic lupus erythematosus
  • Enlargement of multiple lymph nodes
  • Persistent anaemia

Also Read: What’s Retrograde Alopecia, its Causes, Effects, and Remedy



FRONTAL FIBROSING ALOPECIA can be treated by the use of various drugs either applying topically on the skin or by having them orally. Corticosteroids are found to make the worse situation to be controlled by their topical use. By the use of minoxidil, the process of alopecia can be halted. Retinoids, five alpha-reductase inhibitors such as finestridine have shown remarkable recoveries in patients who suffered from FFA.


Frontal fibrosing alopecia most commonly affects the women who are in the menopause stage of their life, having an average age of 50 to 62. The occurrence of this disease is prevailing rapidly in Australia, the USA, Japan, and Europe. In Africa, the disorder of FFA has a close connection with traction alopecia which makes the disease more painful when it proceeds. This disorder is also common in men when they have a genetic variation in genes involved in casing FFA.


Yes, frontal fibrosing alopecia can be halted by the use of proper medication, diagnosis, and managerial practices, but it can’t be eradicated.

  • By using topical clindamycin(corticosteroids)
  • By avoiding the use of excessive sunscreens and moisturizers
  • By managing the dietary regimes to promote hair growth
  • By having systemic drugs to avoid fibrosis
  • By adding vitamin D sources to diet after menopause

Q: What Autoimmune Disease Causes FRONTAL FIBROSING ALOPECIA?

Lichen planopilaris is the core autoimmune disease that causes frontal fibrosing alopecia, and it activates the immune cells against body cells. They attack hair follicles resulting in fibrosis of follicles and bumps at the hairline. Frontal fibrosing alopecia is one of the rare genetic disorders, but it is increasing in prevalence day by day.

Outcomes of the Article

Frontal fibrosing alopecia is one of those disorders which are going to seek attention in the upcoming centuries from every medical professional. It is a prevailing disorder associated with alopecia of eyebrows, eyelashes, hairs lying in the frontal region, and also sideburns. Along with alopecia small facial bumps also appears in the frontal area. Its treatment can only halt the procession of disease to some extent. Diet and management by medical professionals also assist the patient in their suffering.

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