In continuation from our previous article, we will continue to look at other aspects of frontal fibrosing alopecia. Given that we have already looked at what the condition is, the history, the clinical features, the epidemiology as well as the pathogenesis, we will now continue to look at the differential diagnosis, how it presents itself and how it can be treated or contained.

Let’s first start with the differential diagnosis for frontal fibrosing alopecia:

In order to treat frontal fibrosing alopecia properly, it is important that it is diagnosed properly and there has to be complete assurance that it is FFA and not any other condition that presents in a similar manner.

It is important to ensure that the condition is frontal fibrosing alopecia and must not be confused with:

    • A high frontal hairline or high forehead, which is quite common in women.
    • Androgenetic alopecia, or more specifically, in the frontotemporal type of androgenetic alopecia, there is lesser inflammation at the edge of hair and there is also no clear band like pattern.It also occurs as bitemporal recession than frontal recession unlike FFA.Also,androgenetic alopecia in women rarely affects the front part of the hairline.
    • Ophiasis, type of alopecia areata. Alopecia areata tends to affect the eyebrows too, but should not be confused with FFA. It is a smooth hairless patch without any scarring or inflammation unlike FFA.
    • Traction alopecia can occur at the same site, but it does not mean that it should be confused with FFA. Proper history and presence of broken hair at varying length is more in favour of traction alopecia.
    • Senile alopecia does not present the same kind of distribution, but there is loss of hair in the eyebrows.
    • Other types of cicatricial alopecia, including folliculitis decalvans, pseudopelade and keloid acne. There is a progressive course of hair loss in FFA, but it might not be seen in others. There is also lesser inflammation, when it comes to FAA.

The doctor should be able to have a clear and proper understanding of whether the condition is FAA or not, before starting a course of treatment. Since there are so many overlapping features, there is always the chance of confusion, which could lead to wrong treatment as well. This is all the more reason why a differential diagnosis is crucial

Coming back to some of the basics, let’s take a look at what frontal fibrosing alopecia looks like:

      • The loss of hair is similar to a head band occurring over the frontal area, and the continuation of the loss is in a similar pattern.
      • The hair loss is not sudden, it will happen gradually.
      • In certain cases, there is thinning in the eyebrows as well.
      • In a majority of the cases, the condition starts in women who have crossed their menopause.

While there is no clear indication as to what causes frontal fibrosing alopecia, there are a few likely causes:

There are many studies that have shown that FFA could be a result of the immune system of the body attacking the hair follicles and this is what leads to the inflammation as well. And in turn, the inflammation damages the hair follicles further. Since most women who suffer the condition are post their menopause, there is also a consideration that there could hormones in play. There are little chances of hair growing back; however there are methods of disguising and treating the same to limit the loss.

Pre-treatment Diagnosis for frontal fibrosing alopecia:

Before starting on any course of treatment for frontal fibrosing alopecia, it is important to understand that the condition is not a reversible one, and the progression is a slow one. Since the condition still does not have a clear course of treatment that has been proven truly effective, the course of ‘treatment’ charted out by each doctor will vary.

The course of treatment is also decided by way of – scalp biopsy, the type of inflammation, the exact location of the inflammation and manner in which the scalp changes over a pre-decided period of time. All this needs to be taken into consideration, before deciding the suitable therapy and medications. Certain topical steroids have proven effective in arresting the speed at which the condition progresses.

Treatment of Frontal Fibrosing Alopecia

The treatment needs to be given in the manner of application of the above mentioned topical steroids or in the form of infiltrations.

        • One of the preferred first lines of therapy is triamcinolone injections, which are given over the lesions
        • A combination of Minoxidil and Finasteride has also proven to be effective in certain cases.
        • Short course treatments of oral steroids or retinoids can also be tried.
        • Studies have shown that hydroxychloroquine worked in courses that were spread over six and twelve months; and there was a visible improvement. As a matter of fact, improvements were seen within the first six months.

However, the studies did prove that hydroxychloroquine was the most effective of the spectrum of medications, even though there were certain people who had reactions, such as retinopathy and gastric issues.

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