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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Hair loss has a major effect on every one in many ways. It dents our physical attractiveness if we experience thinning. When hair loss is noticeable, the person will try and search for the thinning causes in relation to the hair shedding. In the normal hair cycle, hair grows about half an inch per month, though this tends to slow a little as you get older. As hair gets older, it may enter a resting stage in which it remains on your head but doesn’t grow.

At the end of this stage, the hair usually fall out. The follicle replaces it in about six months. During this time, your hair is in its resting stage. The result can be that your hair falls out early or isn’t replaced. It is the degree of thinning that defines whether loss is a problem that can be addressed. There are many factors that can be attributed to hair loss besides aging, such as pregnancy, poor nutrition, hair pulling disorder, scalp infections, medical conditions, stress, hormonal changes, hereditary loss and prescription medications. There are a number of causes which may contribute to hair loss.

Androgenetic Alopecia

Androgenetic alopecia, also known as male-pattern baldness, is the main reason for thinning hair. It causes 95 percent of all loss. Male-pattern baldness happens when large, active hair follicles change to smaller, less active ones under the effect of dihydrotestosterone, or DHT. If an individual has androgenetic alopecia the overall levels of testosterone may be normal however the activity of 5 alpha reductase is greater than normal which results in increased amounts of dihydrotestosterone in the follicle.

Alopecia Areata

Alopecia areata is an autoimmune disease with unknown causes that typically affects people who are in otherwise good health. An environmental trigger such as a virus may set it off in people who have a genetic predisposition for the condition. With alopecia areata, your hair will usually grow back, although you may lose and re-grow it several times. White blood cells called T-lymphocytes attack the follicle which causes the hair to stop growing and enter into the telogen (resting) phase, then about 3 months later, when the resting phase is over the will then fall out. Only when T-lymphocytes stop attacking the hair follicle will new hair grow.

Cicatricial Alopecia

Cicatricial or scarring alopecia occurs when a skin condition such as lupus erythematosus or lichen planus causes inflammation that scars the hair follicle, preventing new hair from growing. The condition is permanent.

Telogen Effluvium

Telogen effluvium occurs when there is an emotional or physical stress that causes the hair roots to prematurely enter a resting state. In this a sudden or stressful event can cause the follicles to prematurely stop growing and enter into a resting phase. This occurs when there is a change in the number of follicles growing hair. If the number of follicles producing hair drops drastically for any reason during the resting, or telogen phase, there is a significant corresponding increase in dormant, telogen stage hair follicles. Accordingly the result is shedding, or effluvium hair loss. This will then appear as diffuse thinning of hair on the scalp, which may not be even all over.

Other Causes

Pulling disorder can cause thinning too and is called as Traction alopecia. If the pulling is stopped before permanent damage to the root occurs, the hair will usually grow back normally. Chemicals used for bleaching, dying, tinting or straightening cause hair to thin if they are used incorrectly. Excessive brushing can also damage the shaft, causing loss. Poor nutrition, eating disorders and diets lacking protein or iron can cause thinning and loss. The important nutrients for healthy hair include calcium, vitamin D, biotin, sulfur, folic acid, essential fatty acids (flaxseed oil, primrose oil, fish oil), inositol, magnesium, zinc and B vitamins, particularly B5 (pantothenic acid), B3 (niacin) and B12 (coblamin). Most of these vitamins and minerals can be found in a multi-vitamin. High protein foods include eggs, seafood, red meat, dairy food, legumes, nuts and seeds. Foods rich in iron include red meat, dates, prunes, dark-green leafy vegetables, tofu, certain whole grains, oat bran, wheat germ and fortified cereals. Certain medicines which are taken to treat depression, high blood pressure, arthritis or gout can also cause thinning. Birth control pills for women and diseases such as lupus, scalp infections and diabetes can cause loss as can chemotherapy and radiation treatments. Hormonal changes such as pregnancy, menopause and childbirth may cause temporary loss in some women.


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