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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Losing hair is quite traumatic for adults, so imagine when it happens with children. While hair loss is difficult to handle for the young ones, it is up to the adults to understand what is causing it, how it can be treated or handled in the most effective manner.
Now, there could be plenty of reasons why a child could lose hair and looking at them closely will give the appropriate answers towards treating the same. Let’s look at some of the most common causes that lead to hair loss in children:

  • Alopecia areata: Although a non-contagious condition, alopecia areata is said to be caused when the immune system of the body, attacks the hair follicles, causing hair loss. You might notice the sudden appearance of bald patches, which are smooth to touch. There is no real cure for the condition, but it can be controlled with proper treatment. In many cases, there has been complete hair regrowth in a matter of months, but in several other cases, the new hair also falls off.
  • Alopecia totalis and alopecia universalis: This condition is similar to alopecia areata, but the hair loss is more extensive. For instance, in alopecia totalis, the hair loss is all over the head, and in alopecia universalis, the hair loss is all over the body. If your child is suffering from either one of the conditions, the chances of successfully treating the same are less.
  • Tinea capitis: This is actually a fungal infection that is seen quite commonly in children. There are numerous manners in which it presents itself, but the most common one is loss of hair and appearance of scaly patches. The hair will most probably break off at the skin surface and there will be black dots on the scalp.
  • Trichotillomania: This type of hair loss is caused when the child pulls or plucks his or her own hair. One will be able to notice the condition by uneven lengths of hair or patchiness. Most often, the patches are noticed on the side of the head, which corresponds to the dominant hand of the child. In many cases, the condition could be triggered due to stress or anxiety.
  • Telogen effluvium: When there is sudden stress in the form of very high fever, traumatic experiences such as death of a loved one or an accident, or a surgical process, there could be hair loss. Such a condition is called telogen effluvium and in it, the hair follicles get stuck in the telogen phase. From here, they directly fall, which eventually leads to the baldness. However, this is not known to be a permanent condition and hair does grow back in a few weeks or months.
  • Nutritional deficiency: Not eating a proper diet can certainly lead to hair loss. If there is a deficiency of vitamin H (biotin) or zinc, there can be extensive hair fall. Similarly, if there is too much vitamin A in the body, there can be hair loss.
  • Endocrinal issues: In some children, there is a condition called as hypothyroidism, wherein the thyroid is not as productive as it should be. With insufficient thyroid in the body, the metabolism is not regulated properly and that leads to hair loss.
  • Non-medical causes: There are also numerous non-medical causes, including tight hair styles and newborn babies rubbing their head against the crib. These are however, temporary hair loss conditions and can be rectified quite easily.

Now that we have looked at the most common causes of hair loss in children, the next and most obvious step would be to understand the treatments for each of these:

bald child

  • Alopecia areata: Cortisone has proven effective in treating alopecia areata and the same can either be injected or applied in the form of ointments. Slightly older children might also benefit from steroid injections or Minoxidil.
  • Alopecia totalis and alopecia universalis: Treatments used for alopecia areata can be used, in addition to ultraviolet light therapy or even cyclosporine.
  • Tinea capitis: Since this is a fungal infection, antifungal medications are the best way of treating the same. These could be oral or topical, but either will have to be prescribed by a doctor. In addition, it would be advised that the child wash his or her hair with a selenium sulphide shampoo.
  • Trichotillomania: There would be no use of scolding the child, but it would be a good idea to take the child for a counselling session. If the condition has been caused due to anxiety or stress, talking to a counsellor could resolve it.
  • Telogen effluvium: The most common treatments include the usage of topical steroids and keeping the scalp clean.
  • Nutritional deficiency: Quite obviously, eating healthy would be the way out of this condition. Ensure your child has enough nutrients in his or her daily diet and if the condition has been caused due to excessive vitamin A, simply cut the intake of the same.
  • Endocrinal issues: If there is a thyroid related problem, the doctor would be able to suggest a corrective course of treatment. The doctor would also be able to suggest a more appropriate diet, assesing the metabolic rate.

A child losing hair would certainly lead to mental disturbance, which is why, as a parent you will have to tread very carefully. Ensure you instil confidence in the mind of your child, allowing him or her to understand that hair is just a part of the body. In addition, it would be a good idea to talk to the teachers and classmates to ensure that no one makes fun of your child. If the hair loss is too extensive, it would be prudent to invest in a natural looking wig.

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