Botox for Reducing Scalp Sweating in Frontal Fibrosing Alopecia

Botox for Frontal Fibrosing Alopecia Scalp Sweating

Frontal fibrosing alopecia (FFA) is a scarring alopecia associated with hair loss along the frontal hairline. The eyebrows, eyelashes, body hair can also be affected. A 2017 study showed that some women with FFA experience increased sweating in the areas of hair loss. Standard treatments for frontal fibrosing alopecia including topical steroids, steroid injections, and antibiotics were found to be helpful. Interestingly, botulinum toxin treatments (Botox) were also found to be helpful.

We are seeing an increasing amount of women with scalp sweating associated with their FFA. Sweating is controlled in part by the nervous system and this raises the possibility that a specific type of inflammation known as ‘neurogenic’ inflammation may be relevant in FFA. I think we will be hearing more about this area of research in the years ahead.

Treatment of scalp Sweating with Botox in FFA

For the excessive scalp sweating that some patietns with FFA experience, Botox can certainly be considered as an off label (non FDA approved indication). There is evidence that some of the inflammation in FFA is part of what is known as ‘neurogenic inflammation’ and blockade of these nerves will block signals sent to the sweat glands eccrine glands.

 My advice for FFA patients with excessive scalp sweating is to consider Botox in the hairline starting with a conservative number of units before increasing the dose. There seems to be a great (huge) variation in the amount of Botox needed to reduce scalp sweating in FFA. There is no formal protocol for FFA, but I generally recommend starting with 40 units in the affected hairline areas and waiting several months to see how well this work to reduce the sweating. One can certainly increase up to 80-100 units - and even well beyond (100-200 units).  Many patients, but not all, require 100 Units and above. 

Again, even though there is no formal protocol, one might consider diluting a 50 U vial with 1.25 mL and starting with 10 injections (of a 4U / 0.1 mL concentration) spaced 10 mm apart (i.e. 40 units total).  In 4-6 months, a decision can be made as to how well this worked and either proceeding in one of three ways

OPTION 1. Increasing to 60-80 units instead of 40 units and increasing the size of the area injected. This would involve diluting a 100 U bottle in 2.5 mL saline and proceeding with the same technique but injections covering a larger area.

OPTION 2. Diluting the Botox by one half (i.e. diluting a 50 U via with 2.5 mL saline) and injecting more sites.

OPTION 3. Doing nothing different in the case of the patient reporting success with the first trial of Botox and simply waiting for the patient to report that sweating has returned at which point the Botox can be administered again. This is typically every 6-12 months for successfully treated patients.

Reference

Harries et al. Frontal fibrosing alopecia and increased scalp sweating: Is neuorgenetic inflammation the common link. Skin Appendage Disord May 2016; 1(4):179-84