Steroid Injections in Frontal Fibrosing Alopecia: A Treatment to be Considered

Steroid Injections are Helpful in the Treatment of Frontal Fibrosing Alopecia.

Steroid injections with triamcinolone acetonide are frequently performed for many autoimmune hair loss issues. I frequently perform steroid injections for alopecia areata, lichen planopilaris, frontal fibrosing alopecia, discoid lupus, central centrifugal cicatricial alopecia, folliculitis decalvans and more. Steroid injections are a critical part of any dermatology practice.

Triamcinolone acetonide is a type of injectable corticosteroid. Together with treatments like antiandrogens, retinoids, hydroxychloroquine, and topical calcineurin inhibitors steroid injections can be helpful to control inflammation in patients with FFA.

How effective are steroid injections in frontal fibrosing alopecia?

Steroid injections are one of the treatment options for FFA. We have yet to have a clear cut randomized clinical trial examining the effectiveness of steroid injections against placebo in patients with FFA. In fact, that study will never be done as it’s likely to be considered unethical to give patients placebo in a disease that permanently destroys hair. So what we rely on are good studies that look at how well patients with FFA respond when steroid injections are part of their overall treatment plan. Taken together, current studies would suggest that steroid injections probably do something positive in 90% of more of patients with FFA. Most of the time we don’t treat patients with FFA with just a single therapy like steroid injections. In fact, we treat with several therapies to suppress the immune response and save hair. It’s not uncommon to start an oral therapy, one or two topical therapies and …. perform steroid injections.

Banka and colleagues, 2014

in 2014, Banka and colleagues evaluated the benefits of steroid injection treatments in 57 patients with FFA. The authors proposed that 97 % of patients who received steroid injections had benefit in stabilizing the disease.

Vano-Galvan and colleagues, 2014

in 2014, Vano Galvan and colleagues published their data on the effectiveness of many treatments for FFA. The authors identified 130 patients who were treated with steroid injections. The authors proposed that steroid injections helped 34 % of patients improve and helped 49 % stabilize. Steroid injections did not help 5 % of patients.Again, patients in this study were receiving multiple therapies.

Gkini and colleagues, 2018

In 2018, Gkini and colleagues reported outcomes of 40 patients with FFA treated with steroid injections. Only 1 of thee 40 patients was treated with steroid injections along and all other patients were treated with some combination of therapies. This makes the true evaluation of the effects of steroid injections alone (ie as mono therapy) impossible in this study. Nevertheless, the data support some benefits for steroid injections.

Treatment combinations in this study included monotherapy with intralesional injections (one patient, 2.5%), intralesional injections + steroid lotions ± calcineurin inhibitors ± doxycycline (22 patients, 55%), intralesional injections + dutasteride ± steroid lotions ± calcineurin inhibitors ± doxycycline (15 patients, 37.5%), and intralesional injections + hydroxychloroquine ± steroid lotions ± calcineurin inhibitors ± doxycycline (two patients, 5%).

Therapies such as doxycycline, calcineurin inhibitors, hydroxychloroquine are not 100 % effective in FFA. These treatments help many - just not everyone. The fact that all 40 patients in this study by Gkini and colleagues achieved stabilization suggests that the steroid injections were having an important role.

Ramirez and Colleagues, 2005

Harries and Messenger proposed in their analyses of a 2005 study by Ramirez and colleagues that a good or partial response of some kind was seen in up to 89 % of patients treated with steroid injections.

Conclusions

Overall, steroid injections have an important role in FFA treatments. Oral antiandrogens (finasteride, dutasteride) and oral retinoids ( isotretinoin/acitretin) and steroid injections are among the top 3 treatments with good clinical evidence. At the present time, it seems that a vast majority of patients will have some benefit from these treatments. The precise dose we should be using remains controversial and some physicians uses 2.5 mg per mL, some use 5 mg per mL and some use 10 mg per mL and some use 20 mg/mL. Atrophy from the injections is important to monitor and this can occasionally be challenging to differentiate from the atrophy of the disease itself.

References

Banka et al. Frontal fibrosing alopecia: a retrospective clinical review of 62 patients with treatment outcome and long-term follow-up. Int J Dermatol. 2014 Nov;53(11):1324-30.

Gkini et al. A Retrospective Analysis of Efficacy and Safety of Intralesional Triamcinolone Injections in the Treatment of Frontal Fibrosing Alopecia Either as Monotherapy or as a Concomitant Therapy. Int J Trichology. Jul-Aug 2018;10(4):162-168.

Harries MJ, Messenger A. Treatment of frontal fibrosing alopecia and lichen planopilaris. J Eur Acad Dermatol Venereol. 2014;28:1404–5.

Vañó-Galván S et al. Frontal fibrosing alopecia: a multicenter review of 355 patients. J Am Acad Dermatol. 2014 Apr;70(4):670-678.

Moreno-Ramirez. Frontal fibrosing alopecia: a survey in 16 patients. JEADV 2005