Frontal Fibrosing Alopecia and Lichen Planopilaris: Could I be allergic to something?

Contact Allergens in FFA and LPP: Are they relevant ?

There is emerging evidence that some patients with lichen planopilaris and frontal fibrosing alopecia might be allergic to certain products in their environment. We refer to these as contact allergen. This probably does not apply to everyone with these scarring alopecias, but may apply to some.

A study in 2020 examined the possibility that patients with lichen planopilaris and frontal fibrosing alopecia might have such contact allergies. 42 patients with scarring alopecia underwent very specialized allergy “patch testing” to see what allergens they might be allergic too. 62 % of patients in the study had LPP, 26% had FFA and 12 % had both LPP and FFA

Patch testing is an office procedure whereby pure chemical ingredients are placed on the back and observed over 3-5 days to see if allergies develop on the skin. A photo of a patient undergoing patch testing is shown below.

What contact allergies were detected in patients with FFA and LPP?

Patients with FFA and LPP had several allergies.

The most common allergens detected were chemicals known as ‘gallates’, followed by ‘linalool’ and ‘fragrance mix.” Specifically, 26 % of patients were found to be allergic to gallates, 19 % to linalool and 19 % to fragrance mix .

Gallates are something you may never have heard of. These are preservatives added to cosmetic, creams, cleansers to prevent growth of yeast, bacteria and fungi. Linalool is a fragrance found in lots and lots of personal care products likes shampoos, conditioners, cleansers, and hair sprays,

The researchers proposed that the allergies to fragrance containing products and possibly some preservatives may be particularly relevant in patients with FFA and LPP. This is simply because the frequency of positive reactions to fragrance mix and preservatives (MCI/MI) was higher than expected in general population. In other words, it appears that patients with FFA and LPP are more likely to be allergic to fragrance and preservatives than people in the general population who do not have LPP and FFA.

Should patients with FFA and LPP avoid certain allergens?

Most patients with FFA and LPP won’t be allergic to any kind of fragrance or preservative. So the simple answer to the question asked above is - if one doesn’t have any clear evidence of having allergies then randomly avoiding potential allergens probably does not make much sense.

However, if a patient with FFA and LPP is found by their dermatologist to have a relevant allergy, then staying away from the specific allergen makes really good sense. Again, in many cases the only real way to prove someone is allergic to a specific chemical is to do patch testing.

In the study quoted above, allergen avoidance helped patients with FFA and LPP a great deal. Specifically, 58 % of patients with FFA and LPP who avoided the allergen that their doctors told them they needed to avoid had a reduction in scalp itching. Furthermore, 72.7 % of patients with FFA and LPP who avoided the allergen that their doctors told them they needed to avoid had a reduction in scalp redness too.

These are pretty significant numbers!

Summary and Conclusions

We are still int he early days of trying to figure out if allergens in a patient’s environment trigger their LPP or make the LPP they already have a bit worse. It’s seems possible.

It’s becoming clear that some patients with LPP and FFA will improve the way their scalp feels and looks if they stay away from certain allergens. This does not apply to everyone so unfortunately we don’t have any kind of all encompassing statement that applies to everyone with LPP and FFA.

For now, the following actions seem appropriate in my opinion:

1) All patients with LPP and FFA should at the very least have a discussion with their dermatologist about potential allergens they might be coming into contact with. Not everyone with FFA or LPP is going to be sent off to have ‘patch testing’ like the person in the photos above, but some will. Probably more patients wth FFA and LPP need to have patch testing than we are doing now. That’s easy for me to say because current rates are extremely low. But it’s certainly not everyone who needs to undergo patch testing.

2) Fragrance allergens seem pretty relevant for a good proportion of patients with FFA and LPP. Again it’s not everyone. Other allergens besides fragrance may be relevant for some patients with LPP and FFA so not everything is about fragrance. If someone has trouble getting their LPP under control and does not want to progress to stronger and stronger medications and can not undergo patch testing for whatever reason, it makes sense to try a hypoallergenic shampoo. May of these can be purchased from the internet:

Hypoallergnic shampoos include the following:

Vanicream Free and Clear

Ducray Sensinol

AFM Safe Choice

Exederm Shampoo

SEEN shampoo (Fragrance Free version)

TrueCider

Reference

Prasad et  al.  Patch testing and contact allergen avoidance in patients with lichen planopilaris and/or frontal fibrosing alopecia: A cohort study.  J Am AcadDermatol  2020; 83: 659-661.