What can we Learn from Study 10 of Males with FFA

Frontal fibrosing alopecia (FFA) is a scarring alopecia that is characterized by recession of the frontotemporal hairline.  FFA predominantly affects women, although FFA can affect males. The rates of FFA in males and females may, in fact, both be increasing worldwide.

 To date there have been 10 good studies addressing FFA in males. For review of these, download the handout at the following link.

Today, we’ll review the most recent study of these 10 studies - a 2022 study by Moussa and colleagues from Australia.

STUDY 10: Moussa et al, 2022

Authors from Australia set out to evaluate the clinical characteristics and response to treatment of FFA in men. They retrospectively reviewed the records of men with FFA who were seen over a 10 year period  from October 2011 and December 2021.

Thirteen patients with FFA were identified. The mean age of disease onset was 40.5 years (range, 29–66 years). Recession of the anterior hairline was present in all patients. Other areas affected by hair loss included the beard (92.3%), sideburns (76.9%), eyebrows (76.9%) and eyelashes (15.4%).

Scalp itching was present in five cases  (38.5%) and trichodynia was reported in two cases (15.4%), By trichoscopy perifollicular erythema and follicular hyperkeratosis were observed in eight (61.5%) and nine patients (69.2%), respectively. Facial papules were seen in five patients (38.5%). 30.8% of patients had rosacea. Three patients (23.1%) had concurrent androgenetic alopecia (AGA) or male balding.

The mean duration of follow-up was 26.5 months.

All 13 patients were treated with oral minoxidil. The chosen doses ranged from 0.25 to 10 mg daily with a mean dose 2 mg. In nearly all the patients (ie 12 of 13 patients), oral minoxidil was also combined with an oral 5a-reductase inhibitor. In 7 patients, this was finasteride (0.25 mg to 1 mg daily with mean dose 0.6 mg) and in 5 cases this was dutasteride (0.25 to 0.5 mg daily with mean dose 0.4 mg).

Four patients were treated with a class I topical corticosteroid (clobetasol propionate 0.05%). Other immunomodulatory and anti-inflammatory therapies used with the finasteride and oral minoxidil included cyclosporine (1 patient with finasteride and oral minoxidil, minocycline (1 patient with finasteride and oral minoxidil), and topical tacrolimus (1 patient with dutasteride and oral minoxidil and topical steroids). Disease stabilization was noted in eight patients (61.5%) after a mean duration of 6.0 months.  An increase in hair density was also observed in two of the three patients with concurrent AGA.  No adverse events due to treatment were observed during the follow-up period.

Comments.

This was an interesting study and finds a place on the list of FFA studies in males for us all to think about. The study highlights again how common beard hair loss, sideburn hair loss and eyebrow hair loss are in males with FFA. It’s difficult to attach benefit to oral minoxidil or finasteride or dutasteride in this study given that so many patients used two (or more!) drugs at the exact same time. For example, most patients used oral minoxidil together with a 5 alpha reductase inhibitor.  I think the authors would like to make a case that oral minoxidil is worth adding in cases of FFA but the data is not structured in a way that really allows us to make that case.

It sure sounds good, but that wasn’t possible to evaluate here in any way.

It’s reassuring to see that such a high proportion of patients achieve stabilization. The data in this paper would suggest that stabilization just might occur faster with dutasteride (3-4 months) than finasteride (6-7 months) but numbers are small and it’s not really possible to make that in any solid confirmatory manner. These are areas for further study. Other research studies have given a signal that dutasteride just might be more effective than finasteride.

It does seem in this paper by Moussa and colleagues that the authors try to point out to readers that topical minoxidil is probably less useful in FFA than oral minoxidil. They first remind us that based on previous reports, topical minoxidil monotherapy appears of little benefit in halting FFA progression. This is true. However, when we look at the 2019 report  by Garmet et al that they quote we see that those authors state that “Based on these findings it is reasonable to conclude that (topical) minoxidil may be most beneficial when combined with other therapies for the treatment of FFA and when there is a condition of mixed FFA and androgenetic alopecia, which is common.

The reality is that in this 2022 study by Moussa and colleagues we don’t really have much good evidence that oral minoxidil monotherapy is all that consistently helpful and we really only have data that suggests that just like topical minoxidil - oral minoxidil too seems beneficial when combined with other therapies.

Clearly more studies are needed.

What we can conclude from the Moussa et al paper is that 2/3 of male patients with FFA should have reasonable good outcomes - at least in the short term. What happens over 10 and 20 years is not clear and never has been studied. How best to treat the other 1/3 of patients with poorer outcomes is also open to debate.

REFERENCE

Moussa A et al. Clinical features and treatment outcomes of frontal fibrosing alopecia in men. Int J Dermatol. 2022 Jun 21

Gamret AC, Potluri VS, Krishnamurthy K, et al. Frontal fibrosing alopecia: efficacy of treatment modalities. Int J Women’s Health 2019; 11: 273–285.