Hair Transplantation for Frontal Fibrosing Alopecia

Donovan FFA Hair Transplant Candidacy Criteria

The criteria we use in our clinic for evaluating FFA candidacy are more strict and rigorous than the criteria we use for lichen planopilaris. Hair transplants for FFA can be successful, but the overall chances of success are lower than for LPP. 

In order to be a candidate for hair transplant surgery,  ALL FIVE of the following criteria must be met in a patient with FFA:


1.  The PATIENT should be off medications.

Ideally the patient should be off all topical,  oral and injection medications to truly know that the disease is "burned out (burnt out)". However, in some cases, it may be possible to perform a transplant in someone using medications AND who meets criteria 2, 3 and 4 below.  This should only be done on a case by case basis and in rare circumstances. It is a last resort in a well-informed patient. 


2. The PATIENT must not report symptoms related to the FFA in the past 24 months. 

The patient must have no significant itching, burning or pain. One must always keep in mind that the absence of symptoms does not prove the disease is quiet because FFA tends to be quiet a silent condition anyways. In FFA, the presence of symptoms raises suspicion the disease could be active.  Even the periodic development of itching or burning from time to time could indicate the disease has triggers that cause a flare and that the patient is not a candidate for surgery. The patient who dabs a bit of clobetasol now and then on the scalp to control a bit of itching may also have disease that is not completely quiet. 


3. The PHYSICIAN must make note of no clinical evidence of active disease in the past 24 months. 

There must be no scalp clinical evidence of active FFA such as perifollicular erythema, perifollicular scale (follicular hyperkeratosis). This assessment is best done with a patient who has not washed his or her hair for 48 hours. Some scalp redness may be persistent in patients with scarring alopecia even when the disease is quiet. Therefore scalp redness alone does not necessarily equate to a concerning finding. Perifollicular redness however is more concerning for disease activity.  In addition, the patient must have no evidence in the scalp for active lichen planopilaris. In addition, the pull test must be completely negative for anagen hairs and less than 4 for telogen hairs.  A positive pull test for anagen hairs indicates an active scarring alopecia regardless of any other criteria.

In addition to the scalp, there should be no NEW changes in body hair or eyebrows in the past 12 months.  Even if the scalp is quiet, new eyebrow loss indicates an increased change for disease flare following surgery. 


4. Both the PATIENT and PHYSICIAN must demonstrate no evidence of ongoing hair loss over the past 24 months.  

There must be no further hair loss over a period of 24 months of monitoring off the previous hair loss treatment medications. This general includes the patient and physician's perception that there has been no further loss, physician's measurements from the glabella to the frontal hairline showing no changes, as well as serial photographs every 6-12 months showing no changes. 


5. The patient must have sufficient donor hair for the transplant.

Not all patients with FFA have sufficient donor hair even if their disease has become quiet.  This is because many also have coexistent lichen planopilaris.


In situations where there is concern that the FFA may be active or concern that the surgery may not be a success, strong consideration should be given to performing a 'test session' of 50-100 grafts and observing their survival over a period of 6-9 months.

Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887

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