Estrogen, Anti-estrogens and Frontal Fibrosing Alopecia: What have we learned ?

Loss of Estrogen and Use of Anti-Estrogens May have a Role

Frontal fibrosing alopecia is a type of scarring alopecia which is becoming more common around the world. The condition typically affects peri-menopausal and post menopausal women. The disease may start with reduction in eyebrow density and recession of the frontal hairline. Other areas including eyelashes, body hair and hair on other regions of the scalp may be affected.

It is increasingly clear that hormonal factors are involved in the development of frontal fibrosing alopecia. Abnormalities in androgens and estrogens are thought to be involved.

Declining estrogens may have a role in women who are predisposed to develop this condition. The peri-menopausal period is well understood to be associated with steadily declining estrogen. A 2018 case control study by Buendia-Castrano and colleagues showed that menopause occured earlier in women with FFA. This data came from examining records of 104 female FFA patients and 208 controls. The same authors found additional data that interruption of estrogen signaling may have a role - the anti-estrogen tamoxifen was found to be associated with a nearly 15 fold greater risk of developing FFA.

Other studies have also supported the notion that low estrogen environments are somehow associated with the development of FFA. Imhof and colleagues in 2018 showed that 13 % of women in their study had a history of surgically induced menopause through hysterectomy. This data has raised the question as to whether the incidence of hysterectomy is higher than we previously had considered. In the same line of thinking, studies dating back to 2014 showed the early menopause was detected in 14 % of FFA patients.

Premature menopause is defined as menopause occurring in women under 40 years of age. Overall, about 1 % of women in the general population have premature menopause making the condition not really all that rare. The fact that 14 % of women with FFA may have early menopause draws attention to this as a contributing factor.

Conclusion

It is increasingly clear that the decline of estrogen has some sort of a role in FFA. It’s too simple to say that it’s the main reason. All women enter menopause but yet only 1 in every 5000 to 10000 develop FFA. it may be that the decline in estrogen in women who have some sort of a genetic predisposition promotes the development of this autoimmune hair disease. More studies are needed.

Reference

Buendia-Castrano D et al. Hormonal and Gynecological Risk Factors in Frontal Fibrosing Alopecia: A Case-Control Study. Skin Appendage Disord. 2018 Oct;4(4):274-276. doi: 10.1159/000484210. Epub 2017 Dec 8.

Imhof et al. Frontal Fibrosing Alopecia in Women: The Mayo Clinic Experience With 148 Patients, 1992-2016. Mayo Clin Proc. 2018 Nov;93(11):1581-1588. doi: 10.1016/j.mayocp.2018.05.036.

Vano-Galvan et al. Frontal fibrosing alopecia: a multicenter review of 355 patients. J Am Acad Dermatol. 2014 Apr;70(4):670-678. doi: 10.1016/j.jaad.2013.12.003. Epub 2014 Feb 5.