Hair Systems vs Wigs for Scarring Alopecia: Which should I consider?

Is a hair system possible for someone with active scarring alopecia?

Scarring alopecia is a form of hair loss which can lead to permanent bald areas on the scalp. Treatments focus on helping to stop hair loss but do not improve hair in most. Some individuals elect to purchase a wig, hairpiece or hair system while receiving treatment.  For the purposes of the discussion that follows, I will specifically use the term hair system to refer to a scalp camouflaging method whereby synthetic or human hair is attached to a layer of some sort and glued to the scalp with some type of adhesive. I will use the term wig or hairpiece to include a broad array of similar products that attach via clips, tape or elastic.

Two Key factors to consider

The are quite a few factors that go into deciding what type of wig, hairpiece or hair system is appropriate for someone with scarring alopecia. The two main factors to consider when I am meeting with a patient trying to decide what type of system they should purchase are the following: 

(1) How active is the scarring alopecia right now? 

(2) Does the patient need topical steroids, steroid injections or special shampoos as part of his or her ongoing management strategy? 

(1) How active is the scarring alopecia right now? 

If a patient has a very active scarring alopecia (with many symptoms and/or rapid hair loss), it will be important to consider choosing a hair piece or wig with clips or tape over a hair system that is attached to the scalp with adhesive. A patient with an active scarring alopecia needs to have the scalp examined often to determine if treatment is working and to modify the exact treatment.  For some scarring alopecias like folliculitis decalvans it may be important in some cases to frequently shampoo the scalp with antibacterial agents.  An easily removable wig or hairpiece is preferred.

As the scarring alopecia becomes "quieter" it may be possible to consider  shifting to a hair system and more permanent types of adhesive-based attachments. I generally ask patients to coordinate removal of the hair system at their salon on the same day as their follow up appointment with me or if that is not possible to have good pictures taken at the salon in the day that their system is removed, washed and reapplied (generally referred to as a "servicing).

(2) Does the patient need topical steroids, steroid injections or special shampoos as part of his or her ongoing management strategy? 

For patients who answer yes to the above question, a wig or hairpiece will be preferred over a hair system. Topical steroids and steroid injections can be the mainstay of treatment for many patients with scarring alopecia. Even in relatively quiet scarring alopecias, topical steroids may still be needed every few days. For very active scarring alopecias, steroid injections may be needed monthly. As mentioned above under point (1), for some scarring alopecias like folliculitis decalvans it may be important in some cases to frequently shampoo the scalp with antibacterial agent. Therefore, in such cases where there is active disease, a more permanent hair system becomes either impractical or inconvenient. It needs to be removed for these treatments to be properly administered and this is not easy if a hair system is glued to the scalp. 

 

Conclusion

All in all, these are the discussions that patients will want to have with their dermatologist. If topical steroids are needed daily and steroid injections are needed monthly for example (for very active disease) use of a hair system with an adhesive is less preferred over wigs or hairpieces with clip attachments or tape. If possible, these are discussions the dermatologist might have with the wig salon itself to best coordinate the proper care of the patient .

Lichen planus of the hair follicle (lichen planopilaris)

Lichen planopilaris (LPP). In follow up to yesterday's post, here is another example of a hair follicle injured by the inflammatory and scarring reaction that occurs beneath the skin surface in LPP.

Injured hairs in Lichen planopilaris (LPP)

LPP: A Scarring Hair Loss Condition

Lichen planopilaris ("LPP") is a scarring alopecia (scarring hair loss condition). Inflammation first develops around hair follicles which triggers the development of scar tissue (fibrosis) around hairs. This inflammatory reaction causes hairs to eventually die. One such injured hair is shown in the photo.

Many patients first develop scalp itching, burning and tenderness. Once a hair is destroyed, it can not regrow. Early recognition of the disease and aggressive treatment and frequent monitoring is essential.

Lichen planopilaris: A closer look at "follicular hyperkeratosis"

Follicular hyperkeratosis = Perifollicular scale

Lichen planopilaris (also known as "LPP") is a scarring hair loss condition. Individuls affected by the condition develop hair loss, increased hair shedding along with scalp itching, burning and pain.

Scaling in LPP

An up close examination with dermoscopy is shown here and shows classic features including white scale around hairs in early stages. This scale is known as "perifollicular scale" or "follicular hyperkeratosis." This scale is often prominent in active stages of the disease. It can be reduced by treatment and even reduced to some extent by a good shampooing of the scalp.

Treatments for LPP

Treatments include topical steroids, steroid injections, topical calcineurin inhibitors, and oral treatments such as doxycycline, hydroxychloroquine (Plaquenil), methotrexate, mycophenolate mofetil, cyclosporine, and others. Lasers, including the 308 nm excimer laser may also provide benefit.

Is Lichen Planopilaris Caused By A Fungus?

Lichen planopilaris is the long name given to a type of scarring hair loss condition. It is sometimes referred to as follicular lichen planus. The name "lichen" comes from the skin lesions of lichen planus that some patients with lichen planopilaris also have. The skin lesions are flat just like lichens that one might see walking in the forest. 
Lichen planopilaris is not due to a fungus. It is an autoimmune inflammatory condition that causes permanent hair loss. Treatments include anti-inflammatory agents not antifungal agents.

Hair transplants for Scarring Alopecia

How successful are hair transplants in scarring alopecias?

This is an in important question and one that needs good data. I serve as the chair of a committee of the International Society of Hair Restoration Surgery. On Friday we sent out a survey to hair transplant surgeons around the world with the hopes of gathering more information on the successes and failures surgeons have had when transplanting scarring alopecias.

There is no doubt that hair transplantation works wonderfully in some patients with scarring alopecia and does not work well in others. One must always have quiet (inactive) disease for at least 1-2 years before a transplant is attempted.

 

What are the criteria for transplanting scarring alopecia?

In general, a scarring alopecia must be quiet for 1-2 years before a transplant can be even considered. Several years ago I put forth criteria for determining if an individual with lichen planopilaris is a hair transplant candidate:

 

Criteria for Hair Transplantation Candidacy in LPP

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 burnt out and ‘inactive’. However, in RARE 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 as the risk for disease reactivation is high.  A patient using medications to suppress disease activity is at high risk for reactivation following hair transplant surgery. It is a last resort in a well-informed patient.

2. The PATIENT must not report symptoms related to the LPP in the past 12 months, (and ideally 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 but the presence of symptoms certainly 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 LPP in the past 12 months, (and ideally 24 months).

There must be no scalp clinical evidence of active LPP such as perifollicular erythema, perifollicular scale (follicular hyperkeratosis). In addition, the pull test must be negative. 

4. Both the PATIENT and PHYSICIAN must show no evidence of ongoing hair loss over the past 12 months (and ideally 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 as well as serial photographs every 6-12 months showing no changes.  As discussed above, the 12 month waiting time is the standard of care as an accepted definition for hair transplant candidacy.

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

Not all patients with LPP maintain sufficient donor hair even if the disease has become quiet. 

 

Disease Reactivation Following Surgery

My research has focused on the chances of reactivation of LPP after surgery. It is important to be aware that ANY patient with LPP is at risk for reactivation or a 'flare' of their LPP after surgery.  The risk, I estimate, is as follows:

LPP Reactivation Risk (Donovan, J, unpublished data)

i)               A patient with active LPP before their transplant is nearly guaranteed to have a flare of his or her LPP if a hair transplant is done. (estimate 90-100 % chance of flare within 2 years post transplant)

ii)             A patient with partially active LPP before their transplant is very likely to have a flare if a hair transplant is done. (estimate 70-90 % chance of flare within 2 years post transplant)

iii)            A patient with medication induced inactive LPP before their transplant has a moderate chance of a flare if a hair transplant is done (estimate 50-70 % chance of flare within 2 years post transplant)

iv)            A patient with inactive LPP off all medications for 1 year before their transplant has a low chance of a flare if a hair transplant is done (estimate 10-25 % chance of flare within 2 years post transplant)

v)             A patient with inactive LPP off all medications for 2 years before their transplant has a low but definite chance of a flare if a hair transplant is done (estimate less than 10% chance of flare within 2 years post transplant)

Atrophy in FFA: Is it from my topical steroids?

Atrophy in FFA is often from the disease itself 

A common concern from patients with FFA is that their steroids caused atrophy. By atrophy we mean thinning of the skin. Patients with atrophy have thin skin, visible veins. In FFA atrophy leads to blue veins becoming easy to see throughout the frontal scalp and especially at the temples. Patients want new options for treating the disease because they are worried about the atrophy.

FFA Causes Atrophy

There is one assumption that is often wrong here - and that is that steroids are the sole cause of atrophy in FFA. MOST of the time the steroids are not the main cause of the atrophy ! It is very important to keep in mind that the disease itself causes atrophy and visible veins. It is certainly very true that the steroids can cause atrophy too. But FFA itself is usually the leading cause of atrophy in patients with FFA. Many many patients with FFA who have never used steroids can have atrophy - some severe. In fact, severe atrophy is one of the so called poor prognosis signs in FFA. 

Treatment Considerations for Patients with Marked Atrophy

When patients show a considerable amount of atrophy, I usually try to limit this by using non steroids instead of steroid. Non steroids such as pimecrolimus (Elidel) and tacrolimus (Protopic) do not cause atrophy. They seem equivalent although no comparison studies have been done.  My previous research has also shown that finasteride and dutasteride may actually reverse atrophy in a proportion of patients. 

Frontal Fibrosing Alopecia (FFA)

Other than the Front, What is Affected?

Frontal fibrosing alopecia (FFA) is a scarring alopecia that affect women to a much greater extent than men. In FFA the frontal scalp is typically affected. However, the name does not capture the full extent of the hair loss. Patients with FFA frequently develop hair loss around the back of the scalp (behind the ears and very back above the neck), and frequently in the middle of the scalp as well. Eyebrows, eyelashes, arm hair, leg hair, underarm hair and pubic hair are frequently affected.

Partially Treated Lichen Planopilaris

 Scale Gone, Redness Remains

Lichen planopilaris (LPP) is a scarring hair loss condition. The goal of treating LPP is to stop the condition. Successful treatment is associated with a halting of hair loss but also with an improvement in the symptoms and signs of the disease. Patients will notice a reduction in itching and burning and clinically there will be an improvement in scaling and redness around hairs. Sometimes scaling is the first to improve and improvements in redness happen later. This picture shows a patient with partially treated lichen planopilaris. The disease is still active although scaling has improved. The patient's itching has also improved.

Sea of Singles (SOS): A Potential Sign of Scarring Alopecia

Lichen planopilaris (LPP) is a type of scarring hair loss condition. Patients frequently present with scalp itching, and sometimes scalp burning and tenderness. Increased hair shedding is common in the early stages. Hair loss is generally permanent and treatment helps stop the disease or at least slow down progression.

Clinically, dermoscopy (trichoscopy) of LPP often shows perifollicular erythema and perifollicular scale (follicular keratosis).

These findings are not present in all forms of LPP. A less common presentation of LPP is shown in the photo. Patients have hair loss with scalp itching. However, by dermoscopy they have many single hair follicles growing in a base of redness. This is what I have termed the "sea of singles" (SOS) appearance to describe the numerous single hairs and absence of hair follicle units containing 2 and 3 hairs. This form of LPP is similar to Abbasi's subtype described in 2016 and fibrosing aloepcia in a pattern distribution described by Zinkernagel in 2000. The "SOS" trichoscopic appearance is important to remember and provides a clue that the patient may have a scarring alopecia.

 

Reference

Zinkernagel MS et al. Arch Dermatol 2000

Abassi A et al. Dermatol Surg. 2016.

Oral Immunosuppressants for Lichen planopilaris: should I increase my dose?

Dosing oral immunosuppressants for Lichen planopilaris (LPP)

There are many different immunosuppressants and immune modulators that can be used for treating lichen planopilaris. Examples include doxycycline, hydroxychloroquine, methotrexate, mycophenolate, cyclosporine.  I'm often asked what dose a patient should be using? 

What dose should a patient be using? 

When it comes to immunosuppressant medications, I always try to keep patients on the lowest possible dose that controls their disease. Generally I start at fairly standard doses of immunosuppressants and observe what happens to the patient's hair loss. For example, this might be 200 or 400 mg of hydroxychloroquine (Plaquenil) daily, 15-20 mg of methotrexate weekly, 150-300 mg of cyclosporine, 500-1000 mg of mycophenolate mofetil, 100 mg of doxycycline. If the disease is vastly improved after a few months, we may consider going down on the dose or staying at the same dose for a few more months. If the disease is getting worse, we might consider going up on the dose is their is room to go up or changing the immunosuppressant altogether. 

Nausea with Doxycycline: What strategies can help reduce nausea?

Doxycycline and Nausea

Doxycycline is an antibiotic. It's used of course in treating infections but it is commonly used for a variety of scarring alopecias including lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia, folliculitis decalvans and sometimes dissecting cellulitis.

The drugs has two important properties: it stops infection and reduces inflammation. For some conditions such as lichen planopilaris, it's the anti-inflammatory properties that are useful. For other conditions such as folliculitis decalvans, it's the anti-bacterial and anti-inflammatory properties that are key. 

The drug has a number of potential side effects even though it is generally well tolerated for most. It can cause nausea, vomitting, sun sensitivity, headaches, increased chance of yeast infections in women, rash. 

Doxycycline and Nausea

Some patients developed considerable nausea with doxycycline. Some will even vomit.  This can be a short term issue for some users which improves over time. For others it is something that continues and may even require the patient to stop the medication.  Anyone with nausea from doxycycline should speak to their prescriber for advice on how to reduce the nausea. 

Tips to reduce nausea

1.  Take doxycycline with food. Unlike tetracycline, doxycycline still gets absorbed quite well into the blood stream if the patient takes it with food. The food intake really helps to reduce nausea and this should be encouraged

2.  Avoid spicy foods with the doxycycline. Anything that upsets the stomach has the potential to makes things worse with doxycycline. I generally recommend avoiding spicy foods with doxycycline. 

3. Take Gravol.  If nausea continues despite food intake, dimenhydrate (Gravol) can be used 1 hours before the doxycycline is taken. I generally recommend starting with 25 mg Gravol and then 50 mg and then 100 to see what dose can help reduce the nausea. Gravol can make people drowsy and sleepy so this needs to be considered if one is driving or doing anything that requires focus. 

4. Use Ginger. Ginger is also a helpful anti-nausea treatment. There are a number of candies, lozenges on the market that contain ginger and can be used prior to the patient taking the doxycycline. The company that makes Gravol also has a product "Ginger-Gravol" which can be very helpful. this does not contain Gravol and therefore does not cause drowsiness.

5. Reducing the doxycycline dose. For some users, the nausea is dose related. Reducing the dose can help.

Tetracyclines for Scarring Alopecia: Which one should I use?

Tetracycline Antibiotics for Scarring Alopecia

Tetracycline, Doxycyline and Minocycline are members of the tetracycline family of antibiotics. These drugs are commonly used to fight infection but are also frequently used for their anti-inflammatory effects and are therefore used in a variety of scarring alopecias including lichen planopilaris, frontal fibrosing alopecia, and pseudopelade. 

These medications have several well known mechanisms for halting inflammation: they inhibit matrix metalloproteinases, they inhibit angiogenesis, they have antioxidant effects and they block the production of various pro-inflammatory cytokines. 

In terms of treatments for lymphoctic scarring alopecias, all these drugs are fairly similar in terms of efficacy but good studies have yet to be published. Personally I prefer doxycycline over others. 

Doxycycline is the most commonly prescribed tetracycline family member. It can be taken with food and tends to have the least overall chances of side effects compared to minocycline and tetracycline. That is not to say of course it does not have side effects because it certainly does. Doxycycline can cause upset stomach, headaches and tends to be the most photosensitizing.  Headaches and raised intracranial pressure are a rare side effect but nevertheless must be respected. Immediate cessation of the drug and medical attention is needed in anyone with persistent headaches on doxycycline. Women using doxycycline are at increased risk for vaginal yeast infections. The dose is 100 mg once to twice daily. The medication should be taken while seated upright and with plenty of water to avoid heartburn and esophagitis. Doxycycline is safer than tetracycline (see below) for use in those with kidney disease.

Recently, the possible use of low dose sub-antimicrobial doses of doxycycline have emerged on the market. This is sometimes referred to as "SD" or sub-antimicrobial dosing." Such medications are frequently used for inflammatory conditions such as rosacea. I frequently use these drugs in patients with scarring alopecia who I want to transition off higher doses doxycycline. Doxycycline formulation Oracea was approved by the FDA in 2006. Side effects are less than 100 mg conventional doxycycline but may not be appropriate as a first line off label treatment for active scarring alopecias.

Tetracycline is less expensive than doxycycline which is great but it needs to be taken on an empty stomach.  This makes it less convenient. The dose is typically 500 mg twice daily for typical dosing in lichen planopilaris but this can sometimes be increased to three times daily. It must not be used in those with kidney disease and used only with extreme caution in those with liver disease. It must never be used during pregnancy and never in children (particularly under 8 years due to effects on teeth and bones). Tetracycline is less photosensitizing than doxycycline but caution is still needed. Tetracycline is more photosensitizing than minocycline.

Minocycline can sometimes be associated side effects that are not seen commonly with other tetracycline members including a serious lupus like phenomenon and other side effects like malaise and joint pains. Minocycline is a much more frequent cause of serious reactions like hypersensitivity reactions, serum sickness like reactions and single organ dysfunction. Pigmentation issues are also possible. It is less photosensitizing compared to doxycycline and tetracycline. The dose is 100 mg daily and doses up to twice daily may also be considered. Similar to tetracycline and doxycycline, minocycline must never be used in pregnancy.

All in all, one should speak with his or her dermatologist about other specific side effects of the tetracycline group. These medications may be taken for many months to even several years in those with scarring alopecia. Patients should not use retnoid medications while using tetracyclines. Moreover one should not consume iron, magnesium, calcium or aluminum at the same time as their tetracycline as these bind to the tetracycline and block absorption. Tetracyclines (all 3 members) must never be used during pregnancy and never by children under 8 due to teeth discoloration.

Dissecting Cellulitis (DSC)-Healed Sinus Tracts

Dissecting Cellulitis (DSC), is a rare scarring hair loss condition that is characterized by deep inflammation and leads to the formation of draining sinus tracts (especially tunnels that allow pus and inflammation to escape). The diagnosis of DSC in advanced stages is easy as these openings (sinus tracts) can be seen all over the scalp. In early stages, up close exam and use of a dermatoscope can prove extremely helpful.

Early DSC is characterized on dermoscopy by large yellow dots, thin vellus hairs within the area, broken hairs and healing (covered) or open sinus tracts. This picture shows a sinus tract at an earlier stage than the picutre yesterday (panel 4 in our 5 day series). There is inflammation in the skin which gives a red color.

Dissecting Celluliti(DSC)

Healed Sinus Tracts

We will continue our week's theme of Dissecting cellulitis (DSC), a rare scarring hair loss condition. It is characterized by deep inflammation and leads to the formation of draining sinus tracts (especially tunnels that allow pus and inflammation to escape). The diagnosis of DSC in advanced stages is easy as these openings (sinus tracts) can be seen all over the scalp. In early stages, up close exam and use of a dermatoscope can prove to be extremely helpful.

As seen yesterday, early DSC is characterized on dermoscopy by large yellow dots, thin vellus hairs within the area, broken hairs and healing (covered) or open sinus tracts. This picture shows a healed sinus tract (arrow).

Dissecting cellulitis (DSC)

Dissecting cellulitis (DSC) is a rare scarring hair loss condition. It is characterized by deep inflammation and leads to the formation of draining sinus tracts (especially tunnels that allow pus and inflammation to escape - see number 1 and 4 in the picture). The diagnosis of DSC in advanced stages is easy as these openings (sinus tracts) can be seen all over the scalp. In the early stages an up close exam and use of a dermatoscope can prove extremely helpful.

Early DSC is characterized on dermoscopy by large yellow dots, thin vellus hairs within the area, broken hairs and healing (covered) or open sinus tracts. The early stages of the nodule can mimic alopecia areata (see top right, number 3 and 5). A swiss cheese like appearance is common as scarring progresses (number 2). Biopsies of DSC often show deep inflammation but in more advanced cases show inflammation higher up in the skin which can easily be mistaken for another scarring alopecia known as "folliculitis decalvans." Therefore, it is not uncommon for patients to be referred with a diagnosis of biopsy "proven" folliculitis decalvans only to need to explain to them after examining their scalp that what they actually have is DSC.

AGA or LPP: Who is right?

In many fields of medicine, the pathology report provides the final answer as to a patient's diagnosis. We're most familiar with this for example with cancer diagnoses. It comes as a surprise for many patients that scalp biopsy reports are sometimes not so definitive.

Differentiating AGA and LPP

A great example is the diagnosis of early androgenetic alopecia (AGA and early lichen planopilaris (LPP). Sometimes it is pretty clear cut - but not always. Sometimes a diagnosis of LPP is made and the patient really has AGA. Sometimes (although much less commonly) a diagnosis of AGA is made and the patient really has LPP.

LPP: Brief Overview

Lichen planopilaris (LPP) is a scarring alopecia that typically starts with scalp symptoms such as itching and burning. Sometimes the scalp is quite tender in areas. Shedding is often present as well. LPP affects similar areas to androgenetic alopecia (female pattern thinning) so it is a close mimicker. In the early stages, some scalp redness may be present and inflammation may be seen around the hairs clinically. 

AGA: Brief Overview

Androgenetic alopecia (AGA) also starts with shedding. There can be a hint of itching/tingling but not too often. Usually the front of the scalp is more affected by hair loss than the back. 

Biopsies: Helpful or not?

A biopsy can be very helpful provided it is read by an experienced dermatopathologist. Traditionally we have thought of AGA as "non inflammatory" and "non scarring" so one might not think that inflammation and scarring should be present on the biopsy. We know now that's not completely true.  Inflammatory infiltrates are present in AGA in the upper hair follicle and so is loose perifollicular fibrosis. In LPP biopsies, inflammation is also present in the upper hair follicle but it specifically appears to be attacking the hair follicle outer root sheath. (We call this "lichenoid" change). To differentiate AGA and LPP one needs to direct their attention to this specific change in the actual hair follicle. When this specific immune attack is seen, one needs to consider LPP over AGA. Also the amount of perifollicular fibrosis is usually greater as LPP advances. LPP may have other changes in the skin as well that help differentiate it from AGA.

So by biopsy,  androgenetic alopecia and LPP can be confused as both can have inflammation (perifollicular inflammation in the isthmus) and both can have scarring (perifollicular fibrosis).  An experienced dermatopathologist can sort this out. 

So how does one resolve this? Does the patient have AGA or LPP?

One needs to take into account the patient's entire story. If a physician just biopsies every patient that comes into the office, I can guarantee one will make a whole lot more diagnoses of LPP than truly are present. I'm a big believer in this - even though LPP is under diagnosed in the world!  But by listening to the patient's entire story, and examining the scalp and reviewing what the biopsy shows (not just the final read out on the bottom line), one can usually get a fairly good sense. However in rare cases - time is the best judge as a missed case of LPP will likely declare itself over time.

Minoxidil in FFA: Does it help?

I frequently get asked whether minoxidil has any benefit in treating frontal fibrosing alopecia (FFA). It seems that it could provide some benefit but it's not completely clear yet if it is truly helping the patient's FFA or their underlying androgenetic alopecia that many patients with FFA also have. Large scale studies are needed. 

I generally add minoxidil once I have some evidence that a patient is stabilizing with their main anti-inflammatory treatment. This typically includes one or more of topical steroids, steroid injections, doxycycline, hydroxychloroquine and anti-androgens such as finasteride or dutasteride. 

It’s interesting that 32 % of patients in one study had an improvement in their FFA with use of anti-androgens. When one looks at a larger group of 111 FFA patients of which 74.8 % were using minoxidil, one notes that 47 % of patients had an improvement with anti-androgens. So it does seem that patients using minoxidil had better outcomes. There is at least some suggestion here that minoxidil might help. 

Conclusion

Up to 40 % of patients with FFA have androgenetic alopecia so it’s difficult sometimes to decipher whether minoxidil is truly helping the patient’s FFA or whether it is helping their underlying androgenetic alopecia. More good studies are needed.

Reference

Vano-Galvan S et al. Frontal fibrosing alopecia: a multicentre review of 355 patients. J Am Acad Dermatol 2014; 70: 670-678

Is sunscreen use more common in men with FFA?

This is a controversial topic but this study (as well as a study of FFA in women) has caught the attention of many. A study by Kidambi et al compared how 17 men with FFA and 73 men without FFA responded to a lengthy survey. FFA is relatively rare in men but information on a link to sunscreen use was important to investigate given the possible role among women.

A much greater proportion of men with FFA reported using sunscreens (as well as facial moisturizers) at least twice weekly compared to men without FFA. Specifically, 35 % of FFA patients reported such sunscreen use compared to just 4 % of men without FFA.
 

Conclusion

We have a long way to go to definitely prove sunscreens have a role. But two studies now (one in men and one in women) have described potentially the first environmental factor implicated in the way FFA develops. An environmental factor is certainly thought to be responsible given that FFA was relatively unheard of 20 years ago. There are more good studies that are needed.
 

Reference

Aldoori N et al. Frontal fibrosing alopecia: possible association with leave-on facial skin care products and sunscreens; a questionnaire study. Br J Dermatol 2016.

Kidambi AD et al. Frontal fibrosing alopecia in men: an association with facial moisturizers and sunscreen. Br J Dermatol 2017.

Does smoking prevent FFA?

The short answer is that we do not know. A 2017 study by Fonda-Pascual suggested that smoking was somehow protective against the development of FFA and that non-smokers had more severe disease. Other studies, including a study by Dr Messenger's group from the UK did not show this link.

Conclusion

To date, there is no solid information available to suggest that smoking either causes FFA or prevents the development of FFA. Large scale studies will help answer the question for good.
 

References

Aldoori et al. Br J Dermatol 2017.
Fonda-Pascual et al. JEADV 2017.