How do we prevent progression from eyebrow FFA to scalp FFA?

How do I stop by scalp from developing FFA?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in the management of frontal fibrosing alopecia (FFA).

Question

I am 47 years old and have eyebrow loss that my dermatologist feels is FFA. My mother has FFA and so we think my recent loss is also FFA. I have menopause at 41 which seems to fit well with the condition.

I want to know if there is anything I can do right now to stop the stop from becoming involved. My dermatologist does not see any signs whatsoever of FFA in the scalp.

My eyebrows are doing okay with Latisse and Rogaine as well as steroid injections every few months.

Answer

Thank you for this question.

The immune system has a plan for each person and we do not know what exactly that plan is for any given person and it's different for different people. If one wants to reduce the chances of scalp involvement then systemic medications may be needed.

Eyebrow loss can be treated with the options in the following chart. You are already on a solid plan with many of these. I often start with ONE OR MORE of minoxidil, bimatoproast, pimecrolimus and steroid injections and then see how the eyebrows respond. If we are successful then these are the options.

Reducing the chances of scalp involvement in the future may require one or more of the systemic agents (pills) shown in the list below. You may want to have a good discussion with your dermatologist about these various options as there are some reasons why some women can not use these medications at all. The key decisions in my mind would be for you and your dermatologist to figure out where dutasteride, finasteride, isotretinoin or hydroxychloroquine fit in. For many patients, it could be that getting on dutasteride is among the best steps and then waiting to see if any FFA develops.

Preventive Measures in FFA Have Not Been Studied

Your question is such a great one. The best way to prevent FFA of the scalp in someone with eyebrow FFA has not been well studied. For now, most physicians treat and address hair loss as it happens. This is probably not the best plan but most things we do in modern medicine are reactive rather than proactive.

Your point is a very good one and we do need to be thinking about the potential for future scalp hair loss. My feeling is that confirmed eyebrow FFA requires at least one systemic treatment and very very very close follow up. I would advise that a patient take photos every 4-6 months of the eyebrows, eyelashes, frontal hairline, crown, back of the scalp and sideburns.

If there is any evidence that FFA of the frontal hairline develops, then oral isotretinoin together with pimecrolimus cream and steroid injections can be started. Again, close follow up every 3-5 months will be needed to determine if this treatment plan is effective. If not, adding an antihistamine like cetirizine together with hydroxychloroquine would be the way I’d go in the present day (date of this post!)

Thanks again for the question