Microblading for FFA Patients Using Isotretinoin

Is eyebrow microblading safe for FFA patients using isotretinoin?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts regarding isotretinoin and procedures for patients with FFA.

Question

I am a 54 year old female with frontal fibrosing alopecia. Similar to many women, I have lost a significant amount of eyebrows. My scalp FFA has improved a great deal with use of dutasteride, isotretinoin, pimecrolimus and steroid injections. My eyebrow hair loss has halted but unfortunatley it has not grow back.

I am considering microblading for my eyebrows. The lady I see won’t do the microblading if I’m on isotretinoin and says I need to be off 6 months or more. Obviously, I am terrified to stop as it’s helped my scalp and facial bumps a very significant amount.

Should I stop the isotretinoin?

Thank you for your question section of the website so that we can ask questions of this kind.

Answer

Thanks for the great great question.

Isotretinoin is a vitamin A derivative and can affect many parts of the skin including the epidermis, sebaceous gland, and even collagen formation. The diverse affects of isotretinoin on wound healing have generated a long debate about whether patients who use isotretinoin are more likely to have poor wound healing or worse yet - develop a keloid or hypertrophic scar - if they undergo surgery or a procedure on the skin.

In fact, the US FDA advises against patients having laser resurfacing procedures within 6 months of use of isotretinoin.

The general recommendations to avoid surgical procedures have been called into question by various experts around the world in the last few years.

Tattooing in the Eyebrow Region in FFA

It appears that tattooing in the eyebrow area is likely to be safe in patients with FFA who use low doses of isotretinoin (under 10 mg daily). One should be aware that large scale studies have not yet been conducted in FFA but certainly we have had many stable patients in our clinic on low doses of isotretinoin undergo various tattooing procedures without issue.

For those who question the safety, a thorough review of two articles would be advised:

Spring et al, 2017

In 2017 a panel of experts (Spring et al 2017) put forth recommendations on the safety of isotretinoin in various dermatological procedures. Thirty-two relevant publications reported outcomes of 1485 procedures. Overall, the authors concluded that “there was insufficient evidence to support delaying manual dermabrasion, superficial chemical peels, cutaneous surgery, laser hair removal, and fractional ablative and nonablative laser procedures for patients currently receiving or having recently completed isotretinoin therapy. Based on the available literature, mechanical dermabrasion and fully ablative laser are not recommended in the setting of systemic isotretinoin treatment” (Source: Spring et al 2017).

Mysore et al, 2017

In 2017, the Association of Cutaneous Surgeons of India also put forth a recommendation “that microneedling and microdermabrasion treatment can safely be performed in patients administered with isotretinoin”. The level of evidence was 2+ (backed up by well conducted case control studies or cohort studies) and the grade of the recommendation was given a C rating.

The formal view of the Association of Cutaneous Surgeons of India was that “there is insufficient evidence to support the current protocol of avoiding and delaying treatments in the patient group under consideration and recommends that the current practice should be discontinued. The task force concludes that performing procedures such as laser hair removal, fractional lasers for aging and acne scarring, lasers for pigmented skin lesions, fractional radio-frequency microneedling, superficial and medium-depth peels, microdermabrasion, dermaroller, biopsies, radio-frequency ablation, and superficial excisions is safe in patients with concurrent or recent isotretinoin administration.

Conclusion and Comment

My general feeling is that tattooing of eyebrow is likely to be pretty safe for patients with FFA who use low doses of isotretinoin. We have not had problems with patients who use 10 mg daily or less AND whose FFA is fairly stable. I am not a big fan of eyebrow tattooing in patients with super active FFA simply because I have never guided patients through tattooing unless the FFA is somewhat calm. Likely tattooing is even active FFA is safe but of course no data is widely available. We also don’t have patients on higher doses of isotretinoin.

If one is willing to accept a really low risk of problems, then eyebrow tattooing is wonderful - assuming an experienced and competent practitioner is doing the tattooing. Close follow up with the dermatologist is advised so that immediate action can be taken in the event there are problems (ie. administration of topical steroids, steroid injections, topical calcineurin inhibitors). It is fortunately very rare to have problems other than the side effects that anyone experiences with tattooing. The improvement in self confidence and feeling of well being after successful tattooing procedures is great.

If a patient with FFA is not comfortable with any risk whatsoever, then eyebrow tattooing might not be the right procedure for them. At minimum, such a patient should be off isotretinoin for 6 months if they are not comfortable with risk - but again I must emphasize that this is without evidence and one risks worsening their scalp FFA if they stop isotretinoin and the isotretinoin was helping them.

Eyebrow microblading has its own inherent risks (even without isotretinoin!!) so all risks need to be reviewed with the practitioners performing the procedure. Persistent redness, tattoo reactions, bumps, poor uptake of pigment, rapid fading of pigment, allergic reactions are all part of the side effects for anyone with or without FFA. One should never undergo tattooing without first reviewing what sorts of rare side effects occur in anyone.

Finally, one must be aware that pigments don’t always taken up quite as well in FFA. The skin is different in some patients and takes of pigments differently - so multiple procedures may be needed. One must never ever assume that the microblading outcome they will have will necessarily be the same as anyone else who does not have FFA. The skin is different and it’s possible for variations in outcomes.

Fortunately, most patients have really nice results and the vast majority of patients are really pleased with the decision to have microblading and other pigmentation procedures. One should carefully review the risks and benefits with the dermatologist overseeing care as well as the tattoo expert performing the procedure. A full understanding of risks and benefits is needed.

REFERENCE

Mysore V et al. Standard Guidelines of Care: Performing Procedures in Patients on or Recently Administered with Isotretinoin J Cutan Aesthet Surg. 2017 Oct-Dec; 10(4): 186–194.

Spring L et al. Isotretinoin and Timing of Procedural Interventions: A Systematic Review With Consensus Recommendations. JAMA Dermatol . 2017 Aug 1;153(8):802-809.

How long do I need treatment for my FFA?

How long do I need treatment for my FFA?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in treating FFA.

Question

I was diagnosed with frontal fibrosing alopecia last month. I’ve started on hydroxychloroquine and steroid injections. How long am I going to need to do this treatment?

Answer

Thanks for your question. Some patients with FFA need treatment for 1-2 years and some patients with FFA need treatment for 10-20 years. Some never can stop treatment without losing hair. It’s difficult to say for any given person how long they will need treatment but over time you’ll come to know the answer for yourself and your specific case.

The first step in treatment is to stop the disease so that it does not keep getting worse and worse. Once your doctor stops the disease, he or she will want to continue medications a bit longer and see if it stays quiet for many years or starting acting up again and causing more hair loss. If the conditions stays quiet, it may be possible to starting slowly ‘tapering” medications or reducing the dose bit by bit. If the disease stays quiet and you don’t start losing hair again when the dose is tapered then it means that things are truly quiet.

Step 1 therefore is to stop the disease

Step 2 is to keep the disease stopped

Step 3 is to slowly taper some medications (if possible)

There is a view out there in the internet that scarring alopecia simply burn out after a year or two. This is not correct. Some patients of course do have a form that goes inactive rather quickly. But not all do. Some patients need to try many different medications before they find a combination that finally stops the disease. some get the treatment right on the first try.

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

Treatment of Beard Hair Loss in Male Frontal Fibrosing Alopecia (FFA)

Beard Hair Loss in Males with FFA

I’ve selected this question below for this week’s question of the week. It allows us to review treatments for beard hair loss in males with FFA.

Question

I was diagnosed with LPP three months ago. My beard and hair are falling. Also persistent redness is in the beard area. My dermatologist started a steroid (1 month course) and 200 mg hydroxychloroquine treatment. We’re almost in the third month, but I continue see how my beard hairs are falling. Do you think is better to go with Methotrexate instead of keep trying with Hydroxychloroquine? I do not want to lose all my beard hair.

I am male, 34 yo, with itching and redness, hair shedding. I’m on hydroxychloroquine with oral Minoxidil and isotretinoin, healthy man, I’m in the third month of treatment, the hair starts to falling in March and begins in my beard, I lost some of the beard and hair.

Answer

Thanks for this really important question. In case you have not had a chance to review it yet, be sure to review the article on male frontal fibrosing alopecia that I wrote a few weeks ago. It summarizes all the studies on FFA in males published so far. As you’ll see in that article, there is alot of information summarizing the features of male FFA, but few that actually review treatment for FFA in males and fewer yet that specifically focus on the treatment of beard FFA.

It sounds like you are on a really good starting plan. My feeling is generally that I would not abandon a ‘potentially’ good treatment too soon. There is some evidence from medical studies that hydroxychloroquine can help males with FFA. I think that you and your dermatologist may want to make sure you are on an appropriate dose of hydroxychloroquine. Depending on your weight, it might be possible to go up on the dose. The following table is a guide:

It may be possible at this stage to add some very safe treatments to ‘help out’ the hydroxychloroquine and the isotretinoin. I can’t say what is right for you specifically as I don’t know all your information but this might include a mild topical steroid once or twice weekly and the use of a non-steroid like topical pimecroliumus, topical tacrolimus or having a compounding pharmacist make up topical tofacitinib (if possible to do so in your country). I do support using the non steroid quite often because the non steroid does not cause atrophy and generally won’t cause steroid telangiectasias (redness from dilated blood vessels). The beard area in FFA can often be red so we don’t want to over do the steroid effect.

I also advise many of my own patients to start oral cetirizine as this has a pretty good safety profile overall and may provide benefit. 10-20 mg is often used.

Oral minoxidil, isotretinoin and hydroxychloroquine are part of a really solid plan. These other options (cetirizine, topical steroid and topical non steroids) may help. As far as the scalp goes, I am a big fan of getting my own patients on topical or oral finasteride or dutasteride because of how well it helps the scalp. As far as the beard goes, we don’t have any evidence finasteride or dutasteride actually helps the beard in FFA but we also don’t have any evidence that it does not. It could be that finasteride and dutasteride are not only antiandrogenic - but antifibrotic or antinflammatory in some other way.

I would encourage you to take photos of the scalp and beard and eyebrows every 4 weeks. If you have not already, I would encourage you to take a set of photographs today. This will be really helpful as this is what is going to guide you and your doctors about what to do next.

There are two choices if the plan discussed above still does not seem to be working. The first would be to stop the isotretinoin and add oral doxycycline. Doxycycline can be used with hydroxychloroquine but doxycycline can not be used with isotretinoin due to an interaction between the two drugs. This step might be considered before methotrexate but there is nothing really wrong with going to methotrexate immediately next. One of the reasons I often recommend doxycycline over methotrexate to my own patients is because it is safer overall. I often combine hydroxychloroquine with doxycycline (100 mg once to twice daily) and cetrizine (10 mg to 20 mg daily) and add on low dose naltrexone (3 mg nightly) if needed. Topical fluocinonide “gel” is used on the beard once to twice weekly and topical tofacitinib or topical tacrolimus is used 3-5 times weekly on the beard.

In refractory cases, I start methotrexate or cyclosporine or apremilast.

Thanks again for the great question. I do think you are on a really solid plan and you’ve got a good plan for second steps if this does not work. We still don’t have great research studies to guide us as to exactly what to do next but I hope these suggestions are helpful for you.

Here is a list of first, second line and third line treatment (in my opinion) for FFA. As I mentioned above, how best to treat beard FFA is not clear. But this is a general approach.

Combination Treatments for Frontal Fibrosing Alopecia

Can acitretin and finasteride be combined for the treatment of FFA ?

I’ve selected this question below for this week’s question of the week. It allows us to the concept of combination treatments for frontal fibrosing alopecia and specifically address whether finasteride and acitretin can be combined.

QUESTION

I am 49 years old (female) and the clinical diagnosis was initially FFA, but the biopsy was ‘inconclusive’. It is thought that I probably have a combination of telogen effluvium and FFA.  I am still losing hair and the front hairline has receded more than half an inch. So far I've only taken a mild topical steroid for 4 months and then Dermovate for 4 months. I am on HRT and on Lipitor {statin} for high cholesterol, and on cod liver oil.

My doctor suggests either Acitretin or finasteride. It is up to me to decide which I will take.

My question: could I combine both medications?

You have always suggested combination treatments, but I don’t actually recall having read about the combination of Acetrin and Finasteride. 

Also, my doctor suggests 1mg Finasteride – however, some medical articles mention a dose of 2.5mg.

Would you suggest I start with a higher dose and if necessary, decrease it in case of side effects? 

QUESTION

Thanks for the question.

Yes, finasteride and acitretin can be used together by a great number of post-menopausal patients with FFA - but I am not usually a big fan of starting a large number of treatments together on day 1. I generally like starting one treatment and then adding another in the near or distant if at all possible. In other words, if I can “stagger” the start dates, I prefer that for my patients. I’ll go more into that in just a minute. Sometimes we do need to be more aggressive with treatment than other times and need to combine drugs from the start. That’s a clinical judgment. Even when we do start drugs together, I still like to stagger by 2-4 weeks in the event one causes any sort of rare side effect (i.e. rash, nausea, etc) when starting.

But the short answer to your question is that provided you don’t have any contraindication to using finasteride and provided you don’t have any sort of contraindication to using acitretin, you can use them together.   These two treatments are amongst the most effective treatments for FFA and I’m glad you have been considering them. I refer to these as the gold medal or first line treatments for FFA.

You and your doctor can review all the contraindications to these drugs and confirm whether or not you have any contraindications. Women with past or present depression, or past or current breast cancer may not be good candidates for finasteride and similarly women with high cholesterol or any sort of issue related to dryness  (dry lips, dry eyes, vaginal dryness) may not tolerate high doses or acitretin. You have high cholesterol treated with statins. It does not mean you can’t start acitretin but it does mean you are susceptible to cholesterol numbers bumping up. You’ll simply need to follow the numbers with repeat lab tests if you do start. Most are fine.

It always needs to be emphasized for readers that both of these drugs cannot be used in pregnancy and strict attention to contraception is needed in women who still have menstrual cycles.

You are correct that I combine treatments very often when treating scarring alopecia. But I’m not usually one to just pile on the drugs and send someone out the door with 37 prescriptions. If my patient needs only one drug to control the disease, then why use two drugs? If one can get some good control of the disease with one oral medication along with a course of steroid injections or topical calcineurin inhibitors there is no need to use 2 oral medications.  As mentioned above, it’s not always so simple and sometimes clinical judgment tells us that we need to hit the emergency button and pull out all the stops.   Sometimes we don’t even need pills at all and use of topical finasteride, steroid injections and topical minoxidil might be a good plan. Again it comes down to clinical judgment and of course - shared decision making with the patient.

In FFA, we can get a good sense of how well any newly initiated treatment is working in about 3-6 months. So periodic re-evaluation is key and often more important than the first appointment. (A second appointment is often more involved than the first and decisions can become trickier). Remember though that we might be looking for at the follow up appointment might simply be stopping hair loss as our main goal or we might be looking for some hair regrowth as our main goal. It just depends on the specific patient and the exact details of their FFA so far. Not everyone with FFA regrows any hair back - but some of course do. However, stopping the disease from getting worse is the main goal for everyone. 

In cases where I am a bit more worried or situations where past experience tells me one drug is not going to be enough, I might add 2 drugs. So unfortunately there are no definitive rules to treatment of scarring alopecias. I might start finasteride 2.5 mg at a frequency of 3-7 times per week with isotretinoin or acitretin 10 mg daily or isotretinoin or acitretin every other day. In other situations, I will prefer to start one drug and review how the skin and hair is doing in 3-6 months and adjust accordingly.

At the follow up appointment in 3-6 months, we might go up on finasteride if we started 3 times weekly or stay the course with the dosing we used. Similarly, once I review the mandatory blood tests I like to see for anyone with FFA on acitretin , we may similarly go up or down on the dose of this drug. If we just started finasteride at a past appointment, we might add isotretinoin or acitretin at the follow up if we did not start the drug at the first appointment. But if things are going well on finasteride and the other treatments we started (topicals, injections) .. I might not add acitretin at all. 

Finasteride should be at 2.5 mg rather than 1 mg and use of the drug is 3-7 times per week.  Now, before we leave the topic of finasteride it’s probably worth noting that the related drug dutasteride may be slightly more effective than finasteride in treating FFA. More good studies are needed to definitely prove how different each drug is bit that is important to keep in mind. Sometimes I start a patient on 2.5 mg finasteride daily and depending on how things go I might alternate finasteride 2.5 mg daily with dutasteride 0.5 mg daily in the future or switch completely from finasteride to dutasteride. Dutasteride has a very long half-life so if I have any worry about side effects or potential side effects I might start finasteride rather than dutasteride. However the reality is that for most women with FFA these two drugs are very well tolerated.  

As another example, some women find dutasteride and finasteride worsen hot flashes and so if I am worried about this as a side effect in someone already dealing with hot flashes, I might start finasteride 2.5 mg 3 times weekly not dutasteride daily. Of course, depending on the clinical situation, I might not even start it at all - or might prescribe topical finasteride instead.

Sometimes we need to go higher on acitretin or isotretinoin dosing than 10 mg daily. Whether we do depends on how the patient is tolerating the drug and whether they have side effects. A patient with the side effect of unbearable dry lips or dry eyes is not a patient that we are going to want to increase the dose of acitretin or isotretinoin. In fact, we may even go down on the dose or stop and bring on board a silver medal (second line treatment) like hydroxychloroquine.   Similarly, if cholesterols is jumping up (ie LDL cholesterol or triglycerides), we may want to go down one the dose and bring on board another treatment that won’t impact cholesterol.

 

The Treatment of FFA: Combination Examples

The treatment or scarring alopecia requires a lot of decisions based on what the patient sitting in front of me feels about these treatments and the past health of the patient and the activity of the disease currently. If you dig through the charts of patients with FFA in my practice you’ll see a lot of different treatment plans:

a) some use no pills only creams (steroid or calcineurin inhibitors) and/or steroid injections 

b) some use dutasteride or finasteride and creams +/- steroid injections 

c) some use dutasteride or finasteride with doxycycline and/or hydroxychloroquine plus creams +/- steroid injections 

d) some use oral doxycycline +/- oral hydroxychloroquine alone and creams +/- steroid injections 

e) some use dutasteride or finasteride with creams and isotretinoin or acitretin +/-steroid injections 

f) some use dutasteride or finasteride with acitretin or isotretinoin with creams  +/- steroid injections   +/- hydroxychloroquine 

g) some use acitretin or isotretinoin with creams  +/- steroid injections   

h) some use acitretin or isotretinoin with creams  +/- steroid injections   +/- oral hydroxychloroquine 

i) some use topical finasteride in place or oral finasteride or dutasteride in the above

j) some also have oral minoxidil, topical minoxidil, laser therapy, mycophenolate mofetil, methotrexate, cyclosporine, apremilast, tofacitinib added into various patterns of the above examples

Variations on the Same Theme.

It is important to note that within each example there can be hundreds of variations.  Consider two patients who say, “I take dutasteride, hydroxychloroquine and isotretinoin.” 

One  patient might be on dutasteride 4 times each week PLUS at 10 mg isotretinoin 2 times per week PLUS hydroxychloroquine 200 mg daily.

The other patient might be on dutasteride 7 times per week PLUS at 10 mg isotretinoin 3 times per week PLUS hydroxychloroquine 200 mg 4 times per week.

Combinations that Are Not Permitted.

 I have reviewed a lot of the common combinations above in how we manage FFA. Some treatments cannot be used together due to side effects. Common examples are doxycycline with isotretinoin or hydroxychloroquine with cyclosporine. 

I hope this helps. Thanks for submitting the question.

REFERENCE

[1] Acitretin Handout for Patients with Scarring Alopecia

[2] Finasteride Handout for Women

Acitretin, Isotretinoin and Minoxidil for Patient with FFA & AGA: What if they cause shedding?

Retinoids for Patient with FFA & AGA: Do they cause hair shedding that worsens hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to discuss the use of retinoids and minoxidil in FFA .

QUESTION

I am a female age 67. My diagnosis is frontal fibrosing alopecia (FFA) - with a new diagnosis of underlying androgenetic hair loss (AGA). My dermatologist originally planned to put me on Acetrin for FFA but she now says that the shedding usually caused by retinoids will in cases with underlying AGA not be temporary, but will precipitate permanent hair loss, and therefore she does not want to prescribe it.

For review, I have itching all over scalp at different times [behind ears; frontal hairline, crown, temples]. Rosacea [onset only after topical clobetasol ]; thinning all over scalp with exception of crown; hair already thinning at age 50; eyebrow thinning at age 35/40. medicated since April 2020 by first Betnovate, then Dermovate [Clobetasol], then topical Pimecrolimus with Lymecyline. Other medications: HRT [estrogen only], statins [Rosuvastatin], ARB [Candesartan, as the only BP medication that is not linked to alopecia]; in the past decades [but now discontinued because of links to alopecia]: sun blockers and retinol creams.

I do not understand why underlying AGA should make a difference in prescribing this medication. However, I am concerned about hair follicles affected by FFA. I worry that the hair near my hairline, once shed, will not grow back because in FFA, the follicles that still produce hair may not generate new hair after the shedding, as more and more follicles become affected by FFA. I don't know if hair follicles, once affected by FFA, (but not yet dead) continue their cycle from catagen to anagen until such time when they are truly dead.

I have the same concern with Minoxidil, in particular as it was confirmed by another hair clinic that they do not advise the use of Minoxidil in patients with FFA, as Minoxidil stimulates initial shedding and FFA affected follicles would not produce new hair after that. - I would be very grateful if you could give me your opinion on the use of Minoxidil and Acetrin in a case of FFA with AGA.

Many thanks for your help and kind regards

ANSWER

Thanks for the great question. There is a lot to discuss, so let’s get to it.

First, let me say how relevant this question is. A very large proportion of women over 50 years of age with a diagnosis of FFA have a diagnosis of AGA in my opinion. I’d put the number around 55 % to even as high as 70%. So the most common scenario is treating both. Do I worry that any of my treatments are going to worsen the AGA? Not all that much. Is it possible? Sure. Do I see it? Yes, but I’d say less than 1 in 150 women. This is my experience in treating large numbers of patients with FFA.

POINT 1. The Question is Important Because Retinoids are among the Most Effective Treatments for FFA

Retinoids like isotretinoin and acitretin are among the most effective treatments for FFA. They are what I called “gold medal” treatments or first line treatments. Retinoids together with 5 alpha reductase inhibitor drugs are the most effective treatments for FFA. There is still a bit of debate about which drugs are actually better in treatment FFA. A 2017 study by Rakowska and colleagues suggested retinoids are the clear winner. Other studies by Vañó-Galván and colleagues suggested that finasteride and dutasteride (especially dutasteride) are the top treatments.

Here are the treatments that I consider top treatments:

POINT 2. Acitretin and Isotretinoin Can not be Used with Lymecycline

I’m not sure from your story if you are still on Lymecycline or not. It’s important to be aware that these two drugs can’t be used together - ever. So that’s not an option. But if you are off lymecycline, acitretin could be an option provided your cholesterol is under good control with the statin. If you are still on lymecycline and feel that it’s helping, you might decide to continue it and look to other options like dutasteride, finasteride or hydroxychloroquine. Acitretin won’t be possible. These are all discussions that you would want to have with your dermatologist. For some patients with FFA, they are good options - but not everyone.

POINT 3. Shedding can occur with Acitretin but is Not Common on Small Doses used in FFA.

Let’s come back to acitretin. Acitretin can cause shedding in 3 -5 % of users at the typical doses used in treating various diseases. The issue is that in FFA, I normally use much smaller doses - like 10 mg daily or even every other day to start. The risk of shedding is a lot less than 3-5 %. Do we have a number to quote you? Not really but I’d estimate it’s around 1 % and probably less.

How do I know? Well I have a large number of patients with FFA and AGA with on retinoids and I am not answering emails and phone calls very often about shedding issues. It still happens.

Provided you are not on Lymecycline, you certainly could consider going slowly on the dose if that issue something you want to discuss with your dermatologist again.

There are other options too - especially dutasteride (and finasteride). If your dermatologist is worried about shedding and won’t use, then dutasteride is an option. Do these drugs cause shedding? Sure, sometimes. Anything can. Fortunately, it is just not common either. shedding is less likely with dutasteride than acitretin but fortunately both are fairly uncommon. Sometimes, I prescribe acitretin and dutasteride together.

So, to summarize. It’s not impossible to have shedding from acitretin. It’s just not so common at the doses we use in FFA.

POINT 4: If shedding does occur, shed hair is not necessary gone forever.

There is an assumption that is wrong here - and that is that any shed hair is guaranteed to be gone forever. That’s just simply not accurate. You are shedding hairs all the time - and some are going to pop back up through the scalp. The more active the FFA is the less likely the hair is to come back up - but a lot still does even in active FFA. If the FFA is only mildly active - then probably a good deal of the hairs are going to return.

Granted, you are correct that we don’t want shedding if we don’t have do.

But if shedding is going to occur it will be mild most likely and happen around 6-8 weeks after treatment . You’ll have a few week window to stop. So I said that shedding is not common with 10 mg acitretin and I’ll point out that even if shedding does occur, it’s usually not common to massive shedding. So we have two “not commons’ in a row.

The risk of massive chaos with the hair is low.

Is it zero? Well no. But it is low.

Do be sure to review with your dermatologist the role of dutasteride too. Now, you might have contraindications to the drug so that is something you’d need to review with your doctors. I don’t have enough information. But often in situations like this I might consider starting dutasteride 0.5 mg 3 times weekly with acitretin or isotretinoin 10 mg three times weekly (along with steroid injections and topical pimecrolimus) and see where things are at in 4 months. We can go up on dutasteride dosing or up on acitretin dosing. That’s often my plan in situations like this but it may or may not apply to your situation.

POINT 5. Minoxidil is a common treatment for FFA.

Minoxidil can cause shedding. Sure. Is there a big risk that if you get shedding, the hair is not coming back? No. Is there a small chance it’s not coming back? Sure, but it’s small.

Minoxidil can be an important part of managing FFA sometimes. It can also play a key role in helping androgenetic alopecia.

Many of my dermatology colleagues who treat FFA like I do also use minoxidil. It’s not off the table as a treatment. I consider it a silver medal treatment - meaning that I might not start it right away in everyone but I often add it down the road. Some hair specialists use minoxidil immediately in treating FFA. I don’t but some do. I use it as an “add on” in many patients.

Conclusion and Summary

Thanks again for the question. I hope this helps. Minoxidil is commonly used in treating FFA and even in those who have AGA. Is it a first treatment to reach for? Not in my opinion but it’s a good option for many once things are coming a bit more stable. Minoxidil is worked into many patient’s treatment plans for FFA - even if they have AGA.

The acitretin is a good option for many (provided you are not still on Lymecycline or any sort of tetracycline antibiotic). In my opinion there are three treatments that a really need to be discussed for anyone with FFA - the retinoids (acitretin, isotretinoin), the 5 alpha reductase inhibitors (dutasteride or finasteride) and steroid injections. Those discussions are worth having with the dermatologist.

I’m not sure exactly why the other clinic you went to did not want you to use minoxidil. You can read my previous article on “The Six Reasons Why My Practitioner Won’t Start the Treatment You Were Hoping” - the answer certainly lies in one or more of these 6 reasons.

Thank you again

Hydroxychloroquine (Plaquenil) for Frontal Fibrosing Alopecia

Hydroxychloroquine (Plaquenil) for FFA

I’ve selected this question below for this week’s question of the week. It allows us to discuss the use of hydroxychloroquine (Plaquenil) in FFA as well as the rare cardiac effects of hydroxychloroquine.

QUESTION

I am a female in my late 70s with frontal fibrosing alopecia, confirmed by a scalp biopsy. It is being treated with clobetasol .05%, one application per day. I have read that this is not a very effective treatment when used alone. What would you suggest might be used with it?

My dermatologist suggested hydroxychloroquine (plaquenil), but I read that this might have an adverse effect on people with heart disease. Do you agree? The first symptom about six months ago was drastically thinning eyebrows. I am in the third month of treatment and hair loss around the hairline is not yet apparent. I have cardiomyopathy and atrial fibrillation, for which I am taking a blood thinner (Eliquis) plus daily irbesartan, bisoprolol and spironolactone. Do you think any of these drugs might be the cause of my FFA?

ANSWER

Thanks for the great question. I’d like to discuss several important points in the question you ask and the information you have submitted.

Before we go further, I’m going to assume here in your question that the diagnosis is correct. Can I be 100 % sure you have FFA? Well no - not at all. I haven’t seen your scalp and eyebrows and I don’t know all the details of your story. You might reply to me that you have already told me you had a biopsy. Well, biopsies are not 100% either. Nevertheless, it sure sounds like many aspects of your story do, in fact, support a diagnosis of FFA. So I’ll proceed with this assumption. If you do have FFA, this answer then helps. If the diagnosis is not correct, then the answer has helpful points nevertheless for others with the condition.

Let’s look at some aspects of your question:

a) How good is hydroxychloroquine in FFA?

Hydroxychloroquine is helpful in some patients with FFA. I tell my patients it’s a silver medalist. In other words, it can be helpful, it’s just that other treatments are probably better. We will get into that a bit later. That does not mean hydroxychloroquine is useless as a treatment. Not at all. For some patients with FFA, hydroxychloroquine does help. It does not help everyone that is for sure.

Let’s look at some helpful studies from the past evaluating the effectiveness of hydroxychloroquine in FFA treatment.

in 2013, Ladzinski and colleagues proposed that hydroxychloroquine had some benefits in about 50 % of patients,

In a much larger study conducted in 2014, Vano Galvan et al showed that a 15 % of patients with FFA using hydroxychloroquine had some improvement in their disease. 59 % had their disease stabilized. For about one quarter of patients, the drug did nothing helpful at all.

in 2018, Strazzulla and colleagues found that about 70 % of patients had some benefit with hydroxychloroquine - with results being more or less the same ass doxycycline.

A 2010 study by Samroa and colleagues found that hydroxychloroquine reduced redness and inflammation in FFA patients.

Treatment Options for FFA

Before we leave the subject of hydroxychloroquine for treatment of FFA, let’s look at the options for treatment. Every single type of hair loss has treatment options. The thing that is often forgotten is that not all treatments are the same. Some are good. Some are not so good. Some are good but crazy expensive. Some are good and not so expensive. Some are good and fairly safe and some are good and incredibly risky. I divide every disease into gold, silver and bronze medal treatments. 

I personally like this analogy of categorizing treatments because it reminds us of a couple of key things. First, not all treatments are equal. We select treatments by balancing benefit and risk and take into account the safety, affordability, feasibility and effectiveness of treatment (what I have previously termed the "S.A.F.E." Principle. )

The second reason I like the analogy of gold and silver and bronze medal treatments is because it reminds us that this is not always going to be the order. The athlete that received the gold medal in the recent Olympics may not be the athlete that gets the gold medal in the next Olympics. Of course, if the athlete is really good - he or she will probably be up there one the podium in the top spot again in 4 years. The same is true with hair loss treatments. 

As new treatments come out and as they are studied more and more, a certain treatment might just rise into the gold medal spot and push out other treatments that are there now down into silver or bronze positions. Sometimes, a treatment gets removed from the market entirely just as some Olympians get disqualified from the Olympics. They disappear entirely.

In the diagram below, I outline what I consider the gold, silver and bronze treatments for FFA. In FFA, Plaquenil is a silver medallist. It’s not useless. It has reasonable safety (although I will discuss the heart issues next). It’s relatively inexpensive (Plaquenil is about $1300 USD per year whereas Apremilast is $ 18,000 USD per year). It’s easy to use. It’s somewhat helpful. In terms of the SAFE principle, it’s an okay option to keep in mind for many.

b) Does hydroxychloroquine have effects on the heart?

Hydroxychloroquine can have effects on the heart. Fortunately, they are not common but risks do increase with advancing age. In fact, physicians need to be much more on alert for eye, muscle, heart side effects in patients over 65 compared to those under 65. Of course, side effects of this nature can happen at any age - but they are more common with advancing age. Hydroxychloroquine cardiotoxicity is non common - but it is a serious side effect.

Plaquenil “cardiotoxicity” (potential toxicity on the heart) has best been studied inn patients with the autoimmune disease lupus who take the drug and also to seem degree in patients with rheumatoid arthritis. Could it be that a these groups are more likely to experienced heart muscle side effects with Plaquenil? Could be, but more studies are needed. For now, it’s a potential side effect that needs to be considered in everyone. There’s nearly 100 reports in the medical journals now of hydroxychloroquine induced heart toxicity. When it does occur, the patient usually develops a restrictive or dilated cardiomyopathy or has conduction system abnormalities including atrioventricular block and bundle branch block. Studies by Costedoat-Chalumeau showed that when cardiomyopathy is present other signs of toxicity are often present as well - eye toxicity, nerve toxicity, and muscle toxicity.

So who is more likely to get hydroxychloroquine induced cardiomyopathy ? Risk factors are currently proposed to include older age, female sex, longer duration of therapy (>10 years), higher doses of the drug, pre-existing cardiac disease, and renal insufficiency (kidney disease). It’s important to remember that most patients who develop hydroxychloroquine cardiotoxicity have been on the drug a long time - ie 10 years or more. Of course, there are reports in the medical journals of those who have been on it just a few months before developing side effects.

The Lane and Colleagues 2020 Study

Finally, I’d like to tell you about an important study by Lane and colleagues. This was recently published. This was a study of almost 1 million ( 956,374) hydroxychloroquine users so it’s a massive study. Massive studies of this size are important because they allow us to get a better sense of the risk associated with certain drugs. Lane’s study focused non patents with rheumatoid arthritis (not FFA) so we need to always keep that in mind. The researcher showed that long-term hydroxychloroquine use increased cardiovascular mortality 1.65 times compared with control treatments There are some limitations of the study (as there are with any study). nevertheless, it points to the fact that there may be a slight increase risk of heart related effects with long term use of hydroxychloroquine - at least in patients with rheumatoid arthritis. Fortunately, side effects of this nature are still quite uncommon.

In conclusion, there are some small risks with hydroxychloroquine use in your case. This is something you’d certainly want to review with your heart doctors too. Depending on the degree of heart issues (class of heart failure, etc), it may be something they agree with at a low dose, or something they advise against.

c) What would you suggest might be used with clobetasol?

This is actually a very involved question. If you find that use of clobetasol in the manner described and recommended by your doctors stops further hair loss completely - then you don’t need to use anything else. The key to treating FFA is not to pile on more and more drugs but rather to use the safest and simplest approach possible that stops the disease. if clobetasol stops your FFA 100% - then you need not look for anything else.

Is it likely that clobetasol stops your disease 100%? Well, no. But again - it’s not impossible that it does. It’s a silver medallist.

There are some 20 other options available. Again we follow a logical approach to deciding on which other treatments to use. We select treatments that have good evidence from good studies as well as treatments that have good safety.

You may want to review with your doctors other options like topical calcineurin inhibitors (like Pimecrolimus) as well as low doses of steroid injections (2 mg per mL) every few months. Topical clobetasol is going to give atrophy after a few months of daily use so you and your doctors are going to need to decide when to start reducing that dose.

You can also review options like topical anti androgens (topical finasteride) or even oral dutasteride. Starting two times weekly could be something that you are your doctors discuss. You’ll want to carefully review if you have any contraindications to its use (depression, cancer risks, osteoporosis). Adding acitretin once weekly or twice weekly may also be something you discuss.

d) I am taking a blood thinner (Eliquis) plus daily irbesartan, bisoprolol and spironolactone. Do you think any of these drugs might be the cause of my FFA?

Some drugs do contribute to the development of FFA. For example, the antiestrogen tamoxifen is one of them. The drugs on your list have not been implicated to date in the development of FFA. However, some can cause hair loss - just not FFA.

I’ll make a few additional comments at this point. First, your patterns of hair shedding are going to be important in giving you the fullest answer possible. Your story is interesting in that it seems that you have eyebrow loss without scalp frontal loss yet. Yes, that sure sounds like FFA but again I can’t say much more because I don’t know much about your story and haven’t seen your scalp. If your hair shedding is markedly increased the question must be posed to your health care team as to whether there is any component of telogen effluvium as well. All the drugs on your list can cause telogen effluvium - fortunately that’s still really unlikely overall. Most people have no issues of the sort.

Now on to the tricky part. it’s not possible to 100% say that the drugs you are taking had nothing to do with the development of FFA. Beta blockers (like bisoprolol), angiotensin II receptor blockers (like irbesartan) and spironolactone have rarely been involved in skin rashes known as “lichenoid” drug eruptions. There is some similarity between lichenoid drug eruptions and the lichenoid eruption that is part of the pathology of frontal fibrosing alopecia. Have any of the drugs you are taking been convincingly implicated in the development of FFA? No. It is possible there is some link in those with some sort of predisposition to this disease ? Yes.

Conclusion and Summary

Thanks for submitting your question. I do hope this will be helpful in the discussions you have with your doctors. I’ve included references below in the event they too are helpful. I wish you the best of health.

Reference

August C, Holzhausen HJ, Schmoldt A, et al. Histological and ultrastructural findings in chloroquine-induced cardio- myopathy. J Mol Med (Berl) 1995; 73: 73–77.

Baguet JP, Tremel F and Fabre M. Chloroquine cardiomypathy with conduction disorders. Heart 1999; 81: 221–223.

Clark C, Douglas WS. Lichenoid drug eruption induced by spironolactone. Clin Exp Dermatol. 1998 Jan;23(1):43-4

Costedoat-Chalumeau N, Hulot JS, Amoura Z, et al. Cardiomyopathy related to antimalarial therapy with illustra- tive case report. Cardiology 2007; 107: 73–80.

Fesssa et al. Lichen planus-like drug eruptions due to β-blockers: a case report and literature review. Am J Clin Dermatol 2012 Dec 1;13(6):417-21.

Ladzinski et al. Frontal fibrosing alopecia: a retrospective review of 19 patients seen at Duke University. J Am Acad Dermatol. 2013 May;68(5):749-55.

Lane, J. C. E. et al. Risk of hydroxychloroquine alone and in combination with azithromycin in the treatment of rheumatoid arthritis: a multinational, retrospective study. Lancet Rheumatol. (2020).

Massa MC, Jason SM, Gradini R, Welykyj Lichenoid drug eruption secondary to propranolol. Cutis. 1991 Jul;48(1):41-3.PMID: 1831116

Nord JE, Shah PK, Rinaldi RZ, et al. Hydroxychloroquine cardiotoxicity in systemic lupus erythematosus: a report of 2 cases and review of the literature. Semin Ann Rheum Dis 2004; 33: 336–351.

Pfab et al. Lichenoid drug eruption due to an antihypertonic drug containing irbesartan and hydrochlorothiazide. Allergy 2006; 61(6):786-7

Samrao A et al. Frontal fibrosing alopecia: a clinical review of 36 patients. , Chew AL, Price V.Br J Dermatol. 2010 Dec;163(6):1296-300.

Schön MP, Tebbe B, Trautmann C, Orfanos CE. Lichenoid drug eruption induced by spironolactone.Acta Derm Venereol. 1994 Nov;74(6):476.

Strazzulla LC et al . Prognosis, treatment, and disease outcomes in frontal fibrosing alopecia: A retrospective review of 92 cases.. J Am Acad Dermatol. 2018 Jan;78(1):203-205. doi: 10.1016/j.jaad.2017.07.035.

Vano-Galvan S. Frontal fibrosing alopecia: a multicenter review of 355 patients. J Am Acad Dermatol . 2014 Apr;70(4):670-678.

Yogasundaram H, Putko BN, Tien J, Paterson DI, Cujec B, Ringrose J, Oudit GY. Hydroxychloroquine‐induced cardiomyopathy: case report, pathophysiology, diagnosis, and treatment. Can J Cardiol 2014; 30: 1706–1715.

Frontal Fibrosing Alopecia: How soon does treatment take effect? How soon for results?

QUESTION

I was just diagnosed with frontal fibrosing alopecia and have just started treatment. How long will it take for me to see changes?

Answer

This is a great question. I answer this question for patients by first asking them if they are actually asking me “How long does it take to know if the new treatment is working?”

Clarifying this question is very important because patients who undertake a successful treatment plan may not notice ANY changes in their hair at all - which actually means the treatment is working. (This may seem obvious once stated but not always beforehand). Sometimes, a successful treatment will help regrow some hair and sometimes a successful treatment will simply help stop further loss (without regrowth). It’s really important that patients understand that both are potentially good signs.

There are two types of positive changes we look for when evaluating the success of treatment - one type is the “immediate” changes and the second is the “longer term” changes.

The immediate changes we look for after starting a treatment include reduction in symptoms (such as reduction in scalp itching, burning or tenderness) as well as reduction in scalp redness or the amount of scale. Some patients with scarring alopecia, especially those with frontal fibrosing alopecia, don’t always have any scalp symptoms to begin with so monitoring symptoms is not useful for this particular subgroup of patients. Even if the patient does not have symptoms, many do have redness or scaling and this parameter can be reevaluated at various intervals after treatment is started.

These so called “immediate changes” can be seen within a few days (ie rapid reduction in symptoms with some treatments) to a few months (ie reduction in scalp redness and scale within a few weeks of starting a treatment).

The ultimate test and most important test of how well treatment is working has nothing to do with symptoms and has nothing to do with what the scalp looks like - it simply has to do with what a photograph shows. However, to actually get a good sense of changes in  actual hair regrowth growth can take 6-12 months depending on how fast the FFA was moving originally before the treatment was started.

A patient who comes in for a 3-4 month visit and says to me “my scalp feels so much better” may or may not be enroute to better controlling their scarring alopecia. I share their enthusiasm but must advise them that we won’t fully know for 6-12 more months if we are truly winning this fight and successfully stopping the scarring alopecia.

What topical steroids are safe to use in FFA?

Question:

I was diagnosed with frontal fibrosing alopecia and prescribed a topical steroid by my dermatologist. I've been using it for 5 months. I am wondering if it's too strong because my skin seems thin in the area of the hair loss. What topical steroids are best to use for FFA?

Answer:

Topical steroids can be mildly helpful for some patients with FFA. Generally speaking they are not as effective as steroid injections, and oral medications such as finasteride, doxycycline or hydroxychloroquine. Nevertheless, topical steroids do have a role in the treatment of FFA.

There are many classes of topical steroids and they range from class I to class VII. Class I steroids are the strongest and include agents like clobetsol. Class VII steroids include weak steroids like hydrocortisone.  Clobetasol is up to 600 times strong than  hydrocortisone and so has much more potent anti-inflammatory effects.  There's no doubt about it that stronger steroids suppress inflammation better- but that does not mean that stronger steroids are better, especially for FFA. In FFA, we need to consider side effects  - in particular the thinning of the skin that both the steroids and the disease itself can cause. 

Clobetasol, however, carries a greater risk of side effects including thinning of the skin. Patients with FFA already have thin skin to begin with (on account of their disease). So, one needs to be careful when treating FFA not to thin the skin further. Monitoring is needed and photographs are essential in this regard. 

Generally speaking, when someone with FFA notices thinner skin and blue veins appearing it's typically the disease itself that caused this - not the topical steroid. Nevertheless, to limit the side effects of topical steroids, dermatologists frequently prescribe weaker steroids to use on the frontal hairline for those with FFA. Instead of using clboetasol, steroids like fluocinonide or betamethasone are often used. Rather than using daily, these are frequently used every other day to limit side effects.  In addition, a non-steroid medication like pimecrolimus might be used as well. Pimecrolimus does not cause thinning of the skin but the trade off is they are not quite as consistently effective as the topical steroids. 

If clobetasol is going to be used, that is a decision that the dermatologist and the patient must both review together and be comfortable with. Daily use of clobetasol on the frontal hairline for a prolonged period is probably not a good idea when treating FFA. Some physicians might use it a few times per week or daily for a very short period of time. However, daily use of a strong steroid increases the risk of the patient experiencing further thinning of the skin.  

You may wish to review these helpful articles (below) I've written in the past. Thanks again for the question. 

Topical steroids and FFA

General articles on frontal fibrosing alopecia