Treatment of Fibrosing Alopecia in a Pattern Distribution (FAPD)

Fibrosing Alopecia in a Pattern Distribution (FAPD): Is treating the AGA component sufficient?

I’ve selected this question below for this week’s question of the week. It allows us to review the treatment for FAPD.

Question

I was diagnosed with Fibrosing Alopecia in a Pattern Distribution (FAPD). From what I have come to understand it is a scarring alopecia with features of both lichen planopilaris and androgenetic alopecia. I see on your website that the disease seems to be caused by my immune system trying to attack all my miniaturizing hairs.

My question is this: If I treat the androgenetic alopecia fully so that all the miniaturizing hairs reverse, is this sufficient? Do I really need to treat with medications that target the inflammation?

Answer

Thanks for the great question. We’ve covered some features of Fibrosing Alopecia in a Pattern Distribution in past articles so if you haven’t had the chance to check those out, you might consider doing so.

Your question is a great one. Theoretically, the answer sounds like it should be pretty straightforward. If you stop the miniaturization, then the immune system has nothing to attack anymore.

There are two problems here with this kind of assumption:

1) There is an assumption that the management of the AGA and reversal of miniaturization is 100.00% effective - this is not correct.

There is an assumption here that he management of the AGA is 100.00% effective but it is not. Some treatments work very well in some patients to help some of the hairs stop miniaturizing. However, the same treatment may not work very well in the next patient. So there is quite a variability of responses.

Furthermore, for some patients all that we see is that the hair loss does not get worse but the degree of miniaturization simply stays the same.

Treatments for AGA are clearly very important to getting FAPD under control. But it’s best to view the treatments as helping rather than curing.

2) There is an assumption that if the immune system no longer has anything to attack that it just goes quiet.

We need to manage the inflammatory component in most cases of FAPD because as I mentioned in point 1 - the reversal of AGA is not 100%.

Even in situations of the human body where the trigger is removed, we often need anti-inflammatory treatments for a while to remind the immune system to settle down. Management of AGA alone is usually not completely effective - although it sure does help.

Consider my dear friend who complains about every bad driver he sees when we’re driving together. Even after we’ve long passed the bad driver he still seems to go on and on about the prior bad driver - until the next bad driver comes up. The only way to get my friend to leave the subject of the bad driver is to stop him from thinking about it. Somehow, I need to change the conversation or change the music we’re listening to. Once we stop him from focusing on the prior bad driver he’s okay again.

If you assume that my friend will stop talking about the bad driver just because the trigger is not present, you’re mistaken. Once he gets going, he just keeps going.

The immune system is just like this. Yes, the immune system is just like my dear friend. Even when some triggers are long gone, sometimes the immune system just wants to keep the conversation going.

It’s probably just like this in FAPD that is well treated from the perspective of the androgenetic component of the disease. Even though the immune system does not have the same number of miniaturizing hairs that it is patrolling, the immune system just won’t stop talking about what happened in the past.

Of course, if we bring on board some corticosteroids or start oral medications like doxycycline or hydroxychloroquine, we can get the immune system to settle down and focus on something else.