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