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.
General articles on frontal fibrosing alopecia