Frontal Fibrosing Alopecia
Frontal fibrosing alopecia is a type of scarring or permanent hair loss in which an autoimmune inflammatory process—generated by the individual’s own immune system—attacks and irreversibly destroys the hair follicle units, causing scarring on the scalp.
Causes
The exact cause of this disease is still unknown. However, it is currently believed that there is not a single responsible mechanism; rather, the inflammatory process that ultimately destroys the follicular units results from the combination of several factors.
These factors can be grouped into four categories: hormonal, genetic, autoimmune, and environmental factors.
The fact that the disease occurs predominantly in women around menopause (before and after), as well as the use of medications with hormonal mechanisms of action for its treatment, supports the hormonal influence as one of its main pillars. The description of numerous cases affecting members of the same family (especially mothers and daughters) supports a possible genetic component. The potential association of this condition with other autoimmune diseases, such as hypothyroidism, suggests that immune system involvement plays a relevant role. Finally, the hypothesis of environmental factors could explain the marked increase in the number of diagnosed cases in recent years.
The specific environmental triggers have not yet been definitively identified. Numerous studies have been conducted in recent years to clarify this point and to explain the growing number of diagnoses.
Some studies have produced controversial conclusions, such as a possible relationship with the use of sunscreens or anti-aging creams. However, these findings are not strong or conclusive enough to establish specific recommendations, and at present there is insufficient evidence to advise against the use of these products. Ongoing research aims to shed more light on this aspect.
Once we understand the clinical presentation of this alopecia and recognize its symptoms and signs—especially given its increasing incidence—it is essential to diagnose it early and initiate appropriate treatment.
Symptoms
Clinically, this type of alopecia is characterized by a recession of the hairline. The hair progressively grows farther back, resulting in an increasingly larger forehead, both centrally and laterally. The hairline recedes in a band-like pattern, resembling a headband.
In many cases, the first symptom—often appearing years before the hairline recession—is the progressive loss of the eyebrows. Other frequently observed signs include redness of the cheeks, lesions on both temples forming a cobblestone-like texture, or a more pronounced depression along the central blood vessels of the forehead.
Diagnosis
The starting point for an accurate diagnosis of alopecia should always be consultation with a dermatologist specialized in trichology.
Early diagnosis is crucial, as it determines the progression and course of hair loss. If the inflammatory process attacking and destroying the hair follicles is controlled, further hair loss and scarring can be prevented.
In addition to a thorough, targeted medical history and trichological examination, trichoscopy is required. Digital trichoscopy is currently the most valuable diagnostic tool.
Beyond refining the diagnosis, it also facilitates patient follow-up. In frontal fibrosing alopecia, it provides data such as hair shaft count per square centimeter and average diameter, offering an objective assessment of the patient’s baseline condition and response to treatment.
In scarring alopecias, it also allows for a more precise quantification of the degree of inflammation and the activity of the process in each area of the scalp. In some cases, a biopsy may also be necessary to establish a definitive diagnosis.
Treatment
Treatment is based on controlling the two main mechanisms involved: the hormonal factor and the inflammatory factor. The goal is to halt progression so that the band-like recession of the hairline remains stable.
Medications from both groups may be administered topically (gels or creams applied directly to the scalp), through mesotherapy (injections into the affected area), or orally. The choice of route and combination of anti-inflammatory and hormonal-modulating drugs must be individualized for each patient and adjusted according to the stage and activity of the disease.
In the same patient, treatment may be modified over time depending on disease activity, becoming more intensive during periods when signs of greater inflammatory severity are identified.
Further advances in understanding the causes of frontal fibrosing alopecia are expected in the coming years. With current knowledge, it is important to recognize early warning signs—readily identifiable through the clinical features described—and consult a dermatologist specialized in trichology for an accurate and early diagnosis. This enables timely initiation of individualized treatment, which will be adjusted according to the disease’s progression. Additionally, trichoscopic evaluation helps determine the degree of inflammation at any given time, and complementary laboratory tests can rule out possible associations with other autoimmune diseases.