Review
Medical therapy for frontal fibrosing alopecia: A review and clinical approach

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Background

Guidelines for the treatment of frontal fibrosing alopecia (FFA) are limited, and the literature on treatment modalities consists mostly of case reports and cohort studies.

Objectives

In this review, we sought to assess the response of medical therapy for FFA and propose a clinical approach to management.

Methods

A literature search for “frontal fibrosing alopecia” on PubMed returned 270 items. In this review, only studies with treatment regimens and reported outcomes were considered. The majority of studies found were case reports and retrospective cohort studies. Response to therapy was assessed by reported ability to slow or arrest hair loss.

Results

Intralesional steroids and 5α-reductase inhibitors were the most commonly used therapies with the most positive treatment responses (88%, 181/204 for intralesional steroids and 88%, 158/180 for 5α-reductase inhibitors). Oral prednisone was seldom used and only temporarily delayed rapid hair loss. Other therapies evaluated included topical steroids, antibiotics, pioglitazone, systemic retinoids, and hair transplantation.

Limitations

Lack of placebo control studies and uniform outcome measures.

Conclusion

The natural course of FFA is variable. Recession of the frontal hairline might stabilize regardless of treatment. However, early intervention is encouraged in active disease because hair loss is presumed permanent and treatment could modify the disease course.

Section snippets

Methods

All the literature on medical therapies for FFA was retrieved through PubMed. An electronic search of “frontal fibrosing alopecia” on July 19, 2018, resulted in 270 items. Only publications in English on the clinical outcomes of treatment modalities for FFA were considered. A total of 23 studies were identified, and we summarized the details of these studies in Table I. Each study was assigned a level of evidence

Results

The FFA treatment courses of 622 individuals (excluding those without treatments and those with hair transplants) were reviewed. The most common primary agent was intralesional corticosteroids, specifically intralesional triamcinolone acetonide (TAC), which represented 35% (215/622) of therapies, followed by 5α-RIs, which represented 29% (182/622) of therapies. Few studies reported the use of PPAR-γ agonists (1%, 5/622) and immunosuppressants (3%, 17/622).

Discussion

Evaluating the response of individual therapeutic agents is difficult. Monotherapy is seldom used, and most patients reported in the literature are treated with a combination of therapies. The responses of patients on multiple treatment modalities could be attributed to other therapies or the combination of therapies. The natural disease course of FFA is also obscure, and hair loss might be self-limiting if left untreated.1, 2 In a retrospective cohort study, Rallis et al reported that in 6

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    Funding sources: None.

    Conflicts of interest: Dr Shapiro is a consultant for Aclaris Therapeutics, Incyte, and RepliCel Life Sciences and is a principal investigator for RegenLab. Anthony Ho has no conflicts of interest to disclose.

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