No hair on the forehead, sideburns and eyebrows: fibrosing frontal alopecia
“This type of baldness, very common in our socio-health sector, is diagnosed, especially, in post-menopausal women, with an average age of 60, although also in younger women and men”, emphasizes Dr. Raquel Pérez Mesonero, dermatologist specialist in trichology from the Clínica Imema de Madrid.
“Fibrosing frontal alopecia presents a clinical picture that is very, very difficult to treat; even more so when women ask us to solve this cosmetic problem so hurtful to their self-esteem and their beauty”, emphasizes the Dr. Eduardo López Bransurgeon of European and world prestige in hair transplantation.
“Our main goal will be to apply therapies that stop or limit the development of frontal fibrosing alopecia (FFA) for as long as possible. It is a constant struggle to avoid the inflammation of the hair follicles and, therefore, the consequent scarring”.
They assure Dr. Pérez Mesonero and Dr. López Bran in an interview granted to EFEsalut
Why does fibrosing frontal alopecia make women’s lives bitter?
The causes of this acquired primary alopecia, its etiopathogeny, are unknown or inconclusive; medical reasons that advise not to establish clear recommendations.
In fact, the clinical picture was not described until November 1994 by the Australian Steven Kossard in the research article “Postmenopausal frontal fibrosing alopecia. Scarring alopecia in a distribution pattern“, published in the magazine ‘Archives of Dermatological‘.
Since then, different studies indicate that there are genetic, autoimmune, hormonal and environmental factors that influence the appearance and development of receding frontotemporal implantation line, up to eight centimeters of hair loss.
At a genetic level, family cases have been studied in premenopausal men and women, a good number with early menopause or previously subjected to a hysterectomy (removal of the uterus and cervix, even of the ovaries and fallopian tubes).
“It could also be due to the hormonal factor, since the most frequent moment of clinical appearance is in the postmenopausal stage. However, the exact mechanism by which this hormonal alteration would affect the hair follicle is not known”, says the dermatologist.
Another trigger would be our own immune system.
“The biopsies show that the hair follicle is altered by the inflammation, being destroyed by the T lymphocytes of the immune system, cells that form in the bone marrow,” he describes.
In addition, environmental factors may play a role.
“Recent research points to the possibility of the frequent use of cosmetics and photoprotectors in patients affected by this alopecia, without this having been irrefutably verified or the exact mechanism that would explain it being known,” emphasizes Dr. Perez Mesonero.
How is AFF diagnosed if we consider that we are threatened by about 150 types of alopecia?
The diagnosis of this alopecia is usually clinical, and requires a detailed medical interview, medical history, and a careful physical and trichoscopic examination. And a biopsy is usually not necessary in obvious cases.
“The dermatoscope evaluation and trichoscopic technology state-of-the-art technology also allows us to diagnose incipient alopecia, where there has been almost no retraction of the implantation line. These cases may require a confirmatory biopsy”, he distinguishes.
As a primary alopecia, fibrosing frontal alopecia must include a differential diagnosis from other alopecias, such as alopecia areata, due to traction or androgenetic female pattern.
Also, AFF can be concomitant, since the patient can be affected by more than one alopecia.
The most typical symptom of fibrosing frontal alopecia is characterized by a progressive retraction of the first line of hair implantation in the frontotemporal area and on the sideburns, so that the forehead becomes increasingly wider.
“In some cases this can happen exclusively in the area of the sideburns, even in the occipital area of the head”, he adds.
The skin affected by frontal fibrosing alopecia I know is exposed, looks more scarred, hairless, brighter, wrinkle-free and with the appearance of thin, youthful skin.
This destruction of hair on the scalp is usually preceded, several years earlier, by the loss of eyebrow hair, the amount and density of eyelashes and other body hair, in the armpits and pubes.
The symptomatic picture is usually accompanied by itching or stinging in the affected areas of the scalp, with areas of erythema or desquamation, and redness of the follicular exits and loss of these orifices can be observed.
In addition, there are other subtle signs on the skin of these patients that also put us on the trail: presence of wrinkles in the preauricular area, depression of the frontal or temporal veins and granular texture of the skin at the temples.
Complete Dra. Raquel Pérez Mesonero the dermatologist and surgeon.
And what is the prognosis for these women, surely nervous and scared?
“It is crucial that they internalize that, once the definitive damage of this alopecia has occurred to the hair follicle, there is, for the moment, no possibility of recovering the lost hair due to the cicatricial nature of the hair pathology ·lar”, he externalises.
“We can only delay the follicular damage, at best, and alleviate the symptoms. However, not all of these fibrous alopecias progress at the same speed; some remain stable for a long time without treatment after an initial period of pathological activity”, he concludes.
Therapies to minimize the damage of fibrosing frontal alopecia
However, the ideal is to be able to diagnose AFF in early stages to minimize hair loss and have the least possible impact on the patient, implementing any treatment that promotes hair resistance.
“But the success is limited”, accredits the experience Dr. Eduardo López Bran, medical director of the Imema Clinic and head of the Dermatology Service at the Hospital Clínic Universitari San Carlos in the Spanish capital; although as an indefatigable fighter he does not stop in his medical zeal.
All therapies are complementary to each other and must be prescribed after an individual assessment of each patient.
The corticosteroidsapplied topically (shampoos and creams), or through direct infiltrations on the scalp, will try to reduce the inflammation responsible for the destruction of the follicles and improve the associated symptoms.
It also works with the drug finasteride orally, 5 alpha reductase enzyme inhibitor; with immunomodulatory that inhibit calcineurin, hindering the action of T lymphocytes; or using hydroxychloroquine, an anti-inflammatory compound.
In addition, they are used antiandrogens, a first-line treatment to slow progression; the minoxidil for the thickening of downy hairs and follicles not damaged at all; the isotretinoin oral, which improves some skin signs.
Likewise, it can be applied platelet-rich plasma (PRP) and low intensity laserwhich will help reduce inflammation, scarring skin conditions and related symptoms.
In very advanced cases of fibrosing frontal alopecia, eyebrow micropigmentation is recommended.
Doctor López Bran, And how effective are hair transplants in fibrosing frontal alopecia?
“Capillary microsurgery is a very controversial issue in cicatricial alopecia due to the fact that the quality of the skin in which the grafts are implanted is not optimal and, in addition, it is very possible that the disease will reactivate after the transplant , with the consequent harm in the same area”, he says.
“We are facing a set of circumstances that are not comparable to those of other patients who suffer from, for example, androgenetic alopecia”, he completes.
Even so, women demand an effective solution to the high cosmetic impact of AFF, so experts do everything within reach of hand and intelligence.
“We only do a hair transplant in cases where the evolution of alopecia has stopped or stabilized; and always after a detailed study and a kind and sincere interview with the woman, after which he must be very aware of the real expectations of success”, he poses.
The transplanted hair will be healthy hair, taken from the donor area or the back of the patient’s neck, which is not affected by fibrosing pathology. Instead, both the implanted hair and its growth in the recipient area will be conditioned by the disease.
“Most likely, over the years, it will be necessary to do a second hair transplant to consolidate the aesthetic result obtained”, he warns.
“The group of therapies to address the solution of fibrosing frontal alopecia, all in one, help to limit the receding of hair in the frontotemporoparietal area of our patients,” says Dr. Eduardo López Bran, a doctor with deep luminary roots.