frontal fibrosing alopecia

Frontal Fibrosing Alopecia

Frontal Fibrosing Alopecia (FFA) is a primary inflammatory condition where lymphocytes (a type of white blood cells) target and destroy fine and vellus hairs on the scalp, face, and less commonly, the body.

FFA is common amongst postmenopausal women with early symptoms presenting around 50-60 years of age. Initially this condition was only seen in Caucasian women but over the past few years cases have emerged amongst African American and Hispanic women.

FFA presents as a band of hairline recession along the scalp. Itching may or may not be present.  The skin on the forehead and temples is thinner and blood vessels appear prominent in fairer skin.  With the use of a dermatoscope, one can appreciate fine bumps around hair follicles. In areas of long-term or permanent hair loss, the follicles scar over and the follicular openings cannot be visualized.

Women suffering from FFA also notice thinning or complete loss of facial and body hair including eyebrows, sideburns, eyelashes, arms, legs, and underarm hair. The skin surrounding eyebrow hairs may also be affected and can appear red and inflamed.

The cause of FFA is still unknown. FFA is responsive to topical anti-inflammatories and medications that block androgens prompting speculation that there may be a hormonal influence to this condition. The inflammation destroys the stem cells located near the sebaceous glands (article on anatomy of hair follicle) which are needed to regenerate hair. Early diagnosis and treatment is important to halt the progression and if caught early enough, can salvage follicles not yet destroyed by the lymphocytes.

FFA requires a detailed history from the patient, a thorough exam, and if warranted, a biopsy. The work up for FFA is necessary because other hair loss conditions such as traction alopecia and lichen planopilaris can look similar to FFA but require different treatments. It is also important to know that more than one hair disorder can present in the same individual.

Below are photos of individuals with FFA involving the scalp and/or eyebrows.





Alopecia is not a diagnosis



Alopecia, latin for partial or complete absence of hair from an area which normally grows hair, is a diagnosis term but is not a final diagnosis. It is an umbrella term under which there are numerous subsets and reasons for hair loss. I often hear people tell me they were told by physicians and stylists that they have alopecia. This is a broad term similar to saying, “you would like a beverage.” There are many types of beverages of all variations, flavors, consistency, and contents. This also pertains to alopecia. Having a specific diagnosis is important for not only knowing the prognosis of your hair loss but also tailoring treatment towards the pathology, or reason, for the hair loss. For example, if you have hair loss secondary to an auto immune condition, treating with oral supplements and stopping all of your medications is not targeting the reason for the hair loss.

A large part of treating hair loss is education and increasing awareness so individuals present to a dermatologist earlier in their course with hopes to stop the progression and if possibly restore the hair. When I speak at salons and cosmetology schools I explain the umbrella term of alopecia. I also categorize hair loss into different types to show that not all hair loss is the same and should not be treated the same.

There are primary inflammatory conditions where the immune system is the initial cause of inflammation attacking the follicles/sebaceous glands (anatomy of hair follicle unit) causing permanent destruction.  Then there are secondary inflammatory conditions which there is an inciting trigger to cause inflammation, such as traction, chemicals, heat, and trauma. Another way to categorize hair loss is by scarring and non-scarring which helps with prognosis.  Scarring hair loss definitely requires medical intervention to stop the inflammatory process and to prevent progression of further follicle damage and hair loss.  Non-scarring conditions are usually environmental or changes in the body- hormones, stress, medications, infections, etc and are reversible sometimes on their own and sometimes with medical intervention.

In this series I will explain the following types of hair loss and the natural progression of each condition if it isn’t diagnosed and treated earlier in its course.


Scarring hair loss:

  1. Frontal fibrosing alopecia:
  2. Central centrifugal cicatricial alopecia:
  3. Lichen planopilaris
  4. Pseudopelade (Brocq)
  5. Discoid lupus erythematosus
  6. Dissecting cellulitis
  7. Acne keloidalis nuchae
  8. Folliculitis decalvans
  9. Traction alopecia


Non-Scarring hair loss:

  1. Alopecia areata
  2. Telogen effluvium
  3. Trichorrhexis nodosa
  4. Seborrheic dermatitis
  5. Lipedematous alopecia