Frontal fibrosing alopecia (FFA): causes, symptoms and treatment

FFA is a type of scarring (cicatricial) alopecia. In scarring alopecia, inflammation damages the hair follicle so that it is replaced by scar tissue and cannot produce hair again. The British Association of Dermatologists (BAD) explains that in FFA this happens along the front hairline, and that the condition is thought to be a variant of another condition called lichen planopilaris.

The Primary Care Dermatology Society (PCDS) describes FFA as presenting as a progressive, symmetric, band-like hair loss affecting the frontal hairline and the scalp in front of the ears, and less commonly the area behind the ears. Isolated "orphaned" hairs may remain in areas of hair loss, and the eyebrows are often affected, sometimes before the scalp.

FFA is not the same as common pattern hair loss, although the two can occur together. The BAD notes that treatments may help follicles that are inflamed but not yet lost, which is why recognising it early matters.

The BAD says FFA may cause no symptoms at all, or an itchy, painful or burning sensation in a band across the frontal hairline. Many people find the hair loss distressing. The frontal hairline progressively recedes over time and the rate varies from person to person.

There can be some redness and flaky skin around individual hairs. Once a hair has fallen out it will not regrow in that area, and the skin left behind may look slightly paler and smoother than the rest of the forehead. The PCDS adds that atrophy of affected sites with prominent forehead veins, and facial papules, can occur, and that other facial hair including eyelashes and body hair may be involved.

• A hairline that moves backwards, often evenly across the front and sides.

• Loss of eyebrow hair, sometimes the first sign.

• Itching, soreness or burning at the hairline in some people, though others have none.

• Redness or scaling around hairs at the edge of the affected area.

• Smooth, paler skin where hair has been lost.

The BAD says the cause is unknown. It explains that lymphocytes, part of the immune system, attack the hair follicles, and that it is not understood why the front of the scalp is particularly affected. Genetics, overactivity of the immune system and possibly hormones are thought to play a role.

It is not an inherited condition, according to the BAD, although it has occasionally been reported in several members of one family. The PCDS notes that FFA was first described in postmenopausal women and appears infrequently in premenopausal women and more rarely in men.

A GP who suspects scarring hair loss may refer you to a dermatologist. Diagnosis is based on the pattern of hair loss and the appearance of the scalp, often using a magnified view (dermoscopy). The PCDS describes dermoscopic features such as scale surrounding and extending along the proximal part of hair shafts, with mild or absent redness.

The BAD says a skin biopsy may be taken to confirm the diagnosis. A small piece of scalp skin is removed under local anaesthetic and examined under a microscope, and a small scar is left at the site.

The BAD says there are treatments that help slow down or halt further hair loss in some people, and that they may help follicles that are inflamed but not yet lost. It is clear that no treatment can cure FFA in areas where the follicles have gone, that success is variable and that some people cannot find a treatment that works.

The BAD acknowledges that many people find the experience of hair loss distressing. It suggests that joining a patient support group and meeting others with alopecia can make it easier to adjust, and names Alopecia UK as a charity.

Practical options include wigs, which can be bought privately or obtained through the NHS on a consultant's prescription (a financial contribution is usually required in England), according to the BAD. A few people with longer hair find hair extensions help camouflage the problem, although the BAD warns that too much tension on the hair can cause traction alopecia, and eyebrow pencils and eyebrow tattoos help some people with eyebrow loss.

Talk to your dermatologist about how often you should be reviewed. Hydroxychloroquine, if used, requires annual eye checks, and treatment plans are usually adjusted according to how active the condition appears.

On the NHS, FFA is usually diagnosed and managed by a dermatologist after GP referral, with biopsy and follow-up as needed. Because the treatments aim to prevent further loss rather than restore hair, early assessment is useful.

Some people see a private dermatologist or hair specialist for a faster appointment. Treatments are largely the same, and the differences are waiting times and choice of clinician. Be cautious about any service that promises regrowth in scarred areas, as the BAD states that lost follicles cannot regrow.