FRONTAL FIBROSING ALOPECIA WHAT I DO The Ronald O. Perelman Department of Dermatology JERRY SHAPIRO, MD, FAAD PROFESSOR DIRECTOR DISORDERS OF HAIR AND SCALP AAD Chicago 2018
Disclosures Consultant/Investigator/Speaker/Stockholder for: Aclaris Samumed Incyte Pfizer Eirion Applied Biology Replicel Life Sciences Inc. ISDIN Regenlab 2 Keeps.com
MY MEDICAL PRACTICE Unique in that my practice is restricted to only disorders of the scalp and hair 1 hour per patient Patient ends the consultation, not I 35% alopecia areata 30% cicatricial alopecia 35% pattern hair loss and telogen effluvium
My clinic epidemiology on alopecia types Androgenetic alopecia 33% (66) Frontal fibrosing alopecia 23% (46) Alopecia areata 16.5% (33) Acute telogen effluvium 9.5% (19) Lichen planopilaris 10% (20) Central centrifugal cicatricial alopecia 4.5% (9) Lichen simplex chronicus 1.5% (3) Chronic telogen effluvium 1.5% (3) Folliculitis decalvans 0.5% (1) 4
5 **TCM + *IL-TAC qmonthly Improvement Yes Continue prn *IL-TAC: intralesional triamcinolone acetonide **TCM: Tacrolimus 0.3% BID + corticosteroid BID + 5% minoxidil solution BID < 10% FFA Extent of disease No 10% Options: Mycophenolate mofetil Methotrexate Low dose isotretinoin JAK Inhibitors Given risk of koebnerization, consider hair transplantation only after no disease activity 1 year No Doxycycline 100mg BID or Hydroxychloroquine 200mg BID Finasteride or Dutasteride ± **TCM ± *IL-TAC qmonthly ± Prednisone (bridge) Improvement Yes Taper to lowest effective dose
Lichen Planopilaris/Frontal Fibrosing Alopecia (LPP/FFA) PPAR gamma: Peroxisome proliferator-activated receptor gamma Is significantly decreased in LPP patients PPAR gamma is essential for healthy pilosebaceous units Loss of PPAR gamma function central to pathogenesis of LPP and other cicatricial alopecias Actos (pioglitazone)15-30 mgs daily 6
Lichen Planopilaris (LPP): Naltrexone Naltrexone: 3-4-5 mgs daily, reduction of the symptoms November 2017 1140 VOLUME 16 ISSUE 11 Copyright 2017 ORIGINAL ARTICLE Journal of Drugs in Dermatology Novel Treatment Using Low-Dose Naltrexone for Lichen Planopilaris Lauren C. Strazzulla BA, Lorena Avila MD, Kristen Lo Sicco MD, Jerry Shapiro MD The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY 7
Frontal Fibrosing Alopecia Patterned variant of LP Largely affects postmenopausal women > 40 20% can be premenopausal Can occur in men Lonely hairs 8
Frontal Fibrosing Alopecia (FFA) Typically occurs on the frontotemporal region of the scalp, but upper periauricular and occipital localization are common 9
Behind the ears
Frontal Fibrosing Alopecia (FFA) Circumferential Fibrosing Alopecia 11
Frontal Fibrosing Alopecia The band of alopecia is often readily distinguishable from the sun damaged skin of the forehead 12
DELINEATION FROM SUN DAMAGED SKIN
Frontal Fibrosing Alopecia The loss of the eyebrows is a common and helpful diagnostic feature that affects 50% to 95% of individuals, and it can either precede or follow the onset of scalp hair loss 14
Eyebrow involvement in FFA 15
Lonely Hairs of Frontal Fibrosing Alopecia Lonely hairs 16
Frontal Fibrosing Alopecia (FFA) 20
Patient Demographics 14,1% Symptons 11% Auto-immune disease 96% Eyebrows involved 21 Total: 92 Women: 90 Men: 2
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DATA ANALYSIS Findings No of patients Total No of patients 62 Female No of patients 61 Age of presentation 21-82 years Age of onset 18-81 years Male No of patients 01 Age at Presentation 68 years Age of onset 63 years
DATA ANALYSIS Finding No of patients (%) Ethnicity Caucasians 50 (81) Asians (Oriental) 06 (9) East Indian 05 (5) Hispanic 01 (2) Menopausal status Post menopausal 49 (80) Pre menopausal 12 (20)
DATA ANALYSIS Finding No of Patients 62 Symptoms Itching 27 Pain/burning 13 Asymptomatic 22 Hair loss Frontal hairline 62 Eyebrow 50 Axillary and pubic area 33 Body hair 12 Clinical signs Lack of follicular ostia 62 Lonely hair 62 Perifollicular erythema 45
27 Photos for FFA
How do I measure? FFA Glabella to hair line Right and left outer canthi to hair line Sides to hair line 28
Right outer canthus to hairline Glabella to hairline Left outer canthus to hairline Sideburns Sideburns 29
Folliscope Fotofinder 30
Trichoscopy Lichen Planopilaris and FFA are similar 31
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Frontal Fibrosing Alopecia (FFA) Diagnosis: Differential diagnoses: alopecia areata, traction alopecia, FPHL or MPHL The distinction between FFA and LPP is primarily clinical, and the histologic findings are essentially identical. Perifollicular inflammation tends to be less intense than in LPP. 33
What is new? Twice as many women in the FFA group regularly used a sunscreen compared with controls, a difference that was highly significant. 34
What is new? The results support the conclusion from the previous female study that there is an association between FFA and the use of facial moisturisers and sunscreens. 35
What is new? The time course of sunscreen use by the population does seem to parallel the apparent increase in the incidence of FFA. To some extent the predominant distribution of FFA corresponds with the usual sites of moisturizer and sunscreen application. 36
FFA and Sunscreen 37
FFA and Sunscreens Studies with men and women support the conclusion that there is an association between FFA and the use of facial moisturisers and sunscreens. Ingredients possibly to avoid: Oxybenzone and Avobenzone introduced by FDA in 1988. First cases of FFA reported in 1994. Better sunscreens: mineral types Zinc oxide Titanium dioxide 38
F FRONTAL F FIBROSING ALOPECIA AND SURGERY
FFA AND SURGERY
Scarring Alopecias Trichologic emergency Early intervention can potentially avert scarring and secondary complications Take home message Ensure diagnosis with biopsy Trichoscopy helps in following up progress Adjunctive agents/procedures can improve cosmesis Topical minoxidil 5% solution/foam Hair transplantation 44