Frontal fibrosing alopecia: a receding hairline in women

A receding hairline is usually linked with men. When a woman notices her hairline moving back, especially after menopause, one cause doctors consider is frontal fibrosing alopecia (FFA). It is less common than pattern hair loss, but it is important to recognise, because it is a scarring condition and hair lost to scarring does not grow back.

What is frontal fibrosing alopecia?

FFA is a type of hair loss in which inflammation destroys hair follicles along the front and sides of the hairline ¹. Once a follicle is replaced by scar tissue, it cannot produce hair again. That is why the main aim of treatment is to slow or stop the condition progressing, rather than to bring hair back ².

Under the microscope, FFA looks very similar to lichen planopilaris, and it is considered a variant of that condition ³. See scarring alopecia and lichen planopilaris.

Who gets it?

FFA was first described in 1994 and has become increasingly common since then ². It is usually diagnosed in women after menopause, often a few years after their periods stop ¹. It can also appear earlier in life, and men can be affected too ¹.

Signs to look for

• A band of smooth, pale skin along the front and sides of the hairline, where hair used to grow ¹.
• Eyebrow thinning or loss. This is often the first sign. The AAD notes that 80% to 95% of women diagnosed with FFA have lost some or all of their eyebrows ¹. See eyebrow transplants, which are not usually suitable while FFA is active.
• Redness or scaling around hair follicles at the edge of the hairline.
• Lonely hairs, single hairs left standing in the bald band.
• Hair loss elsewhere on the body, such as the arms, legs or underarms, and in men, the beard area ¹.
• Itching or tenderness at the hairline in some people.

In people with darker skin, FFA often comes with darker patches of facial skin called lichen planus pigmentosus, which may be part of the same process ².

How is it different from other hair loss?

Pattern hair loss in women usually causes widening of the parting on top, with the front hairline kept. Traction alopecia from tight hairstyles can also affect the hairline, but there is usually a history of pulling. FFA typically affects the edge of the hairline in a band, often with eyebrow loss, and the skin in the affected area looks smooth and shiny ¹.

Because these conditions can look alike, a doctor's examination matters.

How is it diagnosed?

A dermatologist examines the scalp, eyebrows and skin. Trichoscopy, a magnified view of the scalp, can show signs of scarring and inflammation around follicles. A scalp biopsy is the standard test to confirm the diagnosis ³. Careful clinical photos are also important to judge whether the condition is changing over time ³. See photo tracking.

What causes it?

The cause is not fully understood. Genetic studies have confirmed that some people have an inherited tendency ². Researchers are also looking at environmental factors, including facial skin care products such as moisturisers and sunscreens, and hormones. However, direct causal links have not been confirmed ². There is no reason to stop using sunscreen based on current evidence; talk to your dermatologist if you are worried.

Treatment

There are no validated treatments or formal guidelines yet, and treatment is based largely on case series and expert experience ^{3 2}. A dermatologist may suggest:

• medicines to reduce inflammation, applied to the skin or injected
• tablets that act on hormones or inflammation, depending on the person
• treatment for the eyebrows

Clinical trials of newer medicines, including JAK inhibitors, are in progress ². Treatment needs regular follow-up, as response varies.

Living with FFA

The change in appearance can be upsetting. Some helpful steps:

• Hairstyles with a fringe or side-swept front can soften a receding hairline.
• Eyebrow pencils, powders or semi-durable brow tattooing can restore definition. Ask your dermatologist about timing.
• Scalp micropigmentation or hairpieces may help some people once the condition is stable.
• Support: talking to others with scarring alopecia can help.

A hair transplant is generally only considered, if at all, when the disease has been inactive for a long time, and results are less predictable than in pattern hair loss.

When to see a doctor

See a doctor promptly if your hairline is moving back, your eyebrows are thinning without a clear reason, or you have redness, scaling or itching along the hairline. Since lost hair cannot return, earlier diagnosis protects more of what you have ¹. See seeing a dermatologist.

Frequently asked questions

Can hair grow back in frontal fibrosing alopecia?

Hair in fully scarred areas does not grow back. Treatment aims to stop the condition progressing and protect remaining hair ^{1 2}.

Is FFA caused by sunscreen?

This has been studied, but direct causal links with skin care products have not been confirmed ². Discuss any concerns with a dermatologist.

How is FFA diagnosed?

A dermatologist examines the scalp and may use trichoscopy. A scalp biopsy is the standard test to confirm it ³.

Does FFA only affect women?

It mostly affects women after menopause, but it can occur earlier and in men ¹.

Educational content. Not medical advice.