Frontal Fibrosing Alopecia: A Comprehensive Review with Recent Updates

Frontal fibrosing alopecia (FFA) is a progressive scarring alopecia affecting postmenopausal women. FFA is a primary lymphocytic scarring alopecia and is considered a variant of LPP due to similar histopathology findings in both conditions. The exact etiopathogenesis of FFA is not known. However, some genetic, autoimmunity, hormonal and environmental factors are implicated. However, the loss of the immune privilege of hair follicles and the role of cosmetics and sunscreen have been postulated. The disease is characterised by frontal and temporoparietal hairline recession with shiny, atrophic skin with sideburn involvement. The common trichoscopic findings include perifollicular erythema, follicular hyperkeratosis and loss of follicular openings. The histopathology is characterised by lichenoid lymphocytic infiltrate around the upper part of the hair follicle including the bulge area and concentric perifollicular lamellar fibrosis. There are two diagnostic criteria proposed by Tolkachjov et al. and the International FFA Cooperative Group. Many topical and systemic treatment options are available, but none have shown satisfactory results. Recently, many biological agents have been tried including tofacitinib and tildrakizumab.