On the first day of the 2023 AAD Annual Meeting, Maryanne Makredes Senna, MD, FAAD, kicked off her session, “Frontal Fibrosing Alopecia (FFA) Overview and Emerging Therapies,” with the objective to help dermatologists formulate a straightforward approach to diagnosing lichen planopilaris (LPP) and FFA, understanding the importance of following certain clinical features over time, and her personal approach to treating LPP and FFA.

Dr Senna started with diagnostic considerations and explained the elements that assist dermatologists to help patients:

• Comprehensive history
  • Intake forms allow for comprehensive, yet timely history taking.
  • Patients complete this before the visit.
• Standardized measurements
  • Measure in centimeters from the right lateral canthus, right mid brow, lower glabellar crease, left mid brow, and left lateral canthus to hair line.
• Standardized grading of inflammation symptoms
  • Have patients rate  their scalp, itch, pain, and burning on a scale of 0 (none) to 10 (worst ever).
• Standardized photos
  • Take before and after, same angle photos.

Dr Senna discussed the clues for FFA, which include redness, flaking, or hyperpigmentation that hugs the follicle, loss of eyebrows and sideburns, frontal hair line recession, and scalp symptoms such as itching and burning.

Dr Senna also talked about FFA in Black women and patients with skin of color, “FFA in Black women can present differently—39% in premenopausal (younger) women, accompanied by perifollicular hyperpigmentation along the hair line plus facial hyperpigmentation.”

Regarding FFA in men, Dr Senna noted that in a “US multicenter study of 270 male patients, 30% were incorrectly diagnosed before presenting to a specialty hair clinic and loss of beard hair was a presenting sign in 22%.” She added, “Cicatricial alopecia can present similarly to patterned hair loss in men and women.”

Next, Dr Senna discussed her treatment approach for LPP and FFA. “There’s very limited experience, so a lot of treatment approaches are based on experiences.”

Regarding sunscreens and moisturizers, Dr Senna cautioned, "Until we know more, I advise my patients to avoid chemical sunscreens.” Along with chemical sunscreens, she also recommended avoiding fragrances, including linalool and limonene, and formaldehyde releasers.

Dr Senna then outlined her treatment ladder for LPP, FFA, and central centrifugal cicatricial alopecia.

Mild disease:

• Avoidance of potentially harmful ingredients in personal care
• Topical anti-inflammatory at least 2 to 3 times per week
• Intralesional scalp and/or eyebrow steroid injections every 3 months as needed

Moderate disease:

• Oral hydroxychloroquine
• Phototherapy: ubUVB devices for alopecia and scalp or excimer laser
• Low-dose oral naltrexone

Severe disease:

• Oral Janus kinase inhibitors

Dr Senna concluded the session with some additional management pearls, remarking, “Remember scarring alopecia patients get telogen effluvium too. If [patients] are suddenly shedding hair, screen for this first.”

Reference
Senna MM. FFA overview and emerging therapies. Presented at: AAD Annual Meeting; March 17–21, 2023; New Orleans, LA.