Frontotemporal Fibrosing Alopecia (FFA)

Klinische illustratie van frontale fibroserende alopecie (FFA) met terugwijkende haarlijn en lichte wenkbrauwverdunning

A chronic inflammatory scarring alopecia causing progressive frontal hairline recession and permanent follicle loss

Frontotemporal Fibrosing Alopecia (FFA) is a chronic inflammatory form of scarring hair loss characterized by a progressive recession of the frontal hairline. The condition results in permanent destruction of hair follicles due to inflammation and fibrosis.

FFA most commonly affects postmenopausal women, although cases in men and younger individuals have been documented. Because follicular scarring prevents regrowth, early recognition and medical evaluation are important.

Clinical classification of FFA

Frontotemporal fibrosing alopecia (FFA) is classified as a primary lymphocytic cicatricial alopecia.

It belongs to the lichen planopilaris spectrum of scarring hair disorders and is characterised by perifollicular inflammation leading to progressive follicular fibrosis.

Unlike non-scarring alopecias, follicular destruction in FFA is permanent once fibrosis occurs.

Early Signs of Frontotemporal Fibrosing Alopecia

Frontotemporal fibrosing alopecia often begins subtly. Early recognition improves the chance of slowing disease progression.

Common early signs include:

  • Gradual recession of the frontal hairline
  • Loss or thinning of eyebrows
  • Redness around hair follicles
  • Mild scaling along the hairline
  • Burning, itching, or tight sensation

In early stages, changes may be mistaken for normal hairline maturation or androgenetic alopecia.

What Is Frontotemporal Fibrosing Alopecia?

Frontotemporal Fibrosing Alopecia belongs to the group of scarring alopecias. In these disorders, inflammatory processes target the hair follicle stem cell region. Over time, inflammation leads to fibrotic replacement of the follicle, permanently preventing hair regrowth.

FFA is considered a variant of lichen planopilaris due to shared histopathological characteristics. Unlike non-scarring forms of hair loss such as androgenetic alopecia, follicular damage in FFA is irreversible.

FFA is considered a lymphocytic cicatricial alopecia, meaning immune cells contribute to permanent follicular destruction.

Who Is Most Commonly Affected?

FFA most frequently affects:

  • Postmenopausal women
  • Individuals over the age of 45
  • Patients with autoimmune predisposition

Although less common, men and younger individuals may also develop the condition.

Some studies suggest hormonal factors may influence susceptibility, though definitive mechanisms remain under investigation.

Symptoms of FFA

Common clinical features include, the progression is usually slow but persistent:

  • Gradual recession of the frontal and temporal hairline

  • Thinning or loss of eyebrows

  • Perifollicular redness and scaling

  • Burning, itching, or tightness along the hairline

  • Smooth, pale skin in advanced stages

Underlying Mechanisms

The exact cause of FFA remains under investigation. Current evidence suggests a multifactorial origin involving:

  • Autoimmune-mediated inflammation

  • Genetic susceptibility

  • Hormonal influences

  • Immune dysregulation affecting follicular stem cells

The inflammatory process targets the bulge region of the hair follicle, where stem cells responsible for hair regeneration reside.

Risk Factors and Contributing Factors

While the precise cause remains unknown, research suggests potential contributing factors:

  • Autoimmune dysregulation
  • Genetic susceptibility
  • Hormonal changes
  • Environmental influences

Currently, no single confirmed trigger has been identified.

How FFA Differs from Other Hair Loss Conditions

Unlike androgenetic alopecia, which involves progressive follicle miniaturization, FFA results in permanent scarring and irreversible follicle loss.

Disease Progression

FFA typically progresses slowly over several years.

Common progression patterns:

  • Band-like recession along the frontal hairline
  • Extension toward temporal regions
  • Gradual eyebrow thinning
  • Development of smooth, pale scarred skin

In advanced stages, hair regrowth in affected areas is not possible due to follicular fibrosis.

Diagnosis

Diagnosis is based on:

  • Clinical scalp examination
  • Dermatoscopy (trichoscopy)
  • Scalp biopsy in uncertain cases

Histological evaluation may confirm inflammatory infiltrates and perifollicular fibrosis.

Early diagnosis allows for earlier intervention aimed at slowing disease progression.

Medical guidance: If you notice progressive frontal hairline recession with redness, scaling, or eyebrow thinning, consultation with a dermatologist or specialized hair clinic is recommended.

Dermatoscopy may reveal perifollicular erythema, perifollicular scaling, and absence of follicular openings in scarred areas.

Dermatoscopic features of FFA

Typical findings include:

• Loss of follicular openings in affected areas
• Perifollicular erythema
• Perifollicular scaling
• Absence of vellus hairs at the frontal hairline

In advanced stages, shiny smooth scalp areas reflect permanent follicular fibrosis.

Treatment Options

There is currently no definitive cure for FFA. Treatment focuses on reducing inflammatory activity and preserving remaining hair follicles.

Medical approaches may include:

  • Topical or intralesional corticosteroids
  • Systemic anti-inflammatory medication
  • Immunomodulatory therapy
  • Hormonal modulation in selected patients

The goal of treatment is stabilization rather than regrowth in scarred areas.

Nutritional supplements do not treat scarring alopecias. Management of FFA requires dermatological supervision and anti-inflammatory therapy.

What Happens Without Treatment?

Without intervention, FFA typically progresses gradually. The frontal hairline may continue to recede, and areas of follicular scarring increase. Once scar tissue replaces functional follicles, spontaneous regrowth does not occur.

Early medical management may help limit further follicular destruction.

Why early recognition matters in FFA

Frontotemporal fibrosing alopecia is not a cosmetic variation of hairline maturation.

It is a chronic inflammatory disorder that may lead to irreversible follicular loss.

Because scarring replaces the hair follicle, regrowth is not possible in affected areas once fibrosis is established.

Early medical evaluation improves the likelihood of stabilisation.

When to Seek Medical Evaluation

Medical evaluation is recommended if you notice:

  • Progressive frontal hairline recession
  • Eyebrow thinning
  • Persistent redness or scaling along the hairline
  • Burning or itching sensations

Early intervention may help slow disease progression.

Early medical evaluation by a dermatologist or a specialized hair disorder clinic such as Intermedica Haarkliniek may help guide appropriate management.

Clinical summary: Frontotemporal fibrosing alopecia

Frontotemporal fibrosing alopecia (FFA) is:

• A primary scarring alopecia
• Driven by lymphocytic inflammation
• Characterised by progressive frontal hairline recession
• Frequently associated with eyebrow loss
• Irreversible once follicular fibrosis develops

Because FFA causes permanent follicle destruction, early dermatological evaluation is recommended when symptoms are suspected.

Frequently asked questions about Frontotemporal Fibrosing Alopecia (FFA)

What is frontotemporal fibrosing alopecia (FFA)?

Frontotemporal fibrosing alopecia (FFA) is a chronic scarring (cicatricial) hair loss disorder characterised by progressive recession of the frontal hairline. Inflammation around follicles may lead to permanent follicular damage.

Is FFA a scarring alopecia?

Yes. FFA is scarring. In affected areas, fibrosis can replace functional follicular tissue, which prevents regrowth once scarring is established.

Can hair regrow in areas affected by FFA?

If scarring and loss of follicular openings have occurred, regrowth is usually not possible in those areas. This is why early recognition matters.

Who is most commonly affected by FFA?

FFA most commonly affects postmenopausal women, but it can also occur in men and in younger individuals.

What does FFA typically look like?

FFA often appears as a band-like frontal hairline recession, sometimes involving the temples, frequently with eyebrow thinning. In advanced stages, the scalp skin may look smooth and pale in scarred areas.

Can eyebrow loss be an early sign of FFA?

Yes. Eyebrow thinning or loss is common in FFA and may be an early feature in some individuals.

What symptoms can occur with FFA?

Some people report itch, burning, tenderness, or tightness along the hairline. Redness or scaling around follicles may also be present.

How is FFA different from androgenetic alopecia?

Androgenetic alopecia is usually non-scarring and involves progressive miniaturisation in recognisable patterns. FFA is scarring and inflammatory, with risk of permanent follicle destruction.

How is FFA different from telogen effluvium?

Telogen effluvium is diffuse shedding due to a temporary shift in the hair cycle and is often reversible. FFA is scarring, typically gradual, and may lead to irreversible hair loss in affected areas.

How do clinicians diagnose FFA?

Diagnosis is typically based on the clinical pattern, examination, and dermoscopy (trichoscopy). In some cases, a scalp biopsy may be used to confirm scarring inflammation.

What dermoscopic features support FFA?

Common findings include perifollicular erythema and scale, and in scarred areas, loss of follicular openings. These features help distinguish FFA from non-scarring hair loss.

Is FFA the same as lichen planopilaris (LPP)?

FFA is often considered part of the lichen planopilaris spectrum. They share lymphocytic follicular inflammation, although the clinical presentation can differ.

Is FFA hereditary?

Genetic susceptibility may play a role, but FFA is not inherited in the same straightforward way as pattern hair loss. Immune-mediated mechanisms are central.

Is FFA contagious?

No. FFA is not contagious.

When should medical evaluation be considered?

Medical evaluation is advisable if you notice progressive frontal hairline recession, new eyebrow thinning, persistent redness or scaling at the hairline, or symptoms such as itch or burning.

Can FFA stabilise over time?

The course varies. FFA may progress slowly, and stabilisation is sometimes possible. Early recognition and appropriate clinical management are important.

This page provides general educational information and does not replace medical diagnosis or treatment. For personalized medical advice, consult a qualified healthcare professional.

For a structured comparison of scarring and non-scarring alopecias, see our full overview of hair loss types and medical classification.