What Is Frontal Fibrosing Alopecia (FFA)?

The term “alopecia” describes hair loss on any part of the body. FFA is a form of alopecia that results in hair loss at the sides and front of the scalp. Other parts of the body, particularly the eyebrows and eyelashes, can also be affected. FFA is progressive (gets worse over time) and develops slowly. The hair loss that it causes is usually permanent, but if it is caught and treated early on in the development of the condition, some hair may regrow and its progression may be stopped.

FFA is classed as a type of scarring alopecia. As FFA progresses, hair follicles (the openings on the surface of the skin through which hairs grow) are destroyed and replaced with scar tissue. Although the exact causes of this are unknown, some researchers have suggested that it is an autoimmune disease (a disease caused when the body’s immune system mistakenly starts attacking the body because it has started to recognize something as “foreign”) because immune system cells called lymphocytes start to attack hair follicles. Hormones and genetics may also play a role.

What Are the Symptoms of FFA?

FFA is most often diagnosed in women who have gone through the menopause, with hair loss becoming visible between 2 and 18 years after their menopause started. Before the hair loss becomes noticeable, people with FFA may have a painful and/or itchy scalp, and some people develop a rash of small, scaly bumps that can be yellow, red, or skin-colored, and/or peeling or flaky skin.

As the hair loss develops, the hairline on the forehead starts to recede. Hair can also start to be lost from the legs, arms, face (particularly the eyebrows and beard area), and pubic area. Some people develop small spot-like bumps on the face, and the pain and itchiness that some people experience can continue.

How Is FFA Treated?

Current treatments for FFA include people taking a drug orally (by mouth), it being injected directly into the affected area, or being applied directly to the skin (for example, in the form of a cream). These drugs include steroid hormones and drugs that suppress the immune system. A commonly used immune system-suppressing drug is methotrexate; however, systemic use of methotrexate (where it travels around the whole body and can affect all of it, rather than only acting on a specific area or cell type) can cause serious side effects, such as:

• liver and kidney damage,
• problems with the digestive system, and
• myelosuppression (where the bone marrow produces fewer blood cells than the body needs).

What Did This Study Investigate?

Because methotrexate is linked to a risk of serious side effects, the authors of this study investigated whether administering methotrexate using a technique called “microneedling” might be safe and effective for people with FFA. Microneedling (also called “microinfusion”) is a cosmetic technique that is used to stimulate skin rejuvenation and to treat facial scarring. It is increasingly being used as a way of delivering drugs and vaccines, with one study reporting that it was safe and effective in treating psoriasis (a condition that causes red, inflamed plaques on the skin).

Microneedling uses a device with lots of thin surgical needles to make tiny holes in the top layer of the skin. At the same time, the needles can be used to deliver a drug just under the skin’s surface. In the case of methotrexate, direct delivery to the affected area of the skin means that it may be less likely to affect organ systems inside the body such as the liver and digestive system. It is a technique that also has the advantages of being relatively simple and low cost.

What Did the Study Find?

The authors of the study treated 17 postmenopausal women with FFA. Each participant underwent microneedling three times, with 30 days between sessions. On one side of the face, methotrexate was delivered into the skin during the microneedling process. To act as a control, microneedling was done on the other side of the face but without methotrexate delivery. Participants also gave blood samples on the day of and 30 days after each treatment, so that laboratory tests could be carried out to check whether their liver and kidney function, and blood cell counts, were affected by the treatment.

More than half of the participants had reduced levels of peeling skin and itching after treatment with methotrexate microneedling. The treatment also stopped the progression of FFA, with significant improvements in the condition and regrowth of hair on the side of the face that was treated with methotrexate (but not on the other side). Participants reported that the treatment was tolerable and 95% were either satisfied or very satisfied with the results. Importantly, there were no changes in participants’ liver and kidney function, and total blood cell counts remained the same, suggesting that methotrexate microneedling treatment of FFA is both safe and effective.