Hair Transplantation for Frontal Fibrosing Alopecia: Part of the Solution?

Primary cicatricial alopecias (PCA) are a diverse group of inflammatory hair disorders of unknown aetiology, clinically characterised by the loss of hair shafts, visible follicular ostia, and variable degrees of scalp inflammation. The hair follicle is the primary target of the disease process and persistent inflammation leads to irreversible damage to the hair follicle’s stem cells. Ultimately, replacement of follicular structures by scar-like fibrous tissue occurs. Frontal fibrosing alopecia (FFA) is one of the most common types of PCA. The clinical diagnosis is typically straightforward; FFA is considered to be a subtype of lichen planopilaris (LPP) and is based on similar histopathological findings. An effective medical treatment remains elusive and evidence-based recommendations are weak: intralesional triamcinolone acetonide, finasteride, dutasteride, oral and topical corticosteroids (level of evidence D), and antimalarials (level of evidence E). Despite medical treatment, the course of FFA is uncertain and, in the best scenario, these drugs can only stop disease progression. In daily practice, we have observed that the cosmetic impact of FFA on women is a frequent cause of anxiety, and just halting the alopecia process is generally not sufficient in most cases. Some patients with FFA insistently demand a hair transplant despite being properly informed of the high risk of hair loss a few months after the procedure. How could hair transplantation be part of the solution for FFA? Literature regarding hair transplantation for FFA is scarce. Publications by Nusbaum et al. and Jiménez et al.