Understanding Fibrosing Alopecia

Frontal fibrosing alopecia (FFA) is a potentially permanent hair loss condition, believed to be of autoimmune origin (1). FFA belongs to a group of inflammatory ‘scarring’ alopecia (2) where underlying skin structures are destroyed, and microscopic scar tissue develops.

FFA is overwhelmingly observed in post-menopausal women, but occasionally seen in pre-menopausal women and males. Although medical consensus is that FFA is autoimmune activated, some believe its origins may also arise from hormonal upheaval during the menopause (3). Studies revealed a significant number of subjects reported experiencing a severe stressful episode in their life immediately prior to the onset of FFA.

Certain autoimmune conditions appear during the menopausal stages as a result of the profound re-modelling the immune system undergoes due to progesterone loss and oestrogen withdrawal. FFA and autoimmune thyroiditis are the two common conditions triggered at menopause (Briden: 2021).

Presentation:

To the trained eye the appearance and classic presentation of FFA is sufficiently obvious to suspect this scarring condition:

• The affected frontal hairline margin is recessed by 2-4cms (or more), with empty hair follicles revealing an outward ‘eruptive’ appearance.
• The skin shade of the forehead is often sharply demarcated between affected and non-affected skin. Skin within the impacted area has a desolate, scarred appearance; the skin’s hue often has a look of smooth ‘candle wax’ in its appearance.
• Image enhancement confirms a near barren epidermis where follicles and pores have been obliterated and absorbed, and normal skin activity is absent.
• Biopsied histopathology habitually finds significantly more cell apoptosis (4), inflammation and destruction of the underlying skin structures than in similar scarring alopecia such as Lichen Planus (5).  

Palliative treatments offered by medical specialists:

• Corticosteroids – injected or as a topical therapy to aid in minimizing the inflammatory response.
• Hydroxychloroquine (proprietary name: Plaquenil) is a disease-modifying, anti-rheumatic drug (DMARD) used for rheumatoid arthritis and lupus.
• Immunosuppressant or anti-androgen drugs.

ALL these prescription medications carry significant potential adverse effects, so the client should be closely and continuously monitored by their prescribing specialist.

 Wholistic treatment approach and treatment:

Consultation process should always commence with a thorough assessment of the client’s individual health history to ascertain what may be the precipitating or driving factors behind the onset of FFA:

• A chronicle of other autoimmune conditions; skin, thyroid, diabetes or other metabolic disorders.
• Gut dysbiosis: around 90% of lymphoid tissue are found in the gastrointestinal tract (termed ‘GALT’- gut associated lymphoid tissue) – Van Zanden: 2017. This is essential to the body’s immune defenses.

If the immune system becomes ‘distracted’ by a dysfunctional gut (termed: ‘dysbiosis’) – from whatever cause – it may become disorientated and over-stimulated, leading to the production of antibodies to attack the thyroid gland or the skin (of which the hair follicles are an appendage).

Hair follicles are normally ‘immune response protected’ skin appendages. Autoimmune conditions such as alopecia areata result when the immune concessions against this tissue-specific autoimmune state are withdrawn.

Some probiotics – particularly Lactobacillus rhamnosus GG have demonstrated an effectiveness in reducing the severity of autoimmune disease, atopic and other allergy conditions.

• Elevated inflammatory hormones or nutrients:

Insulin and copper in excess are very inflammatory to the body, and both are commonly seen in western women as insulin resistance and oestrogen dominance. Elevated copper is frequently seen in women taking synthetic hormonal therapy as a contraceptive or HRT (6).

Where considerable copper dominance exists, it can exert what Baratosy (2005) describes as an ‘anti-nutrient’, toxic metal influence – potentially more noxious and inflammatory to the body than lead, cadmium, aluminum or mercury.

• Deficiency of immunologically calming hormones or nutrients:

In contrast to inflammatory elements, Vitamin D and zinc are both immunologically calming to the body as well as being the two most important nutrients for hair follicle activity. Vitamin D deficiency can also disorientate the immune system and trigger an autoimmune reaction in pre-disposed people. Magnesium and Vitamin E are also believed to help reduce chronic inflammation by various mechanisms.

Omega-3 fatty acids (EPA/DHA) (7) have known anti-inflammatory properties. EPA/DHA O3’s is abundant in the fatty skins of fish such as cod, salmon, sardines, mackerel, tuna, shellfish and some algae. Past research has recommended consumption of the fish over taking O3 capsules because any exposure to oxygen during commercial processing quickly renders the O3 fatty acid rancid.

The adrenal hormone Cortisol is the body’s most important anti-inflammatory natural steroid (8). Because of its potent anti-inflammatory effects, Cortisol insufficiency should always be considered where ‘unequally localised’ inflammatory conditions such as acne, eczema, or other skin rashes; ovarian cyst pain, colitis, swollen joints, or asymmetrical ear infections persist (Rebic: 2010). Its’s also reasonable to assume a deficiency of Cortisol could be a catalyst in the onset of FFA (9).

Once all precipitating factors have been assessed and addressed, some oral or topical treatments may assist limiting the inflammatory trajectory of FFA in its early stages. Dietary (10) and lifestyle changes where appropriate may also be very helpful.

Some treatments for consideration:

• Activance Rhodanide range of topical spray treatments:

Rhodanide (aka Thiocyanate) is vitaminoid molecule which the body naturally produces. Rhodanide is a vital ingredient for cellular regeneration of the hair follicle and helps slow tissue anti-ageing. Activance is formulated with a natural anti-microbial and an anti-inflammatory agent which actively aids in the treatment folliculitis, pustular or inflammatory scalp/skin conditions.

• Aromatherapy or Ayurvedic essential oils:

There are a plethora of plants, herbs, trees, fruit and flowers from which essential oils can be extracted. Some of the best known with the most potent anti-inflammatory properties are Thyme, Clove, Peppermint, Ginger root, Roman Chamomile, Lavender, Helichrysum (11), Turmeric, Rose, Eucalyptus and Melaleuca oils; Fennel and Bergamot to list just a few.

• L-tyrosine amino acid and Inositol:

Tyrosine is a safe, effective, and multipurpose non-drug immunomodulation therapy for autoimmune problems, particularly those involving the skin and its appendages (12).

(Myo)-Inositol is natural carbohydrate sugar found in the brain and tissues of mammals. Inositol is an extremely versatile, effective, and safe nutrient for stabilising insulin-glucose levels, reducing thyroid antibodies and promoting systemic anti-inflammatory effects (13) within the body (Wentz: 2018). Unlike many medications Inositol has no known side effects when used appropriately.

• Aloe Vera:

Aloe (Vera) is long known for its therapeutic properties – particularly its anti-inflammatory and immunomodulating effects on the skin. Of the many species found, Barbadensis (14) is regarded as the most medicinal and anti-inflammatory for the skin and can be administered orally or used topically.

Barbadensis’ spikey leaves produce anti-inflammatory chemical compounds called anthraquinones which are known to reduce swelling, inflammation and promote a more rapid healing process.

Aloe has also been touted as an adjunct treatment with anti-cancer, antioxidant, anti-diabetic, and anti-hyperlipidaemic (15) properties but these claims are yet to be clinically proven.

For the topical treatment of early FFA, Barbadensis gel can be squeezed from the leaves and applied to the affected frontal hairline margin. Alternately the leaves can be thinly sliced and applied to FFA areas of concern – the client should lay in the semi-prone or prone position of 30-60 minutes to allow the aloe’s therapeutic actions to be optimised. Aloe Vera can also be taken as an oral liquid drink. 

• Cold compress:

Cold compresses or ‘cool therapy’ is known to reduce the inflammatory severity of autoimmune conditions such as acne rosacea in 70% of patients (Journal of Dermatology).

• Low level laser light (LLLT) and Protein-rich Plasma (PRP) therapies:

Either (or both) therapies may be beneficial in reducing the inevitable inflammatory destruction of FFA if commenced early (16).

Copyright – Anthony Pearce 2022

 

1. Co-existence of FFA and other autoimmune disorders – such as discoid erythematosus lupus and Sjogren’s syndrome – suggests a common pathogenic setting to these conditions.
2. The medical term is cicatricial and relates to a group of destructive skin conditions which progressively obliterate underlying the skin appendages: hair follicles, sweat and sebaceous (oil) glands.
3. As a woman enters and proceeds through the menopause there is often a seismic downshifting and rearranging of the sex hormones: progesterone, the oestrogens, and testosterone.
4. Programmed cell death.
5. AKA Lichen Planopilarus.
6. Synthetic hormone replacement therapy.
7. EPA (eicosapentaenoic acid), DHA (docosahexaenoic acid) are long-chain omega-3 polyunsaturated fatty acids (O-3s).
8. The major sex hormone Progesterone is also known to be immunologically calming.
9. In pre-disposed individuals.
10. Consult a dietician regarding an anti-inflammatory and/or low GI (glycaemic index) diet.
11. Helichrysum essential oil is derived from the Helichrysum Italicum plant found around the Mediterranean and areas of southern Europe. The oil can be found in all green parts of the plant, including stems and leaves. Dried flowers from the plant are used for medicinal purposes.
12. Hair follicles, sweat and sebaceous (oil) glands.
13. Inositol’s de-alkalising properties helps decrease inflammatory processes within the body.
14. AKA: Barbadensis-Miller Aloe.
15. Cholesterol-lowering.
16. It’s advisable to consult with an experienced, qualified practitioner as to your suitability for these treatments rather than trust the advice of commercial hair loss clinic’s salespeople.