Chapters Transcript Cicatricial Alopecia: Updates in LPP and FFA Course: 44th Annual Advances in Dermatology So we're gonna talk about frontal fibrosing alopecia, which really is an epidemic now. We see it all the time. I see at least 3 or 4 cases a day now in my clinic, it's nonstop. These are my um conflicts. And my practice is unique, and many of you know I spend 1 hour per patient. The patient ends the consultation, not I. And uh when it comes to syiatricial alopecias, around 30% um of all my patients have sciattricial alopecias. And when it comes to LP and uh LPP and frontal fibrosis, this is the kind of percentage there is, but actually I'm seeing more and more FFA. And we published a lot of this um in many different uh in many different articles. The latest one was a few years ago, and um I'm gonna talk about what's new and how I treat it. What is the definition? Clinical clinically it's loss of follicular osteo, histopath obliteration of the hair follicle. And there are primary cicatricial alopecias, where there's per preferential destruction of follicular epithelium with sparing of interfalicular dermis. And here are just examples of the kinds of things that we see in our office. We divide them into lymphocytic, neutrophilic, or mixed depending on um the infiltrate, and treatment decisions may be based on the infiltrate, whether it is lymphocytic or neutrophilic. Now we, we published an uh CME article on the evaluation diagnosis of the hair loss patient, and in it we have all sorts of things with dermoscopy, um, that you may find useful. Our co-author was Lydia Rudnika, who is one of the experts, uh, in Poland of uh dermoscopy. And when it comes to trichoscopy, and we'll go over it, what it looks like in FFA and LPP. Now there are no uh placebo controlled double blind randomized studies on therapeutics. There's no evidence-based medicine, so how do I treat FFA? The clinical indications for treatment are activity, whether there's hyperkeratosis, erythema. Pull test positive, symptomatic if there's itch, burn, or hurting. Um, typically occurs on the frontal, uh, temporal region of the scalp, but can also occur above the ears and actually can go around the whole scalp. The band of alopecia is often readily distinguishable from sun damaged skin of the forehead. Most common in postmenopausal women, but 20% of cases occur in younger women, and the youngest case I've ever seen is age 18. It usually presents in patients who are between 55 and 65 years of age, and I must say I'm seeing more and more in men now as well. It seems to be getting more common in men. So it can start with loss of eyebrows, uh, facial papules reflect vellus hair involvement, and we'll talk about that. Frontal recession can be measured by the distance between the labella and the frontal hairline. So these are typical cases that we see. I'm sure you're all familiar with frontal fibrosing alopecia. We made the cover of BJD. Where uh guidelines, um, for clinical trials, uh we came up with, and this is just an example of the kinds of things that we see. We can see a lot of atrophy. There many people uh blame the atrophy on the injections, but actually the condition itself can cause atrophy and sometimes it's hard to tell the difference between atrophy from the injections or from the disease itself. So what we like to do is measure exactly um the distance between the outer. Canine in the hairline, uh, as well as the glabella and the hairline, and we do lots of measurements every time a patient comes in. This was a patient, uh, this was a paper we published. This was when I was in Vancouver, even we looked at 62 cases, and then this is from NYU, 92 cases, and I can say that eyebrow involvement was 96%, symptoms 14%, so many don't have symptoms burning, itch, or hurting. Autoimmune disease, 11%. Um, and you'll see in this study of 92, only two were men, but we're seeing more and more men with it. I like to show patients this, uh, this chart that's basically or table that says we can stabilize 70% of people. I can tell people, I can, there's a good chance that I can help them, but it may take, look at the months, it may take 10.4 months to finally get this thing stabilized. I cannot re. Grow hair from this condition. I can only stop it from getting worse. Every time they lose a hair, they lose it permanently. This is a trichologic emergency. And here's an example of typical uh frontal fibrosing alopecia with eyebrows and um and uh the forehead involvement. Uh, we published this quite a few years ago looking at medical therapy for frontal fibrosing alopecia and I'd like to go through this, um. Uh, I'd like to go through this in terms of, um, uh, the algorithm. If it's rapidly progressive, we might do oral prednisone at 40 mg a day for 1 week, taper for eight weeks. If it's uh slowly progressive, then, uh, it depends. If the hairline recession is less than 1 centimeter, we'll use uh uh we'll use tacrolimus clobetazole monoxoil in a mixture, uh, twice a day, and we'll also inject with trimsinolone. Seanide, 2 mg per CC and we'll do that once a month and we'll continue until we get the thing uh totally, um, stabilized. If the recession is more than 1 centimeter, there's uh tacrolimus clobetazole monoxoil, the injections, and we may try a 5 alpha reductase inhibitor as as uh dutasteride is something we use in postmenopausal women a lot. Uh, hydroxychloroquine is something else, 200 mg twice a day, uh, doxycycline, um, plus or minus low dose oralmonoxidil, pioglitazone, 15 mg per day. We also use naltrexone. We were the first to use naltrexone for, um, uh, for frontal fibrosing alopecia. Other options include mycophenolate mofatil, uh, methotrexate, cyclosporin, or retinoid, the Or laser, which we're using more and more of. I'm finding it very useful. Uh, we may get, if we're able to get a Jack inhibitor, uh, we can use that, and I, I am using obsolura, which is rexolutinib a lot, and I'm finding success with that, but they have to use a lot of it and under oclusion if possible, and the insurance won't pay for this condition, so it's, you're lucky if they have something like the li or eczema, then you can use it. Uh, some people are willing to pay out of pocket for it, uh, and then there's platelet rich plasma, and then, so these are the kinds of things that we use on our patients. Now, when it comes to, uh, looking what other people have used, the most common thing is intralesional steroids and 5 alpha reductase inhibitors in, uh, postmenopausal women, I'll use dutasteride, 0.5 mg a day. Sorry, uh, yeah, 0.5 mg a day, or we use, uh, in other, uh, younger women finestride, and the reason we use finestride in younger women of childbearing age is that, uh, we ask them to stop at one month before they decide to get pregnant. If we give them duetari, the half-life is very long and may take 6 months to get out of the system, so I prefer to use it in postmenopausal women. Uh, we rarely use um oral prednisone at all, and these are other things that have been used, and ioglitazone is something that we're using as well. When a patient comes in with FFA, this is the kind of uh photographs we take. We always take pictures of their eyebrows, as well as the sides of the scalp, as well as the front. And when it comes to monitoring patients, we always measure things like I told you, we glabella to hairline, uh, right outer countus to hairline, left outer countus to hairline, and we'll also do the sideburn area. So everybody gets 5 readings every time they come in. And again, this is the algorithm that we use and I I'll just um also talk about the papules that some of these people get. Some people get these um Uh, these cobblestoning papules all over their face. I, uh, we can use oral isotretinoin loading dose of 4 mg per day for 2 weeks. This is a, um, this was uh studied by Rodrigo Permez, uh, and he, and he, uh, and I've done it and it seems to work very well. Maintenance dose 10 to 20 mg 3 times a week for 3 to 6 months, and many people are, are actually cured from this, OK, and from that. So here's an example. Of the facial papal resolution with oral isotreadinone. I have had a patient using obsolura and they did extremely well with just the obsolura, but they have to put lots on and a thick and uh the thin film of obsolura doesn't seem to work. OK, and what about uh dutasteride? I use a lot of dutasteride, especially in postmenopausal women. So again, this is the um the um. The algorithm that we use. What about in mails? Same thing we published in Mails showing that it, it basically, uh, we use the same kind of um uh um protocol. Again, uh, the other people have noticed more and more cases of it in men. What about uh sunscreens? Uh, are they related? There was a lot of talk about this. There's studies showing there was a relationship, uh, possibly between, um, uh, chemical sunscreens like oxybenzone or avobenzone and frontal fibrosing alopecia. This may be true, we're not sure. Um, there's an, uh, not only in association with that, but also patch testing. There may be certain things the Harvard Group found out 76% had positive patch testing to products of the head or neck, and avoidance of these for three months led to decreased scalp symptoms. So there may be something in Linaul and limonine seem to be the two, The culprits, but there are other ones as well, so I tell patients try to use fragrance free, um um shampoos and things like that. Um, so also, so when people are using facial moisturizers or sunscreens, uh, we wanna make sure they're. Free fragrance mix free, uh, Linaul, uh, no avobenzone, no oxybenzone. Uh patients can be counseled on the ingredient avoidance, and um, uh, we prefer sunscreens with mineral based products, zinc oxide or titanium dioxide. Uh, there are people who disagree and say sunscreens have nothing to do with it. This is John McGrath from England who's very well respected. He didn't feel it had anything to do with it, and it's a big controversy. Now when it comes to hair transplants, we did do them when I was in Vancouver. We did a test area of around 50 grafts to see if they took. These are patients off treatment for at least 2 years, uh, and, um, and you can see here the regrowth, it's not that thick, but patients can be quite happy with hair transplants as well, but you have to make sure that it, it could, you have to warn them it may get reactivated. Now I'll quickly talk about the lichen planopylaris. This is what we see in our offices all the time as well. It can be quite extensive. This is in an eight year old with uh almost like a pseudo Palata Brock type of thing. Pseudo Palata Brock is exactly the same as like in Plano Polaris. I've gone to the papers from 1895 by Brock, um, because I speak French and. And uh he describes Lichen planopylaris. OK, and so this was in a very young boy, this is the typical what we see in Lichen planopylaris. And then when we look at the trichoscopy, loss of follicular ostea, peri follicular scaling, and there may be pigment incontinence as well. The treatment of lichen planopylaris, again, um, it's a bit different than LPP because it's not on the face. So we look at if it's rapidly progressive, it's oral prednisone, if it's um. If it's, uh, if it has less than 10% scalp involvement, we'll use traminol acetate 10 mg for CC, not 2.5. We want something stronger, plus we'll use our tacrolimus clobetasol monoxy mixture twice a day. It stabilizes great. OK, if, if, uh, it, it doesn't, then we have to go to other types of treatments as well. If there are more than 10% scalp involvement, consider again injections, tacrolimus cobetazole monoxidil. Consider uh doxycycline. 100 mg twice a day or hydroxychloroquine 200 mg twice a day and then you decide if it stabilizes and you always taper to the lowest dose. If it doesn't seem to work, add pioglitazone. You're the first to do that, uh, adding pioglitazone 15 mg per day, and it does help some people also I'm using more naltrexone as well at 3 mg per day, we get that compounded by the pharmacy. Again, other options uh are mycophenolate mofatil. Uh, methotrexate, cyclosporin, low dose isotredone and Jack inhibitors, and of course the um. I, I would also try obsolur if possible, um, and also the, um, the 308 nanometer eczemer laser. I really think the eczemer laser has a place, uh, in the treatment of this condition. And we, again, here we showed the low dose naltrexone helped these individuals. Uh, here we have, um, a p glitazone. Again, we were one of the first to use it in this condition as well. And um again, the 308 nanometer eczemer laser, always consider that, and patients may have hard access to get it. Many of us don't have the extract laser in our offices. We do at NYU, but other places don't. If they live in Connecticut, they may have to go to Yukon for it. Uh, they may have to go to some other office that has this laser, you, you can get it over the internet, you can buy your own, but it's a few $1000 to get it. So this is uh basically the algorithm that we use. And so this is a trichologic emergency. Early intervention is very important to avert scarring and secondary complications. Ensure the diagnosis with a biopsy, trichoscopy helps in following up progress. Disease directed medical therapy is only indicated in those with active disease. Adjunctive agents can improve cosmetic appearance, like there are all sorts of powders. Some even get scalp micropigmentation. And then in hair transplantation consider only if the condition has not been active for at least 2 years off treatment. I'd like to also thank our NYU group, of course, Kristen Loigo just gave this excellent lecture. Um, it's part of it she's like my right hand in the hair group, and then we now have two medical student research fellows, Mbika Noa and Disa Desai as well. I want to thank them for all their hard work, the number of papers they've published in their one year here has been phenomenal. Thank you very much. Published June 6, 2024 Created by Related Presenters Jerry Shapiro, MD View full profile
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