Efficacy of Isotretinoin and Acitretin in Treatment of Frontal Fibrosing Alopecia: Retrospective Analysis of 54 Cases
October 2017 | Volume 16 | Issue 10 | Original Article | 988 | Copyright © 2017
Adriana Rakowska MD PhD,a Agnieszka Gradzińska MD,a Małgorzata Olszewska MD PhD,a and Lidia Rudnicka MD PhDb
aDepartment of Dermatology, Medical University of Warsaw, Warsaw, Poland bDepartment of Neuropeptides, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
This study aimed to assess the efficacy of systemic retinoids in treating frontal fibrosing alopecia (FFA). It was based on a retrospective analysis of 54 female patients with FFA treated with: oral isotretinoin at the daily dose of 20 mg (29/54) or acitretin at the daily dose of 20 mg (11/54) or with oral finasteride 5 mg/daily (14/54). The study was conducted between 2007 and 2017. The basic of the study is the measurement of distance between the frontal hairline and the glabellar crease prior to the commencement of treatment and after 6, 12, and 24 months. The treatment with systemic retinoids lasted between 12 and 16 months (the mean duration of treatment was 13.5 months). The primary treatment goal was defined as no further progression of disease after 12 months of treatment, while the secondary treatment goal was defined as no further progression of disease following the discontinuation of systemic retinoids. The primary treatment goal was achieved by 76% (23/29) of patients treated with isotretinoin, 73% (8/11) of patients treated with acitretin, and 43% (6/14) of patients treated with finasteride. The secondary treatment goal was achieved by 72% (21/29) of patients treated with isotretinoin, 73% (8/11) of patients treated with acitretin, and 43% (6/14) of patients treated with finasteride. Thus, the administration of systemic retinoids may be beneficial for the stabilization of frontal hairline in patients with FFA.
J Drugs Dermatol. 2017;16(10):988-992.
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Frontal brosing alopecia (FFA) is a lymphocyte-mediated primary cicatricial alopecia predominantly affecting the frontal hairline. It was first described by Kossard in 1994. The clinical characteristic of FFA is a progressive and symmetrical recession of the frontotemporal hairline.1 In most patients, the disease is accompanied by the loss of eyebrow hair. Some patients also lose body hair and show facial papules.2,3 Although the disease typically affects postmenopausal women, there were also described certain cases where it was observed in younger women and men.4,5 FFA is a disease entity with many unknowns, including its exact pathogenesis or most efficacious treatment. The course of the disease is usually progressive. On average, the frontotemporal hairline recedes by 0.4 - 1.7 mm per month.3 Hair loss is permanent and irreversible. Lonely hairs, surrounded by areas of fibrosis, are present in most patients. FFA is a lymphocyte-mediated primary cicatricial alopecia. It shares histopathological features with lichen planopilaris (LPP) and presents with reduction in the number of hair follicles, perifollicular lymphocytic inflammatory infiltrate, and fibrosis.6,7 FFA is currently recognized as a subtype of lichen planopilaris. Treatment strategies for LPP depend on disease severity, patient age, and preferences, as well as physician experience.8-10 As for all types of cicatricial alopecia, the key objective of treatment is to alleviate symptoms and halt the scarring process. First-line treatments for LPP include ultrapotent topical corticosteroids or intralesional corticosteroids injections.9,11-13 Other suggested treatment modalities include the oral administration of prednisone, cyclosporine, mycophenolate mofetil, azathioprine, hydroxychloroquine, thalidomide, tetracycline, and griseofulvin.8,9,11,12,14 Some authors suggest the use of retinoids in treating patients with LPP who showed no or only partial response to at least first-line or second-line drugs.8,13 Although the mechanism of action of retinoids is not yet clearly understood, it may involve either the normalization of the hair follicular keratinocyte antigen expression and the suppression of inflammatory cellular infiltration.15 Literature describes some cases where acitretin, isotretinoin, and etretinate were used in LPP,9,11,13,16 but not in FFA.
The aim of this retrospective study was to assess the efficacy of systemic retinoids in FFA treatment. It was carried out in the form of a retrospective analysis (2007-2017) and approved locally by the Institutional Review Board. The inclusion criteria for participation in the study were as follows: the diagnosis of FFA and the completion of training on retinoid or finasteride treatment. The diagnosis was based on clinical evaluation, trichoscopy and, in doubtful cases, on pathology evaluation. Twenty-nine patients were treated with 20 mg isotretinoin daily. Eleven patients