BJD GENERAL DERMATOLOGY British Journal of Dermatology Frontal fibrosing alopecia: possible association with leave-on facial skin care products and sunscreens; a questionnaire study* N. Aldoori,1 K. Dobson,1 C.R. Holden,1 A.J. McDonagh,1 M. Harries2 and A.G. Messenger1 1Department of Dermatology, Royal Hallamshire Hospital, Sheffield S10 2JF, U.K. 2The Dermatology Centre, Manchester University, Salford Royal NHS Foundation Trust, Salford M6 8HD, U.K. Linked Comment: Donati. Br J Dermatol 2016; 175:675–676. Summary Correspondence Background Since its first description in 1994, frontal fibrosing alopecia (FFA) has become Andrew G. Messenger. increasingly common, suggesting that environmental factors are involved in the aetiology. E-mail: a.g.messenger@sheffield.ac.uk Objectives To identify possible causative environmental factors in FFA. Methods A questionnaire enquiring about exposure to a wide range of lifestyle, Accepted for publication social and medical factors was completed by 105 women with FFA and 100 age- 10 May 2016 and sex-matched control subjects. A subcohort of women with FFA was patch Funding sources tested to an extended British standard series of allergens. The study was supported by a grant from the Results The use of sunscreens was significantly greater in the FFA group compared British Skin Foundation. with controls. Subjects with FFA also showed a trend towards more frequent use of facial moisturizers and foundations but, compared with controls, the differ- Conflicts of interest ence in frequencies just failed to reach statistical significance. The frequency of None declared. hair shampooing, oral contraceptive use, hair colouring and facial hair removal *Plain language summary available online were significantly lower in the FFA group than in controls. Thyroid disease was more common in subjects with FFA than controls and there was a high fre- DOI 10.1111/bjd.14535 quency of positive patch tests in women with FFA, mainly to fragrances. Conclusions Our findings suggest an association between FFA and the use of facial skin care products. The high frequency of sunscreen use in patients with FFA, and the fact that many facial skin care products now contain sunscreens, raises the possibility of a causative role for sunscreen chemicals. The high frequency of positive patch tests in women with FFA and the association with thyroid disease may indicate a predisposition to immune-mediated disease. What’s already known about this topic? • Frontal fibrosing alopecia (FFA) is an inflammatory scarring alopecia that mainly involves the frontal and frontal/temporal hairline and eyebrows. The histopathol- ogy is identical to that of lichen planopilaris. • FFA mainly affects postmenopausal women although it also occurs in younger women and occasionally in men. • First reported in 1994, FFA remained rare during the 1990s but has become increasingly common in the last 10–15 years. What does this study add? • Leave-on facial skin care products are implicated in the aetiology of FFA. • It is suggested that sunscreen chemicals play a causative role. • It is suggested that there is an increased predisposition to immune-mediated dis- ease in FFA. 762 British Journal of Dermatology (2016) 175, pp762–767 © 2016 British Association of Dermatologists Frontal fibrosing alopecia, N. Aldoori et al. 763 Frontal fibrosing alopecia (FFA) is an irreversible scarring Subjects alopecia that mainly affects postmenopausal women.1,2 The histopathology is identical to that of lichen planopilaris (LPP) Patients were recruited during 2012 at two sites in the U.K., but the clinical presentation is distinctive and differs from that the Royal Hallamshire Hospital, Sheffield, and Salford Royal of classical LPP. The disease is characterized by progressive NHS Foundation Trust, Salford, Greater Manchester. They regression of the frontal and temporal hairline, in most cases were recruited from general dermatology clinics and dedicated accompanied and sometimes preceded by loss of the eye- specialist hair clinics. The diagnosis of FFA was made by a brows. Follicular erythema and scale is commonly seen along consultant dermatologist with specialist expertise in hair dis- the receding hairline. The progression of the alopecia is vari- ease. The clinical diagnosis was based on typical scarring able and unpredictable, although it can spontaneously stabi- alopecia affecting the frontal hairline and causing recession. lize.3 Some women also report loss of hair from other body Additional features included complete or partial loss of eye- sites, such as the limbs and the axillae. Although predomi- brows, follicular erythema of the frontal hairline and involve- nantly a condition of postmenopausal women, FFA also occurs ment of the hairline over the sides of the scalp. – in premenopausal women and has been reported in men.4 6 Those patients in whom a dual diagnosis of FFA and a fur- Frontal fibrosing alopecia was first described by Kossard in ther form of scarring or nonscarring alopecia was made were 1994 in six postmenopausal women.1 One of the authors of excluded from the study. this paper (A.G.M.) had seen a single case in 19933 but, as far Control subjects were women aged over 40 years with no as is known, no other cases were observed before this time. history of hair loss. They were recruited through advertise- FFA remained rare during the 1990s. However, particularly ments to hospital staff on the hospitals’ intranet and from over the last 10 years, it has become increasingly common, a friends and family of the authors. All FFA and control subjects development that is occurring worldwide. Most published ser- were unrelated. ies have been in Caucasian women in westernized societies but cases have also been reported in women of African ethnic- Questionnaire ity from Africa and the U.S.A.,7,8 and from Japan.9,10 A review published in 2012 reported FFA as the most common form of We devised a questionnaire that enquired about exposure to a primary cicatricial alopecia seen by dermatologists in four of wide range of lifestyle, social and medical factors. Table 1 lists 11 regions of the U.K.11 The recent onset and rising incidence the subsections of the FFA questionnaire. Where relevant the of FFA strongly suggests that an environmental factor is subsections asked about the frequency of use, length of use involved in the aetiology. and the particular products used. The questionnaire sent to the A putative environmental cause for FFA needs to explain: control subjects excluded the section regarding hair loss but was otherwise identical. 1 the time course of the disease incidence: we hypothesize the first exposure probably occurred during the 1970s or 1980s (the onset of hair loss in Kossard’s cases occurred during the 1980s) and that there has been a large increase Table 1 Questionnaire categories in exposure in the last 10–15 years; 2 the predominant distribution of hair loss affecting eye- Demographic details brows and the frontal and temporal hairline; Profession History of hair loss 3 the predominant expression of the disease in post- Distribution of hair loss menopausal women and the occasional presentation in Previous medical history younger women and in men. Menopause history Hormonal medications, including hormone replacement therapy, In addition we expect that all women with FFA will have oral contraceptive pill, intrauterine device been exposed to a putative cause. Other prescribed medication In this study we used a questionnaire approach to investi- Over-the-counter medication gate exposure of subjects with FFA and an age- and sex- Smoking history matched control group to a range of potentially relevant Alcohol history environmental factors. Following the observation that some Facial skin care products (cleanser, toner, moisturizer, patients with FFA also complained of facial irritation we also foundation, sunscreen) Hair care products (shampoo, conditioner, hair spray, hair performed patch testing in a more limited cohort and com- mousse, hair gel) pared the results with those obtained in the overall patch- Hair care practices (perming, colouring, hair styling, heated tested population. styling aids) Hair removal (plucking, shaving, waxing, electrolysis, laser, intense pulsed light) Methods Facial resurfacing (chemical peels, laser resurfacing) The study was approved by the National Research Ethics Ser- Computer screen usage vice South Central – Berkshire Committee. © 2016 British Association of Dermatologists British Journal of Dermatology (2016) 175, pp762–767 764 Frontal fibrosing alopecia, N. Aldoori et al. Patch testing 7%, P < 0Á05). There were no other significant disease associations. A group of 40 patients with FFA were patch tested to the Bri- tish Society for Cutaneous Allergy Standard Series (http:// www.cutaneousallergy.org/downloads/BSCA_baseline_series_ Medication 2014.pdf) plus hydroperoxides of limonene and linalool. Comparison between the FFA and control groups with regard Patch tests were applied to the back using FinnTM chambers on to contraception and hormonal medication showed a similar ScanporTM tape and read at 48 and 96 h. history for use of intrauterine device (37% vs. 38%, respec- tively) and hormone replacement therapy (21% vs. 23%). Statistical analysis A history of oral contraceptive usage was significantly higher in the control group (FFA 65Á7%, control 85%, P < 0Á01) There were no pre-existing data on which to base a power (Fig. 2). Thyroxine was taken more commonly by subjects calculation to determine the number of subjects required. with FFA than controls (16% vs. 6%, P < 0Á05). There were Therefore, a sample size of 100 cases of FFA and a similar no other associations in either group with other prescribed or number of control subjects was selected on an empirical basis. over-the-counter medications. Comparisons between FFA and control groups were ana- lysed using Fisher’s exact test. A probability of less than 5% (P < 0Á05) that differences between the two groups occurred Alcohol and smoking by chance was taken as statistically significant. To correct for There was no difference between FFA and control subjects multiple testing the data were then analysed using the Ben- with regard to alcohol intake or cigarette smoking.