Case Report: Managing Frontal Fibrosing Alopecia in a 55-Year-Old Woman

Introduction

Frontal fibrosing alopecia (FFA) is a chronic scarring alopecia that causes recession of the frontal hairline and loss of eyebrows, most commonly affecting postmenopausal women. At our dermatology clinics in Houston and Katy, Texas, we frequently evaluate and treat women struggling with this progressive form of hair loss. This case highlights a 55-year-old female with a history of FFA who presented for follow-up and treatment adjustment.

Patient Case

A 55-year-old woman presented for follow-up evaluation of frontal fibrosing alopecia. She reported progressive hair loss on the medial frontal scalp, left lateral forehead, and right inferior lateral forehead, with associated scalp inflammation.

She had previously undergone treatment with hydroxychloroquine, dutasteride, and a topical compounded tacrolimus. She also tried oral minoxidil (2.5 mg daily) and fluocinonide solution prescribed by another dermatologist. Despite these efforts, active inflammation persisted.

Examination

• Findings: Scarring alopecia with frontoparietal hairline recession, dermoscopic evidence of perifollicular erythema, and scaling.

• Distribution: Medial frontal scalp, left lateral forehead, right inferior lateral forehead.

• General: Well developed, well nourished, alert, and in no acute distress.

Diagnosis

• Frontal Fibrosing Alopecia (L66.12)

Treatment Plan

We reviewed treatment options, including oral finasteride, dutasteride, intralesional corticosteroid (ILK) injections, topical immunomodulators, and oral minoxidil. After detailed counseling on benefits and side effects, the patient elected to proceed with:

• Oral minoxidil (2.5 mg daily)

• Oral dutasteride (0.5 mg daily)

• Fluocinonide 0.05% topical solution (for flares, 2 weeks per month as needed)

• Topical compounded tacrolimus 0.3% / tofacitinib 2% solution (daily application for scalp inflammation)

We discussed the risks of oral minoxidil (dizziness, swelling, unwanted hair growth, blood pressure changes) and the side effects of dutasteride (sexual dysfunction, teratogenicity). The patient acknowledged understanding and agreed to ongoing monitoring.

Discussion

Frontal fibrosing alopecia is a challenging condition because it is both scarring and progressive. Early intervention is critical to slow hairline recession. This case highlights the importance of multi-modal therapy, combining oral medications, topical anti-inflammatory treatments, and careful follow-up.

Patients should be counseled that while regrowth is limited, early treatment can help preserve remaining hair and reduce inflammation.

Follow-Up

The patient will return in 2 months for reassessment. If there is no improvement, hydroxychloroquine may be reconsidered as part of the treatment plan.

Key Takeaway

At our dermatology practices in Houston and Katy, Texas, we specialize in managing complex hair loss conditions such as frontal fibrosing alopecia, tailoring therapy to slow progression and preserve scalp health.