Lichen planopilaris & FFA — when follicles are permanently destroyed

What are scarring alopecias?

In normal hair loss (e.g., androgenetic), follicles shrink or become inactive—but they generally remain intact. A transplant or conservative therapy can reactivate or replace them.

With scarring alopecias, it's different. Here, the hair follicle is completely destroyed by inflammatory processes that attack the stem cells in the follicle. What is destroyed cannot be regenerated. Hair lost in this area is permanently lost.

Characteristics of scarring alopecias

• Gradual onset, often unnoticed
• Smooth, scarred skin patches without visible follicular openings
• Often perifollicular redness at the active margin
• Sometimes itching, burning, pain
• Permanently destroyed areas
• Active inflammation can persist for years

Most common forms

• Lichen planopilaris (LPP) — especially the crown region
• Frontal fibrosing alopecia (FFA) — a variant of LPP, affecting the frontal hairline
• Folliculitis decalvans — back of the head, often bacterial-inflammatory
• Pseudopelade Brocq — circular scarred patches
• Dissecting cellulitis — men, back of the head, very rare

The first two are the most common and will be discussed in detail here.

Lichen planopilaris (LPP)

LPP is a T-cell-mediated inflammatory disease of the hair follicles. It primarily occurs between 30 and 70 years of age, affecting women approximately twice as often as men.

Typical symptoms

• Gradual loss at the crown or back of the head
• Smooth, skin-colored areas without follicular openings
• Perifollicular redness and scaling at the active margin
• Itching, burning, or pain (in 50–80% of affected individuals)
• Sometimes visible individual hairs in the center of the areas (“tufting”)
• Gradual enlargement of the affected areas over months

Causes

The exact triggers are unclear. Discussed factors include:

• Autoimmune component
• Hormonal factors (more common postmenopause)
• Genetic predisposition
• Environmental factors (some studies discuss sunscreens)
• Other lichen planus diseases on the body as an indicator

Diagnosis

• Trichoscopy: absent follicular openings, perifollicular hyperkeratosis
• Skin biopsy from the active margin: shows characteristic inflammatory pattern
• Anamnesis for other lichen planus sites on the body

Frontal fibrosing alopecia (FFA)

FFA is a variant of LPP that specifically affects the frontal hairline. It has been rapidly increasing in incidence over the last 20 years, primarily in postmenopausal women—but increasingly also in premenopausal women and men.

Typical presentation

• Band-like recession of the frontal hairline by 1–8 cm
• Eyebrow loss (in 50–80% of female patients, often the first sign)
• Sometimes loss of eyelashes and body hair
• Smooth, pale forehead skin without follicular openings
• Small isolated hairs ("lonely hairs") in the scarred area
• Sometimes pigment changes of the facial skin

Why FFA is often misdiagnosed

FFA is often dismissed as "normal frontal hairline recession during menopause." The consequences are significant:

• Several years delay until correct diagnosis
• During this time, scarring continues to progress
• Lost areas cannot be restored
• With early diagnosis, progression can be effectively halted

Risk indicators

• Women over 50 years old
• Eyebrow loss without other identifiable cause
• Symmetrical loss of the frontal hairline
• Pale, smooth forehead skin
• Family history of FFA

Diagnosis — why it is often delayed

Scarring alopecias are diagnosed, on average, only 2–5 years after onset. This is far too late—during this time, many follicles are lost that could have been saved with earlier therapy.

Why diagnosis is often delayed

• In the early stages, the areas look like "normal hair loss"
• Patients do not see obvious signs of inflammation
• General practitioners do not recognize trichoscopic findings
• The disease is relatively rare and not well known
• Symptoms like itching are attributed to "stress"

When you should consult a specialist

• Localized hair loss areas that are growing
• Smooth skin patches without visible pores
• Eyebrow loss without an identifiable cause
• Persistent itching, burning, or pain on the scalp
• Family history of scarring alopecia
• Visible receding hairline (especially postmenopausal)

Correct diagnostics

1. Anamnesis with a focus on symptoms, course, family history
2. Trichoscopy with targeted search for scar-like changes
3. Skin biopsy from the active margin (4 mm punch) — gold standard
4. Histopathological analysis shows the specific inflammatory pattern
5. If necessary, blood diagnostics (ANA, thyroid, hormone status)

A diagnosis based solely on visual inspection is insufficient—a biopsy is usually necessary for certainty.

Treatment options — stopping is the goal

The most important therapeutic goal: stopping the active inflammation. What has already been destroyed cannot be restored — but progression can usually be significantly slowed down or halted.

Topical therapies

• High-potency corticosteroid ointments (e.g., Clobetasol) — evening application to the active area
• Tacrolimus ointment as an alternative
• topical hair growth therapy as supplementary stimulation (can support remaining follicles)

Intralesional injections

• Triamcinolone injections every 4–8 weeks into the active border — very effective

Systemic therapies

• Hydroxychloroquine (Plaquenil) — important basic therapy, often for years
• Doxycycline in low doses as an anti-inflammatory
• Methotrexate or Mycophenolate for more severe courses
• 5-alpha-reductase inhibitors (DHT blockers, stronger DHT blockers) — well effective off-label for FFA
• Pioglitazone — newer studies show efficacy in LPP

Realistic treatment goal

With early treatment, progression can be effectively stopped in 70–90% of cases. Sometimes, slight regrowth of remaining follicles is even possible. But: scarred areas remain scarred.

Duration of therapy

Scarring alopecias are chronic diseases. Therapy usually lasts several years, often lifelong in a reduced dose. Regular check-ups every 3–6 months.

Transplantation for scarring alopecia?

Hair transplantation for scarring alopecias is possible—but only under very specific conditions.

Prerequisites for a transplant

• At least 12–24 months of stable phase without further progression
• Active inflammation must be completely controlled
• Patient must reliably adhere to concomitant therapy
• Trichoscopy shows no signs of active inflammation
• Realistic expectations — no complete restoration

Risks of transplantation into scarred tissue

• Reactivation of inflammation possible — loss of new follicles
• Poorer engraftment rate than in healthy tissue (often only 50–70%)
• Possible flare-up of the underlying disease
• Donor area may also be affected by the disease

Realistic expectation

For a patient with stabilized FFA, we can move the hairline down by a few centimeters—but not completely restore the original frontal line. An improvement of 30–60% is realistic, with a good final result after 18–24 months.

Alternative options

• SMP (Scalp Micropigmentation) for optical camouflage
• Eyebrow transplantation for FFA patients with eyebrow loss (after a stable phase)
• Pretrichial lift — surgical hairline advancement
• Toupee or wigs for extensive loss

The treatment of the underlying disease always takes precedence over any cosmetic treatment.

Frequently asked questions

Is scarring alopecia curable?

No. But in most cases, progression can be significantly slowed down or stopped with the right therapy. Follicles that have already been destroyed are permanently lost. Early diagnosis is therefore crucial.

How do I distinguish scarring from normal alopecia?

Scarring alopecias show smooth, pale skin patches without visible follicular openings—often with perifollicular redness at the edges. Normal hair loss (androgenetic) leaves the follicular openings visible. Only trichoscopy and biopsy provide certainty.

What is FFA?

Frontal fibrosing alopecia—a variant of lichen planopilaris affecting the frontal hairline. Band-like recession of the hairline, often combined with eyebrow loss. Most commonly affects postmenopausal women.

Can I still get a hair transplant with FFA?

Yes—but only after at least 12–24 months of a stable phase without further progression. Prerequisite: active inflammation must be completely controlled. Thorough risk education before any operation.

Who treats scarring alopecias?

Dermatologists specializing in hair. As a specialized dermatological practice, we are equipped for this. In very severe cases, co-treatment with rheumatology or endocrinology.

Will the disease continue to progress?

Untreated, almost always. With correct therapy, progression can be effectively stopped in 70–90% of cases. Sometimes the disease stabilizes on its own after a few years—but this is not predictable.