The jury is still out on the cause of frontal fibrosing alopecia but the increasing worldwide incidence over the last 20 years suggests it is a new disease involving an environmental factor.
Dermatologist and president of the Institute of Trichologists in London Professor Andrew Messenger told the ACD ASM that – controversially – sunscreens were the top suspect.
He said a survey comparing lifestyle and exposures of women with and without frontal fibrosing alopecia found sunscreen use was significantly more common in affected women.
Use of other leave-on facial products including cleansers, toners, foundations and moisturisers was not significantly different between the two groups of women.
And a recent Australian study supported those earlier findings, he said.
Professor Messenger said another recent study had also confirmed the ubiquity of titanium dioxide along the hair shafts of people with and without frontal fibrosing alopecia.
While the time course of the disease and predominant pattern of hair loss supported the sunscreen theory, there were other factors arguing against it.
For example, hair loss in frontal fibrosing alopecia also occurred on the limbs and there could be other “confounding factors of affluence” at play.
Professor Messenger told the limbic a reasonable sized series had reported frontal fibrosing alopecia (FFA) in black Africans.
“One of the arguments against sunscreens [in FFA] is that Africans don’t use sunscreens but some of them do.”
He said about 14% of black skinned Africans and 22% of Indians were using sunscreens.
“It’s possible they are getting sunscreens from other sources such as skin-lightening agents. About a third of them use skin-lightening agents and we don’t really know what’s in them.”
Professor Messenger said he was understandably nervous about talking about sunscreens and FFA in Australia.
“One of the criticisms we have had is that it is irresponsible to talk about this sort of thing when there is an important public health message about using these products.”
“There are drugs that we are putting on the skin. Most drugs have other effects besides the one you are using them for so it wouldn’t be all that surprising if we were finding other effects. And as a clinician I am always in the business of balancing the good and bad. I do use treatments which I know have risks and side effects to them. I think it is probably going to be the same with sunscreens.”
He said the risk of FFA in individuals was small but not negligible.
“You have to balance the risks. In the UK for example, there’s no point using a sunscreen all through the winter but in Queensland there probably is.”
He told the meeting there was a wide range of treatments on offer but no standout option.
“Due to the lack of randomised clinical trials and the lack of a control group in clinical studies, treatment of FFA is not evidence based.”
“The aim of treatment is to stop disease progression. This might be achieved with topical, intralesional and oral treatments, often combined together.”