Frontal fibrosing alopecia (FFA) is a scarring alopecia which predominantly affects postmenopausal women. It is thought to be a variant of lichen planopilaris (LPP) with a distinct clinical presentation of frontal scalp erythema and perifollicular hyperkeratosis with resulting progressive hairline recession as well as variable eyebrow thinning. Both entities are often recalcitrant to therapy.
We report a case in which a significant clinical response was achieved with the addition of a topical calcineurin inhibitor (tacrolimus or pimecrolimus) to the usual regimen of intralesional steroids (ILK). The patient was started initially on topical steroids and ILK for over 12 months, however significant reduction in pruritus, perifollicular erythema, hyperkeratosis as well as increased hair density was only observed after the addition of tacrolimus cream.
Tacrolimus has been reported to be very effective for treatment of erosive and oral lichen planus, but to date no case reports have shown significant improvement in the treatment of LPP or FFA. Besides its anti-inflammatory properties, one theory suggests that tacrolimus can induce telogen hairs to enter into anagen phase of hair growth and also increase the size of the hair follicles. It is likely the combination of anagen phase promotion and inflammation reduction produced by topical calcineurin inhibitors that resulted in marked reduction of erythema and hyperkeratosis in our patient. It is also interesting to note that cyclosporine, an oral calcineurin inhibitor has been shown to be effective for LPP, a fact that again supports the value of this particular group of anti-inflammatory drugs in the treatment of this entity.