Frontal fibrosing alopecia in men: an association with facial moisturizers and sunscreens

Dear Editor, Frontal fibrosing alopecia (FFA) was first described by Kossard in 1994 in six postmenopausal women.1 FFA remained rare during the 1990s, but in the last 10–15 years it has become increasingly common, a phenomenon observed worldwide. The recent onset and apparently rising incidence of FFA suggest involvement of environmental factors in the aetiology. We previously reported a questionnaire study in women with FFA that asked about a wide range of medical, social and environmental exposures. The results suggested an association between FFA and leave‐on facial products, including moisturizers and sunscreens.2 However, although the regular use of moisturizers was greater in women with FFA, these products are used by most women and we were unable to show a significant difference in their use between women with FFA and similarly aged controls. The use of primary sunscreens was significantly greater among women with FFA than in controls, but we were not able to assess whether patients were also exposed to sunscreens from other sources. We have therefore repeated our questionnaire study in men with FFA, as we anticipated that their use of leave‐on facial skincare products would be lower than in women. As FFA is rare in men, patients were recruited from across the U.K. and one case was recruited from Belgium. In all cases the diagnosis was made by a clinician with special expertise in hair disease, and it was supported by histology in most cases. The clinical diagnosis was based on scarring alopecia affecting the frontal hairline causing recession of the hairline. Additional features included loss of eyebrows, follicular erythema of the frontal hairline and loss of sideburn and beard hair. Male controls aged 35–80 years were recruited from three sites (Sheffield, Salford and Glasgow). The patients completed a questionnaire similar to that used in our female study, but inviting more detailed information on the use of facial skincare and hair care products. Male patients with FFA were asked about the timing and distribution of hair loss, but otherwise the questionnaires completed by both groups were identical. Seventeen men with FFA and 73 controls were recruited. The mean age of onset of hair loss in the patients with FFA was 54·5 years (range 35–77). All had loss of hair from the frontal hairline, and 16 (94%) had lost eyebrows. Twelve men (71%) reported loss of hair from the beard and 13 (76%) reported loss of hair from the limbs. All men with FFA reported using facial moisturizers, compared with 40% in the control group. Facial moisturizers were used at least twice a week by 94% of patients with FFA, but by only 32% of controls (P < 0·001) (Table 1). Sixteen patients reported using moisturizers for a period consistent with their use prior to the onset of FFA. The use of primary sunscreens by men with FFA was significantly more common than by controls. Overall 35% of men with FFA reported using a sunscreen at least twice a week all year round, compared with 4% of controls (P = 0·0012). Reported use of skincare and hair care products by patients with frontal fibrosing alopecia (FFA) and controls Values are n (%) unless stated otherwise. aTwice a week or more frequently. bTwice a week or more frequently all year round. cAt least once a year. Sunscreen includes exposure to sunscreen chemicals in primary sunscreens and moisturizers. Analyses were performed after excluding subjects who failed to answer the question. Frequencies in the FFA and control groups were compared using Fisher's exact test. Reported use of skincare and hair care products by patients with frontal fibrosing alopecia (FFA) and controls Values are n (%) unless stated otherwise. aTwice a week or more frequently. bTwice a week or more frequently all year round. cAt least once a year. Sunscreen includes exposure to sunscreen chemicals in primary sunscreens and moisturizers. Analyses were performed after excluding subjects who failed to answer the question. Frequencies in the FFA and control groups were compared using Fisher's exact test. When moisturizers containing sunscreen chemicals were included in the analysis, at least 71% of men with FFA applied a product containing a sunscreen at least twice a week all year round, compared with 11% of controls (P < 0·001). One man with FFA applied a sunscreen product once a week all year round. Four men with FFA did not provide adequate information on the products they used to enable us to assess their sunscreen exposure. There was no difference between the two groups in the use of hair care and other facial skincare products (scrubs, masks, aftershave, cleansers), medications, smoking or alcohol. Although the numbers are small these results support the conclusion from the previous female study2 that there is an association between FFA and the use of facial moisturizers and sunscreens. The time course of sunscreen use by the population does seem to parallel the apparent increase in the incidence of FFA, and to some extent the predominant distribution of FFA matches the usual sites of moisturizer and sunscreen application. On the other hand, a causative role for leave‐on facial products does not readily explain the frequency of hair loss on the limbs and occipital hairline seen in some men and women, or the occasional association with cutaneous or mucosal lichen planus.3 Although the frequency of use was significantly greater than in controls, we have also not shown that all men with FFA were applying sunscreens, a prerequisite were this to be the cause of FFA. A study from Scotland found that women with FFA had a higher degree of affluence than expected.4 There is also an association between sunscreen use and higher socioeconomic status,5 6 and it is possible that our results reflect this demographic rather than indicating a causative link. In summary, our results in a cohort of men with FFA support a previous suggestion that there is an association between FFA and the use of leave‐on facial skincare products and sunscreens. This may indicate a causal role, but our results do not provide proof. The absence of a test that provides more conclusive evidence of cause is a significant limitation, and the development of such a test should be a focus of future research into this increasingly common disorder. Conflicts of interest: none declared.