Risk Factors for Frontal Fibrosing Alopecia

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The association of frontal fibrosing alopecia with demographic and exposition factors in a multiracial population was evaluated.

Certain commercial dermatology products may be associated with risk for frontal fibrosing alopecia (FFA), according to study data published in the Journal of the American Academy of Dermatology. In a cohort study of Brazilian adults, FFA was associated with formalin hair straightening and regular use of facial soap and moisturizers. However, FFA was not associated with use of sunscreen, as proposed in other studies of alopecia.  

This multicenter case-control study recruited patients from 11 medical centers in Brazil. Adult patients older than 18 years of age with a clinical diagnosis of FFA were matched to control patients with nonscarring alopecia who received care at the same centers. Participants completed electronic questionnaires which captured demographic characteristics, environmental exposures, diet, and hair and skin care. Participants also reported comorbid medical conditions. Multiple logistic regression was used to identify correlates of FFA. Analyses were adjusted for age, sex, menopause, and race/ethnicity.

A total of 451 patients with FFA were matched to 451 patients with nonscarring alopecia. Demographic and clinical characteristics were comparable in patients and control patients. Mean age was 53 ± 13 years in the FFA group and 49 ± 14 years in the control group. The majority of all participants were women (96%). Familial history of FFA was observed in 9% of cases. Overall, 60% and 44% of patients and control patients had undergone menopause, respectively. In regression models, FFA was significantly associated with hair straightening with formalin (odds ratio [OR], 3.18; 95% confidence interval [CI], 2.11-4.80), regular use of nonprescription facial soap (OR, 2.09; 95% CI, 1.50-2.90), and regular use of nonprescription facial moisturizing creams (OR, 1.99; 95% CI, 1.39-2.86). Current smoking (OR, 0.33; 95% CI, 0.21-0.51) and regular use of antiresidue or clarifying shampoo (OR, 0.35, 95% CI, 0.19-0.67) each had negative associations with FFA. Thyroid disorders (P =.002) and rosacea (P =.001) were more common in patients with FFA compared with control participants. FFA was not significantly associated with sunscreen use.

Limitations of the study, as cited by the researchers, include possible recall bias and slight differences in the patient and control patient groups.

Although environmental risk factors for FFA remain controversial, results from this study suggest to the investigators that formalin hair straightening and frequent use of facial soaps and moisturizers may contribute to FFA risk. “This study reinforces the possibility of exogenous particles triggering FFA,” they wrote.


Ramos PM, Anzai A, Duque-Estrada B, et al. Risk factors for frontal fibrosing alopecia: a case-control study in a multiracial population [published online August 22, 2020]. J Am Acad Dermatol. doi: 10.1016/j.jaad.2020.08.076