Frontal fibrosing alopecia (FFA) is a scarring alopecia that causes irreversible hair loss following a phase of variable inflammatory activity.1 Since the publication of the first case in 1994,2 the incidence rate of FFA has been steadily increasing in dermatology consultations.3 However, despite its growing incidence, the definitive causes of FFA remain unclear, although evidence suggests a genetic basis influenced by endocrine and environmental factors that trigger disease expression.4–7 From an epidemiological standpoint, FFA primarily affects postmenopausal women, although cases have also been reported in premenopausal women and, rarely, in men.8,9

Diagnosis of FFA is usually clinical, based on physical examination and trichoscopy, while biopsy is reserved for cases with diagnostic uncertainty.10 Several clinical patterns have been described: type 1 (linear pattern), type 2 (diffuse pattern)—associated with a poorer prognosis—and type 3 (double-line pattern); less common variants, such as the “tiara” pattern, have also been reported.11 Therapeutic management relies on 2 main pillars: topical and intralesional anti-inflammatory agents, and oral 5-alpha-reductase inhibitors.12,13 Additional treatments may include oral anti-inflammatory drugs such as hydroxychloroquine,14 or injectable therapies such as platelet-rich plasma (PRP).15 However, the absence of approved targeted therapies and the scarcity of randomized clinical trials remain major challenges for FFA management in dermatology practice.

Given the increasing number of new FFA diagnoses in our setting, the aim of this document is to provide an updated guideline on the diagnostic and therapeutic management of FFA, based on expert consensus and the available scientific evidence.

This consensus was developed by members of the Spanish Group of Trichology and Onychology (GETO-AEDV) of the Spanish Academy of Dermatology and Venereology (AEDV) using a modified Delphi method. A scientific committee composed of eight GETO-AEDV members—each with over 5 years of experience in trichology—was formed. The project was presented to the GETO-AEDV assembly, and volunteers with prior scientific publications on FFA were invited to join the committee. A qualitative literature review was, then, conducted, including articles published in Spanish and/or English since 2014. Afterwards, a structured questionnaire was designed with 4 thematic blocks: general aspects, diagnosis, treatment, and special situations. All GETO-AEDV members were invited to participate as panelists. The questionnaire included 106 statements and was distributed online to 22 Spanish dermatologists, all GETO-AEDV members with extensive experience managing FFA. The study was conducted in full compliance with the principles outlined in the Declaration of Helsinki.

Two voting rounds were conducted in January and February 2025, where panelists rated each statement using a 9-point Likert scale (1=strongly disagree, 9=strongly agree). Responses were grouped as disagreement (1–3), neutral (4–6), and agreement (7–9). A statement was considered to have reached consensus if (1) the median score was within 1–3 or 7–9; (2) fewer than one-third of votes fell outside that range; (3) the interquartile range (IQR) was ≤3.

After the first round, the committee reviewed non-consensual items and revised wording where necessary. A second round of voting followed. At the end, the committee drafted the final consensus document, assigning each recommendation a Level of Evidence (LE) and Grade of Recommendation (GR) according to the Oxford Centre for Evidence-Based Medicine.16

In the first round, a total of 95 items achieved consensus. After rewording 2 items, the second round yielded 8 additional consensual recommendations, totaling 103 of 106 statements (97%) (Supplementary data, Tables 1–4).

Recommendations on the therapeutic management of FFA

Regarding the therapeutic management of FFA, the panelists reached a consensus that, given the irreversible nature of hair loss in this condition, a combined treatment regimen should be used, employing drugs with different mechanisms of action and routes of administration to increase the likelihood of therapeutic success. After diagnosis, follow-up visits should be scheduled every 3–4 months until inflammatory activity is controlled. Once inflammation has been stabilized, patients should be seen every 6 months to monitor for new inflammatory flare-ups, although this frequency should be individualized based on the patient's condition, clinical findings, and associated symptoms. This follow-up scheme, along with specific recommendations for FFA monitoring at each visit, is shown in Fig. 1 and Supplementary Fig. 1 (Supplementary data).

Fig. 1.

Follow-up schedule for patients diagnosed with FFA.

Optimal medical therapy should be tailored according to the progression of alopecia and the degree of inflammation, always in agreement with the patient and considering their preferences to improve treatment adherence. Therapy should be maintained at least until stabilization of alopecia and resolution of inflammatory signs. The recommendations for considering discontinuation of medical treatment are presented in Supplementary Table 5 (Supplementary data).

Topical treatment

The panelists agreed that the first-line therapy for FFA is topical treatment with a very high-potency corticosteroid along with a calcineurin inhibitor to reduce the risk of skin atrophy associated with chronic topical corticosteroid use. The algorithm for topical treatment along the frontal hairline is summarized in Fig. 2.

Fig. 2.

Algorithm for the topical treatment of FFA.

Regarding the treatment of eyebrow involvement, the panelists’ recommendations are summarized in Table 2.

This consensus document provides practical recommendations for the diagnosis and therapeutic management of FFA in routine clinical practice, based on both available scientific evidence and expert opinion. Although FFA diagnosis can generally be made easily using clinical and trichoscopic criteria, there may be diagnostic uncertainty in certain cases—such as atypical presentations or male patients—where the involvement of a dermatopathologist specialized in trichology is essential.17,18 While endocrine disruptors have been involved in the pathogenesis of FFA, controversy surrounds the use of cosmetic products containing such agents in patients with FFA.4,19–21 Based on the available evidence, the panel recommended avoiding products containing these substances, such as organic soluble filters (in sunscreens) or benzyl salicylate (in other cosmetics).

Because of the rising incidence rate of FFA in dermatology practice, it is likely that most dermatologists will eventually face the therapeutic challenge of managing this condition.3 The lack of approved targeted therapies and the limited scientific evidence supporting current treatments were identified as major obstacles in this consensus.22 However, other aspects of management can also generate uncertainty—for example, determining the optimal timing for treatment withdrawal. Considering the risk of symptom recurrence,23 the experts agreed on criteria to guide treatment discontinuation, while leaving open the possibility of indefinite chronic therapy, provided it is discussed and agreed upon with the patient. As it happens with other trichologic diseases, the panel emphasized the importance of clear patient communication and accurate information sharing regarding disease prognosis, to foster realistic expectations about potential treatment outcomes.24,25

Regarding optimal medical therapy, and given the irreversible nature of hair loss in FFA, the consensus advocates for a combined therapeutic approach from diagnosis, including systemic therapy from the outset in patients with poor prognostic factors.12,13,23,26,27 As first-line therapy, unless contraindicated or declined, the combination of high-potency topical corticosteroids with a calcineurin inhibitor and oral dutasteride was recommended.28,29 Intralesional corticosteroid injections may be added in cases with moderate or severe inflammatory activity. Among other oral agents, hydroxychloroquine was positioned as the anti-inflammatory drug of choice in patients with severe inflammatory activity or poor prognostic indicators at diagnosis. In these cases, ophthalmologic monitoring is important due to the potential risk of retinopathy.30 While there is some evidence supporting the use of topical JAK inhibitors as adjuvant therapy, no clinical trials have yet evaluated the safety and efficacy profile of oral JAK inhibitors for FFA treatment.31,32 However, it is possible that these agents may become part of the therapeutic arsenal in the future.33

This study has several limitations, including the lack of randomized clinical trials evaluating FFA treatments, which reduces the level of evidence and strength of recommendations for most of the statements included in this consensus. Furthermore, the selection criteria used to include panelists—restricted to GETO-AEDV members—could have introduced a selection bias.

Given the increasing incidence rate of FFA in dermatology practice and the scarcity of approved specific treatments, managing this condition is likely to become an increasingly common challenge for dermatologists. This national consensus document aims to serve as a guideline for the diagnosis and management of FFA in routine clinical practice.

David Saceda-Corralo declared to have received honoraria for participating in strategic advisory board meetings for Pfizer and as a speaker for Pfizer, Lilly, L’Oréal, and Cantabria Labs.

Andrea Combalia declared to have received honoraria as a speaker for Lilly, Pfizer, Isdin, and Cantabria Labs.

Cristina Pindado-Ortega declared to have received honoraria as a speaker for Novartis, Janssen, Lilly, ISDIN, UCB, Sanofi, Almirall, and Leo Pharma.

Sergio Vañó-Galván declared to have received honoraria for participating in strategic advisory boards for Pfizer, Lilly, and Cantabria Labs, and as a speaker for Pfizer, Lilly, L’Oréal, Pierre Fabre, and Cantabria Labs.

Pablo Fernández-Crehuet, Gloria Garnacho, María Librada Porriño-Bustamante, and Cristina Serranodeclare declared no conflicts of interest whatsoever.