A Slow, Quiet Recession

Frontal fibrosing alopecia (FFA) is a scarring alopecia that progressively erases the frontal hairline in women — usually post-menopausal, though increasingly seen in younger women too. It is often missed for years because the recession is gradual and the loss looks "natural" at first.

FFA is part of the lichen planopilaris family — a chronic inflammatory condition that destroys the follicle stem cells. Once a follicle is destroyed by FFA, it does not come back, and any transplant placed in active disease has a very high failure rate.

Diagnostic Signs

FFA has a recognisable visual signature:

• Symmetrical band-shaped recession of the frontal hairline (often 1–4 cm)
• Loss of eyebrow density, especially the lateral two-thirds (the "tails")
• Pale, smooth skin in the recessed area — no surviving follicles, no hair stubble
• Sometimes single isolated "lonely hairs" remain in the recessed zone
• On dermoscopy: perifollicular erythema and scaling around the leading edge

Disease Activity vs. Stability

Treatment success depends entirely on whether the disease is currently active. A dermatologist (ideally a trichologist) confirms activity through clinical exam, dermoscopy, and sometimes biopsy. The standard medical regimen — hydroxychloroquine, topical/oral steroids, finasteride, occasionally JAK inhibitors — aims to halt progression.

Surgical treatment requires at least 18–24 months of confirmed inactivity. Operating on active FFA almost always fails.

SMP as the Practical Option

For stable FFA we often recommend SMP rather than a transplant: it does not depend on follicle survival, costs less, has no recovery time, and produces immediately visible results. Hairline restoration with SMP — rebuilding the lost band of pigment — gives a natural-looking front line at any haircut length.