FFA and Rosacea: What’s the link?
Rosacea in FFA Patients Linked to Greater Scalp inflammation, Greater Body Mass and Lower progesterone Levels
Several studies to date have suggested an association between the scarring alopecia frontal fibrosing alopecia (FFA) and the common dermatologic condition known as acne rosacea (or simply “rosacea”). How exactly the two are linked is not entirely clear.
Image of a woman with rosacea.
In 2019, Moreno-Arrones and colleagues conducted a multicentre case-control study and recruited 335 individuals with FFA to 329 patients who did not have FFA. Women with FFA were found to have a nearly two fold greater incidence of rosacea compared to women without FFA (OR = 1.91; 95% CI 1.07-3.39).
Porriño-Bustamante and colleagues also performed their own cross sectional study back in 2019 comparing patients with FFA to controls. In that study, the authors compared 99 women with frontal fibrosing alopecia to 40 controls. 62 % of women with FFA had rosacea compares to 30% of women without FFA. Women with more advanced stages of FFA were the most likely to report having rosacea compared with women with less advanced stages.
For women with FFA, three factors were found to be associated with a higher chance of having rosacea. In order of importance, these appeared to be 1) perifollicular erythema on the scalp 2) low serum progesterone levels and 3) higher body mass index. We still don’t know how these are related (and if giving progesterone or lowering weight affects rosacea in women with FFA).
A recently study by Liu et al estimated that women with FFA have a 2.46 fold increased risk of developing rosacea and the pooled prevalence was around 23 %. Muller Ramos found that women with rosacea have a 2 fold increased risk of developing FFA. This reinforces the bidirectional relationship between FFA and rosacea.
COMMENT
Women with FFA are at increased risk to develop rosacea and women with rosacea are at increased risk to develop FFA. We call this a ‘bidirectional’ relationship. However, what needs to be understood is whether “FFA associated rosacea” is precisely the same as rosacea in the general population. It seems to be but I’m not sure we know this in every single cass. Inflammation of the small vellus hairs of the face is known to be a part of FFA but is not so much a feature of typical rosacea in the exact same way. Pindado-Ortega showed in 2018 that most patients who were diagnosed with rosacea (28 of 35) ended up having the so called erythematotelangiectatic subtype of rosacea and 7 of the 35 had the so called papulopustular subtype. For now, rosacea in FFA is viewed as the same as rosacea in the general population. More studies will clarify the precise etiology.
It appears that FFA may be a negative prognostic factor in some ways although more studies are needed. Cid et al in 2020 showed that women with FFA plus rosacea were more likely to require systemic treatment than women without rosacea.
References
Moreno-Arrones OM et al. Risk factors associated with frontal fibrosing alopecia: a multicentre case-control study. Clin Exp Dermatol . 2019 Jun;44(4):404-410. doi: 10.1111/ced.13785. Epub 2018 Sep 26.
Pindado-Ortega C et al. Frontal fibrosing alopecia and cutaneous comorbidities: A potential relationship with rosacea. J Am Acad Dermatol . 2018 Mar;78(3):596-597.e1. doi: 10.1016/j.jaad.2017.09.004.
Walker JL, Robinson-Bostom L, Landow S. Four diseases, two associations, one patient: a case of frontal fibrosing alopecia, lichen planus pigmentosus, acne rosacea, and morbihan disease. Skinmed. 2016;14((3)):225–8.
Liu L et al. Association between frontal fibrosing Alopecia and Rosacea: Results from clinical observational studies and gene expression profiles. Front Immunol 2022 Aug 24:13:985081.
Müller Ramos P et al. Risk factors for frontal fibrosing alopecia: A case-control study in a multiracial population. J Am Acad Dermatol. 2021 Mar;84(3):712-718.doi: 10.1016/j.jaad.2020.08.076. Epub 2020 Aug 22.