Frontal fibrosing alopecia and sunscreen use: a cross-sectional study of actinic damage

Article summary by Tejashri Venkatesh | MD Candidate 2025 | Chicago Medical School at Rosalind Franklin University

The association between frontal fibrosing alopecia (FFA) and sunscreen use is highly controversial1-4. Patients with FFA report higher rates of sunscreen use than control subjects5-7, however it is unclear if increased sunscreen use is a cause or a consequence of FFA2. Logically, more sunscreen use should be associated with lesser actinic (sun) damage. An article published in 2022 aimed to evaluate actinic damage in patients with FFA.

A cross-sectional study was conducted on women in Spain, including 101 patients with FFA and 40 control subjects. Actinic damage was assessed on the face, based on cutaneous signs of solar lentigines, actinic keratoses, basal cell carcinomas and squamous cell carcinomas.

Consistent with previous reports5-7, patients with FFA had significantly greater sunscreen use compared with control subjects. Moreover, patients with FFA were found to have significantly more actinic damage and solar lentigines compared to control subjects, regardless of skin phototype (skin tone). No differences were found between patients with FFA who used sunscreen and those who did not use sunscreen regarding the following characteristics:

• Skin phototype
• Presence of peripheral alopecia (eyebrow, eyelash and limb alopecia)
• Presence of trichoscopic signs of inflammation (perifollicular erythema and follicular hyperkeratosis)
• Presence of histopathologic signs of inflammation (sebaceous gland involvement and presence of inflammatory infiltrate)

The study results suggest that sunscreen use and actinic damage are independently associated with FFA. Higher use of sunscreens by patients with FFA compared with healthy controls may have several explanations including that patients seeking care for hair loss may have more appearance-related concerns, higher economic status2,8, more frequent dermatology visits, or presence of another skin condition.

Data shows that patients with FFA demonstrate higher rates of rosacea compared to control subjects7,9, suggesting that more sensitive skin and lighter skin phototypes may be related to the higher rates of actinic damage observed in these patients.

Despite increased use of sunscreen by patients with FFA compared to healthy controls, they demonstrate a higher prevalence of actinic damage. A likely explanation is that patients with FFA started using sunscreen due to the development of sun-damaged skin and solar lentigines.

Trichoscopic signs of inflammation marking disease activity, early histopathologic signs of FFA including loss of sebaceous glands and presence of inflammatory infiltrate11-13, and alopecia in the eyebrows, eyelashes and limbs that is frequently noted in FFA8,14-16 were observed consistently within the cohort of patients with FFA, regardless of sunscreen use. This provides evidence against the notion that sunscreen is involved in the development of FFA.

In conclusion, the study findings suggest that the higher use of sunscreen in patients with FFA might be a consequence of greater actinic damage rather than a cause of the alopecia.

Further research is necessary to corroborate this hypothesis and identify other potential triggers leading to the observed rise in prevalence of FFA.

See full article here.

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