According to Jerry Shapiro, MD, professor of dermatology at the New York University Grossman School of Medicine, a patient with cicatricial alopecia represents a “trichological emergency.” Dr. Shapiro presented a unique session on hair and hair loss at Maui Derm NP+PA Fall 2024, where he urged healthcare professionals to act quickly to prevent further hair loss in these patients.
Shapiro also touched on how he is incorporating artificial intelligence into his practice, how JAK inhibitors impact treatment for patients with alopecia, and the complex treatment algorithm for lichen pilaris.
This transcript has been edited for clarity.
Dermatology Times: Tell us about the session on hair that you presented at Maui Derm NP+PA Fall and why it is important to provide this education to an audience of advanced practice physicians.
Jerry Shapiro, MD: This session is very important for everyone in dermatology because we talk about new things and treatments for hair problems. Alopecia is a big problem in dermatology right now because there are now more treatments. And it’s because we have more treatments that we can really make a difference in people’s lives. There are new treatments for male pattern baldness, alopecia areata, and even cicatricial alopecia. When I started in dermatology over 30 years ago, there was really very little we could offer our patients. Now, there’s a ton of stuff to try. I show my patients a menu of things to try and they choose what’s best for them.
DT: What recent advances in the treatment and management of alopecia are you most excited about?
JS: I’m very excited about JAK inhibitors. I think they could be effective not only for alopecia areata but also for cicatricial alopecia. They reduce inflammation. By reducing inflammation, they improve symptoms. They calm inflammation in the scalp. I think this class of drugs could have a really big impact on both alopecia areata and cicatricial alopecia.
Low-dose oral minoxidil is increasingly being used for male pattern baldness instead of topical minoxidil, which has been used for decades. We now use low-dose oral minoxidil in various milligram doses, which really works for male pattern baldness. It also works for alopecia areata, enhancing the effect of JAK inhibitors. It also works for cicatricial alopecia, improving background hair growth.
DT: Can you talk about the differences in evaluating cicatricial and non-scarring alopecia?
JS: Cicatricial alopecia is permanent hair loss. It has to do with the stem cells of the hair follicle, which are in the bulging part of the hair follicle. That part somehow becomes a target for immune cells, which attack the immune cells and destroy the hair follicle. In the case of alopecia areata, the immune cells burrow into the base of the hair follicle. So this is reversible, but in the case of cicatricial alopecia, the inflammation happens in the stem cell part and completely destroys the hair follicle.
DT: Can you explain the treatment algorithm for lichen pilaris?
JS: It’s very complicated, but it depends on how much hair loss the patient has and how much hair they’re losing to determine how aggressively we treat them. If it’s not too extensive on the scalp, we treat it with cortisone injections. We also try creams that contain tacrolimus, clobetasol, and minoxidil to see what effects they have.
Now, if that doesn’t work, then we have to go to stronger medications. I definitely would inject cortisone around the scar. I would use that from the beginning sometimes, because it really helps to prevent the scar from spreading. Then we have to look at other treatments. For example, for certain types of cicatricial alopecia, finasteride or dutasteride can be used. There’s something called frontal fibrosing alopecia, and for that we use a lot of 5-alpha reductase inhibitors. Dutasteride is what we use most often. And then there are other medications like doxycycline and hydroxychloroquine. Both can be used and are not contraindicated. Because we want to be really aggressive, we use those in addition to the other ones that we just talked about.
If that doesn’t work, then there’s the excimer laser, which is a 308 nanometer laser that we use. We even use it on the eyebrow area for people with frontal fibrosing alopecia. We’ve found that this really helps because it calms the inflammation in that area. And then there are the powerful treatments like mycophenolate mofetil, cyclosporine, methotrexate, and then there’s the JAK inhibitors, which I really think could help with cicatricial alopecia, even though they’re not officially approved.
DT: How has artificial intelligence impacted your practice?
JS: I use AI on almost all my patients now. It allows me to measure how many hairs are in a given area, and I can get the number of hairs per square centimeter. It also gives me the width of the hair. Before, I had to do it manually. About five years ago, I would manually count the hairs in an area. Now I can take a picture, send it to the cloud, and get an answer in 45 seconds. Before, it would take me nine minutes to count the hairs in an area. Now I get an answer in 45 seconds, and I can get a much more accurate average. Before, I would only take five or six hairs and get an average. Now I can take every hair in that area, 150, 180, 200 hairs, and get an accurate average.
DT: Anything else you’d like to add?
JS: With cicatricial alopecia, this is a trichological emergency. The hair that falls out is gone forever, so it’s important to address it right away and not wait for a diagnosis. I see a lot of patients, but I saw a patient last week who had a large patch of lichen pilaris that had been left untreated for a long time. This patient needs to be seen by a dermatologist, NP, PA, whoever, who can treat this and put out the fire.
reference:
Shapiro J. Hair Update 2024. Presented at: Maui Derm NP+PA Fall, September 15-18, 2024, Nashville, TN.
