Jerry Shapiro, MD: Advances in Hair Loss Management and Treatment

A patient with scarring alopecia represents a “trichologic emergency,” according to Jerry Shapiro, MD, professor of dermatology at the NYU Grossman School of Medicine. Shapiro delivered his signature session on hair and hair loss at Maui Derm NP+PA Fall 2024, urging providers to act quickly to prevent any further hair loss in these patients.

Shapiro also touched on how he incorporates artificial intelligence in his practice, how JAK inhibitors factor into care for patients with alopecia, and the complicated treatment algorithm for lichen planopilaris.

This transcript has been edited for clarity.

Dermatology Times: Tell us about your session on hair presented at Maui Derm NP+PA Fall, and why it’s important to provide this education to an audience of advanced practice providers?

Jerry Shapiro, MD: This session is very important for everybody in dermatology because we talk about the new things [and] how to treat hair issues. Alopecia is now a huge issue now in dermatology because now we have more treatments, and because there are more treatments, we can really make a difference in people's lives. So we have new treatments for androgenetic alopecia, for alopecia areata, even cicatricial alopecia. When I started dermatology over 30 years ago, there was really very little we could offer patients. Now, there is a cupboard full of things we can try. I show patients a menu of things we can try, and we choose what's best for them.

DT: What are some of most recent advancements in terms of the treatment and management of hair loss that you are most excited about?

JS: I'm very excited about JAK inhibitors. I feel they have a place, not only in alopecia areata, but also cicatricial alopecia, and they reduce inflammation. And by reducing inflammation, we make the condition better. It puts out the fire that's within the scalp. I feel that this class of drugs can really, really make a difference in both alopecia areata and cicatricial alopecia.

For androgenetic alopecia, we're now using more and more low dose oral minoxidil instead of the topical minoxidil, which has been used for decades now. We now use low-dose oral minoxidil at different milligram doses for people, and it really does work for androgenetic alopecia, but it also helps alopecia areata, making JAK inhibitors work better. It also works in cicatricial alopecia because it makes the background hair grow better.

DT: Can you discuss the differences in evaluation between scarring and non-scarring alopecia?

JS:Scarring alopecia is a permanent hair loss. It involves the stem cells of the hair follicle, which are located in the bulge area. That area somehow is a target for your immune cells… goes right after them and actually destroys the hair follicle. [With] alopecia areata, the immune cells go underneath it at the base of the follicle. So it's reversible, but [with] cicatricial alopecia, the inflammation is in a stem cell area that destroys the hair follicle fully.

DT: Can you discuss the treatment algorithm for Lichen planopilaris?

JS: It's very complicated, but it depends on how much a person has lost, how much hair they've lost, and then we decide how aggressive we're going to be. If it's not that much of the scalp involved, we'll treat with injections of cortisone. We'll also try a cream that has tacrolimus, clobetasol, and minoxidil, and we see how that works.

Now, if that doesn't work, then we have to really go to much stronger medications, definitely injections of cortisone around the scarred area, and we may even use that right from the beginning as well, because it really helps prevent the area from spreading. And then we have to also think of other treatments, like sometimes finasteride or dutasteride can be used in scarring alopecia if they are of a certain type. There's something called frontal fibrosing alopecia, and we use a lot of the 5α-reductase inhibitors for this. The most common one we use is dutasteride… And then there are other medications, such as doxycycline and hydroxychloroquine. You can use both; they're not contraindicated. You want to be really aggressive, and so we use the that in addition to all the other things I just discussed.

And if all that doesn't work, there's the excimer laser. That is a laser with 308 nanometer so we'll use that, and we'll even use it on the eyebrow area of people who have frontal fibrosing alopecia. We find that it really helps them because it kind of puts out the fire that they have in that area. Then there are really big gun therapies, such as mycophenolate mofetil, cyclosporin, methotrexate, and I really think JAK inhibitors have a place for scarring alopecia, although [they’re] not officially approved.

DT: How has artificial intelligence impacted your practice?

JS: I use AI almost on every patient now. That's how I can measure how much hair is in a specific area, and get the number of hairs per square centimeter. And then I can also get the widths of the hair as well. Before we had to do it manually. Up until around 5 years ago, we counted hairs manually in a target area. Now we can take a photograph and we can send it to the cloud and get the answer back in 45 seconds, when before, it took us 9 minutes to count hairs in an area. Now we can get an answer 45 seconds and get a better average as well. Before we used to only take maybe 5 or 6 hairs and take an average. Now we can take all the hairs in that area, 150, 180, 200 hairs, and get a good average.

DT: Is there anything else you would like to add?

JS: For scarring alopecia, this is a trichologic emergency. Every hair they lose will be gone forever, so it's important to get on top of it and not sit on the diagnosis. So many times I see people… Just last week, I saw somebody with a large patch of lichen planopilaris that was kind of ignored for a long time. They need to see a dermatologist, NP, PA, whoever can treat this and stop this fire and put it out.

Reference:

Shapiro J. Hair update 2024. Presented at: Maui Derm NP+PA Fall; September 15-18, 2024; Nashville, Tennessee.