Advances in Diagnosing, Treating Scarring vs Nonscarring Alopecia: Jerry Shapiro, MD

Scarring and nonscarring alopecias demand very different treatment strategies, making precise diagnosis critical to preserving and regrowing hair, says Jerry Shapiro, MD, professor of dermatology at New York University (NYU) Langone Health Center. Tools and treatments like trichoscopy, Janus kinase (JAK) inhibitors, and extended-release minoxidil are reshaping outcomes and expectations for patients living with hair loss.

This transcript was lightly edited; captions were auto-generated.

Transcript

With so many types of nonscarring and scarring alopecias, how do you approach differentiating them in clinical practice, and why is accurate diagnosis so critical for treatment success?

I'll answer the last question. First, the accurate diagnosis is really important because [there are] different treatments for scarring vs nonscarring, so there is some intersection. But really the aim for scarring is to keep the hair and stop it from spreading. Well, for nonscarring, that is a reversible condition. And so we're trying to regrow hair. There are 2 different determinants, and how do we distinguish [them]? We use something called trichoscopy, which magnifies the hair 20 to 30 times and allows us to really look at the inflammatory reaction against the hair, and we can determine whether it's scarring or nonscarring by looking at the pores and seeing if they're present or not.

What emerging therapies or recent advances in the management of alopecia are you most excited about, and how are they changing patient outcomes?

I think there are 2 things for alopecia areata. We now have, as of 2022, JAK inhibitors, and we now have 3 of them—probably soon 4—that will really change and benefit patients. The innovation of JAK inhibitors for alopecia areata is really getting strong, so that's changing a lot. For androgenetic alopecia, there are all sorts of different products, including slow-release minoxidil, something that's not immediate release and that seems to be safer and work better and faster and more efficiently. And so that's the new thing. For androgenetic and for scarring alopecias, we're finding that JAK inhibitors also help as well. There are certain ones that work better than others, and I think that's going to be the route that people are going to take.

When managing scarring alopecias, what strategies do you use to halt progression and preserve hair, and how has this evolved with recent research?

I think that we need to save the hair follicle, and one way to save it is to preserve the stem cells and to reduce the inflammation around stem cells, because once the stem cells are gone, there's irreversible hair loss. Our job is to target the inflammation around the hair stem cells, and so the JAK inhibitors may help. There are all sorts of things that we can do to help that, to make a difference to preserve the hair follicle, and hopefully reverse even the hair loss. If it's caught really early in scarring alopecia or in nonscarring alopecia, just to revive the stem cells.