Hair Loss Pearls by Dr. Hawkins from Skin Sanity Asheville

1. Inject where the disease lives

Intralesional steroid only works if it reaches the part of the follicle under attack, and that depth differs by diagnosis. In alopecia areata, inflammation targets the hair bulb, roughly 4 mm down. In scarring alopecias such as frontal fibrosing alopecia (FFA), lichen planopilaris (LPP) and central centrifugal cicatricial alopecia (CCCA), it targets the stem-cell bulge, closer to 2 mm.

Match the needle to the target: a 4 mm needle for alopecia areata and a 1.5 mm needle for scarring disease, in 32 or 34 gauge. A 0.5 mL syringe lowers injection pressure, which means less pain and more control.

2. Expect more than one diagnosis, and biopsy

In patients of color, hair loss is often multifactorial. Traction alopecia and CCCA frequently overlap in the same scalp, and trichoscopy alone can be genuinely hard to read.

I told the story of a colleague who rarely biopsied hair loss and now insists on it, because the overlap changes treatment. When more than one process could be driving the loss, tissue is what tells you which ones you are actually treating.

3. Seb derm or LPP? Treat first, then decide

A red, scaly, itchy scalp can be seborrheic dermatitis or early lichen planopilaris, and the two can look alike. Rather than biopsying every case, I start empirically with clobetasol and a medicated anti-dandruff shampoo (I like Vichy Dercos), then reassess.

If it clears, you've spared the patient a scar and a lot of worry. If it's still ambiguous, that's when to biopsy.

4. Scarring alopecia: one backbone, then layer

Scarring alopecias destroy follicles permanently, so the goal is to stop progression early. I start nearly every patient on a common backbone: low-dose doxycycline, topical clobetasol and topical tofacitinib.

Then I layer on a disease-specific agent:

For FFA, dutasteride has real data behind it: about 62% stabilization at one year, and up to about 90% at higher weekly dosing (Pindado-Ortega, 2021). For refractory disease, high-dose oral JAK inhibitors such as upadacitinib 30 mg or baricitinib 4 mg can work, and the dose matters.

5. Adherence is the whole game

This was the heart of the talk. Compliance with topical minoxidil is roughly 20% at six months, which means the patient who uses it faithfully is the exception. The best treatment in the world does nothing if it sits in a cabinet.

So I combine the anti-androgen (dutasteride, finasteride or spironolactone) and minoxidil into a single compounded oral capsule. One pill a day, no topical, and far fewer reasons to stop.

6. Address DHT, or what are you doing?

In androgenetic (pattern) hair loss, DHT is the driver, so a plan that doesn't address it is incomplete. The right 5-alpha reductase inhibitor depends on who is in front of you:

On side-effect fears: in a 2024 analysis (Lauck), only finasteride 5 mg showed a significant sexual-dysfunction signal. Risk runs from 5 mg, to 1 mg, to topical, from highest to lowest.

7. Pattern hair loss: combination beats either alone

For androgenetic alopecia, the hierarchy is simple: combination therapy beats finasteride, and finasteride beats minoxidil. The regimens I showed before-and-after results for were finasteride 1 mg plus oral minoxidil 2.5 mg in men, and dutasteride 0.5 mg plus oral minoxidil 1.25 mg in women.

The ladder is easy to remember, and the photos make the case better than any slide of numbers.

8. Alopecia areata: pulse plus JAK, and oral minoxidil for everyone

This is the protocol I eventually built for my wife. For moderate to severe alopecia areata, I layer pulsed dexamethasone (0.1 mg/kg on two consecutive days each week) with a JAK inhibitor. The combination outperforms either alone; in one series, tofacitinib plus oral minoxidil brought 67% of patients to the SALT25 endpoint (Wambier, Craiglow and King, 2021).

Every moderate to severe alopecia areata patient I treat also gets oral minoxidil.

9. Know when to send patients to a surgeon

Medical therapy is the foundation, but it has limits. I suggest referring for a hair transplant consultation in three situations:

• Pattern hair loss that has plateaued after about six months of consistent medical treatment
• Traction alopecia, where follicles in the affected area are often permanently lost
• Any time you've hit the wall with medications and procedures

A good surgical referral partner tells patients when surgery isn't the answer, too.

10. Measure it: can you prove they're better?

Every hair loss patient eventually asks, “Am I better?” Most of us have dermoscopy photos, but it's hard to find the exact same spot on the scalp at the next visit, and measuring by hand is tedious.

The fix is consistent, relocatable measurement: standardized photography, phototrichograms or tools like TrichoScan. I founded TrichoMap to solve this problem; it pins dermoscopy images to a map of the whole scalp so the same sites can be tracked over time. Whatever method you use, measuring is what turns “I think it's working” into proof, and patients who can see progress are more likely to stick with treatment.

The takeaway: be aggressive

Empathy is why I do this work, but what I asked the room to take home was aggression. Treat hair loss early, address the root cause, make the plan easy to follow, and measure the results. Topical minoxidil alone is rarely enough.

If you're a patient, the same principles apply to you. Hair loss is treatable, earlier is better, and you deserve a plan that fits your diagnosis and your life.

Thank you to the Skin Sanity team for having me in Asheville, and to everyone who stayed for the last talk of the weekend. Let's go treat some hair loss.

Spencer Hawkins, MD, is a board-certified dermatologist and ISHRS fellowship-trained hair restoration surgeon. He founded Hair Medicine Institute in Alpharetta, Georgia, and is the founder of TrichoMap.