PracticalDermatology

Meena Singh, MD, has a passion for treating hair loss, especially in Black women. Dr. Singh, a dermatologist and Mohs micrographic surgeon in Shawnee, KS, completed a fellowship with the International Society for Hair Restoration Surgery and is trained in all hair transplantation techniques including strip excision, manual/motorized/robotic follicular unit extraction, as well as transplanting into scarring alopecias. She also stars in TLC’s Bad Hair Day where she and colleagues provide life-changing procedures and treatments for people who have extreme hair-related medical issues.

Dr. Singh spoke to Practical Dermatology® about what’s possible with today’s growing toolbox of alopecia treatments and how she pairs them to address even the most aggressive forms of scarring alopecias.

What’s new and exciting in alopecia?

Meena Singh, MD: Biorestorative or biostimulatory treatments. For each form of hair loss, the biostimulatory therapies are the most exciting. They include platelet-rich plasma (PRP) therapy, growth factor therapy with microneedling, and different devices to introduce growth factors into areas where we feel that hair can grow back. This is a good option for patients who are experiencing hair loss but are not candidates for a hair transplant yet. We also have two FDA-approved treatments for alopecia areata: Litfulo (ritlecitinib) and Olumiant (baricitinib). Both are Janus kinase (JAK) inhibitors.

Are you happy with the new JAK inhibitor options?

Dr. Singh: I am a big fan of JAK inhibitors because of their mechanism of action. They are selective for one or more of the Janus kinase family of enzymes (JAK1, JAK2, JAK3, TYK2) and interfere with the JAK-STAT signaling pathway in lymphocytes. Many dermatologists were using, Xeljanz (tofacitinib) off-label to treat alopecia until the FDA approved baricitinib for alopecia areata in June 2022. I have had success using these medications off-label for patients with scarring alopecias as well. They are quite successful at reducing inflammation in frontal fibrosing alopecia (FFA) and lichen planopilaris.

Any tips on treating inflammatory forms of alopecia?

Dr. Singh: I would recommend encouraging regrowth using oral or topical minoxidil for FFA and any inflammatory or scarring types of alopecia. Topical or oral minoxidil promotes hair growth directly. In my practice, the best results I see in patients with inflammatory alopecias are with a combination of anti-inflammatory treatment, direct stimulation of regrowth with minoxidil, and the addition of a biostimulatory therapy.

What’s new with central centrifugal cicatricial alopecia (CCCA)?

Dr. Singh: I treat a lot of CCCA, and my tip would be to also start aiming to create a biostimulatory environment for these patients. I do see some regrowth in scarring areas with CCCA.

What about traction alopecia?

Dr. Singh: Traction alopecia is the best form of alopecia to treat with hair transplants. Most patients with traction alopecia have afro-textured hair that provides a higher perceived density of grafts per cm2 so there are not as many needed grafts to cover the area, and this is not an advancing form of alopecia.

Can a patient have overlapping types of alopecia?

Dr. Singh: Yes, many patients have more than one form of alopecia. Traction alopecia is a good example. If a patient has CCCA, one way to cover the balding area in the crown is to pull the hair back, increasing the risk for traction alopecia.

How do you make a differential diagnosis?

Dr. Singh: The main key to diagnosing alopecia is to determine whether it is non-scarring or inflammatory, scarring alopecia. This involves dermoscopy, but also taking a really good history and trying to tease out any inciting factors and looking for any signs of inflammation such as itching, burning, tenderness, or hair breakage. I would always do one or two biopsies and use the dermoscopy to determine where to perform the biopsies.

What should Black women with hair loss know about treatment options and managing their symptoms?

Dr. Singh: With Black women, traction alopecia and CCCA are the most common types of alopecia. Because these can be quite cosmetically disfiguring and are often more advanced upon presentation, I highly recommend treating them aggressively right away. Don’t try monotherapy and wait 8 to 9 months to see if it works. Start with a combination of oral and non-surgical treatments, including intralesional steroid injections. I biopsy every Black woman who has hair loss even if I am thinking clinically that she has a non-scarring type of alopecia. I want to know with certainty that they don’t have any inflammation around the hair follicle. It’s also important to discuss hair styling options because certain hairstyles can further compromise the existing hair loss.