Dr. Amy McMichael Highlights Breakthrough Alopecia Therapies

Anyone not using low-dose oral minoxidil yet has “missed the boat.” That was the message from Amy McMichael, MD, during her presentation on non-scarring hair loss at the 2026 Winter Clinical Dermatology Conference in Hawaii.

Dr. McMichael, who before her presentation was named the conference’s Educator of the Year, shared a data-rich update spanning everything from new US Food and Drug Administration (FDA) approvals in alopecia areata (AA) to off-label use, oral therapeutics in development, and pregnancy-safe treatment strategies.

ALOPECIA AREATA JAK INHIBITOR PIPELINE EXPANDS

The treatment landscape for severe alopecia areata continues to evolve with multiple JAK inhibitors now approved and more on the way.

FDA-approved therapies Dr. McMichael highlighted include:

• Ritlecitinib: Now FDA-approved for patients 12 and older, ritlecitinib is the only JAK inhibitor approved for adolescents with severe AA. The JAK3/TEC kinase inhibitor is taken once daily.
• Baricitinib: The first JAK inhibitor approved for AA, baricitinib is for adults only (18+), with either 2-mg or 4-mg doses.
• Deuruxolitinib: FDA-approved in July 2025, this JAK1/JAK2 inhibitor requires twice-daily 8mg dosing. Notably, a 12-mg BID dose that demonstrated superior efficacy in trials was not approved.

A caveat for deuruxolitinib, Dr. McMichael noted, is that it now requires CYP2C9 genetic testing to screen for poor metabolizers, even though patients with this genotype in clinical trials tolerated the drug without serious issues. Dr. McMichael walked attendees through practical steps for navigating this process, emphasizing that the test is covered and processed through LabCorp.

NEW DATA ON JAK INHIBITORS

Dr. McMichael emphasized the fast onset of action with deuruxolitinib: “We saw statistically significant regrowth as early as 8 weeks, which is earlier than other JAKs, though there are no head-to-head comparisons yet,” she said.

Long-term follow-up data for all 3 approved agents are showing sustained efficacy and no new safety concerns, she noted:

• Baricitinib: Now backed by 4-year safety data with more than 1,300 patients and 2,700 patient-years of exposure. No increase in cancer or cardiac events compared to general population.
• Ritlecitinib: 2-year data show stable hair regrowth and continued safety in adolescents and adults.

Patient adherence to lab monitoring remains a challenge. Dr. McMichael shared real-world insights showing that most patients fail to follow strict lab testing schedules. She now recommends lab monitoring every 6 months, rather than every 4 months, as a realistic and still safe compromise.

UPADACITINIB FOR AA

Already widely used for atopic dermatitis and rheumatoid arthritis, upadacitinib is on track for AA approval, Dr. McMichael noted. New phase 3 data show:

• 44% to 54% of patients achieving at least 88% scalp coverage (SALT ≤20) at Week 24.
• No new safety signals compared to its known profile in AD.

“This is exciting because we know this drug well from AD, and it has impressive efficacy in AA,” Dr. McMichael said, hinting that FDA approval may follow later this year.

CONSENSUS HIGHLIGHTS

Dr. McMichael also reviewed new international consensus findings from a global panel of 74 hair experts across 6 continents.

Trichoscopy (scalp dermoscopy), per the consensus, is essential for assessing inflammation, disease severity, and prognosis in AA. Additionally, psychosocialmorbidity should factor into treatment eligibility, especially for patients with severe emotional impact but less visible hair loss.

“This can help justify systemic therapies to payers,” Dr. McMichael said.

CLARIFYING THE ROLE OF DUPILUMAB

The buzz around dupilumab for alopecia areata has grown, particularly in pediatric patients, but Dr. McMichael urged caution. In a controlled trial, only patients with elevated IgE or co-existing atopic dermatitis showed meaningful improvement.

“Don’t prescribe dupilumab for AA unless you’ve documented high IgE or true atopic comorbidity,” she said.

LOW-DOSE ORAL MINOXIDIL

Dr. McMichael championed low-dose oral minoxidil (LDOM) as a “go-to” treatment for pattern hair loss and other non-scarring conditions. She noted that it is effective for AGA, telogen effluvium, traction alopecia, endocrine therapy-related alopecia, and even persistent post-chemo hair loss.

Contraindications include: pericardial effusion, pulmonary hypertension, hypotension, tachycardia, kidney disease, pheochromocytoma, and pregnancy.

A new extended-release minoxidil formulation in development may offer improved safety by avoiding peak serum concentrations, she said, while still delivering therapeutic benefit. Phase 2 data show notable improvement by 4 months, with additional studies underway in women.

A GOLDEN ERA

Additional highlights included clascoterone 5%  showing promise for male AGA, with more data expected soon.

Fractional laser therapy can enhance outcomes for AGA when paired with medical therapies, though it should not be used alone.

For breastfeeding patients, she recommends avoiding JAKs, methotrexate, and certain antiandrogens but supports the use of topical minoxidil, LDOM (with caution), and plant-based products.

“This is a golden era for alopecia areata,” Dr. McMichael concluded. “We finally have real options, and even more on the way. But you have got to stay current and know which drug fits which patient.”