Building a Repeatable Workup for Hair Loss
Broadcasting from RAPIDS 2026 in Fort Lauderdale, host Eileen Cheever, PA-C, sat down with Dr. Oyetewa Asempa to unpack her podium session on scarring and non-scarring alopecia. Dr. Asempa's central message: run the same sequence on every patient so nothing slips through. She starts with history — how long it's been going on, plus a standard list of questions she asks each time.
From there she moves to the global exam: what you see from the door, and what you see when you part the hair with your hands. One of her biggest tips is that you have to get in there physically. As she put it, 'You really can't diagnose hair loss just from looking at how they're sitting. You really gotta kinda get to the root.' Cheever noted that this hands-on approach also resonates with patients—it signals you’re thorough and invested in their care.
The rest of her ladder includes trichoscopy (the physical exam that gives a microscopic view), histology when trichoscopy isn’t enough, and blood work—reviewing old labs and ordering new ones as needed. Finally, she counts response to treatment as diagnostic feedback. If a patient doesn't respond, Dr. Asempa doesn't assume the treatment failed — she reconsiders whether she has the right diagnosis.
Five Things to Read on Every Trichoscopy Exam
Dr. Asempa called trichoscopy an underappreciated art, and she teaches her residents and trainees to check five features every single time they look through the dermatoscope.
First, the hairs themselves — caliber (thin vs. large) and how many are emerging from each follicular orifice. Second, pigment — is the scalp hyperpigmented, hypopigmented, and how does the pigment appear? Third, vasculature — redness or enlarged vessels. Fourth, the interfollicular space — how much space sits between hairs and whether follicles are missing. Fifth, scale — both its presence and its position, meaning whether it sits between the hairs or around the base of the follicle.
She framed trichoscopy as complementary to biopsy, blood work, and history rather than a standalone test — an essential piece of the diagnostic picture.
The Styling Conversation Without the Judgment
With 15-minute visits, Dr. Asempa said it's tough to talk styling — but styling drives treatment response. If a patient wears very tight styles or a style that blocks daily scalp access, a topical regimen simply won't work. To save time, she hands out a guide that grades hairstyles A, B, C, or F based on their impact on hair health.
Her tone is deliberate. She never tells a patient not to do a style directly, because, as she explained, styling is 'so emotional and spiritual.' Instead, she explains how a style may be affecting the scalp and how they can mitigate it. Some patients tell her they hear her and are going to keep the style anyway — and her response is to do their best within that reality, as long as the patient understands the potential impact. Cheever praised this as a way to preserve trust while still delivering the education patients need.
Distinguishing LPP from CCCA — and the Anatomy Behind Alopecia Areata
Dr. Asempa acknowledged that shifting between lichen planopilaris (LPP) and CCCA can be elusive since both may start with tenderness and sensitivity. On trichoscopy, CCCA tends to show less prominent scale than LPP, though the two can look similar — which is where biopsy earns its keep, given the slightly different treatment algorithms.
She offered demographic and exam anchors: CCCA classically appears in African-American patients, often with perifollicular hyperpigmentation or a gray color, and roughly half her CCCA patients have no tenderness. LPP, by contrast, can occur in any patient and tends to be very tender and red, favoring the vertex, with prominent perifollicular scale right around the follicle.
On alopecia areata pathophysiology, Dr. Asempa explained the concept of follicular immune privilege — the bottom of the hair is meant to be hidden from the immune system. When that privilege is lost, T lymphocytes swarm the bulb 'like a swarm of bees.' The good news: the bulge region, where stem cells live, is separate from the bulb, so the inflammation is robust but not permanently destructive. She contrasted this with lichen planopilaris, where inflammation targets the isthmus near the bulge and damages stem cells, causing permanent loss.
Case Focus: Acne Keloidalis Nuchae
Dr. Asempa walked through a case of a man in his mid-30s with Acne Keloidalis Nuchae (AKN), calling the name a misnomer — there's no true acne, no true keloid, and it's not always in the nuchal area. Her first tip: examine the whole scalp on every hair-loss patient, because AKN papules often appear higher up on the crown or frontal scalp.
Her treatment ladder starts with topical antibiotics and topical anti-inflammatories, then injected steroids, then systemics — systemic retinoids or antibiotics — with surgical excision reserved as a worst-case scenario. She emphasized AKN is multifactorial: even perfect hair-removal practices don't guarantee prevention. She counsels patients to avoid direct razor shaving and constant friction from helmets or hats, acknowledging that football players and military members often can't avoid it — and she writes shaving waivers for military patients.
On mechanism, Dr. Asempa pointed to a likely androgen role (AKN is far more common in male patients), friction, and an abnormal immune response to commensal flora such as Staph aureus and Demodex. Agents like selenium sulfide or topical antibiotics can help reduce that commensal burden.