Why Hair Loss Deserves a Second Look
Kicking off a three-part hair loss series for National Hair Loss Awareness Month, PAs Buchi Neita and Lisa Weiss open with an honest reframe: hair loss visits are often the ones clinicians dread because they run long, can get emotional, and historically came with few great treatment options. Weiss admits she lit up at the topic partly because she's an androgenetic alopecia patient herself, and partly because she believes hair loss is widely misunderstood in derm and that newer advancements make it more rewarding to treat.
Neita is candid that hair loss wasn't an early interest for her either — those longer, emotional visits weren't something she gravitated toward. But as she honed her clinical skills over the years, she came to enjoy it, noting that when patients have success, they refer everyone. Neither host claims to want to be the sole 'hair loss person' in the clinic; instead, both frame the goal as being a resource for other APPs and helping patients understand that hair loss is not a 'death sentence' with nothing to offer.
Setting Up the Visit: Give Hair Loss the Time It Deserves
Both hosts agree that the first decision happens before you even discuss the hair: is there time in this visit to do it justice? Weiss says she'll address it in the moment when the cause is obvious and quick to manage — a recent pregnancy, a 40-pound weight loss, a major stressor. If it's not that straightforward, she sits down and explains that hair loss requires its own visit so they can land on the correct diagnosis and treatment algorithm. When she suspects a biopsy will help, she'll do it at that initial visit so results are ready for the dedicated follow-up.
Neita takes a similar approach and errs toward bringing patients back, because even 'quick' reassurance conversations tend to balloon. She works patients in within a week or two and asks them to prepare: bring or pull up recent lab work, and — especially for Black women wearing extensions, sewn- or glued-down wigs, or braids — take those styles down so she can properly evaluate the scalp. Both stress that patients are receptive when you explain the why. As Neita tells them, it has nothing to do with a copay; it's about protecting the deep dive a hair loss visit actually needs.
The History: Follow the Clues, Including GLP-1s and Family Patterns
The lead-off questions Weiss uses: how long has this been going on, is there any family history of hair loss, what styling trends have they used, and any changes in diet or major stressors. Neita flags nutrition and the GLP-1 era as increasingly important — patients losing large amounts of weight quickly, or simply having no appetite and eating one meal a day, which can affect hair growth and iron levels. Psychosocial history matters too; even low-grade chronic stress can manifest as hair loss.
On family history, Weiss ties it to specific conditions. For androgenetic alopecia, she asks about relatives — either side — who noticed a widening part, a shrinking ponytail, or a shift from thick to thin hair. She shares that her own androgenetic alopecia is traced to the women on her father's side and appeared in her early 20s, a reminder that it can show up earlier than expected. For alopecia areata, she asks about autoimmune disease in the family. Neita adds that CCCA carries a genetic component as well, citing the work of Dr. Crystal Aguh from Johns Hopkins on scarring hair loss in Black women, and recommends asking about family history when CCCA is on the differential.
The hosts round out the history with symptom review — burning, itching, stinging, flaking, redness, and concomitant seborrheic dermatitis — plus detailed styling and coloring practices for all patients, not just women with textured hair. Daily blow-drying and flat-ironing, bleaching, and dyeing can wear down hair integrity, and what patients call 'hair loss' may actually be breakage. Neita recounts an older white patient whose hair was breaking, not failing to grow, from heat and harsh products; already on minoxidil for hypertension, she was referred to a stylist rather than started on new treatment.
The Exam: Touch the Scalp, Look Beyond It, and Explain Every Step
Weiss relies heavily on dermoscopy and pattern recognition — central part widening and bitemporal recession for androgenetic alopecia, preserved versus lost frontal edge for traction, and the patchy or ophiasis patterns of alopecia areata. Neita emphasizes actually examining the patient, noting how many arrive having seen providers who never touched their hair. She recommends asking permission, gloving up when there are heavy products, and using a cotton-tipped applicator to part and thoroughly inspect the entire scalp. She also looks beyond the scalp: the conchal bowls for discoid lupus, and facial papules, thinning lateral brows, and lichen planus pigmentosus clues for frontal fibrosing alopecia.
Both hosts return to the patient-provider relationship, especially across background differences. Weiss adopted Neita's pearl of always asking to touch a patient's hair and telling patients she cares for hair of every background — small gestures that build trust and respect for the time and effort behind a style. Knowing common styles (locs versus sister locs, braids versus knotless braids, relaxed versus straightened hair) and which carry higher traction risk is part of a good exam. Neita performs pull tests frequently, particularly with GLP-1–associated shedding, while cautioning that a recent wash can give false results. She never dismisses the patient who brings in a bag of hair, and she talks patients through every maneuver so nothing feels distressing.
Labs: Targeted, Not a Million-Dollar Workup
Both hosts push back on the reflex to order a huge autoimmune battery. Weiss draws ferritin regularly, checks thyroid (often already managed by primary care) when it hasn't been drawn recently, and checks vitamin D frequently. Neita adds a CBC, noting how many younger, premenopausal women walk around anemic with low ferritins. Neither orders ANA or autoimmune panels without a specific concern like discoid lupus, warning that a positive ANA can open a can of worms.
Weiss offers a crucial counseling point: labs are not the be-all and end-all. Even a real deficiency may not be what's causing the hair loss. She also warns patients up front that hair-related labs and biopsies may not be covered by insurance, since companies often treat hair as cosmetic — so a surprise bill doesn't sour the relationship.