A Role Reversal, and Why the Exam Comes First
In this third installment of the SkinSync hair loss mini series, the podcast flips its usual format: regular co-host Lisa Weiss steps into the interviewer's chair while resident host Buchi Neita takes the guest seat as the resident scarring alopecia expert. Neita explains that this niche found her rather than the other way around — as a provider of color treating women of color, particularly Black women, scarring alopecia is so common in her practice that she was 'forced to become an expert in it.' On a given day she sees no fewer than four to seven scarring hair loss patients.
Her core message: you cannot make these diagnoses without a thorough history and a hands-on exam. Neita reviews age, medication list (she specifically flags GLPs), and medical history before she even walks in the door, then does a deep scalp exam once inside. If a patient arrives with glued-down extensions, a wig, or braids that block the scalp, she reschedules rather than performing an incomplete exam. Both hosts stress pulling out the dermatoscope for trichoscopy every time — Weiss notes that the more you look at normal scalps, the faster you recognize the abnormal ones. The hallmark to hunt for across all scarring alopecias is loss of the follicular ostia, and in early cases (especially early CCCA) a biopsy may be needed to confirm.
Neita also treats hair loss as its own dedicated visit — almost always separate from skin checks or acne — because a proper hair loss appointment rarely takes less than 15 to 20 minutes and often involves detailed counseling and injections.
Traction Alopecia: Start With a Compliment, Then Change the Hairstyle
Neita walks through how she counsels patients on traction alopecia. History is key — ask not just about current styling but about ponytails, weaves, and braids over the past 5 and 10 years, and have patients pull up old photos if needed. She candidly describes the cultural normalization of scalp pain, from tight braids to relaxers left on 'until it starts burning,' and reframes that for patients: styling should never cause pain, sores, tension, or bumps.
For the delicate conversation — especially across a racial mismatch — she credits an approach she attributes to Dr. Candrice Heath: start with a compliment on the patient's hairstyle before introducing your concern. That same gentleness applies to parents of children with tight braids. Treatment is worthless if the causative style continues, so she shows patients photos of high-risk versus lower-tension styles (citing a helpful JAMA article) and offers alternatives rather than blanket bans.
Her treatment stack leans on combination topicals: topical corticosteroids, compounded topical minoxidil (often an oil-based formulation up to 7%), and added tretinoin — which she notes, per Dr. Crystal Aguh, makes minoxidil more effective. She adds intralesional triamcinolone around 5 mg/mL roughly every six weeks for active early disease, sometimes oral minoxidil, and occasionally over-the-counter peptide, caffeine, or niacinamide topicals.
CCCA: Under-Recognized, and Where the Kitchen Sink Comes In
Neita calls CCCA the majority of the hair loss she sees, yet says it's under-recognized. The biggest complaint she hears from Black patients about prior clinicians is simple: they weren't examined. She urges providers to touch the scalp, respect textured-hair care practices (don't tell these patients to shampoo daily), and always offer alternatives.
CCCA typically presents at the vertex in African American women, sometimes with tenderness, burning, or itching — but it can be completely asymptomatic, so absence of symptoms doesn't rule it out. On trichoscopy, she looks for loss of follicular ostia and peripilar (whitish-gray) halos. She biopsies early breakage cases with a 4 mm punch to confirm inflammation. She also counsels on associations — the PADI3 gene (positive in about 24% of CCCA patients per her citation) and links to breast cancer, uterine fibroids, and type 2 diabetes — using the visit to nudge patients toward primary care screening and mammograms.
Treatment is aggressive combination therapy: a compounded topical of minoxidil, a strong steroid (clobetasol or betamethasone), and a little tretinoin, plus — a favorite pearl — topical metformin at 10% once daily, which she's found surprisingly effective even in moderate-to-late disease. She adds oral antibiotics such as doxycycline (100–200 mg, lower doses for maintenance) and has used oral finasteride in select patients. Compliance is a real barrier, so she compounds agents together where feasible to simplify regimens.
FFA, LPP, and the Case for JAK Inhibitors
Frontal fibrosing alopecia is becoming more common, often caught incidentally on routine skin exams. Neita is honest about prognosis — she considers FFA one of the more aggressive scarring alopecias, and once a follicle is gone, it's gone. The hope she offers is preservation: keep existing hair, reduce further loss, and thicken what remains. Diagnostic clues include perifollicular scale and erythema, the 'lonely hair' sign (distinct from the fringe sign of traction), fine flesh-toned facial papules, eyebrow loss, and lichen planus pigmentosus in Black and Indian women. Because a chemical-sunscreen link is theorized, she switches patients to mineral-only sunscreen.
For both FFA and the more patchy lichen planopilaris, Neita's standout recommendation is JAK inhibitors — compounded topical (she mentions tofacitinib and off-label topical delgocitinib) for early-to-mid disease, and oral JAKs for moderate-to-late disease. She's been impressed by how quickly they cut inflammation, erythema, itch, and burn, sparing patients from potent steroids on already-thin, atrophy-prone frontal scalp. Weiss echoes strong off-label results and, as a steroid steward, calls it a real win.
Discoid Lupus and the Neutrophilic Scarring Alopecias
For discoid lupus erythematosus — common in Black women, typically ages 20 to 40 — Neita always biopsies to confirm, and leads with reassurance: only about 5% progress to systemic lupus. She refers and orders lab testing if there are systemic signs. Later-stage disease shows hypo- and hyperpigmentation, erythema, follicular plugging, and thick red vessels on dermoscopy. Treatment includes topical steroids, nonsteroidals, intralesional Kenalog, and hydroxychloroquine, with rheumatology referral and biologics (currently approved for SLE) for late, refractory cases.
Among neutrophilic disorders, folliculitis decalvans is flagged by tufted hairs—the ‘doll hair’ sign of multiple hairs emerging from one follicle—plus inflammatory papules and pustules, usually at the vertex in Black men. Treat early with topical and oral antibiotics and topical steroids. Dissecting cellulitis, which Neita frames as 'HS of the scalp' within the follicular occlusion tetrad, presents with inflamed, tender, draining nodules and sinus tracts. Her go-to is isotretinoin dosed like acne (1–1.5 mg/kg/day), cooling severe inflammation first with doxycycline or minocycline and a low starting dose before ramping up. Biologics used in HS also have published efficacy here.