A Full-Scalp Approach to Alopecia
Recorded live from the Elevate-Derm Summer Conference in San Diego, Lisa Weiss, PA-C of the Elevate-Derm Alliance sits down first with Dr. Oyetewa Asempa, CEO and founder of Align Dermatology and former assistant professor of dermatology at Baylor College of Medicine, who specializes in hair loss and scalp disorders. Asempa stresses that her first-visit workup is the same regardless of what the patient looks like: she starts by asking the patient what they think is going on, takes a detailed history (family history, styling, products), and then performs what she calls her 'global exam.'
That global exam means touching the hair and parting through every part of the scalp—not just the area the patient points to. Asempa takes standardized photos of specific scalp areas on every patient, even where they insist there's no loss, because patients often miss involvement elsewhere. She then uses her trichoscope (dermoscopy of the scalp) across the whole scalp, reviews labs, and orders more as needed. Roughly 70% of the time, she says, trichoscopy alone gets her to the diagnosis, so she is not a biopsy-heavy clinician — though some cases still require one.
Weiss echoes this as a practical pearl: patients aren't always great historians, so examining the entire scalp rather than fixating on the chief complaint can catch a completely different process.
Styling, Hair Care, and Seborrheic Dermatitis in Skin of Color
Asempa keeps styling conversations objective rather than demonizing specific styles, acknowledging that hair carries cultural and religious meaning. Her advice scales to severity: a patient with 50% bare scalp gets more latitude because dignity matters, while a patient with early loss who can still get coverage is counseled to stop extensions, which add weight and tension. For patients who insist on extensions for a special event, she gives harm-reduction guidelines — don't leave them in too long, don't let them be too tight. She favors styles that keep the patient's real hair off the shoulders and out of the hands without pulling tightly, and even suggests soft claw clips over tight ponytail holders for straight-haired patients to avoid a bald spot at the back.
On hair care regimens, the two non-negotiables are washing frequency and conditioning every single wash. Her preferred washing frequency is once a week for curly and coily hair (up to 14 days for thermally straightened hair without significant seborrheic dermatitis), two to three times weekly for wavy hair, and four to five times weekly for straight hair. She emphasizes using a real shampoo to clean scalp and hair so the conditioner can work, loves deep conditioning treatments, and reserves oils for sealing the ends — not the scalp directly.
For seborrheic dermatitis, Asempa first establishes washing frequency, but she warns against asking that question while examining the scalp — it reads as judgmental and invites inaccurate answers. Because curly-haired patients shouldn't wash daily, she favors leave-on treatments over shampoo-based ones. Her go-to is a clobetasol 3% foam. If that fails, she layers an exfoliant (polyhydroxy acid, lactic acid) on the scalp for 30 minutes before shampooing with a zinc pyrithione or salicylic acid shampoo, follows with the patient's regular moisturizing shampoo and conditioner on the ends, and adds a topical steroid if still not clear.
CCCA and Melasma: Nuance, Combinations, and Social-Media Buzz
Asempa diagnoses CCCA most of the time with dermoscopy, looking for follicular dropout (loss of the follicular ostia) and gray, white, purple, or brown discoloration around follicles, with occasional scale or erythema. She reminds listeners that CCCA is a full-scalp disease — it isn't limited to the vertex and can be missed on the back of the scalp. When findings overlap with LPP or androgenetic alopecia (both can show miniaturization), she biopsies. And multiple diagnoses are common: her average patient has three to four scalp conditions at once.
On melasma, Asempa frames it as both a vascular and a pigment disease, triggered by sun, heat, and strong emotions, not just UV exposure. First-line remains a combined hydroquinone (the Kligman-style triple combination of hydroquinone, a retinoid, and a topical steroid), and newer data support up to six continuous months before a break. For cycling off, she loves oral tranexamic acid, alternating three months of combined hydroquinone with three months of tranexamic acid — though not every patient is a candidate (clot history, or simply unwilling to take a pill).
Asked about the social-media hype around azelaic acid, Asempa says it genuinely helps by preventing pigment transfer to keratinocytes, but it's weak as monotherapy. She keeps it in the routine essentially always, running it alongside the hydroquinone months and continuing it when patients come off hydroquinone or become pregnant. Prevention is central to her counseling: she counsels on realistic sun protection (sunscreen, clothing, hats, shade), oral polypodium leucotomos, and heat avoidance — even a handheld fan at the beach — since heat from sun, hot yoga, ovens, and saunas can all flare pigment. She closes by describing Align Dermatology, her new remote hair-loss practice built around a cheap-enough polarized dermoscopic device and an app that coaches patients to take better photos, launching across a growing number of states, with a plan to refer patients who truly need in-person care, injections, or biopsy.
Choosing Psoriasis Therapy Across Special Populations
Dr. Jashin Wu joins to tackle the crowded psoriasis toolbox. For mild disease (traditionally under 3% BSA), he favors non-steroidal topicals like tapinarof and roflumilast cream — both once daily, with no steroid-atrophy worries and no complicated rotating regimens. For moderate disease he likes oral options, mentioning deucravacitinib (approved in March of this year) as a once-daily pill that doesn't require pre-treatment labs or TB screening. For more severe disease or infrequent dosing, he points to the IL-17 and IL-23 blockers.
Wu then walks through special populations. In pregnancy, certolizumab is his preference because it lacks the Fc portion and shows minimal placental transfer (citing the CRIB study), and it's also a good choice for patients actively trying to conceive — unlike methotrexate. In depression, he'd avoid brodalumab given its boxed warning and REMS, notes the suicidal-ideation warnings on bimekizumab and apremilast, and defaults to other options for medical-legal reasons. For obesity, he's moved away from weight-based infliximab toward IL-23 blockers like risankizumab and guselkumab, which work well regardless of weight. In pediatrics, he notes ustekinumab and other biologics dosed infrequently, plus apremilast (approved for age six and up) for kids who can swallow or take a compounded form. For geriatrics he leans on the IL-23 class as the 'cleanest' for infection and cancer risk.
On perioperative management, Wu says low-risk surgeries generally don't require stopping biologics; for small molecules he'd hold a week or two before and after. For cancer history, he's no longer very worried about recurrence with modern agents but stresses clearing the plan with oncology. He's enthusiastic about GLP-1s in psoriasis — weight loss improves systemic drug efficacy, and the agents may add anti-inflammatory benefit, with AAD data this year suggesting improvement when a GLP-1 is combined with secukinumab. Finally, he calls topical (and oral) steroids among the most dangerous drugs dermatology prescribes, citing studies linking topical steroid use to increased diabetes risk, and argues that payer-driven step-therapy toward steroids isn't in patients' best interest.