At the 2025 ODAC Dermatology Conference, Dr. Amy McMichael, distinguished professor of dermatology at Wake Forest University School of Medicine, shared her expertise on “Management Strategies for Nonscarring Alopecias.” She focused on pattern hair loss and alopecia areata, weaving in evidence and practical pearls.
Pattern Hair Loss
Dr. McMichael discussed important management considerations for pattern hair loss, emphasizing combination treatment and shared decision-making with patients. While there are several FDA-approved options—minoxidil 5% (the preferred percentage) and 2%, finasteride 1 mg daily, and low-level light therapy—in real-world clinical settings, dermatologists can offer patients many more choices.
Oral minoxidil has been effective in 61% to 100% of cases of pattern hair loss; although its efficacy is similar to that of topical formulations, its compliance is higher. Doses range from 0.25 mg to 5 mg once to twice daily; Dr. McMichael starts women at 1.25 mg and men and at 2.5 mg. Adverse effects include hypertrichosis, postural hypotension, temporary telogen effluvium after 4 weeks, dyspnea, and headache. Less commonly used routes of minoxidil include sublingual and mesotherapy.
Oral hormonal treatments, such as spironolactone and 5 alpha-reductase inhibitors finasteride and dutasteride, are also effective. Based on Gupta AK et al’s research, dutasteride 0.5 mg daily had the highest probability of being the most efficacious treatment for men, compared with, in descending order, finasteride 5 mg daily, minoxidil 5 mg daily, finasteride 1 mg daily, minoxidil 5%, and minoxidil 2%. Dutasteride mesotherapy and bicalutamide are other, less recommended, hormonal medications. Bicalutamide 50 mg daily or every other day for 24 weeks resulted in significant improvement in 57% of patients with pattern hair loss. Adverse effects include temporary liver enzyme elevation, transient amenorrhea, endometrial hyperplasia, and migraine.
Procedures, including platelet-rich plasma and surgical hair restoration, are important adjuncts to medical treatment. Hairpieces are another great resource but may interfere with topical treatments.
Alopecia Areata
Dr. McMichael began her discussion of alopecia areata management with an update on epidemiology. Prevalence ratios were significantly higher among Asian, Black, and Hispanic/Latino patients, compared to white patients. With this nuanced burden of disease in mind, Dr. McMichael proceeded to focus on the critical role of oral Janus kinase (JAK) inhibitors in managing severe alopecia areata.
Ritlecitinib 50 mg daily is a JAK3 and TEC kinase inhibitor approved for patients who are at least 12 years old. Deuruxolitinib 8 mg twice daily is a JAK1 and JAK2 inhibitor approved for patients who are at least 18 years old. It has a quick onset and should be avoided in patients who are poor metabolizers of CYP2C9 or are taking moderate or strong CYP2C9 inhibitors. Baricitinib is a reversible JAK1 and JAK2 inhibitor approved for patients who are at least 18 years old. Dr. McMichael prefers to start patients on 4 mg daily, because the BRAVE-AA phase 3 clinical trials found that a significantly higher percentage of patients taking 4 mg daily achieved a SALT score of at most 20 compared to 2 mg daily. Baricitinib has shown durable effects off drug for over 3 months. Upadacitinib is in phase 3 trials.
Dr. McMichael attempts not to overcomplicate her discussion of adverse events of JAK inhibitors with patients, as there have been minimal serious adverse events with real-world use. Potential serious adverse events include serious infection, thromboembolism, major cardiovascular events, and malignancy. Concurrent live vaccines should be avoided. Monitoring testing includes tuberculosis and hepatitis baseline screen, complete blood count with differential, liver function tests, and lipid panel.
Acknowledging insurance-related barriers to care, Dr. McMichael reviewed the Alopecia Areata Scale, highlighting secondary criteria to consider when assessing severity. Those criteria include diffuse or multifocal positive hair pull test, inadequate response after at least 6 months of treatment, noticeable alopecia of eyebrows or eyelashes, and negative impact on psychosocial functioning.
Conclusion
The treatment landscape for nonscarring alopecias is diverse and expanding. A personalized, evidence-based approach to management can significantly and safely improve patient lives.
This information was presented by Dr. Amy McMichael at the 2025 Annual 2025 ODAC Dermatology Conference in Florida. This summary was written by Cynthia Chan, MD, a dermatology resident at Montefiore Medical Center/Albert Einstein College of Medicine. Dr. Chan was one of the five residents selected to participate in the Young Dermatology Leader Mentorship Program sponsored by Sun Pharma and organized by Derm In-Review.
