Dr. Crystal Aguh discusses her key points from her lecture Advances in Alopecia at the 6th Annual Elevate-Derm Alliance Conference at the JW Marriott Water Street in Tampa, Florida.

In this video

In conversation with PA Buchi Nita, Dr. Aguh explains why minoxidil — though it "doesn't seem cool or exciting" — remains "so effective," and how compounding can improve on over-the-counter versions. Because minoxidil needs the enzyme sulfotransferase to work, adding retinoic acid activates the drug (and likely boosts penetration) so that non-responders respond; she compounds it in a topical steroid base and tailors it to hair texture to cut irritation and improve compliance. On oral minoxidil, she shares her adult dosing (starting women at 1.25 mg, men at 2.5 mg and titrating up), counsels women on hypertrichosis with the reminder that "it is much easier to remove hair than it is to grow hair," and walks through managing lightheadedness, dizziness and palpitations by dropping to the highest tolerated dose or discontinuing.

She gives finasteride a "thumbs down" — preferring minoxidil in men to avoid hormonal side effects, and finding the data lacking as a primary treatment in women — while flagging post-finasteride syndrome and systemic absorption risk even from topical contact. For alopecia areata, she frames the JAK inhibitor conversation around quality of life and black box warnings, and notes patients who developed their current episode fewer than 10 years ago are more likely to respond, so "the sooner the better." She calls topical JAK inhibitors first line for frontal fibrosing alopecia — now more common than CCCA and appearing across all backgrounds — favoring compounded tofacitinib 2% cream since high-potency steroids cause hairline atrophy. Finally, she untangles a common diagnostic pitfall: dissecting cellulitis is "hidradenitis of the scalp," while folliculitis decalvans behaves more like lichen planopilaris with tufted follicles.

  • Adding retinoic acid to minoxidil activates the drug via sulfotransferase (and aids penetration) so prior non-responders can respond; compound it in a steroid base and tailor to hair type to reduce irritation and boost compliance.
  • Start oral minoxidil at 1.25 mg/day in women and 2.5 mg/day in men, titrate after a month, and remember higher doses only help up to a point once receptors saturate; manage side effects by lowering to the highest tolerated dose or stopping.
  • Finasteride gets a "thumbs down" — minoxidil is preferred in men to avoid hormonal issues, the data don't support it as primary therapy in women, and watch for post-finasteride syndrome plus systemic absorption from topical contact.
  • For alopecia areata, JAK inhibitor response is best when the current episode began fewer than 10 years ago — regrow hair within that window to "restart the clock."
  • Topical JAK inhibitors (compounded tofacitinib 2% cream, ~$40) are first line for FFA since high-potency steroids atrophy the hairline; and never conflate dissecting cellulitis (hidradenitis of the scalp) with folliculitis decalvans (lichen planopilaris–like, tufted follicles) — they are treated differently.