Dr. Aguh highlights her lecture How I Treat the Tough Stuff: Alopecia Tips & Tricks in this engaging interview 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 walks through several high-yield clinical pearls for treating alopecia in patients with textured hair. She describes the Downy Hair Sign — a finding unique to curly-haired patients in which autoimmune disease softens tightly curled hair into "baby-like" texture — and calls it "high yield" for alopecia areata and a marker of active disease. With lupus, she notes, it signals severe systemic involvement (ANA greater than 1:640 and association with lupus nephritis), and she has diagnosed patients with lupus "just by looking at their hair."

She also stresses that hair quality, not just the scalp, matters: fragile curly hair can break all the way to the scalp and be misdiagnosed as scarring alopecia when patients "just need to take care of their hair." Much of the discussion centers on insulin resistance in CCCA — present in 75% of her clinic's patients — and why dermatology providers should order a fasting insulin and HOMA-IR rather than relying on A1C alone. She closes on metformin (topical or oral, sometimes compounded with clobetasol) and on rethinking "protective styles" as convenient rather than truly protective.

  • The Downy Hair Sign — soft, baby-like texture in curly hair — is a high-yield marker of active alopecia areata; inject those areas while the curl pattern still looks altered, and expect the curl to fully return in remission.
  • In lupus, the Downy Hair Sign signals severe systemic disease (ANA >1:640, associated with lupus nephritis); it can also point to widespread immune deficiency in HIV/AIDS.
  • Don't rely on A1C alone to rule out insulin resistance — check fasting insulin and calculate HOMA-IR, because high insulin often drives skin disease (CCCA, psoriasis, HS, acanthosis nigricans, skin tags, hirsutism) long before A1C rises.
  • Screening for insulin resistance is dermatology's job too: 75% of her CCCA patients showed insulin resistance, and a HOMA-IR greater than 2 can qualify patients for a GLP-1 agonist.
  • Metformin helps in CCCA topically or orally; she compounds topical metformin with clobetasol as a go-to and uses low-dose oral metformin when there's systemic metabolic evidence.
  • Match the style to the patient: box braids are fine for moisturizing but not for traction alopecia, and dry hair should avoid crochet braids — use styles in break periods (four weeks on, eight weeks off), not as a crutch.