Common Mistakes in Managing Hair Loss and Pigmentary Disorders

Oyetewa Asemba, MD, is a dermatologist currently practicing in Houston, Texas, who will soon relocate to Dallas. Speaking with Dermatology Times at the Elevate conference, she outlined recurring mistakes in the evaluation and treatment of hair loss and pigmentary disorders. Asemba pointed to thorough scalp examination, shampoo counseling tailored to hair type, treatment vehicle selection based on styling practices, and concurrent management of hyperpigmentation as areas where clinicians can improve patient care.

The Case for a Full Scalp Exam

Asemba identified failure to examine the scalp as one of the most common mistakes clinicians make during hair loss visits. She said patients frequently report feeling dismissed or judged by a previous provider when their scalp was not assessed directly. In some cases, clinicians may hesitate to touch or manipulate the hair because they are concerned about disrupting a patient's hairstyle.

If a patient has come to you for hair loss, they are expecting you to get in there, Asemba said.

Patients who arrive with extensions or hairstyles that prevent adequate visualization of the scalp can be asked to return with their hair loose, she explained. Rather than causing offense, communicating why complete access to the scalp is necessary can help establish rapport.

"I need to look at your entire scalp, so I would love for you to come back when I can really access the entire scalp," Asemba said.

Matching Shampoo Frequency to Hair Type

Another common mistake is prescribing a shampoo regimen without accounting for hair texture and the patient's typical washing frequency, Asemba said. Patients with curly hair may not need to wash their hair every day, and frequent washing can remove needed moisture and contribute to breakage.

"Curly hair patients should not wash every day because it will cause breakage for their hair," Asemba said.

In comparison, Asemba explained that patients with straighter or wavier hair may require more frequent washing because sebum more easily coats the hair and can attract dirt and dust. With curly hair, sebum has more difficulty traveling down the hair shaft, making added conditioners and oils important sources of moisture.

Explaining why washing recommendations differ by hair type can help patients understand the rationale behind a prescribed regimen and determine whether it realistically fits into their existing hair care routine.

Choosing Vehicles Based on Hair Styling Habits

Treatment selection should also account for how patients typically style their hair. Asemba pointed to roflumilast 0.3% foam as an example. She described the water-based foam as one of her preferred treatments for seborrheic dermatitis and inflammatory disorders and estimated that it is effective for approximately 85% of patients in her own clinical experience.

However, the vehicle may not be appropriate for every patient's styling routine. For a patient with curly hair who has thermally straightened their hair with a blowout or silk press, applying a water-based treatment can cause the hair to revert toward its natural texture.

"If someone paid $400 for their special blowout, they might be very upset with you for giving them a water-based treatment," Asemba said.

Asking patients how they typically wear and style their hair before prescribing a topical therapy can therefore help clinicians select a vehicle that is more compatible with their routine and more practical for continued use.

Treating Hyperpigmentation Alongside Inflammation

Asemba also highlighted hyperpigmentation as an important quality-of-life concern. For some patients, she said, the pigmentation left behind by an inflammatory skin condition can be more distressing than the underlying disease itself.

"It's devastating for a lot of people, and it's actually more devastating than the diseases that cause it," Asemba said.

Asemba recommended addressing post-inflammatory hyperpigmentation (PIH) alongside the underlying inflammatory condition rather than waiting for the inflammation to resolve before discussing pigmentation. Acne is one example in which she incorporates pigment management into the treatment plan from the beginning.

"If you have acne, I know it's going to cause hyperpigmentation. So we should already be doing some things for your pigment now as we're treating the acne," Asemba said.

According to Asemba, this approach can help build rapport with patients while also helping prevent some PIH. She noted that complete return to baseline pigmentation is not always achievable, making discussions about quality of life and patient expectations an important part of management.

Individualizing Hair and Pigmentary Disorder Care

Primary pigmentary disorders that are not post-inflammatory can present additional treatment challenges, Asemba said. Unlike PIH, in which clinicians can address the inflammatory trigger while managing pigmentation, these disorders may occur independently and present as dark spots, making treatment more difficult.

Across hair loss and pigmentary disorder care, Asemba emphasized that treatment decisions should account for more than the diagnosis alone. Examining the scalp, understanding hair texture and styling practices, and addressing patients' concerns about pigmentation can help clinicians develop treatment plans that better align with patients' individual needs and routines.

References

1. Asempa OB. Baylor College of Medicine. Accessed August 12, 2026. https://mychart.bcm.edu/MyChartPRD/app/providers/OyetewaAsempaMD/WP-246CQtC1pzfv-2FhJYtbhgWuuA-3D-3D-24af7N22GfX8LSlEslqYupEZ0KtkRdfZp8NhmA33Exzy4-3D
2. 6 curly hair care tips from dermatologists. American Academy of Dermatology Association. Accessed August 12, 2026. https://www.aad.org/public/everyday-care/hair-scalp-care/hair/curly-hair-care
3. ZORYVE (roflumilast) topical foam, 0.3% prescribing information. US Food and Drug Administration. Revised 2025. Accessed August 12, 2026. https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/215985s015sdn642lbl.pdf
4. Tips for healthy hair. American Academy of Dermatology Association. Accessed August 12, 2026. https://www.aad.org/public/everyday-care/hair-scalp-care/hair/healthy-hair-tips