Jerry Shapiro, MD’s Step-by-Step Guide to Diagnosing and Managing Hair Loss

At this year’s Maui Derm NP+PA Fall Conference, Jerry Shapiro, MD, of New York University Langone Medical Center, shared expert insights and cases from his renowned hair disorders practice, focusing on the diagnosis and management of scarring alopecia.¹ At his practice, Shapiro sees about 10 to 11 patients a day and specializes only in conditions of the scalp and hair.

“We do spend 1 hour with the patient, and the patient ends the consult. Never end the consult. I always ask the patient their initiative [and] when they want to end,” he told attendees.

In his lecture, Shapiro emphasized a structured, algorithmic approach to evaluating alopecia, with particular attention to distinguishing scarring from non-scarring forms. As he noted, scarring alopecias are characterized by permanent follicular destruction, necessitating early and aggressive intervention.

Shapiro detailed his initial evaluation process, which includes a thorough patient history, clinical scalp examination, hair pull and card tests, and trichoscopy. He stressed the importance of dermoscopy (≥10x magnification) in identifying key diagnostic features such as loss of follicular ostia, perifollicular scaling, erythema, and pigmentary changes. He classified scarring alopecias based on inflammatory infiltrates: lymphocytic (e.g., lichen planopilaris or LPP, frontal fibrosing alopecia or FFA, lupus erythematosus), neutrophilic (e.g., folliculitis decalvans), and mixed types. For active LPP, he uses an inflammation-guided treatment algorithm. Rapidly progressive cases are treated with short courses of oral prednisone (40 mg daily, tapered over 8 weeks). For localized disease defined as <10% scalp involvement, he uses intralesional triamcinolone acetonide (10 mg/mL, 2 mL total/month) and a compounded topical mixture of clobetasol, fluocinonide, and minoxidil.

Additionally, Shapiro highlighted the shift toward lower-dose doxycycline (20 mg BID) for its anti-inflammatory benefit, citing evidence of comparable efficacy to high-dose regimens. He also discussed adjunctive therapies, including low-dose naltrexone, pioglitazone (15 to 30 mg/day), and excimer laser therapy. Topical and oral JAK inhibitors are emerging as promising options, though access remains challenging. Methotrexate and cyclosporine are reserved for refractory cases. Throughout the session, Shapiro emphasized early diagnosis, personalized regimens, and comprehensive patient education to improve outcomes in cicatricial alopecia.

Regarding the treatment of female patients with androgenetic hair loss, Shapiro highlighted the utility of combining low-dose oral minoxidil (LDOM) with anti-androgens such as spironolactone, citing prior work by Rodney Sinclair, MBBS, MD, FACD.² While some combinations showed promise, no statistically significant superiority was observed between 5-alpha reductase inhibitors and androgen receptor blockers in available studies.

Platelet-rich plasma (PRP) therapy remains widely used and Shapiro detailed his own randomized, double-blind, placebo-controlled study, which showed a significant increase in hair counts on the PRP-treated side. However, placebo-treated sides also improved, possibly due to PRP diffusion or microcirculation. Based on these findings, he recommends an initial series of three monthly PRP treatments, followed by maintenance sessions every 6 to 9 months, provided the response exceeds 10 hairs/cm².

Dutasteride mesotherapy, though popular in Europe, was found ineffective in Shapiro's practice, potentially due to formulation issues. Regarding exosomes, another new therapy, he cautioned that despite promising early data (particularly from Korea), their use remains restricted in the US due to safety concerns. He also discussed a novel FDA-cleared 1565 nm non-ablative laser for hair loss, citing early success and a 90% positive response rate.

Finally, Shapiro also shared his stepwise treatment algorithm for female pattern hair loss based on severity. This includes topical and oral minoxidil, finasteride, dutasteride, spironolactone, and PRP. Hair transplantation is reserved for cases with >50% scalp involvement and adequate donor supply. In cases of >91% involvement, prostheses are advised. He also touched on telogen effluvium diagnosis, emphasizing the importance of trigger identification, lab evaluation, and visual tools to guide patient counseling.

Overall, Shapiro’s lecture provided an evidence-based yet practical roadmap for treating diverse hair loss disorders using a combination of established and investigational therapies.

Stay tuned to Dermatology Times all week for exclusive conference coverage and expert insights from Maui Derm NP+PA Fall.

References

1. Shapiro J. Hair Update 2025. Presented at: Maui Derm NP+PA Fall 2025; September 20-23, 2025; Nashville, Tennessee.

2. Sinclair RD. Female pattern hair loss: a pilot study investigating combination therapy with low-dose oral minoxidil and spironolactone. Int J Dermatol. 2018;57(1):104-109. doi:10.1111/ijd.13838