Early Signs of Scarring Alopecia, Pipeline Outlook, With Bejamin Ungar, MD

Early Clinical Clues of Scarring Alopecia

Itching, stinging, burning, tenderness, or pain alongside hair loss should raise early suspicion for scarring alopecia, according to Benjamin Ungar, MD, director of the Alopecia Center of Excellence at the Kimberly and Eric J. Waldman department of dermatology at Mount Sinai. Ungar addressed early diagnostic clues, pipeline therapies, and practical takeaways during his session, "Hair Update 2026," at Maui Derm NP+PA Summer 2026 in Colorado Springs.¹

“Now, it’s often the case that people may have symptoms for other conditions affecting a scalp, like seborrheic dermatitis, but that should at least prompt careful evaluation for the potential for scarring alopecia,” Ungar told HCPLive.

Trichoscopy can help identify early or mild disease before a biopsy is pursued, he said. Signs such as erythema and perifollicular scaling on trichoscopy are not diagnostic on their own but can warrant closer workup, including biopsy in many cases.

Alopecia Pipeline: What to Watch

Evidence-based treatments for scarring alopecia remain limited, and Ungar said there is still substantial work needed to establish reliable options. He pointed to early and small clinical studies suggesting that topical and oral JAK inhibitors may help patients with scarring alopecia, a population that currently has no FDA-approved therapies.² Ungar called this the area of hair loss research he is most excited to watch, given the unmet need.

Promising JAK inhibitors for scarring alopecia include oral options like tofacitinib, baricitinib, and upadacitinib, which are especially useful for lichen planopilaris and frontal fibrosing alopecia.³ Topical options like tofacitinib and ruxolitinib can be safer choices for localized conditions. The dual TYK2/JAK1 inhibitor brepocitinib is also promising for lichen planopilaris, frontal fibrosing alopecia, and central centrifugal cicatricial alopecia.

2 Takeaways: Oral Minoxidil for Alopecia and Managing Patient Expectations on JAK Inhibitor Regrowth

Asked for a single practical change clinicians could bring back to the clinic, Ungar said the complexity of hair loss makes it difficult to choose just 1, so he offered 2 instead. The first is broader use of low-dose oral minoxidil, which he uses as both monotherapy and as an adjunctive treatment, particularly in inflammatory alopecia.

The second is setting patient expectations around treatment timelines. Ungar said hair regrowth can take a long time even with well-established, evidence-based treatments such as JAK inhibitors for alopecia areata.

“Making sure that patients understand that it takes time can be extremely beneficial in achieving good outcomes,” Ungar said. “If patients’ expectations are not set on the timeframe, then they may stop therapy early. They may be very concerned that it's not working. The last thing we want to do is have a patient stop before it starts working, when really all it would take is giving it a little more time. So be patient with treatments and give it time to really assess if it's effective.”

Read the first part of our interview with Ungar on the emergence of JAK inhibitors for alopecia areata and scarring alopecia here: JAK Inhibitors, Oral Minoxidil Reshape Hair Loss Care

References

1. Ungar B. Hair Update 2026. Presented at: Maui Derm NP+PA Summer 2026; 2026.

2. Green L, Guttman E, Lebwohl, et al. Exploring novel management options for alopecia areata. AJMC. Published on March 3, 2026. Accessed July 10, 2026. https://www.ajmc.com/view/exploring-novel-management-options-for-alopecia-areata

3. Martin A, Sharma D, Su M, Kreytak C, Senna MM. A review of Janus kinase inhibitor use in scarring alopecia. JAAD Reviews. 2025;3:190-195. doi:10.1016/j.jdrv.2025.01.007