Spotlighting Complex Cases of Atopic Dermatitis and Hair Loss, with Tiffany Mayo, MD

In a talk given at the 2025 Revolutionizing Atopic Dermatitis (RAD) Conference in Nashville, TN, Tiffany Mayo, MD, discussed the association between atopic dermatitis and alopecia, emphasizing the need to address hair loss in patients with atopic dermatitis and address patients' concerns in a more well-rounded manner.

Mayo, known for her work as an assistant professor of dermatology for the University of Alabama at Birmingham, highlighted studies showing a minor association between atopic dermatitis and alopecia. During the presentation, it was noted that scalp assessments are often neglected.

“I really want to talk about the full spectrum of hair loss in our patients with atopic dermatitis,” Mayo expressed. “So we're going to review atopic dermatitis comorbidities, including alopecia areata, as well as other hair loss that may be seen. We want to analyze the effects of atopic dermatitis on hair health completely, investigate the association between alopecia areata and atopic dermatitis, and then discuss how that itch-scratch cycle may affect our patients in some of the presentations that we have with alopecia.”

Mayo touched on some of the biggest concerns she believes healthcare providers should have over hair loss and its relationship to atopic dermatitis, highlighting the neglect of this subject that can be seen in many clinicians’ offices.

“When we think about the spectrum of comorbidities, often we don't think about alopecia in our patients with atopic dermatitis,” Mayo said. “But our patients are living with alopecia, and it is quite impactful to them…Many studies have shown, looking at atopic dermatitis, that alopecia is a minor association, so it is seen in some publications. But when we look at those bigger studies on atopic dermatitis, scalp assessments are usually not reported on. They're more so looking at the body, looking at flexural sites. So we don't know a lot about the association between the scalp and how that may impact the hair.”

Patients do not always bring up the topic of hair to clinicians. This is the reason, she noted, that it is up to physicians to bring the subject up or risk neglecting the topic.

“We know that barrier dysfunction is really a pivotal issue in patients with atopic dermatitis,” Mayo said. “That also means that barrier dysfunction, including the scalp, may lead to sensitization from products such as shampoos, conditioners, and various styling products. I don't know if you all have opened certain products and then immediately smell this beautiful, fragrant smell. There aren't many products that you can buy over the counter that don't have these smells. We know that there are irritants in these products that may be affecting our patients with atopic dermatitis.”

A case study illustrated how a patient's scalp itch and hair thinning were exacerbated by a new hair dye, leading to a diagnosis of alopecia areata.

“This is one of my patients who comes in with an itchy scalp, a 56-year-old female history of atopic dermatitis, coming in for scalp pruritis and hair thinning,” Mayo explained. “No new medications, no significant past medical history other than the atopic dermatitis that had been pretty well-controlled using topicals…I'm about to nail this early [central centrifugal cicatricial alopecia], right? I give the patient a potent topical steroid, intralesional. I've found that biopsy when I'm concerned about early CCCA, sometimes isn't that revealing, and so I'll often see the patient back in 4 to 6 months when I start them on the regimen.”

In this case study, Mayo highlighted that she saw this same patient back in 4 months, noting significantly more trichorrhexis than before.

“Then I had to kind of sit down and think and ask her more questions,” Mayo said. “She is telling me, ‘This is driving me crazy, all of my eczema is flaring! My scalp is itchy and I can't sleep at night.’ So I did a biopsy, and I did not see the CCCA that I thought I was going to see. I saw a little bit of mild androgenetic alopecia and spongiotic dermatitis. Then, more questions for the patient revealed that the patient had the onset of this intense pruritus after she got her beautiful new hair dye, which I didn't know was new at the time.”

The patient had not been aware of this hair dye’s relevance at the time of the original discussion.

“That gets us to this question, whether this scalp atopic dermatitis…or is this allergic contact dermatitis?” Mayo said. “My issue when I saw this patient is that I fell into the trap of too narrow a differential diagnosis. I think that happens to the best of us, when we see so much alopecia that we don’t want to miss it. I was probably on the other end of the spectrum, but I missed the thing that was right in my face. I do think a lot of times, especially in skin of color patients, we miss the atopic dermatitis because it looks like PIH, so we just have to make sure that we're expanding our differential, truly listening to our patients, and really thinking about what may be going on.”

Mayo stressed the importance of expanding differential diagnoses, using appropriate therapies, and considering systemic treatments for patients with significant scalp disease. She also discussed the overlap of atopic dermatitis with autoimmune diseases and the potential benefits of antihistamines in managing alopecia areata.

For additional information on this topic and related information, check out the latest conference coverage at RAD 2025.

The quotes contained in this description of Mayo’s session were edited for clarity.