What to do when the first-line therapies fail? Try again!

If at first you don’t succeed, try try again.

There is a very well know phrase that if at first you don’t succeed, try try again. It’s a reminder that in tough situations, we should not give up too easily.

It’s debated in history where the actual quote came from. Some say that it’s attributed to the the American educator Thomas H Palmer in his essay that was published in The Teacher’s Manual (1840). 

'Tis a lesson you should heed,
Try, try again.
If at first you don't succeed,
Try, try again. 

Others say that it was a gentleman by the name of Edward Hickson who popularized the proverb in his book The Singing Master in 1836 - four years earlier than Thomas Palmer." Some attribute a version of the quote to Robert the Bruce, king of Scotland. Apparently he may have told his troops in 1314 that “ If at first you don't succeed try, try and try again." shortly before a blood battle with the English.

Regardless of who gets the credit, I like the quote and its message. It’s a very simple lesson but an important one - sometimes we should not give up too easily.

Thomas Palmer and Edward Hickson would certainly do well as hair specialists. Managing hair loss is often about failing and trying again and failing yet again and trying yet again until something finally goes right. It’s not always about striking success on the first try. In fact, the vast majority of patients I see have not had success the first time around. They have not had success with “first-line therapies” and so we try again - this time with so called “second-line therapies.”

These are the patients with androgenetic alopecia who did not improve with topical minoxidil or had side effects with oral anti-androgens. We can give up or try again with oral minoxidil, topical anti-androgens or a low level laser.

These are the patients with alopecia areata who did not improve with topical steroids or steroid injections. We can give up or try again with diphencyprone, tofacitinib or oral minoxidil.

These are the patients with lichen planopilaris who did not improve with steroid injections and topical steroids or hydroxychloroquine. We can give up or try again with low dose naltrexone, mycophenolate mofetil or doxycycline or isotretinoin.

Failure is very much a part of being a hair loss specialist. If at first one does not succeed, we have the option to regroup, think about new strategies... and try again.