4000 Patient Questions: Lessons Learned

What I Learn Answering Patient Questions 

I enjoy answering patent questions on a variety of forums  - including our many social media platforms (Instagram, Facebook), Realself.com, Drugs.com, as well as  our website. Today, marks the 4,000 th question I've answered about hair loss on Realself.com.

Such an event prompts me to pause and reflect back on many questions I've answered across various sites.  How would I summarize common concerns from patients? What errors do people make in their assumptions about their hair?

Below I'll summarize the Top 10 Lessons I've Learned from Answering Questions

TOP 10 LESSONS

1. Many people underestimate the importance of an "up-close" examination and review of their story

One of the common errors I see as a participant in various online platforms is that many people underestimate what it takes to actually diagnose hair loss. One needs a full story, a full examination and often a full review of blood tests.  A sentence or two from a patient is never enough. A photo is sometimes helpful but one can never confidently diagnose hair loss with 100% confidence with a photo.  There are far too many hair loss conditions that mimic each other to rely solely on a photo.

2.  Many people assume blood tests hold the answer.

Blood tests are important in diagnosing hair loss, but they are only a part of the full evaluation. Many people with hair loss are disappointed that their blood tests returned 'normal' and wonder how this can be. The reality is that many patients with hair loss have normal blood tests and even when they are abnormal it does not necessarily mean the lab test is relevant to the patient's hair loss! Is a ferritin level of 31 relevant to hair loss in a female patient? Probably not even through it is true that we like the value to be above 50.  Is a low vitamin D level relevant? Probably not even through it is true that we like the value above a certain level.  Many times, blood tests can be slightly abnormal and have little or no relevance for the hair. Many patients focus excessively on these numbers while the real diagnosis goes undiscovered.

3.  Androgenetic alopecia is generally undiagnosed. 

In all the forums I participate in and questions I answer, there is an underrecognition of the presence of androgenetic alopecia both in men and women. Most young men between 20 and 30 who have concerns about shedding have androgenetic alopecia. Not all of course, but a much higher proportion than recognized. There is a similar failure to recognize the presence of androgenetic alopecia in women. 

4.  PRP treatments are overused

It would appear that platelet rich plasma (PRP) has become the panacea for all hair loss. This is unfortunate. While PRP can help certain conditions (and we used it in our clinic too) to some degree its overall value in my opinion is overstated.   PRP is a highly non-specific treatment.  What is needed in so many of the questions I read is a highly specific approach. 

5. Scalp biopsies are not preformed nearly enough

There is most certainly an under usage of the scalp biopsy. Countless numbers of dilemmas, confusions and conundrums that I come across can be solved through use of a scalp biopsy. 

6. Hair transplants are too often performed in young male patients. 

Among the most concerning situations I see frequently is the use and recommendation of hair transplantation to young patients. This is a particularly worrisome trend in those 18-22 but generally speaking in all males under 25. Hair transplantation is rarely if ever a good idea in a young male. 

7. There is a failure to recognize that 2 diagnoses may be present.

There is often a tendency among questions and posts from readers to want to decide between diagnosis 1 and diagnosis 2 without realizing that both diagnoses may be present. Many women have both androgenetic alopecia and telogen effluvium for example. 

8.  There is an over reliance on hair supplements

There is an increasing popularity with hair supplements without search for the underlying cause. What is needed for anyone with hair loss is a diagnosis. Discussions about treatment come second.  

9.  Family history is given too much attention

Family history is given too much attention by many patients. The genetic balding patterns of the family are clearly important but they should not be used as the main criteria to rule out a diagnosis. There are countless numbers of patients who claim that they can not have patterned hair loss because no such history exists in the family.  This reasoning rarely ever holds true. 

10.  Most patients lack appropriate follow up

Many types of hair loss, especially androgeneetic alopecia, are life long concerns. Far too many patients have seen a physician once or twice and been sent on their way to deal with their issues on their own. Most types of hair loss require a follow up evaluation to carefully evaluate effectiveness, and side effects. 

Conclusion

I've enjoyed answering thousands of questions from patients.  I'm moving on to question 4001 shortly on the website Realself.com and found this an appropriate time to reflect on commonalities from individuals across the world.  Generally speaking, it would appear that greater emphasis is needed on the thorough evaluation and follow up of hair loss. Biopsies are underused in the world of hair loss. In my opinion, hair supplements, PRP and hair transplantation are all to often inappropriately recommended.