My practitioner does not want to start me on a treatment that I want to start!

A Closer Look at the 6 Reasons Why Practitioners Won’t Start The Treatment You Were Hoping.

There are many reasons why an individual with hair loss might walk into the appointment hoping to start a specific treatment and walk out of the appointment with recommendations to start a completely different treatment. Let’s take a look at these reasons.

REASON 1. The practitioner knows that the treatment does not help this clinical condition and therefore can not recommend  it.

Sometimes a patient wants to start a treatment that simply won’t help at all. A patient might want to start ginger supplements for treatment of advanced autoimmune hair loss. The practitioner knows this is not going to help and does not recommend it.

Another example is a patient with androgenetic alopecia who want to start a JAK inhibitor like Tofacitinib. Somewhere the patient has heard that exciting things are in the “pipeline” for the use of JAK inhibitors in treating androgenetic hair loss. When I see a patient with this request, I advise the patient that tofacitinib does not help AGA in any meaningful way and I can not prescribed it to them. I advise them that they are correct that other JAK inhibitors in the future could be different.

REASON 2. The practitioner does not know if the treatment helps this condition and therefore can not recommend it. The lack of knowledge may or may not be shared with the patient.

Sometimes a practitioner is not familiar with a treatment. It would be against good practice ethics for any practitioner to prescribe a treatment if he or she has no knowledge about it. 

Consider a patient who has just attended an online webinar about the latest advances in treatment of a certain type of hair loss. If the patient ends up in the office of a practitioner who is not familiar with this treatment or not up to date on the latest information, the practitioner may not feel comfortable to recommend the treatment. Sometimes, the practitioner may let the patient know they have no knowledge of the new treatment. Some do -but some don’t. However, in many cases the practitioner will simply advise the patient “that treatment is not something I recommend.”

REASON 3. The practitioner knows the treatment helps many people with this condition but the practitioner believes it’s potentially harmful for this particular individual. (Risks outweigh any benefits).

Sometimes a patient really wants a treatment but is unaware of just how bad of an idea it would be to start the treatment. Consider a 19 year old male with severe depression who hasn’t left his home in 7 months due to depression stemming from his hair loss. The male tells you that all he needs is finasteride pills to treat his hair loss. He tells you that this will solve his depression and hair loss. sometimes even his parents tell you that all you need to do to turn things around is prescribe finasteride.

This is a bad idea. Prescribing 1 mg oral finasteride daily would not usually be advised in a situation like this as the medication could potentially even worsen depression. Suicidal ideation is an evolving concern of finasteride and this need to be taken seriously.

Lots of other examples exist as well.

REASON 4. The  practitioner knows  the treatment helps this condition but the practitioner believes that another option is better for this particular individual.

Sometimes a patient wants to start a treatment but the practitioner knows another treatment is simply a better option.

Consider a 33 year old healthy woman with 3 coin shaped patches of alopecia areata. She wants to start prednisone pills because she heard it can regrow her hair rapidly. Her sister has alopecia areata and prednisone helped her a great deal.

In this case the practitioner recommends against prednisone and recommends steroid injections along with use of topical minoxidil daily to the 3 patches. The practitioner believes this option for steroid injections is safer for the patient and equally likely (if not more likely) to help and avoids the harmful effects of systemic steroids like prednisone.

REASON 5. The practitioner knows (or does not know) the treatment helps this condition but encourages the patient to select a different option - one that will benefit the practitioner more than the patient.  This can be quickly recognized by the use of a “scare tactic” by the practitioner. 

Sometimes a practitioner advises against a certain treatment that a patient really wants because the practitioner puts his or her interest above the interest of the patient.

Consider a 26 year old female patient with early onset androgenetic alopecia who has been reading alot about topical minoxidil. The patient would like to get more information about this treatment and so visits the office of a hair specialist. The hair specialist advises against it saying “You don’t want to use that chemical - it has so many side effects! we routinely recommend these shampoos and supplements and monthly PRP as it helps everyone! And it’s drug free and chemical free! ”

It would be financially better for the practitioner if the patient signed up for platelet rich plasma treatments and took home the supplements rather than have the patient leave the office and use topical minoxidil. The practitioner therefore scares the patient into believing their chosen treatment is harmful.

Consider a 21 year old patient with patchy alopecia areata who has been reading a lot about steroid injections and how well they work. The patient is a little nervous about using steroids but sees that many patients have really benefited. The patient would like to get more information about this treatment and so visits the office of a hair specialist. The hair specialist advises against it saying “You don’t want to use steroids- it has so many side effects!”

It would be financially better for the practitioner if the patient signed up for the hot oil and light treatments the office provides rather than have the patient leave the office and see another specialist for steroid injections. The practitioner therefore scares the patient into believing their chosen treatment is harmful. In some cases the practitioner has absolutely no knowledge about steroid injections and in some cases they do. It does not matter either way - the focus is on signing up the patient for hot oil treatments.

Other examples exist too and sometimes treatment the patient is directed to is not related to any direct financial benefit of using another treatment.

Consider a 42 year old female patient with new onset lichen planopilaris who has been reading about use of steroid injections. She would like to try them and so gets a referral to local dermatologist. Little does the patient know, but the dermatologist does not like to do steroid injections. The dermatologist feels the injections take too long and it’s just not a treatment they want to have in their office. it’s a disruptive thing to have in the practice. The dermatologist replies to the patient’s request for steroid injections with “That’s not a treatment that I have found to be effective in my experience and so I don’t offer that, sorry.” The patient leaves with a prescription for topical clobetasol and doxycycline and it’s not until 3 years later that she realizes that steroid injections really helped her.

Finally, consider the 35 year old patient with hair loss due to folliculitis decalvans who has been reading about use of oral isotretinoin for treatment. The patient would like to try this treatment and so gets a referral to local dermatologist. The dermatologist has a clinical trial in place for folliculitis decalvans and really wants to recruit more patients as the dermatologist does not have enough trial patients yet. The dermatologist advises the patient about options for isotretinoin but steers the discussion in favor of the clinical trial drug. The dermatologist tries to be as balanced as possible about his conflict of interest but really wants the patient to sign up for the trial. “You can try isotretinoin if you want but I think this new drug is going to be a blockbuster. Side effects of the trial drug seem to be way way less than isotretinoin.’ The patient is confused and does not want to disappoint the practitioner and so signs up for the trial.

REASON 6: A mix of the above.

Sometimes a mix of the above reasons is possible.

Conclusion and Summary

There is a wide range of actual reasons why a patient can walk into an appointment with hopes to start a certain treatment and leave the appointment without receiving that treatment. Sometimes, starting that treatment is just a bad idea. Sometimes it’s a good idea - but other reasons direct the practitioner elsewhere with his or her recommendations. It can be difficult sometimes for a patient to spot the reasons. However, the more well read and informed the patient is the more apparent the reason actually becomes.