"My hair loss just won't stop!"
When treating hair loss, most clinicians start with one or more standard treatments (often called first-line treatments) before moving on to more advanced treatments (called second-line and third-line treatments). Consider the scenario where a given treatment or set of treatments is just not helping. A treatment is given and the patient returns for follow up (or contacts the office prior to the follow up appointment) with concerns that the treatment is simply not working and the hair loss is progressing.
This scenario can occur for any type of hair loss, including both the non-scarring and scarring forms of hair loss. What considerations must the clinician give in such situations where the patient declares their hair loss is not stopping?
N.O.N.S.T.O.P - A helpful memory tool for challenging types of hair loss
In my teaching of doctors about hair loss, I often use a memory tool "NON STOP" to help remember factors that should be taken into account when a patient says “My hair loss is not stopping.” The memory tool is helpful. I encourage physicians to write these down the side of the page and slowly work their way through each possibility.
N - Not correct diagnosis
O - Other treatments needed!
N - Not using the treatment
S - Second diagnosis is present
T - Treatment is problematic
O - Options don’t exist
P - Perception is not correct.
1) Not the Correct Diagnosis.
First, one must ask, is the diagnosis correct? One must remain critical of his or her diagnosis at all times – as there are many mimickers of hair loss.
For example, when seeing a patient with lichen planopilaris, one must ask….is this really lichen planopilaris or is this folliculitis decalvans? The list of possibilities go on and on for varioius types of hair loss. Is the patient I’m seeing misdiagnosed as folliculitis decalvans when it’s really seborrheic dermatitis and androgenetic alopecia? Is this diffuse alopecia areata instead of androgenetic alopecia?
2) Other treatments are needed
For every hair loss condition, there is a list of potentially helpful treatments. Some hair conditions won’t stop with a single treatment alone and require a second treatment to be added. For example, a female patient with genetic hair loss might find her hair loss has progressed despite evidence that the minoxidil they are using is helpful. Such a patient may require spironolactone to be added to the plan.
Sometimes the treatment that was started doesn’t actually help and it needs to be stopped and replaced with the second treatment. If in the same example above the same female patient with genetic hair loss might found her hair loss has progressed with no real change after using minoxidil, such a patient may consider stopping minoxidil altogether and replacing it with spironolactone.
3) Not using the treatment
It might sound obvious, but not all patients use the treatments we recommend. Some are afraid of possible side effects, some might find it difficult to work the treatment into their routine. Some can’t afford the treatment and don’t feel comfortable discussing that with their physician. Whatever the reason (or reasons), compliance or adherence with the prescribed treatment plan might not be full.
A 43 year old male patient using topical minoxidil who finds it difficult to apply and just can’t work it into his routine on account of frequent traveling for work may consider whether finasteride works better for him.
A 76 year old female patient on a fixed income may not want to use topical clobetasol shampoo but appreciates the cost savings of using the lotion formulation.
4) Second diagnosis is present
In addition to asking if the diagnosis is correct (point 1, above), one needs to ask if a second diagnosis is in fact present. It’s not uncommon for a patient to have more than one hair loss condition and all the diagnoses need to be properly address in order for the hair loss to be stopped.
For example, a high proportion of patients with lichen planopilaris have thyroid abnormalities. Has this been checked? Has anyone considered the possibility that the 25 year old female patient with genetic hair loss is still shedding because her iron is very, very low?
All hair loss conditions need to be addressed in order to help the hair loss stop.
5) The treatment is problematic and causing hair loss
It’s not a common scenario but one must ask whether the treatment is actually causing hair loss. Treatments like minoxidil and finasteride frequently cause worsening shedding during the first 2 months of starting. With proper counselling at the time of giving the prescription, most patients will be prepared for this and will know to continue despite the shedding.
But what about hair loss that continues?
Rarely a treatment can cause hair loss. For example, rarely a treatment will flare a scarring alopecia. Hydroxychloroquine (a treatment for LPP/FFA and discoid lupus) can rarely cause hair shedding in some people. A minority of patients using spironolactone for female pattern hair loss will find their hair loss worsens despite treatment.
6) Options don’t actually exist.
Rarely, there are hair loss conditions that are resistant or refractory to all known treatment methods. This is not common but certainly it does exist. There are some forms of scarring alopecia that rarely just don’t respond to treatment, and some forms of androgenetic alopecia and alopecia areata that simply don’t improve even with the most aggressive methods. One needs to always keep this in mind and ask the question – is it possible this patient has a particularly aggressive form of hair loss? This can only be answered after carefully considering all the reasons discussed here.
7) Perception is not correct.
Once a patient experiences hair loss for the first time, he or she becomes acutely aware of his or her hair loss. Generally, I would say that patients truly are the best judges of whether they have lost hair or not – but not always. The ultimate method of evaluation is a photograph, and ideally up close measurements as well. There can often be many surprises whereby a patient’s hair loss is stable or even improving and the perception is that it has worsened. Photographs are extremely important when evaluating hair loss.
Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299