National Scarring Alopecia Awareness Month (Day 21, Myth 6): Does one always start with the "most effective" treatments?

Starting Treatment - A Look at the SAFE Principle

It seems counter intuitive but the “most effective” treatment for scarring alopecia is not always the one that is tried “first.”

Every time a treatment is considered we must reflect on four things :

How safe is it?
How affordable is it?
How feasible is it to do the treatment?
How effective is it?

This is the “S.A.F.E” principle as the the letter of safe, affordable, feasible and effective spells SAFE.
All four factors must be considered when deciding on treatment.

Consider the scarring hair loss condition lichen planopilaris for a moment. The most effective treatment based on all studies is probably cyclosporine. So do we prescribe cyclosporine when a patient first develops a patch of LPP on the scalp? Well, no. Not to start.

If the area of hair loss is small, we start with topical steroids and perhaps steroid injections. A calcineurin inhibitor might be considered too along with reasonably safe oral treatments like doxycycline, or cetirizine. Cyclosporine would not automatically be used even though it might be the best. Cyclosporine is a potent immunosuppressive medication with potential for side effects like kidney issues, high blood pressure, tremors, electrolyte issues, cholesterol issues, increased cancer risk.

Do we use cyclosporine in LPP?
Absolutely we do - just not as a first line agent.

Every treatment we want to use, we need to think about all components of the “SAFE” principle. A treatment that is reasonably effective will often beat out another more effective treatment if that treatment is safer, more affordable and easier to use.

But all decisions must involve the patient. For some people, safety is the only thing that matters. They don’t mind all that much how much it costs of how easy it is to do. All that matters is safety.

For others it’s affordability that matters most. it does not matter that drug B is twice as effective as drug A when it is 30 times more expensive.

Together the patient and specialist must review together all aspects of the SAFE principle and decide what to use for treatment.

In many cases, the “most effective” treatment may not be the “best” one we start with.