The Treatment Plan with too Much "SAHLT" - Common, Confounding and Confusing

When treatment plans are too “SAHLTy”?

A common problem I see with many treatment plans nowadays is that too many treatments are started at the same time and the end result is that nobody knows what helped and what did not. The patient leaves the office will plan to start this pill or that, this laser, this treatment and this supplement.

When I teach doctors about hair loss, I tell them to be careful of prescribing a treatment plan with too much SAHLT. SAHLT is my mnemonic or teaching tool to remember the words

SIMULTANEOUS ADMINISTRATION OF HAIR LOSS TREATMENTS (SAHLT)

THE SAHLTy PLAN: What is it?

Unless you’ve stepped foot in my office, you may have never heard of the SAHLTy plan, so let me give you some examples.

Example 1. A 42 year old female patient with androgenetic alopecia is seen in clinic and prescribed minoxidil, spironolactone and PRP sessions every 3 months. (3 simultaneous treatments)

Example 2: A 25 year old male with male balding is seen in the office and prescribed finasteride 1 mg, oral minoxidil 0.5 mg and low level laser therapy three times weekly. (3 simultaneous treatments)

Example 3: A 52 year old female with lichen planopilaris is seen in clinic with massive itching, burning and tenderness and started on prednisone, hydroxychloroquine and doxycycline along with clobetasol lotion daily. A laser device is added too. (5 simultaneous treatments)

What’s common with all three of these plans? There are pretty high in SAHLT. They all involve the SIMULTANEOUS administration of hair loss treatments. They involve multiple treatment plans which leaves the patient and the physician having no good sense of what is ultimately helping and what is not.

Are SAHLTy Plans Ever Helpful?

Sometimes, a SAHLTy treatment plan is necessary such as in a rapidly progressive disease state. However, the patient and the physician need to be aware (….and tell each other!) that they are really not going to have a clue what helped and what did not.

You might be surprised to hear that sometimes a SAHLTy plan is wonderful too. Sometimes when I see a patient in clinic, I’m happy they used a SAHLTy plan. For example, consider a 38 year old female with androgenetic alopecia who started topical minoxidil 5 % foam, laser, PRP and a hair and nail supplement one year ago and comes in to see me with ongoing hair loss. She tells me she used these treatments religiously but feels these treatments did absolutely nothing to stop the loss. In this case, her SAHLTy treatment plan helps me out alot becasue I know immediately that minoxidil, laser, PRP and hair and nail supplements don’t help her. I now don’t need to spend time evaluating their effects - they are all unhelpful for her and we can now move on to other treatments. In her case, we started oral spironolactone and I’ll see her back in 6 months.

Do I ever use SAHLT?

Sure. Sometimes there are reasons to start two treatments at the same time because there is a feeling that timing is important. However, I tell patients that we are not going to know what is helping. If I do start treatments, I observe carefully if there are periods where one of the treatments was stopped.

For example, consider the 27 year old female who comes to see me having started topical minoxidil and low level laser at the same time. She has used these treatments for 18 months. However, she has not been able to use her laser for a period of 1 full month back 5 months ago because she was traveling abroad and could not take the laser with her. Upon her return she noted that her hair is shedding more than it ever had been in the last 12 months. The conclusion here is that even though both treatments (minoxidil and laser) were started at the same time, I now have at least some evidence that the laser actually was helping her based on her story of worsening loss when it was stopped.

I don’t generally recommend stopping any treatment to figure out if it was working or not because most of the time patients do not catch up to the same level of success they once had.

Reducing SAHLT in the Treatment Plan

Let me be the first to say that SAHLTy treatment plans often give the happiest patients - at least short term. If you your patients to be happy quickly, adding the SAHLT works well. (Most physicians want their patients to be happy quickly). Start 4 treatments and once and you massively increase the odds something will work! But when you consider that treatments are LIFELONG for many conditions, COST money, and have potential SIDE EFFECTS, it is simply not a rationale plan in my opinion.

Consider the 42 year old male using minoxidil, finasteride, laser and PRP - all started at the same time 5 years ago. He feels happy that he has been able to keep his hair. Le't’s suppose for the sake of argument that it’s only the finasteride that is actually helping him.

Is it great he’s happy? Sure. I”m happy he’s happy!

But consider this for a moment

a) 30 years of using minoxidil that is not working could adds up to $ 15,000 over 30 years.

b) 30 years of using PRP that is not working could adds up to $ 100,000 over 30 years.

I can assure you that this happy patient would be happier with $115,000 in his pocket and it would have only taken a bit longer to figure out what helps and what doesn’t. Imagine what he might do with $115,000! I can’t even start because this is all too common. My recommendation is that we seek to always know what is helping and what is not. There are times when simultaneous treatments are needed. There are times when it simply is not.