The Telemedicine Consultation For Hair Loss: Is it Suitable for Everyone?

Doctor, Don’t You Need to See My Scalp?

A proportion of patients in my practice conduct their visit via telemedicine consultations. I’ve devoted this article to the telemedicine consultation - who are they for? who are they not for? what are the risks?. Telemedicine consultations go by many names, including video conferencing, remote consultations. Telemedicine consultations are defined as a type of consultation whereby the patient and the doctor are not in the same physical space.

Telemedicine consultations are not appropriate for everyone with hair loss. When it comes to telemedicine consultations, I divide discussions into two groups: (1) patients I’ve never met who ask me to help them via a telemedicine consultation and (2) patients who I’ve already seen in the office in the past who now require a telemedicine consultation as part of their follow up care.

The Basic Rules of Telemedicine Consultations

The basic rules of telemedicine consultations are pretty simple:

(1) Provided I have photos, blood tests and a very detailed questionnaire filled out, telemedicine consults are OCCASIONALLY a good idea for a patient I’ve never met before. (Some subtle diagnoses may be missed)

(2) Telemedicine consults are QUITE OFTEN a good idea for patient I’ve never met before if they have had a scalp biopsy in the recent past and send this to me along with photos, blood tests and a very detailed questionnaire. (It’s less likely that a subtle diagnosis will be missed).

(3) Telemedicine consults are VERY OFTEN a good idea for my existing patients provided there is no dramatic worsening of their disease or concerning signs (what I term red flags).

PART A. When is A Telemedicine Consultation Appropriate for the New Hair Loss Patient?

Most “first time” patients benefit from an up close examination in the office. In other words, most first time patients are encouraged to attend an in person visit rather than a telemedicine consultation if possible. This allows me to use trichoscopy (up close examination) and confirm the diagnosis with the greatest certainty. The only time a telemedicine consultation make a lot of sense for a brand new patient is when I’m pretty confident about the diagnosis after reviewing their photos, blood tests and health questionnaire information (pertaining to their hair loss). If after reviewing everything, my feeling is “this could only be diagnosis X” - then a telemedicine consultation is a very reasonable plan. That’s the basic principle that guides all telemedicine consultations.

PART B. A Helpful Algorithm for Deciding on the Appropriateness of a Telemedicine Consultation for a First Time (New) Patient

PART C. When is A Telemedicine Consultation Appropriate for the Existing Hair Loss Patient of the Practice?

Although telemedicine consultations might not be appropriate for every new patient who consults me about their hair loss, it should be noted that telemedicine consultations are often a very reasonable approach for many current, existing patient of the practice who I’ve had the opportunity to evaluate in person in past visits.

The mistake people make is assuming I need to see the scalp ‘up close’ in properly evaluating the scalp every time they have an appointment. That’s true for a first time visit. That’s sometimes true for follow up visits (ie second and third visits) but very often it’s not true for the follow up visit. What matters most in the follow up visit is determining if the hair density has improved or not - and this can be ascertained simply with photos that the patient takes at home. If the hair density has improved, seeing the scalp “up close” adds very little to how I make decisions for most people. In other words, if the patient’s hair is better, seeing the scalp up close is usually not going to change my mind about the bigger treatment plan.

Phrased another way, I might say that while there is no doubt about it that a person should ideally be seen in person for an initial appointment, that’s simply not the reality fo everyone for a follow up appointment. Some patients should be seen in person for a follow up but some patients do not need to be seen in person.

PART D. Deciding on Telemedicine for the Follow up (Existing) Patient.

Two things are important for deciding on the appropriateness of a follow up visit by telemedicine:

QUESTION 1: Is there more hair on the scalp, less hair or the same amount as the last visit ?

QUESTION 2: If the hair density is worse, and the patient has a non scarring alopecia, are there any “red flag signs” that warrant an up close scalp examination by trichoscopy?

PART E. A Helpful Algorithm for Deciding on the Appropriateness of a Telemedicine Consultation for a Follow up (Existing) Patient

PART F. The Most Important Questions to Ask at the Follow up Visit

There are many questions that need to be asked at the follow up visit. The answers to these questions help determine how the patient is responding to treatment and also help determine whether any diagnoses might have been missed in the past. The answers to these questions help guide decisions as to whether or not the patient should come for an up close examination.

PART G. The EIGHT “Red Flags” of the Follow up Consultation

There are several pieces of information that a patient might share during a follow up telemedicine consultation that make it important to consider seeing the patient in person rather than by telemedicine. I refer to these as the red flags. They generally apply to patients who have been diagnosed with non scarring alopecia at a previous visit (androgenetic alopecia, telogen effluvium). Patients who were diagnosed at a last visit with a non scarring hair loss condition but now present with worsening hair loss on the eyebrows or eyelashes or body hair should ideally be seen in person so trichoscopy can be done. The same is true for patients with non scarring alopecia who present with worsening of shedding or worsening of scalp symptoms. Furthermore, if the photos sent in by the patient suggest that a new diagnosis might be present or raise questions as to whether the original diagnosis is correct a telemedicine consultation might not be the best way of conducing the interview. Finally, if the patient was expected to have an improvement in a certain aspect of their symptoms (Like shedding or scalp symptoms) but failed to achieve this sort of improvement, a follow up should be considered in person so that trichsocopy may be performed.

PART H. The Follow up Visit

In my practice, I use a standard follow up template for every telemedicine consultation I conduct. It allows me to ensure that I have properly reviewed all the key things that I need to review with the patent. It also helps me determine if there are any red flags - and not miss any. For any patient with non scarring alopecia who answers yes to any of the red flags, consideration should be given to possibly having an in person examination so that the scalp may be examined.

The FOLLOW Up Visit Intake Sheet

SUMMARY

Telemedicine consultations can be a wonderful means of assisting patients with concerns about hair loss. The telemedicine consultation is often appropriate for the existing patient in the practice whose scalp has been properly examined in the past. In many cases, I do not require the patient to have an up close (trichoscopy) examination because that is not how treatment decisions are going to be made. This type of consultation is also frequently appropriate for new patients who have already had a scalp biopsy. Telemedicine consultations may be appropriate for a new patient even if they have never had a biopsy but one must exercise a good deal of caution. Not every new patient can be properly evaluated via telemedicine. Subtle diagnoses may be missed in some cases. One must carefully review photos, blood tests and patient historical details (questionnaires or a carefully obtained history). If there remains a reasonable possibility that a subtle diagnosis might be missed an in person visit should be encouraged. Hair specialists who are new to the practice of hair loss medicine should be extremely cautious with offering consultations for new patients via telemedicine - as these are the most challenging of the telemedicine consultation scenarios discussed. A newer hair specialist may not appreciate what they are missing and may not be able to determined the chances or likelihood that they might be missing a diagnosis.