Treatment Fatigue in the Hair Loss Patient: It's Real, It's Just We Really Don't Talk About it

Treatment Fatigue: What is it? What do we do about it?

“Treatment Fatigue” is a term that describes a feeling of exhaustion that many patients with hair loss have with carrying out their treatment plan. It can be experienced by patients with any type of hair loss. In general, though treatment fatigue is more common among patients with immune mediated hair loss such as scarring alopecia and alopecia areata. But patients with androgenetic hair loss and other types of hair loss can experience treatment fatigue too. 

Example of Treatment Fatigue

Consider as an example the 52 year old female with scarring alopecia who applies the steroid clobetasol to the scalp three times weekly on Monday, Wednesday and Friday. She applies a weaker steroid fluocinonide to the frontal scalp on Tuesday and Fridays and uses Pimecrolimus on that same area Mondays, Wednesday and Saturday. Pimecrolimus and Minoxidil (Rogaine) are applied to the eyebrows on alternating days and bimatoprost (Latisse) is applied to the eyelids nightly to help eyelashes. Dutasteride is taken five times per week and hydroxychloroquine is taken seven days per week. Once every three months the patient goes into the clinic for steroid injections.

Even though the treatments are working, the patient is feeling tired of carrying out her treatment routine. She finds much of her day is spent thinking about when and how to apply the medications and when to shampoo the scalp. The routine is tiring and sometimes this protocol gets her down. There is no clear stop date to when this treatment will no longer be needed….so it’s difficult to get a sense if this will be going on for 6 more months or 6 more years.

Treatment Fatigue is Common

It’s not a well discussed issue in my opinion but this patient has “treatment fatigue.” It’s a feeling of exhaustion with treatment routines. It’s a feeling that doing all these steps is a burden. It’s common and a normal reaction. For some the treatment fatigue is short lived for others it’s persistent.

Treatment fatigue need not always be applicable only to patients applying a large number of medications. Some patients who apply just a single medication can develop treatment fatigue too.  Many patients who use topical minoxidil daily experience periods of treatment fatigue. Some patients who do PRP (platelet rich plasma) treatments every 3 months can also develop a treatment fatigue. Whether or not someone gets treatment feature depends a lot on the individual person.

Treatment Fatigue and the Internal Battery we All Have

Treatment fatigue simply relates to an inner feeling that one’s medication routines are draining their internal battery in a way that is not sustainable. 

We all wake up each morning with a either a full charged or at least somewhat charged “internal battery” and then use various amounts of physical and mental energy through the day to carry out our daily tasks. When someone feels that carrying out their treatment plan is draining their physical or mental energy to too great of a degree and making it that much more challenging to find the energy to carry out all the array of other tasks in the day they were hoping to get done, it’s likely we are dealing with the issue of treatment fatigue.

Top Tips to Address Treatment Fatigue

It’s important to ask patients from time to time if their treatment routine is sustainable. Sometimes patients will share this information openly or give clues during the consultation.  Patients who miss doses or patients who say that they just consider it hard to find the time to apply the medications may be having treatment fatigue. 

Here are some helpful tips that patients have shared through the years.

1. Write the treatment plan out on a calendar or on a piece of paper. One patient says to me “I just do what the sheet says” If it’s Tuesday and the sheet says to apply clobetasol today, I do it. For some crossing things out on a calendar after applying medications helps too. One of my patients prints out a calendar and keeps it in a certain spot in the house and crosses out words on the calendar as they are done.

2. Keep treatment times the same time every day, if possible. By avoiding guess work in when to apply medications, it relieves alot of stress. If clobetasol is going to be applied in the morning, then stick to the morning.

3. Ask your doctors if any medications can be applied together. The goal of helping people to reduce treatment fatigue is to make things simpler. Applying minoxidil at 9 am and pimecrolimus cream at 6 pm zaps more energy from some of my patients than applying it all together. In some cases, applying medications together is not worse than applying them separately. For example I will have some of my patients with frontal fibrosing alopecia who use minoxidil and pimecrolimus apply minoxidil first and then put the thicker pimecrolimus cream over top.

4. Try an app reminder. There are lots of free medication apps that send reminders right to one’s phone. They are easy to use and can be downloaded from the app store by searching “medications reminders”. Apps like this relieve the brain power that goes into remembering to use medications. As one patient tells me they save that little bit of battery life in the brain so as to devote to something else. “My smartphone can do all the thinking so I don’t need to.”

5. Simplify things where possible. Using a medication three days per week like Monday, Wednesday and Friday may be easier for some then using it four days per week.

6. Consider switching from topical to oral medications. We often use topical medications over oral medications if possible because of their better safety. But some patients are willing to accept the risk of oral medications over topical ones for improved quality of life and reduced treatment fatigue. It’s not always up to us as physicians to make those decisions. For example, some patients are much happier with using oral minoxidil and an oral antiandrogen than topical minoxidil or a topical antiandrogen. They find it easier and less time consuming and has less of an effect on their hair style. Now my preference is often to start with the topical option in many cases over the oral option, but each patient needs to do what is right for them (with the appropriate counseling from the doctor).

7. Ask your doctor if you are applying medications too slowly. For some of my patients, applying medications quickly and according to the schedule rather than slowly and methodically (and missing doses when time is short) is a better plan.

8. Have someone else apply the medications or bring the medications. In some cases, we just need to assign the task of doing all the medication applications to someone else. I’ve been pretty touched over the years at all the spouses, partners, girlfriends, boyfriends, etc who take on the responsibility of applying medications in order to relieve “treatment fatigue.” One of my patients “jokes” that she needs to bring her husband to every appointment because he is in charge of the scalp routines. in all fact, it’s not so much a joke but a reality. For her, this change from her being responsible for all the medication applications to him being responsible dramatically improved her quality of life. She does not think about her hair quite as much as has a bit more energy saved up in the batteries each day to devote to something else. This is not something that all patients would want to do or would be able to do but it is an option that one needs to keep in mind.

Treatment fatigue is real and we all need to watch for it and help our patients with strategies that work well with them to overcome treatment fatigue.