Treatment Ladder for Hair Loss: Logical and Evidence based

Treatment Ladders: What is a treatment ladder?



For any type of hair loss, there are many potential treatments.  Some types of hair loss may actually have 10-15 different treatments available. How does one choose which to start with? How does once decide which treatment to use if the first treatment does not work? In short, decisions on treatment are often make with use of a ‘treatment ladder.”  A treatment ladder is a term that describes a logical approach to how one should progress onto different treatments if a previous one proves ineffective.  In essence, a treatment ladder refers to a guide to how one should move “step by step” to additional treatments. If one treatment does not work one moves up to the next treatment on the treatment ladder. Treatment ladders helps clinicians balance effectiveness of treatment with safety.

Treatment Ladders for All Hair Loss

In my view, every hair loss condition has a treatment ladder. If there are 15 treatments for hair loss, one does not simply reach into a hat and decide on treatment based on the name that is pulled out of the hat. Also, one does not decide on treatment based on what was reported on the news, or what  a neighbour or friend had benefit from.  If there are 15 treatments available for a given hair loss condition, one arranges those 15 treatments on a treatment ladder for the given condition and severity of condition and moves forward with decisions on treatments based on that treatment ladder. 


Treatment Ladders: Alopecia Areata as an Example.


Let’s consider a 33 year old female with 5-6 patches of alopecia areata. She comes in with a clip from the newspaper on the oral medication “tofacitinib”  and wants to start it. It is true that oral tofacitinib can help alopecia areata, but is this a good option?

Well, an appropriate ladder for a 27 year old with 5-6 patches with alopecia areata could include:


TIER 1: Topical steroids and/or steroid Injections (with minoxidil)

TIER 2: Topical Immunotherapy (DPCP or Anthralin) or Prednisone Taper (with minoxidil)

TIER 3: Oral Methotrexate or Sulfasalazine or Platelet Rich Plasma (PRP)

TIER 4: Oral Tofacitinib


This is an example. The order of the ladder (or choices for treatment) will differ from physician to physician. But this would be ‘my’ ladder for a 33 year old female with alopecia areata totalling 5-6 patches. You can see that oral tofacitinib is on the list but not at the top of the list.  



Without a treatment ladder one needs to guess if a treatment should be used or not. Treatment ladders are important in any practice and essential in my practice to ensure that evidence based principles are used wherever possible in the treatment of 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 Whistler office at 604.283.1887

Share This