THE 23 PrincipLES of MY PRACTICE

MY PRACTICE - MY PERSONAL VIEWS

I have been honoured to have helped many patients with hair loss. The following are my personal views and opinions and provide insight into how I practice as a hair loss physician. 

A. My General Principles about Diagnosis & Evaluation of Hair Loss

Principle 1: The most important question an individual with hair loss can ask is "What is my actual diagnosis or reason for my hair loss? Is there more than one reason?"  In fact, the failure to identify the correct diagnosis is the most common mistake people (and physicians) make about hair loss.

Principle 2: One must set out to uncover all the causes for a person’s hair loss rather than the single cause. There are countless numbers of different hair loss conditions and a person can have one, two three, four or rarely five conditions at the same time. It is true that you may have the same hair loss condition that your mother, father, or friend has - but you might not. 

Principle 3: Scarring hair loss conditions (also called the 'cicatricial alopecias') are much more common that we currently recognize. They are great mimickers of other conditions, and poorly recognized and generally under diagnosed. 

Principle 4: A careful history of a patient's hair loss, a full evaluation of the scalp using trichoscopy and review of any necessary blood tests are how one reaches a diagnosis of hair loss.  All of these steps are important, but a detailed story of the patent's hair loss and health is probably the most important. One can often be accurate about the diagnosis of hair loss from a photo, but I would never be so bold as to state I can confirm anyone's diagnosis based on a photo. 

Principle 5: All women with hair loss require blood tests as part of the appropriate evaluation. The exact blood tests the physician should order will differ from patient to patient according to their history of hair loss. However, one can rarely be completely confident of a diagnosis until blood test results have returned. 

Principle 6: There are far more health conditions associated with hair loss than we currently recognize in conventional practice. As just one example  - the relationship between early male balding and heart disease, blood pressure problems and cholesterol problems. But the examples are many.

Principle 7: One of the most helpful ways to evaluate the success of treatment is a simple camera. If a camera shows improvement - there is likely improvement. If a camera shows that there is less hair on the scalp after 9-12 months of treatment, the treatment is likely not helping to regrow hair. It really does not matter if one sees little sprouts of hair, or hair trying to grow; if there is less hair there is less hair.

Principle 8. Scalp biopsies are under-utilized. They are not needed in every patient with hair loss - and less than 5 % of patients who come to see us have biopsies. However, many patients would receive the correct diagnosis - and get started on the right treatment sooner -  if a biopsy was done.

Principle 9: There are far more hair loss conditions and patterns of hair loss than are recognized in textbooks. What we have now gives us a framework  - but it is incomplete. The field of hair loss medicine also evolves over time. With the increasing complexity of the world, and introduction of new medications, new types of infections, food, pollution, environmental changes and eventually even space travel …. there will be new hair loss conditions that we will see arise.

Principle 10: The internet can potentially be a very, very wonderful resource for anyone with hair loss but the internet can also be very, very harmful to an individual with hair loss.  

Principle 11: I don’t set out each day to have happy patients. I feel this should always be a pleasant side effect that comes with good patient care.

B. My General Principles About the Treatment of Hair Loss. 

Principle 12: One can not even begin to discuss treatment until a diagnosis has been given. Every effort must be made to determine the diagnosis of an individual's hair loss.   Far too many people wonder about how best to treat their hair loss without really knowing what caused it. 

Principle 13: The early diagnosis of hair loss and early treatment generally leads to better long term outcomes.

Principle 14: When deciding on a particular treatment, one must ask "Have clinical research studies have been done on this treatment - and if so, how many studies have been published in the medical journals and how good are these studies?" These simple questions are not asked enough and this leads to many patients wasting time with ineffective treatments.  In the world of science, we refer to this as evidence based medicine or “EBM.”

Principle 15: When deciding on what treatment the patient should use to treat his or her hair loss, the practitioner and the patient together must communicate with each other. The practitioner who does not understand the patient will often choose treatments that the patient will not use, can not use, or can not tolerate. Similarly, the patient who does not understand the viewpoint and experience of the practitioner will often choose treatments that are ineffective for them, poorly tolerated for them or less than ideal for them. Shared decision making is the ideal structure of the patient-physician relationship.

Principle 16:  Recommendations for treatment must be made according to what I have termed the S.A.F.E Principle. Treatments must be safe, affordable, feasible and effective.  A new treatment that is very expensive and not very effective should never win out over an effective treatment that has long been used and is inexpensive. 

Principle 17: Scalp inflammation likely plays a more important role in many types of hair loss than we currently realize.  Inflammation in general is poorly understood in humans and likely has a role in most diseases. 

Principle 18: Our diet plays a far greater role in hair loss than we current understand. Careful studies of the role of diet are hard to do and receive little funding. But what we put in our mouths has the potential to influence many types of hair loss.  

Principle 19: A high proportion of women with androgenetic alopecia are not good candidates for hair transplantation. Some are candidates for the procedure of course - but this requires expertise to select those who in fact are good candidates. Far fewer women than men are good candidates for surgery. Hair transplantation can be a good option for many men - but only after age 25. In discussing hair transplant options, the long term hair loss pattern of the patient must never be ignored. A young man appears to have endless hair for surgery. If we could fast forward to his 50s or 60s we would often see that in fact there is little donor hair there.

Principle 20:  There is no treatment that is guaranteed. One can never promise results. 70 % of patients using minoxidil for treating the early stages of androgenetic alopecia are going to be disappointed because they have no results and will need to consider other options.  But 30 % will be pleased.  Approximately 50 % of patients with lichen planopilaris starting with topical steroids steroid injections and hydroxychloroquine are going to be pleased with their outcomes in controlling their disease - but a good proportion are not going to be pleased and other medicines will be needed (methotrexate, doxycycline, mycophenolate, etc).  One can't promise results. 

Principle 21: No drug is free of potential side effects. However, one must understand whether the potential side effect is 'very rare', 'rare' 'common' or 'very common.' 

Principle 22: Natural, holistic, and traditional treatments are wonderful and always welcome - provided they help. I'm not against naturopathic, holistic, ayurvedic medicine provided it will help my patients. I'm against anything and everything that wastes my patient's time, money, energy and drains their spirit. 

Principle 23: Not pursuing treatment for one's hair loss is always an option. This should always be remembered.