Sneaky Hair Loss

by Dr. Molly Stout, WDS News You Can Use Committee 

We’ve all felt the sinking feeling of a well-oiled clinic veering off track by an impending lengthy hair loss visit. Dr. Maria Colavincenzo, a mentor of mine since residency at Northwestern, would often use the term “sneaky hair loss” to describe any patient scheduled for a dermatology visit who at the end of the visit would mention “I’ve noticed my hair shedding, thinning, etc.” Sneaky hair loss has the capacity to derail even the most efficient clinics. Herein are a few pearls to make your surprise hair loss visits less scary.

The Chapter Book Analogy:

A dear friend and colleague, Dr. Janelle Nassim, often uses this approach, which I find helpful in setting the foundation for a positive and longitudinal therapeutic relationship. If you’ve done an extensive visit, and the patient then brings up hair loss, rather than put off their concern to be discussed at another visit, frame your approach to their care this way: “The story of our relationship has just begun. Your skin check visit, acne, and eczema plan have been chapter one. For chapter two, we’ll delve into your hair concerns.” Often patients are worried that they won’t be able to get in to see you for a year if it took them that long to get in initially. Reassure them that you have openings for established patients.

The polite and realistic boundary:

Dermatologists know hair loss is complicated, often multifactorial and carries a lot of emotional burden. Our patients are often influenced by “hair specialists” online promising quick fixes (for a price!) that can be delivered to their doorstep. It’s no surprise they think their hair can be solved in 2 minutes. I’ve had success saying “Hair loss involves an extensive evaluation and treatment discussion, it would be a disservice to you for me to rush through it at the end of your visit, I want to give this concern the attention it deserves” and sometimes a little humor can help break the ice “I promise you won’t go bald before your next appointment”.

The Intake Form:

Two of my favorite dermatologists, Dr. Tania Phillips and Dr. Mitalee Christman, have a handout for their sneaky hair loss patients. This was adapted from Dr. Lynne Goldberg’s hair clinic at Boston University. If there isn’t time to address hair loss (there rarely is!), the patient can complete a questionnaire before they leave that will be uploaded into their chart in anticipation of the next visit. It gives the patient something to do, and shortcuts the history next time.

Labs for now:

Patients can become stuck on the root cause of their hair loss more than addressing the treatment. In my telogen effluvium patients without a clear historical trigger, I’ll often order TSH + T4 and Ferritin to evaluate an underlying cause. Printing off a lab requisition is quick and gives the patient an actionable step to do prior to your full evaluation. Assuming they haven’t already had lab work, you can say “I often check a few labs in my patients with hair shedding, why don’t you get these drawn in the meantime prior to our next appointment.”

The Bucket approach to discussing treatments:

Whether you’ve made it to the dedicated hair loss visit, or your patient seems like someone who will straightforwardly go forth with your initial plan at the end of their regular visit, always discuss treatment options in a concise and organized manner. I like to first present the different treatments in broad categories (buckets) because it can pare down our discussion. You don’t need to waste time talking about all the side effects of spironolactone if the patient is categorically against taking an oral pill for their hair. Find which bucket they fall into and go from there.

I say “There are 3 buckets of treatment; Foams and solutions you put on your scalp, pills you take, and procedures we do to you to make your hair grow. Which would you be open to learning more about?”

When in doubt, let them vent:

Patients trust the doctor who listens to them. We cannot discount the identity value that someone’s hair gives them, and the grief tied to losing it. Sitting down, putting aside the iPad, and just being there with a patient goes a long way. You may be the first person to witness them truly break down. When my toddler has a tantrum on an airplane, two minutes can feel like 2 hours, and that’s the same for emotionally charged visits. Your whole day isn’t going to blow up over this cry. That being said, educate your staff that hair loss visits should not be double booked. If your schedule allows, follow hair loss slots with quicker established, Accutane or wart slots.

Sneaky hair loss doesn’t need to be a sour patch in a sweet clinic - It can mark the start of a trusting clinical relationship. A final pearl to assuage your fears - Remember your WDS colleagues, especially those who specialize in hair disorders, will always be happy for the referral.