With the emphasis on emergent conditions and chronic disease management, dermatology sometimes overlooks the importance of hair. Patients who have seen a dermatologist may exhibit signs and symptoms of alopecia, but they are often unaware that their hair loss may be slowed or even reversed, and they never ask for help. Taking an active role in treating hair can be an easy addition to any dermatology practice.
Matt Leavitt, DO, presented on the clinical management of hair at the 2021 Winter Clinical Dermatology Conference. He is founder and executive chairman of Advanced Dermatology & Cosmetic Surgery, as well as chairman of the Orlando Dermatology Residency Program, an executive medical advisor for Bosley, and assistant professor at the University of Central Florida (Orlando) and at Kansas City University of Medicine and Biosciences (MO).
“There is a tremendous interest in hair,” said Dr Leavitt. “When I gave my talk at Winter Clinical, Dr [Darrel] Rigel said they had an overwhelming number of questions in the Q&A session. The interest level is exceedingly high.”
In an interview with The Dermatologist, Dr Leavitt spoke about the ins and outs of growing a hair practice within your current dermatology office.
What are a few quick hitting pearls you can share when it comes to diagnosing and treating hair loss?
First and foremost, sometimes it is hard to get an accurate diagnosis, and without the right diagnosis, you’re probably not going to recommend the appropriate treatment. So, my first pearl is to just get the diagnosis right. The first thing you can use to get to the right diagnosis is history, which is as important in hair loss as the actual examination. In terms of the examination, there are a couple of basic things to do that help with making the right diagnosis. First, you should quickly determine if the patient has scarring or nonscarring hair loss; then, you should look to see if it is diffuse or localized, pattern or nonpattern, and inflammatory or noninflammatory. This combination of history and exam is going to narrow your diagnosis down to one or two possibilities.
Remember that the most common diagnosis is male pattern and female pattern hair loss. A number one tip I would give when it comes to male/female pattern hair loss is not one modality, by itself, is going to give the greatest chance of success. It’s not just minoxidil, finasteride, or spironolactone—all key names in terms of this hair loss—but it’s a combination of those agents. For instance, in female pattern, do not just use minoxidil, but if you’re going to use minoxidil solely, use 5% minoxidil foam. Because compliance can be an issue, have patients use it at bedtime. While the instructions say apply twice a day, it works well enough with a bedtime application that compliance becomes less of a problem. Secondly, with female pattern, I recommend that you at least try to combine minoxidil with spironolactone. This has very few side effects. In male patterned alopecia, if there is resistance to daily finasteride, consider topical finasteride or oral finasteride every other day.
What about compliance—do you find differences in compliance with various patient groups?
I find a difference in compliance on two levels. One is younger patients, generally those younger than 30 years. Both men and women in this age group tend to be less compliant. The other level is male vs female. I find that women are more compliant than men. The ideal treatments for hair loss tend to involve more than one modality, and excellent compliance with the treatment regimen unsurprisingly is key.
One of the keys to getting good compliance is that you have to be able to set expectations and then show results. Start by setting the right expectation by explaining what they may see and how quickly. The hair cycle has a 3-month resting period, the telogen cycle, and it takes a while to get hair growing again. When it does, the hair grows, on average, about a half an inch a month. It is often very difficult for patients to know if their therapy is working. They get frustrated too quickly. You have to set that expectation that the first goal to treatment is slowing down the hair loss or stabilizing the hair loss and then the second goal is growing the hair, which is only going to grow a half inch per month.
To help with setting those expectations, I use a dermatoscope and actually take pictures with the dermatoscope to keep track of growth. I also use my video microscope, which allows me to actually show the patient their progress on a microscopic level so they can see new hairs coming through the scalp pores. Another way to do it is to comb the hair back and hold down the front hairs to show hair growing in the frontal hair line.
It is really critical that you share with patients what the expectations are and then you show them visible progress. Otherwise, compliance wanes. To do that, you have to see these patients more frequently, on average every 4 to 8 weeks. This should not be an every 6-month visit until they are actually stable and doing well.
Is there anything in the therapeutic pipeline that excites you for the future of hair?
There is no question that hair loss research is robust. There are a number of developing options that are exciting. For example, clascoterone cream is already approved for acne topically, and clascoterone solution has a similar anti-androgen mechanism of action for the scalp. Early studies have indicated that it is going to have benefit for our patients with hair loss.
One of the options that has received attention over the last several years is platelet-rich plasma (PRP). PRP has benefit, but it’s not a home run. On the horizon, however, are exosomes. We still need an understanding of how the FDA is going to view them, but there is some evidence that exosomes contain more growth factors than PRP. We should be able to inject exosomes to help stimulate new hair growth. It is not widely available and is expensive right now, but it is something that is an exciting potential future treatment. Low-level laser therapy is another effective treatment for hair loss.
What is your go-to hair pearl?
When somebody really starts to lose their hair, earlier treatment is better. Patients respond very well to some of the easier treatments, such as topical minoxidil, when we begin therapy early.
How can dermatologists reach potential hair patients?
Start with your own practice; it is easier and more cost-effective than anything you can do externally.
Educate your staff. Give them a hair talk on what you do, why, and how so that the whole staff is knowledgeable and can be a resource to the patient. If you have more than one provider, you certainly want to educate the other providers that this is an area of interest for you and that you would appreciate their referrals.
Aside from staff, you should have marketing/education materials that call attention to hair loss, such as something simple like a brochure. These materials should let patients know that not only are you knowledgeable, but also that you have a passion for treating hair loss. Patients should know that they can contact your practice if they are experiencing hair loss or if they feel that their hair is not as thick as it used to be. For so many patients with hair loss, they want to be able to feel that you identify and have empathy for their hair loss. Reach out to existing patients and create access in your schedule so they can make an appointment and address their hair concerns.
Once you work your way through those internal methods, you can educate/market outside your practice. Your first move should be to your referral sources, whether it is primary care or other dermatologists who want to refer hair patients to you. Give talks to other clinicians in your area (though in the era of COVID that may need to be a Zoom talk). Many want to learn about hair loss, and people want to know that they have a resource to send patients.
It is not that hard to build a hair loss practice if you have passion for it and if you have the knowledge. It has the potential to build very quickly.
What’s the one major concept you want your peers and colleagues to take into their hair practice?
There are many different facets to hair: beauty, medical, procedural, surgical. For beauty, simple things such as having the right haircut or using the right products makes a difference. On the medical side, we need to remember the differences in treatment approach based on the diagnosis, from an androgen receptor for androgenetic alopecia vs treating an inflammatory process in cicatricial alopecia. For procedural, we should understand all of the available options, such as laser devices, PRP, exosomes, scalp micropigmentation and their benefits, even if they are not total home runs. Lastly, for surgical, if the patient is highly motivated and is a good candidate, there is a good chance they will do very well with hair transplants.
