Q&A: ‘Setting appropriate expectations’ key to helping patients with alopecia

Alopecia, a condition with various subtypes and etiologies, is a “common and distressing clinical complaint in the primary care setting,” researchers wrote in Frontiers in Medicine.

Ahmad M. Al AboudMD, a consulting dermatologist and cutaneous laser surgeon at King Abdullah Medical City in Saudi Arabia, and Patrick M. Zito, of the University of Miami’s Miller School of Medicine, wrote in StatPearls that obtaining an “accurate history” can help physicians determine the type of hair loss. This includes asking patients about when their hair loss began; the number of hairs they lose daily; their diet, routines and general health; history of male hormone, thyroid, iron and ovarian tests and familial hair loss; type of shampoo and conditioner; and recent psychological stresses.

The researchers also noted that diagnosing the correct type of alopecia involves obtaining a complete blood count and iron panel and conducting tests that ascertain autoantibodies, follicular stimulating hormones, free testosterone, luteinizing hormones, ovarian hormones, thyroid function and total testosterone. In some instances, chest X-rays, fungal cultures, KOH preparation and MRI may be required.

An interprofessional team allows “optimal management” for patients with hair loss, according to Al Aboud and Zito. They wrote that this consists of primary care physicians, dermatologists and nurse practitioners working together to make a diagnosis and develop a care plan; pharmacists and specialty care nurses providing patient education; and pharmacists monitoring patients’ reaction to and compliance with prescriptions.

Paradi Mirmirani, MD, of the department of dermatology at the University of California at San Francisco, recently coauthored a clinical review in JAMA about treatment approaches to non-scarring alopecia. Healio Primary Care spoke with Mirmirani about the paper and what PCPs should consider when treating patients with the condition.

Healio Primary Care: How common is hair loss?

Mirmirani: Hair loss is common in both men and women and may affect up to 50% of patients.

Healio Primary Care: What are the most important points in your recent clinical update about diagnosing and treating hair loss in primary care?

Mirmirani: The focus of the article is on non‐scarring hair loss, which is the most common type seen in primary care. A helpful strategy in making the diagnosis is to identify the pattern of hair loss. We review typical features and examples of patterned diffuse and patchy hair loss.

Healio Primary Care: What are some common mistakes that PCPs make in diagnosing and treating hair loss?

Mirmirani: Setting appropriate expectations for treatment is critical. Helping patients understand that hair growth can take time and may not improve for 4 to 6 months after initiation of therapy is key to establishing a therapeutic alliance.

Healio Primary Care: When should a patient with hair loss be referred to a dermatologist?

Mirmirani: Anyone who presents with significant itch, pain, redness, scale and/or crust, or who an abnormally smooth appearance of the skin may have scarring alopecia — an inflammatory condition in which the follicular structures are damaged and leads to

permanent hair loss. If there is a suspicion of a scarring alopecia, the patient should be referred to a dermatologist for further evaluation and confirmation of the diagnosis.

References:

Al Aboud AM, Zito PM. Alopecia. StatPearls. Last updated Sept. 29, 2020.

Mirimirani P, Fu, J. JAMA. 2021;doi: 10.1001/jama.2020.19313.

Xu L, et al. Front Med (Lausanne). 2017;doi:10.3389/fmed.2017.00112.