Attitude Gaps

Although general dermatologists are trained as experts in disorders of the hair, skin, and nails, there are unique challenges in caring for hair patients. One of the most significant gaps in dermatologists’ care for patients with hair disorders is a fundamental one: a relative lack of dermatologists interested in caring for patients with hair complaints, which may limit patient access to care. Potential barriers to caring for hair patients are many and may include provider perception of visits for hair concerns as time-consuming, with strong emotional undertones, often without simple or rapid treatment options for the patients’ conditions. These challenges may seem even more difficult in the current and evolving health care environment, where clinical efficiency and quantifiable positive outcomes may be stressed, steering some dermatologists away from the care of patients with hair disorders altogether, and others toward boutique practices out of reach financially for many patients, potentially limiting the availability of expert care.

An era has been entered into that promises continued strides in the basic science understanding and clinical therapeutic developments toward treating the range of hair disorders, with remarkable recent progress regarding some of the most common hair disorders, including appreciating the role of the janus kinase pathway in alopecia areata, prostaglandins in androgenetic alopecia, and a possible therapeutic role for platelet-rich plasma, to give but a few examples. Increasing awareness of and enthusiasm regarding these advancements going forward may serve to combat at least some of the barriers affecting providers’ attitudes toward caring for hair patients in the future. Practical solutions to facilitate the care of hair patients include spreading complaints over multiple visits to enable dedicating adequate time to address patients’ concerns.

Two other significant attitude gaps are notable in the care of hair patients. The first is a potential underestimation of the effect of hair disorders of the quality of patients’ lives. There is the concept of “the difficult hair loss patient,” yet there may be among providers a tendency to perceive hair loss as a relatively trivial problem, a failure to grasp the dramatic consequences that hair loss can have on patients’ lives. Moreover, the author found that providers’ perceived severity of a patient’s hair loss does not correlate with the impact on quality of life, and even objectively mild alopecia may be a significant detriment to quality of life. In a growing body of literature, many conditions commonly managed by dermatologists, quintessentially psoriasis and atopic dermatitis, have been shown to have great effects on quality of life ; thus, dermatologists are increasingly familiar with the concept of assessing quality of life in the management of cutaneous disorders. Application of the same sensitivity in assessing alopecia patients, whether through careful history taking or dedicated screening surveys, may lead to better overall care of these patients.

A second gap in the care of hair patients might also be addressed with increased screening as to emotional and psychological health states: the potential failure to recognize the presentation of body dysmorphic disorder (BDD) among patients with hair complaints. BDD is a psychiatric condition with significant impact on patients’ health and survival, including a high prevalence of suicidality among patients. Although patients with BDD are likely overrepresented in dermatology clinics in general because of the visible nature of the complaints in this field, recent reports suggest that the prevalence of BDD among patients with hair complaints is significantly higher than among general dermatology patients. Screening for BDD among hair patients may serve to identify those at increased risk and who may benefit most from treatment of their underlying psychiatric condition, above and beyond treatments directed at their perceived hair disorders. Barriers to inquiring as to the emotional and psychiatric state of hair patients relate primarily to the perception that significant additional time would be needed in an already time-consuming visit. However, brief screening instruments have been validated in dermatology patients, and patients with BDD, in the long run, will not be managed effectively or efficiently without addressing the underlying mental health state.

Knowledge Gaps

Knowledge gaps may affect the care of patients with both scarring and nonscarring alopecias, delaying accurate diagnosis and appropriate treatment. In the case of scarring alopecias, particularly frontal fibrosing alopecia (FFA) and central centrifugal cicatricial alopecia (CCCA), patients often suffer from a delay in diagnosis. With any scarring process, a delay in diagnosis is particularly problematic because it can mean a missed opportunity to prevent progressive and often permanent alopecia.

FFA, first described in 1994 as a unique subtype of lichen planopilaris primarily affecting postmenopausal Caucasian women, has undergone a dramatic increase in incidence in recent years. The factors underlying this remarkable change remain largely unknown. Furthermore, with the increase of FFA, the condition is no longer restricted to postmenopausal Caucasian women, but has now been reported in women of various skin types and ethnic backgrounds, many premenopausal, and there are increasing reports of FFA in male patients ( Figs. 1–3 ).

Eyebrow alopecia in a male patient with FFA.

Severe scarring alopecia in an African American woman with FFA.

Lonely hair sign, frontal hair line recession in an Asian American woman with FFA.

General dermatologists should be aware of this recent dynamic and be on the lookout for this once rare but increasingly prevalent condition, which may present initially with somewhat subtle clinical findings. Potentially confounding the clinical diagnosis of FFA, despite its designation as a subtype of lichen planopilaris, often the expected symptoms and signs of inflammation (pain or pruritus, perifollicular papules, erythema, or scale) may be minimal. Biopsies from seemingly inactive FFA often reveal an active underlying process, and patients will continue to lose hair.

Especially when the signs of inflammation are subtle, FFA may be misdiagnosed, often as androgenetic alopecia or alopecia areata. Close inspection of the eyebrows and frontal hairline for subtle clues may aid in detecting FFA in an earlier state. In the absence of obvious inflammatory papules, these may include frontal hairline alopecia in association with eyebrow alopecia, and a rather pathognomonic “lonely hair sign” of isolated remaining terminal hairs at the scarred hairline. Given the expectation of hairline recession related to androgenetic alopecia in male patients, loss of beard, sideburn, or eyebrow hair is the more likely presenting complaint in this group (and can be misdiagnosed as alopecia areata). Finally, associated skin-colored facial papules have been described and represent FFA affecting the facial hair follicles, which may be another clue. A high level of suspicion and low threshold to biopsy when the diagnosis of FFA is being considered may prevent delayed diagnosis.

CCCA is another cicatricial alopecia wherein knowledge gaps may delay diagnosis and appropriate treatment. CCCA is a common cause of hair loss among African American women, typically starting in the crown or central scalp. The exact causes and pathological mechanisms remain unclear, with a possible but uncertain role of hair practices in disease progression. Patients may or may not have symptoms of scalp tenderness, pruritus, or sensitivity preceding or accompanying clinically obvious alopecia. Especially in cases of asymptomatic alopecia, this diagnosis may not be considered early on. Because the common distribution of CCCA over the crown overlaps with distribution of female pattern hair loss, early CCCA may be misdiagnosed as female pattern/androgenetic alopecia and not recognized until there has been significant progression of irreversible scarring. Clues to CCCA may include a subtle shininess or smooth quality to the alopecic scalp (from scarring over of follicular ostia), and any signs of inflammation, such as erythema, perifollicular hyperpigmentation, scale, or edema. More recently, focal hair breakage on the crown has been described as a potential early sign of CCCA.

Skill Gap

Another potential gap affecting the care of hair patients may relate to level of comfort with dermoscopic evaluation of the scalp and hair (trichoscopy). In recent years, appreciation of the potential role of dermoscopy in the evaluation of dermatologic conditions has extended far beyond neoplastic conditions to include a wide range of inflammatory and noninflammatory processes, among them the hair disorders. From hair shaft miniaturization to “yellow dots” to vascular patterns, a wealth of recent literature has elucidated a whole new realm of potentially useful examination findings. Because dermoscopy is an acquired skill with a learning curve, the ability to recognize and incorporate these findings into a routine scalp assessment remains an area where many dermatologists may not yet feel confident. With time, practice, and clarification of these patterns via further study, it is likely that the role of trichoscopy in the care of hair patients will continue to blossom in the future.

Specific Practice Gaps: Treatment

The treatment of hair disorders is fraught with many practice gaps regarding uncertainty as to the ideal management of both nonscarring and particularly scarring alopecias. Nearly every common hair disorder has an associated practice gap related to an overall paucity of evidence-based treatment options. Common clinical scenarios leave many currently unanswered questions: When topical minoxidil and oral antiandrogens are not effective in curtailing androgenetic alopecia, the most common hair disorder affecting millions of men and women, what other options do we have? What should we do when intralesional steroid injections are not effective in alopecia areata, and how should we treat extensive cases, such as alopecia totalis and alopecia universalis? What is the proper algorithm for treatment of CCCA, FFA? Can anything help seemingly “burned out scarring alopecia,” and is there a role for hair transplant or stem cell therapy in the future?

These questions are just some of the myriad of remaining questions facing dermatologists who manage hair disorders, and these incompletely answered questions about treatment remain perhaps the most significant gap in clinical practice. If the current pace of investigation and discovery continues, there is optimism that today’s research will ultimately inform these questions in the not-so-distant future, with the potential to bridge some of the many gaps in the clinical care for hair patients.