Patient Decision Making and the Acute Stress Reaction: What does the hair specialst need to know?

Decision Making by Patients is Impaired During the Acute Stress Reaction:

The practice of medicine is different nowadays. We advise patients on their options and help them figure out what’s best for them. Physicians no longer tell patients to “do this or that.” 

The old saying “take 2 aspirins and call me in the morning” no longer applies. Nowadays, we say something closer to “you might consider taking 1 or 2 aspirins if you are comfortable with the side effects we reviewed together or you might consider pursuing one or more of the other options we discussed.”

There is one important exception - and that is the acutely frightened, scared and terrified patient who has what we can an “acute stress reaction (ASR).” An example a patient experiencing an ASR is a patient with rapid hair loss. Many such patients have lost the ability to think clearly due to fear. These patients need more guidance than simply leaving all decisions up to them. Asking the patient “what do you think?” about certain recommendations the hair specialist gives has many challenges when the person sitting across from them cannot think clearly due to fear.

Medical research has focused on how people make decisions under stress. We don't talk about it all that much but evidence is pretty clear - many of us don't make good decisions under stress. We make mistakes. We buy things our non stressed self would not buy. We don't buy things that our non stressed self would buy. We say things our non stressed self would not say. We don't say things that our non stressed self would shout out. Stress hormones and other neurotransmitters affect how the brain makes decisions. Elegant animal studies back up this simple concept. When we are stressed we behave differently and make decisions that we otherwise would not make.

The entire issue is open to lengthy and complex discussions about ethics and informed consent. Is the acute stressed patient really making informed consent? Many patients suffering acute stress reactions (ASR) are left to figure things out on their own and some are taken advantage of by aggressive marketing. Many patients experiencing ASR’s will choose any option that they are presented. Internet marketing has preyed on many of my own patients experiencing ASRs.

In my view, there are times when we need to hold on to the steering wheel of the driver and there are times when we can offer suggestions from the passenger seat. We need to help our patients in the same manner that we someday would want to be helped when put in a similar situation. We need to help our patients who are experiencing ASR's to make decisions that really reflect what their non stressed self would make. It's certainly not easy but it certainly is how things should be done.

On the media's reporting of "cures for baldness" - is there a cure for this?

On the Misrepresentation of Hair Research Findings by the Media

Several week ago, I wrote a article about the unusual practices on the media when reporting new hair research findings. The basic tenant of the article was that most articles that are written in the media have a exaggerated hope and unrealistic bias towards convincing the public that the new research finding bring us fairly close to a cure.  Interested readers can read the article here

On the Reporting of Infinitely Amazing Discoveries

 

A new osteoporosis drug as a model of the media's bias

As an example of the misrepresentation of the media, we'll focus on a recent study from Professor Ralf Paus's lab in Manchester. The results were published in the May 8 edition of PLOS BIOLOGY. Paus' group re-examined the molecular mechanisms of an old immunosuppressive drug, Cyclosporine A (CsA) which is known to promote hair growth.  Prof Paus' team ultimately uncovered a completely new understanding of how cyclosporine affects hair follicles.  The researchers carried out a full gene expression analysis of isolated human scalp hair follicles treated with CsA and found that CsA reduces the expression of SFRP1, a protein that inhibits the development and growth of many tissues, including hair follicles.  After some further work, the group found that a drug called WAY-316606 also antagonizes SFRP1. Surprisingly, WAY-316606 was originally developed to treat osteoporosis.

The Misrepresentation of the Media : 15 Examples

Even though WAY-316606 could impact the SFRP1 pathway, it's completely unknown whether the drug could have any benefit on human hair disorders. Yet the media's spin on the findings were that it was fairly close to a 'cure'. Here are some headlines from articles about the preliminary research of WAY-316606 which shows this misrepresented and skewed view:

Conclusion

The media has come down with a serious case of excitement. The only problem is that many of these stories are not accurate, not realistic and manipulate the public away from the truth.  Whatever condition it is the media has, it's contagious and spreads quickly - I'm not even sure it's curable. 

On the Use of Scalp Magnification by the Public and Untrained

Warnings on the Use of Scalp Magnification

Magnified Scalp Examination

Looking at the scalp up close is interesting and fascinating. Nowadays, for relatively inexpensive prices (under $50 USD), anyone can purchase a handheld microscope to look at the scalp up close. Some clinics have fancier devices.

For simplicity, I’m just going to refer to the various forms of scalp examination using some type of magnified lens as Magnified Scalp Examination (MSE). For those who wish to be precise, there is some difference between a magnifying glass, a magnified device and a polarizing dermatoscope. But for the sake of discussion, I will refer to all as MSE.

The Misuse of MSE by Professionals

Let me be the first to say that MSE is frequently misused both knowingly and unknowingly. It’s a topic not talked about often, (and in fact I’m really not sure it’s ever been talked about).  There are certainly a proportion of salons, clinics, offices, establishments that use MSE with a client in a somewhat deceptive manner. Generally the client or patient is examined with the MSE device and told and even shown that follicles that are “plugged” or follicles that are “dying.”  The purpose of course of giving this assessment is often to encourage clients to do something on an urgent or semi-urgent basis to “unplug” hairs or prevent more hairs from “dying.” Frankly, it usually means encouraging the patient to buy something that the establishment offers for sale. Sadly, all too often what is seen is not really a plugged follicle and the concept of hair death is exaggerated.

Worse yet,  many clinics not only sell patients a variety of treatments but then use MSE at various follow up appointments to convince a patient that they see “new hairs sprouting” and may even use a MSE device to show the patient or client the new hairs. (In case readers did not know, the human scalp is ALWAYS full of some new hair growth and one can always find a new hair or two).

Training in MSE

I’m not against professionals using various forms of MSE, but sadly many have very limited training and really have limited understanding of the hundreds and hundreds of patterns and findings that can be seen. I’m sorry to say that MSE frequently becomes simply a marketing tool.

But I would like to add that patients like it when their professionals use MSE. Patients even expect it and in many cases state how pleased they are that “someone took the time to really look up close.” The quality of the advice is often overlooked. But the entire show is too often deceiving and the script is too often the same. (“look at your plugged pores and dying hairs”).

MSE is appropriate of course in many situations and when used appropriately can be a great teaching tool for patients. Patients with genetic hair loss looking at a camera image can appreciate that their follicles are getting thinner and thinner. They may be redness and inflammation.  When two areas of the scalp are compared 'before' and 'after' it can become very clear that an improvement or worsening has occurred. This is how MSE is best used. 

The Misuse of MSE by the Public

There is a huge increase in the number of people in the general public buying various forms of MSE equipment on the internet and using it in their homes home for the purpose of self-diagnosis. There’s nothing wrong with this provided it is only used for general interest. Using MSE for self diagnosis has its problems.

See previous article: The Self Diagnosis of Hair Loss: A DIY Project to Avoid.

Too often, patients who buy MSE devices for personal use use these devices in a manner that only increases their anxiety and confusion. There is nothing wrong with being inquisitive and taking charge of one’s own health. However, when it comes at the expense of one’s emotional health, it’s dangerous.

Ten years ago, I don’t think there was even one patient who ever emailed or brought in photos of the scalp they obtained with MSE. Now it happens at  least weekly. Patients see things “up close” with their MSE devices and convince themselves they have a particular condition when they do not. 

The examples are numerous. The patient who sees a single skinny hair on the scalp and convinces herself she has female balding (when in fact it’s a normal finding). Or how about the patient who sees scale around a hair and convinces himself he has scarring alopecia (when in fact the finding represents simple dandruff). Consider too the patient who sees a strange hair and convinces herself she has alopecia areata (when in fact the hair has no significance in this case). Today I received further emails from patients who had performed MSE at home only to encounter confusion. 

It’s okay to be curious. But what often happens in these cases is that the patient’s emotional health is jeopardized by their use of MSE. One can not underestimate the stress that patients feel when they think they have a particular condition.

Conclusion

MSE is wonderful. Let me be the first to say that without my dermatoscope, I would not be able to practice hair dermatology in the same way.  Patients also love MSE - which makes them vulnerable to its misuse.

If one attends clinics, salons, offices that use various MSE devices, that is wonderful.  But one needs to be weary of any clinic offering extensive advice based on the findings of MSE, especially when using terminology that involves discussion about 'plugged follicles' and 'dying' hairs. Such terms are too often meant to scare and confuse.  When discussion is focused on hair density changes, inflammation, miniaturization, hair follicle calibre measurements (in micrometers), the likelihood that a valid assessment is being performed goes up considerably. Of course, it's still no guarantee and all patients must be aware of the basics of the "buyer beware" concepts.

To use a MSE without appropriate training is unprofessional. To use an MSE device to deceive is unethical and possibly even illegal in some jurisdictions. More work is needed by professional organizations worldwide to establish ethical guidelines for the public in multiple areas of evaluating and treating hair loss. 

On the Reporting of Infinitely Amazing Discoveries

 When the media makes things infinitely amazing

The media frequently lives on a level of excitement and adrenaline that few humans can sustain for very long. In a world filled with much negative news, it is interesting that this does not seem to be the case when it comes to reporting about new hair research.

I have noticed three emerging trends when it comes to the reporting of new research in the world of hair loss.

Observation 1: Hair research findings that are not really all that interesting and not really all that promising get reported as “breakthroughs” and the ultimate “cure.”

Observation 2: Hair research findings that are somewhat interesting and somewhat promising get reported as “breakthroughs” and the ultimate “cure.”

Observation 3: Hair research findings that are truly breakthroughs and truly promising get reported as “breakthroughs” and the ultimate “cure.”

In a world with much negative news, one might admire the media's tremendous positivity (and tremendous consistency) when it comes to reporting new hair research. But what must not be forgotten is the countless numbers of people that act on these reports - either emotionally, physically or financially.

It is the responsibility of the media to help people understand if new hair loss research best fits in a category of not all that promising, somewhat promising or truly a breakthrough. Every hair loss discovery adds to our body of knowledge but not every discovery needs to be reported as infinitely amazing.

Is your hairline 'maturing' or a 'balding'?

Is your hairline 'maturing' or a 'balding'?

It’s a little known fact among many men that the frontal hairline actually changes shape between the ages of 17 and 27 – even if that man doesn’t proceed to develop genetic balding. We refer to this normal change as ‘maturation’ of the hairline and we say that the man noticing these changes has a ‘maturing’ hairline. Eventually the hairline stops ‘maturing’ and we say that the man has a ‘mature’ hairline.  Not all men’s hairlines proceed through this normal process of ‘maturation’ but most do.

The concept of a maturing hairline is extremely important to know about so that medical treatment or surgical treatment is not recommended to patients who don’t require it. For example, a 23 year old man who notices his hairline thinning out slightly in the area just above his eyebrows may not have genetic hair loss - but rather a ‘maturing’ hairline. He doesn’t need to begin any sort of treatment whatsoever. Several studies have shown that men with maturing hairlines don’t necessarily go on to develop balding. These are two completely separate processes!

Hairline maturation diagram

The following diagram helps to explain the process by which the hairline matures and how it differs from genetic hair loss. The hairline of a boy or early adolescent is relatively flat and we refer to this as a ‘juvenile” hairline.  Between age 17 and 27, many men (but not all) start to notice that the hairline directly above the middle section of the eyebrow starts to undergo thinning (maturing).   

In fact, if you wrinkle your forehead, you’ll see a series of lines that run side to side. The highest forehead wrinkle often marks a spot where the ‘juvenile’ hairline was once located. A ‘mature’ hairline is usually about 1-1.5 cm above this. In true genetic balding (male pattern hair loss), the hairline may recede beyond this 1.5 cm point and undergo even more significant recession in temple area. 

Why is this concept important?

Understanding the concept of hairline maturation is especially important when it comes to designing natural looking hairlines during a hair transplant.  Attempting to lower a ‘maturing’ hairline is a young man is usually not a good idea. Many young men want a more ‘juvenile’ hairline when they first meet for a hair transplant consultation.  However, by proceeding down that route,  the young man runs the risk of having his new hairline take on an unnatural looking appearance when compared to other males as he approaches his 30s, 40s and 50s.

Other References of Interest

Rassman WR, Pak JP and Kim J. Phenotype of normal hairline maturation. Facial Plast Surg Clin North Am 2013; 21: 317-23

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Spiders, Rain and Hair Growth

Yesterday, by accident, I killed spider.  And then it rained.  In fact, it poured. To some, this information will come as no surprise.  After all, it’s common knowledge to many people that killing a spider will cause it to rain.  But is it really true? Does killing a spider cause it to rain?  To the best of my knowledge there has never been a scientific study examining the relationship between spider killing and rainstorm patterns. 

As a hair specialist, I hear myths about hair loss every day and consider it an important part of my practice to spend time with patients to help separate fact from fiction.  When I’m asked if a specific product will help with hair growth, I generally respond with one of the following 3 answers:

Yes, there is good scientific evidence that this is likely to be helpful ...

or

I think this will probably help your hair, but there is only a small amount of scientific evidence for this claim  ....

or

There is no scientific evidence at present that this does anything to help your hair

Why do we need "scientific evidence"? 

If a patient says to me that a product helped them grows hair, then doesn’t it help grow hair?  Unfortunately, the answer is no. It's not that I don't believe what a patient might tell me. It's simply that there are too many reasons why a patient’s hair might have grown  - even if he or she were to put water on top. Certain types of hair loss conditions improve - even if you do nothing.

Let’s revisit the spider story again. There is no scientific evidence that killing spiders causes it to rain. To prove whether killing spiders causes it to rain, we would need to design a "scientific study" using 1000’s of spiders.   To design a really good scientific study, we would need to design a study with at least two big groups of spiders. In one group the spiders would be stepped on and in the other group they would not be stepped on. And then we’d check to see if it was more likely to rain on the days that spiders were killed. But is that enough of proof? The answer is still no! We’d need to make sure that all the spiders were the same types of spiders and that they were the same age of spiders.  (After all, maybe stepping on young 'garden' spiders causes it to rain but stepping on older 'house' spiders has no effect.) Furthermore, we’d need to make sure that the killing was done at the same time of year.  (Maybe stepping on a spider in the month of September causes it to rain but stepping on spiders in the month of May has no effect).  We would also need to clearly define where it is that we’ll be watching for the rain drops to occur.  (Perhaps killing a spider in Paris, France causes it to rain in Sydney, Australia).

You can see that if would cost a lot of money and take a lot of time to design a study to prove if stepping on spiders causes it to rain.  And so, the study has never been done.  Do we really 100 % know if killing a spider has anything to do with rainfall patterns in the world ? The answer is no. And that’s why I try to avoid stepping on them and continue to spread the myth to help other people avoid killing spiders too. But deep down, do I really think that killing spiders causes it to rain? The answer is, of course, no. 

Thousands of Hair Studies Needed

There are thousands of products on the market for hair and hair loss.  Some products have no scientific evidence that they help hair loss or help with hair growth.  They might help hair growth, but we simply don't know. Certainly, some products do help. To test if a product helps, it would cost money and it would take time.  When a patient tells me that a product helped with hair loss, I tuck the fact into the back of my mind but I usually don’t get very excited. When two different patients tell me that the same product helped them, I still tuck the information into the fact of my mind but usually don’t get very excited. When 10-15 people tell me about a specific product, I think about designing a small study or researching the evidence that this could be true. I remain aware of the possibility that it may be turn out that the product still offers no help for hair loss.

Sound Science Needed for Everything Consumers Put Trust In

This past week I learned that Reebok was made to pay 25 milliion dollars in customer refunds to settle charges of deceptive advertising of a specific type of shoe.  Previous advertising by the Reebok company had claimed the the shoe helped to strengthen and tone muscles.  The company had advertized that this specific shoe could lead to 28 percent more strength and tone in the buttocks, 11 percent more strength in the hamstring muscles and 11 percent more strength in the calf muscles than an ordinary walking shoe. The US Federal Trade Commision stated that it wanted national advertisers to realize that they need to excercise responsibility to ensure claims are supported by "sound science."

The Future of Hair as a Science

Some incredibly exciting hair research discoveries are taking place all over the world. Incredible people are doing incredible work. This means that new treatments for hair loss are waiting us in the years ahead. We need to always make sure that detailed and rigorous scientific research methods are used to help clearly define which treatments help individuals with hair loss and which do not.