What Combination Locks Teach us About Managing Hair Loss

Getting all the Numbers Right Opens the Lock

There are many ways people can physically lock up their personal belongings. Key locks and combination locks are popular ways of securing one’s belongings. With a key lock, one simply needs to have the right key and the lock can be unlocked. With a combination lock, one needs the right digits and enter them in the right order.

Combination Locks and Hair Loss

Combination locks remind me a lot about how we treat hair loss. Nobody ever expects to be able to open a three digit combination lock if only remember 1 or 2 of the required combination numbers can be remembered. Unless they can all be entered, the lock is simply not going to open.

Every day, I see patients with hair loss who tell me they their treatments just aren’t working. For example, they might have lichen planopilaris and tell me their topical steroids aren’t working. They might have androgenetic alopecia and tell me their minoxidil is not working. They might have alopecia areata and tell me their steroid injections aren’t working. In many cases, the patient is absolutely right - the current treatments just aren’t the right treatments and we need to change them. Sometimes, however, the treatments are actually just fine, it’s just we have not addressed the other hair loss conditions that are present. The patient and his or her physician was expecting success but several other hair loss conditions are present and have not been addressed. We can’t successfully open the lock unless we enter all the numbers and we can’t successfully treat hair loss unless all the conditions that are present are treated.

Consider the 46 year old female patient with lichen planopilaris who is using topical steroids (clobetasol). She feels the hair shedding is a bit better but she’s still losing hair and it’s still quite itchy. What I soon realize is that the patient also has seborrheic dermatitis and has low vitamin D, and low zinc. I also suspect an allergic contact dermatitis from a shampoo ingredient. After examining the patient, I recommended that she continue the topical steroids, supplement with oral vitamin D and oral zinc, add a low allergen anti dandruff shampoo (such as Free and Clear Antidandruff) and avoid her regular shampoo until patch testing is arranged by a dermatologist. Within a few weeks the patient finds her scalp feels better and looks better and hair shedding is reduced further. She’s glad she does not need stronger immunosuppressants for her particular case… and so am I.

Conclusion

With many hair loss treatments, we often expect the treatments to work. But too often we forget to ask ourselves if any other conditions are present. Many patients are surprised to leave the office with 2, 3 or 4 hair and scalp diagnoses but they should not be really too surprised. We can’t open a four number combination lock by entering just 1 number. Similarly, we can’t successfully and completely treat a scalp disorder whereby four conditions are contributing if we are just trying to deal with only one of the conditions.