Dear Editor

In a retrospective study of women with female pattern hair loss (FPHL) in a tertiary referral center, fifty-nine percent of patients were found to have failed to attend any follow-up appointments. Data analysis was performed from case notes on 210 patients with a diagnosis of FPHL seen between January and December 2011 at the respective center. The mean age of the patients was 45.5 years. Topical minoxidil was recommended in the majority of patients. Twenty-three patients reported side effects from treatments, mainly irritation of the scalp, and facial hair [1].

In our center, patients with FPHL comply with follow-up appointments in over 90%. As with any medical problem the patient complaining of hair loss requires a comprehensive medical history, physical examination, and appropriate laboratory evaluation to identify the cause. The clinician has a host of diagnostic techniques that enable classification of the patient’s disorder as a shedding disorder or a decreased density disease and documentation of true pathology or only perceived pathology. Once the diagnosis is certain, treatment appropriate for that diagnosis is likely to control the problem. And yet, few dermatologic complaints carry as much emotional overtones as hair loss. Adding to the patient’s worry may be prior frustrating experiences with physicians. Treatment options are available, though limited, in terms of indications and efficacy. FPHL is a well understood condition with good treatment options. Success depends both on comprehension of the underlying pathology and on unpatronizing sympathy from the part of the physician. Ultimately, patients need to be educated about the basics of the hair cycle and why patience is required for effective cosmetic recovery. Communication is an important component of patient care. For a successful encounter at an office visit, one needs to be sure that the patient’s key concerns have been addressed. Treatment success relies on patient compliance. Rather than being the patient’s failure, patient non-compliance results from failure of the physician to ensure confidence and motivation [2].

Due to the fairly standardized imaging and limited amount of diagnoses compared to clinical dermatology, dermoscopic images have become a center of interest for automated medical image analysis and its commercial utilization. Yet, commercial multi-parameter computer-assisted dermoscopic imaging with external expert analysis is the least effective in clinical practice and only adds to patient’s cost. Another problem is overreliance on technology and skill loss in attending physicians [3].

Adherence to treatment or to follow-up appointments reflects the degree of patient compliance. Patient compliance describes the degree to which a patient correctly follows medical advice and instruction. Patient perception of the balance between the necessity for treatment and concerns over its use is a powerful predictor of adherence with treatment. This perception of the cost-benefit ratio of treatment explains why compliance with therapy for long-term conditions, can be particularly poor. Since both the patient and the health-care provider affect compliance, a positive physician-patient relationship and regular follow-up visits are the most important factor in determining the degree of patient compliance. The major barriers to compliance are listed in Table 1.

Таблица 1. Основные препятствия для соблюдения пациентом режима и схемы лечения

Major recommendations for improvement of patient compliance are listed in Table 2.

Таблица 2. Рекомендации по улучшению соблюдения пациентом режима и схемы лечения

In the treatment of alopecia there are short-term and long-term compliance issues to be taken into account. Accordingly, regular follow-up visits at 3, 6 and 12 months are recommended with standardized global photography in tandem with epiluminiscence microscopic imaging, later twice a year, typically in February and August, when due to seasonal variations of hair growth and shedding, telogen rates are the lowest and highest, respectively [4]. An additional visit at 1 month is optional in regard to drug tolerance issues, especially in the elderly female patients on oral minoxidil. Short term compliance issues that are addressed by the physician within the first three months of therapy are: winning the patient’s confidence in the diagnosis and treatment plan, and detecting problems relating to the prescribed treatment regimen, or drug tolerance. The overall goal is to gain short-term compliance as a prerequisite to long-term adherence to treatment. We usually simplify dose regimens by prescribing women 5% topical minoxidil once daily or low dose oral minoxidil instead of 2% topical minoxidil b.i.d., and choose a propylene glycol free American Witch Hazel-based topical minoxidil compound to prevent scalp irritation [5]. Long term compliance issues that are addressed at 6, 12 months of follow up and thereafter are: treatment efficacy and sustainability, long term toxicities, and treatment costs [6].

Ultimately, in the long-term treatment of an oligosymptomatic condition such as FPHL, neglect may become a problem, since the patient may take the pharmacologically induced condition for granted. On the other hand, forgetfulness is a frequent cause of non-compliance in the elderly (>70).

Finally, patients with psychological overlays may pose particular problems. The issue of overvalued ideas in relation to the condition of the hair is not always easy to resolve, however, the best way to alleviate the emotional distress caused by hair loss is to effectively eliminate the underlying cause. The psychological effects of hair loss may be hard to differentiate clinically form pre-existing psychopathology. Nevertheless, patients with personality disorders tend to experience more distress from hair loss than non-disordered patients, since these individuals lack a secure sense of self and effective coping skills, and therefore may be especially vulnerable to the adverse effects of hair loss. Also, patients with personality disorders tend to be more difficult to handle with respect to treatment. Patient compliance issues are a problem in patients with paranoid, avoidant, or passive-aggressive (negativistic) personality disorders; nocebo reactions are more frequent in patients with paranoid, passive-aggressive (negativistic), or histrionic personality disorders; and overvalued ideas are typical for patients with histrionic or narcissistic personality disorders. The physician should be careful not to be judgmental or scolding because this may rapidly close down communication [7].

Considering all of these points, the benchmark for failure to attend follow-up consultations in women with FPHL should be well under the quoted 59%, with a usually high patient satisfaction rate according to our experience.

Авторы заявляют об отсутствии конфликта интересов.