Ralph M. Trüeb1
(1)
Center for Dermatology and Hair Diseases, Wallisellen, Switzerland
Abstract
Global photographic assessment has successfully been established as a standard method for objectively monitoring hair growth in the course of the finasteride trials in men since 1992. Since its introduction, the technique has proven to be essential for follow-up of hair loss patients undergoing long-term treatment in daily clinical practice as well.
It does not matter how slowly you go so long as you do not stop.
Confucius (551 BC–479 BC)
4.1 Global Photographic Assessment
Global photographic assessment has successfully been established as a standard method for objectively monitoring hair growth in the course of the finasteride trials in men since 1992. Since its introduction, the technique has proven to be essential for follow-up of hair loss patients undergoing long-term treatment in daily clinical practice as well.
For clinical study purposes, the method is used in tandem with the phototrichogram technique. While the latter yields a quantitative measure of the hair number (n), hair density (n/cm2), ratio of anagen to telogen phase hairs (%), hair thickness (μm), and linear hair growth rate (mm/day) within a defined area of the scalp, the former reflects the overall clinical changes in the patient over time in a standardized manner.
Global photographs represent head shots taken at short distance from the patient and are therefore different from the close-up photographs used in the phototrichogram technique. For this purpose, the patient’s head is positioned in a stereotactic device in which the patient’s chin and forehead are fixed and on which a given camera and flash device are mounted (Fig. 4.1), ensuring that the view, magnification, and lighting are the same at consecutive visits, thus enabling precise follow-up of the same scalp area of interest. The stereotactic camera device can be converted to the scalp area of interest with frontal and vertex (center of the scalp whorl) views.
Fig. 4.1
Stereotactic device with mounted camera
The length, color, shape, and combing of the hair must remain as constant as possible throughout follow-up. Patients must be informed not to change their hairstyle much, as different hairstyles can change how the hair looks. They should also not use cosmetic treatments like having a perm, coloring, or use hair-thickening products. Patient’s hair should be washed on the morning of photography, and no hairstyling products, such as mousse, gel, or spray, should be used. No water should be applied to the hair during hair preparation for the photograph, since this affects the appearance of hair density, especially when the hair is thin. Usually, the hair is neatly parted in the middle. Ultimately, the result of global photographs is easily falsified, if photographs are taken with different degrees of flash lighting for each photograph. More light reflectance on the skin and hair can give the impression of less hair, while correspondingly less lighting can give the impression of more hair. As a result, photographs taken without fixing the photographic system and maintaining consistency in the way the photographs are taken can look very different and bias the results.
We conducted a 6-month, prospective, open, multicenter cohort study in 265 men with male pattern hair loss treated with oral finasteride 1 mg/day in the office of 52 Swiss dermatologists. The patient’s head was placed in a stereotactic device, and photographs were taken of the vertex and frontal areas. Study endpoints were to determine treatment efficacy in an office-based environment and reliability and acceptance of the photographic method. The photographic method was well accepted by the physicians. The office-based photographic system allowed reliable assessment of change during treatment of male pattern hair loss with oral finasteride. The data generated in this manner corresponded to the antecedent results of the multicenter, placebo-controlled studies with oral finasteride.
The original supplier of this kind of equipment is Canfield Scientific. Clinical studies with minoxidil and finasteride both used photographic apparatus from Canfield Scientific.
Global photographs can be combined with any other quantitative hair growth method complementing clinical data.
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In daily clinical practice, a combination of global photography with trichoscopic examination and photography is recommended.
4.2 Hair Loss-Related Life Quality Index
Finlay et al. were the first to quantify the effect of hair loss on quality of life (QoL) using the Dermatology Life Quality Index (DLQI). It represents a 10-item questionnaire with the aim to measure how much a skin problem has affected the patient’s life over the preceding week. For the study, patients were recruited from an alopecia support group. With a 90 % response rate, 70 questionnaires were returned.
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DLQI scores in responders with hair loss were comparable to those formerly recorded in patients with severe psoriasis. Forty percent of patients also felt dissatisfied with the way in which their doctor dealt with them.
The authors concluded that the study specifically identified the feelings of loss of self-confidence, low self-esteem, and heightened self-consciousness in people affected by hair loss. The hair loss continued to have a significant impact on life quality well after the initial event. For daily clinical practice, the Dermatology Life Quality Index (DLQI) questionnaire and instructions for use and scoring can be downloaded from www.dermatology.org.uk/quality/dlqi/quality-dlqi-questionnaire.html.
Fischer et al. alternatively developed the Hairdex as a tool for evaluation of disease-specific life quality in hair patients following the Skindex questionnaire for patients with skin diseases. It consists of a 48-item questionnaire with hair-specific questions. The Hairdex was evaluated in 75 female hair patients with the aim to prove the questionnaire’s statistical values, reliability, validity, general acceptance, and accuracy. The authors found that hair loss leads to a great difference in the life quality of patients with hair loss, whether slightly visible or obviously visible, and patients with non-visible hair loss, especially in the categories: emotions, self-confidence, and stigmatization. The convergent and discriminant validity of the questionnaire was found to be satisfactory, and the acceptance of the questionnaire to be very good with 90 %. For use, readers must refer to the original publication (in German).
4.3 Patient Compliance Issues
Treatment success relies on patient compliance that, on its part, relies on confidence and motivation. Noncompliance is a major obstacle to the delivery of effective hair loss treatment. More often than being a failure of the patient, patient noncompliance results from failure of the physician to ensure the essential confidence and motivation for successful treatment.
Patient compliance describes the degree to which a patient correctly follows medical advice and instruction. It most commonly refers to drug prescriptions, but it can also apply to the use of medical devices, self-care, or therapeutic sessions. 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 risk–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 4.1.
Table 4.1
Major barriers to patient compliance
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Denial of the problem |
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Lack of comprehension of treatment benefits |
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Occurrence or fear of side effects |
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Cost of the treatment |
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Complexity of treatment regimen |
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Poor previous experience |
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Poor communication and lack of trust |
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Neglect and forgetfulness |
In general, efforts to improve compliance have been aimed at simplifying medication packaging, providing effective medication reminders, improving patient education, including handouts, and limiting the number of medications prescribed simultaneously. Major recommendations for improvement of patient compliance are listed in Table 4.2.
Table 4.2
Recommendations for improvement of patient compliance
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Only recommending treatments that are effective in circumstances when they are required |
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Prescribing the minimum number of different medications, for example, combining active ingredients into a single compound |
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Simplifying dosage regimen by selecting different treatment or using a preparation that needs fewer doses during the day |
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Selecting treatments with lower levels of side effects or fewer concerns for long-term risks |
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Discussing possible side effects and whether it is important to continue medication regardless of those effects |
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Advice on minimizing or coping with side effects |
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Regular follow-up for reassurance on drug safety and treatment benefits |
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Developing trust so patients don’t fear embarrassment or anger if unable to take a particular drug, allowing the doctor to propose a more acceptable alternative |
In the treatment of female alopecia, there are short-term compliance issues and long-term compliance issues to be taken into account. Accordingly, regular follow-up visits at 3, 6, and 12 months are recommended, 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.
An additional visit at 1 month is optional in regard to drug tolerance issues, especially in the elderly put on topical minoxidil.
Short-term compliance issues that are addressed by the physician within the first 3 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.
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The overall goal is to gain short-term compliance as a prerequisite to long-term adherence to treatment.
Based on health communication research, the four steps in Table 4.3 have been suggested to help establish the right conditions for patient adherence to treatment.
Table 4.3
Four steps to patient adherence
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1. Begin from the patient’s perspective: Use the patient’s story as the starting place. Listen for the patient’s meanings, language, and values as she tells her story. Use the patient’s language as much as possible. Translate biomedical terms into terms the patient understands |
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2. Include feelings in the discussion: Ask the patient how she feels about her situation. Actively listen, using the patient’s terms to reflect on what she is saying. Show the patient you care by expressing your feelings about her progress, problems, etc. |
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3. Base treatment goals on the patient’s values: Ask the patient how much she prefers to participate in medical decision making. Allow the patient to participate to the extent that she is willing. Guide the patient to set goals, establish steps she is willing to take, and identify barriers to self-care based on her own needs and values |
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4. Support patient learning: Ask the patient what other sources she has consulted for information about her condition and help her make accurate sense of it. Provide or direct the patient to the information she is seeking |
From Stone et al. (1998)
The difference between the terms compliance and adherence is not just semantic, it is at the heart of the physician’s relationship with patients. While compliance implies an involuntary act of submission to authority, the physician needs to influence patients to become and remain adherents of good self-care. To do this, three key conditions need to be established in the communication with patients: shared values, shared language, and mutual respect.
The following open-ended questions, developed by the Bayer Institute for Health Care Communications, can help gain the patient’s adherence under various circumstances:
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To clarify the patient’s expectations and meanings:
“What were you hoping I would be able to do for you today?”
“You have quite a bit of experience with doctors, what works best for you?”
“Why did you come to see me at this time?”
To clarify what you need from the patient:
“I’d like to be your doctor and to help you with this problem/condition. For me to be effective, though, I’m going to need your help. Would you be willing to [ ]?”
To acknowledge differences in values or points of view:
“I find it difficult to proceed knowing that you have a different view of the situation than I do.”
“I’m wondering if we are working together as well as we might be able to.”
To encourage problem solving:
“I want to solve this problem we seem to be having. My thoughts about the situation are [ ]. What are your thoughts?”
“Is there something that I can do at this point to help us work together more effectively?”
To express empathy:
“That must be very difficult for you. I’m sorry.”
To acknowledge the patient’s difficulty:
“This appears to be difficult for you to talk about. Is there some way I can make it easier?”
“I understand that you are scared at the thought of surgery. Let’s talk more about it.”
To agree on a diagnosis:
“I’ve arrived at one explanation of what the difficulty is. [Provide the explanation.] How does that fit in with what you have been thinking?”
Long-term compliance issues that are addressed at 6 and 12 months of follow-up and thereafter are treatment efficacy and sustainability, long-term toxicities, and treatment costs.
Patients should be aware of the existence of seasonal fluctuations in hair growth and shedding, at times complicating the assessment of pharmacological effects. Awareness of these fluctuations is prerequisite to providing the correct cause and prognosis to the patient, ensuring patient adherence to therapy.
Finally, in the long-term treatment of an oligosymptomatic condition, 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 noncompliance in the elderly.
Suggested Reading
Global Photographic Assessment
Canfield D (1996) Photographic documentation of hair growth in androgenetic alopecia. Dermatol Clin 14:713–721PubMedCrossRef
DiBernardo BE, Giampapa VC, Vogel J (1996) Standardized hair photography. Dermatol Surg 22:945–952PubMed
Olsen EA (2003) Current and novel methods for assessing efficacy of hair growth promoters in pattern hair loss. J Am Acad Dermatol 48:253–262PubMedCrossRef
Trüeb RM, Itin P, Itin und Schweizerische Arbeitsgruppe für Trichologie (2001) Photographic documentation of the effectiveness of 1 mg. oral finasteride in treatment of androgenic alopecia in the man in routine general practice in Switzerland. Praxis (Bern 1994) 90:2087–2093
Hair Loss-Related Life Quality Index
Chren MM (2012) The Skindex instruments to measure the effects of skin disease on quality of life. Dermatol Clin 30:231–236PubMedCentralPubMedCrossRef
Fischer TW, Schmidt S, Strauss B, Elsner P (2001) Hairdex: a tool for evaluation of disease-specific quality of life in patients with hair diseases. Hautarzt 52:219–227PubMedCrossRef
Williamson D, Gonzalez M, Finlay AY (2001) The effect of hair loss on quality of life. J Eur Acad Dermatol Venereol 15:137–139PubMedCrossRef
Patient Compliance Issues
Keller V, White MK, Carroll JG, Segal E (1995) “Difficult” physician-patient relationships workbook. Bayer Institute for Health Care Communication, West Haven
Marinker M, Shaw J (2003) Not to be taken as directed. BMJ 326:348–349PubMedCentralPubMedCrossRef
Ngoh LN (2003) Health literacy: a barrier to pharmacist-patient communication and medication adherence. J Am Pharm Assoc 49:e132–e146CrossRef
Stone MS, Bronkesh SJ, Gerbarg ZB, Wood SD (1998) Improving patient compliance. Strategic medicine. www.patientcompliancemedia.com/Improving_Patient_Compliance_article.pdf. Accessed Jan 1998.
White MK, Keller V, Carroll JG (1995) Physician-patient communication workbook. Bayer Institute for Health Care Communication, West Haven
World Health Organization (2003) Adherence to long-term therapies: evidence for action. WHO, Geneva. http://www.who.int/chp/knowledge/publications/adherence_full_report.pdf