Female Alopecia: Guide to Successful Management 2013th Edition

5. Patient Expectation Management

Ralph M. Trüeb¹

(1)

Center for Dermatology and Hair Diseases, Wallisellen, Switzerland

Abstract

Few dermatologic problems carry as much emotional overtones as the complaint of hair loss in women. Adding to the patient’s worry may be prior frustrating experiences with physicians, who tend to trivialize complaints of hair loss or dismiss them completely. Even if the complaint of hair loss may at times seem disproportionate to the extent of recognizable hair loss, the proportion of women suffering of truly imaginary hair loss (psychogenic pseudoeffluvium) is negligible.

It is easier to write a prescription than to come to an understanding with the patient.

Franz Kafka, A Country Doctor (1920)

Few dermatologic problems carry as much emotional overtones as the complaint of hair loss in women. Adding to the patient’s worry may be prior frustrating experiences with physicians, who tend to trivialize complaints of hair loss or dismiss them completely. Even if the complaint of hair loss may at times seem disproportionate to the extent of recognizable hair loss, the proportion of women suffering of truly imaginary hair loss (psychogenic pseudoeffluvium) is negligible.

A detailed patient history focussing on chronology of events, examination of the scalp and pattern of hair loss, a simple pull test, ­dermoscopy of the scalp and hair, a few pertinent screening blood tests, and a scalp biopsy in selected cases – as outlined in the respective chapters – will usually establish a specific diagnosis. Once the diagnosis is certain, treatment appropriate for that diagnosis is likely to control the problem.

Treatment options are available, though limited, both in terms of indications and of efficacy. Success depends not only on comprehension of the underlying pathology but also on unpatronizing sympathy from the part of the physician. Ultimately, patients need to be educated about the basics of the hair cycle and why considerable patience is required for effective cosmetic recovery. Success relies on patient compliance that, on its part, relies on confidence in the physician and treatment. Rather than being a failure of the patient, patient noncompliance results from failure of the physician to build up that confidence.

The Latin maxim TVTO CELERITER IVCVNDE stands for safely, swiftly, and gladly and was originally coined by Asclepiades of Bithynia (124–56 BC), personal physician and near friend of notable personalities of Ancient Rome, such as Cicero and Marc Anthony. While the foreign Greek physicians were originally encountered with much distrust by the Romans and especially its aristocracy, Asclepiades ­managed to convince through his high learning, brilliant medical achievements, and worldly wisdom. Above all, he was always attentive and sympathetic to the individual needs of his patients. Asclepiades was born in Prusa. He traveled much when young and at first settled at Rome as a ­rhetorician. Though he did not succeed in that profession, he eventually acquired great reputation as a physician. Asclepiades began by vilifying the principles and practices of his predecessors and by asserting that he had discovered a more effective method of treating diseases than had been before known to the world. His remedies were directed to the restoration of harmony.

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A part of the great popularity which Asclepiades enjoyed depended upon his attending to every need of his patients and indulging their inclinations.

Finally, Asclepiades advocated humane treatment of mental disorders. His teachings are ­surprisingly modern; therefore, Asclepiades is considered to be a pioneer physician in both the medical sciences and psychotherapy.

The same way Asclepiades won the Roman populace and aristocracy for his cause, the physician must advance to build up his reputation and to secure the confidence of his patients. A liaison with patients, respect for their individuality, and professional expertise are preliminary to creating an atmosphere of mutual trust, which, on the one side, enables the physician’s professional contribution to the healing process and, on the other side, assists patients to draw also from their own mental self-healing capacities. This is where, at times, success in treating hair loss disorders may supersede evidence-based medicine. The patient often expects more than a 63 % chance of success with topical minoxidil in androgenetic alopecia, more than temporary success in the treatment of alopecia areata, and more than merely halting the disease process in the inflammatory scarring alopecias. It is that difference which has to be found out and cultivated that determines whether or not the patient will belong to the 63 % responders to minoxidil, whether or not treatment of alopecia will be successful and long lasting, and whether or not regrowth of some hair may be seen in the inflammatory scarring alopecias.

5.1 Listening to the Patient

Communication is an important component of patient care. Traditionally, communication in medical school curricula is incorporated informally as part of rounds and faculty feedback but without a specific focus on skills of communicating. Communication skills are not a question of talent. One’s effectiveness in communication can be improved through training and through experience.

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For a successful encounter at an office visit, one needs to be sure that the patient’s key concerns have been directly and specifically solicited and addressed.

To be effective, the physician must gain an understanding of the patient’s perspective on her illness. Patient concerns can be wide ranging, including fear of hair loss and disfigurement; apprehension of scalp symptoms; distrust of the medical profession or of pharmacologic agents; concern about loss of wholeness, role, status, or independence; denial of reality of medical ­conditions; grief; and other uniquely personal issues. Patient values, cultures, and preferences need to be explored. Gender is another element that needs to be taken into consideration. Ensuring key issues that are verbalized openly is fundamental to effective patient–doctor communication. Appropriate reassurance or pragmatic suggestions to help with problem solving and setting up a structured plan of action may be an important part of the patient care that is required.

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The physician should be careful not to be judgmental or scolding because this may rapidly close down communication. Sometimes the patient gains therapeutic benefit just from venting concerns in a safe environment with a caring physician.

Hair loss is a common dermatologic problem. Psychological research confirms a negative effect of visible hair loss on social perceptions and body image satisfaction. A thorough evaluation, a specific diagnosis, effective treatment, and appropriate counseling all also have some psychological efficacy.

In 1993, Cash compared psychological effects of androgenetic alopecia on women with balding men and found that androgenetic hair loss was clearly a stressful experience for both sexes but substantially more distressing for women. Relative to control subjects, women with androgenetic alopecia possessed a more negative body image and a pattern of less adaptive functioning (Table 5.1).

Table 5.1

Descriptions of female androgenetic alopecia patients’ specific effects attributed to hair loss

Effects attributed to hair loss	%
Adverse effects
Wish I had more hair	98
Think about my hair loss	97
Try to figure out if I am losing more hair	95
Feel frustrated or helpless about my hair loss	93
Spend time looking at my hair in the mirror	92
Worry about my looks	92
Feel self-conscious about my looks	92
Have negative thoughts about my hair	91
Worry about whether others will notice my hair loss	90
Worry about how much hair I am going to lose	89
Notice people who are balding	83
Think about how I used to look	78
Notice what other people look like	78
Have the thought why me?	75
Think I am not as attractive as I used to be	72
Wonder what other people think about my looks	71
Have thoughts that I am unattractive	68
Try to think what I would look like with more hair loss	67
Feel depressed or despondent	63
Worry about getting older	62
Worry that my spouse or partner will find me less attractive	60
Feel embarrassment	55
Feel envious of good-looking people of my sex	53
Feel sensitive to personal criticism	50
Am conscious of how others react to me	43
Feel I look older than I am	42
People comment about my hair loss	36
Get friendly teasing or kidding from others	20
Behavioral coping
Try to figure out what to do about my hair loss	98
Try to hide my hair loss	94
Talk to my hairstylist about my hair loss	82
Try to improve my hairstyle	79
Do things to improve my looks	75
Talk to friends of my own sex about my hair loss	71
Spend time on my appearance	70
Talk to my partner about my hair loss	64
Seek reassurance about my looks	62
Try to improve my figure or physique	44

From Cash et al. (1993)

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Physicians should recognize that androgenetic alopecia goes well beyond the simple physical aspects of hair loss and growth.

Patients’ psychological reactions to hair loss are less related to physicians’ ratings than to patients’ own perceptions of the extent of their hair loss. Even in women with slight hair loss, that loss is imbued with considerable emotional meaning that the physician should not ignore.

5.2 Adjustment Disorders

Even though most patients with hair disorders experience significant psychological impact, it is usually not of an intensity to qualify as a mental illness. Nevertheless, the impact that hair disorders have on body image significantly contributes to the overall impact on the patient’s quality of life.

If one appreciates the psychosocial impact of hair disease, there is no doubt that appropriate treatment frequently has a huge bearing on the patients’ quality of life.

The clinician should keep in mind that the distress the patient feels from having a hair disease can be handled both dermatologically and psychologically. Some patients have difficulties adjusting to hair loss. As a result, the individual may have difficulty with his or her mood and behavior. From a psychopathological point of view, adjustment disorders may result from the stressful event of hair loss, depending on its ­acuity, extent, and prognosis. An adjustment disorder is a debilitating reaction to a stressful event or situation. These symptoms or behaviors are clinically significant as evidenced by either of the following: distress that is in excess of what would be expected or significant impairment in social, occupational, or educational functioning. Adjustment disorders subtypes include:

· Adjustment disorder with depressed mood (DSM-IV 309.0, ICD-10 F43.20)

· Adjustment disorder with anxiety (DSM-IV 309.24, ICD-10 F43.28)

· Adjustment disorder with mixed anxiety and depressed mood (DSM-IV 309.28, ICD-10 F43.22)

· Adjustment disorder with disturbance of conduct (DSM-IV 309.3, ICD-10 F43.24)

· Adjustment disorder with mixed disturbance of emotions and conduct (DSM-IV 309.4, ICD F43.25).

Associated features may be somatic and/or sexual dysfunction and feelings of guilt and/or obsession.

The best way to alleviate the emotional distress caused by hair disease is to eliminate the hair disease that is causing the problem.

In other words, the intensity of the distress that the patient feels should be part of the clinician’s formula in deciding how aggressively to treat the hair disease. For example, a decision to use or not to use minoxidil in a patient with a borderline clinical state of androgenetic alopecia, or to recommend or not to recommend hair surgery to a patient with permanent alopecia, may hinge on the amount of distress the patient feels from the alopecia.

Besides being a sympathetic and concerned professional, a dermatologist may give a referral to a support organization such as the National Alopecia Areata Foundation. First, many of these support organizations specialize in providing educational materials to patients and their relatives so they have an opportunity to inform themselves with respect to the nature and prognosis of their hair problem. Second, being part of such an organization breaks the sense of isolation patients often feel. Finally, by learning more about different treatment options, there is less risk that the patients will prematurely give up on treatment in despair and resign themselves to having uncontrolled alopecia. Keeping up hope is critical in not losing a positive outlook, in spite of having a chronic or recurrent condition.

5.2.1 Hypochondriacal Disorder and Body Dysmorphic Disorder

The patient with hypochondriacal disorder has no real illness but is overly obsessed over normal bodily functions. They read into the sensations of these normal bodily functions the presence of a feared illness. Because of misinterpreting bodily symptoms, they become preoccupied with ideas or fears of having a serious illness, while appropriate medical investigation and reassurance do not relieve these ideas. These ideas cause distress that is clinically important or impairs work, social, or personal functioning. They are not delusional and are not restricted to concern about appearance as in body dysmorphic disorder (see below). Hypochondriacal disorder usually develops in middle age or later and tends to run a chronic course. Patients typically seek many tests and much reassurance from their doctor.

Probably the more important group of problem patients for the dermatologist in practice is that with body dysmorphic disorder or dysmorphophobia (a term that is incorrect, since we are not dealing with a phobic disorder). It is classified together with hypochondriacal disorder (DSM-IV 300.7, ICD-10 F45.2), though this classification will probably be abandoned in future in favor of a new class of its own. This disorder tends to occur in younger adults. The patient becomes preoccupied with a nonexistent or minimal ­cosmetic defect and persistently seeks medical attention to correct it. Cases of body dysmorphic disorder can range from relatively mild to very severe. The patient is preoccupied with an imagined defect of appearance or is excessively concerned about a slight physical anomaly. This preoccupation causes clinically important ­distress or impairs work, social, or personal functioning. Another term used for body dysmorphic syndrome is Thersites complex, named after Thersites who was the ugliest soldier in Odysseus’ army, according to Homer.

One of various theories attempting to make the onset of body dysmorphic disorder understandable is the self-discrepancy theory, in which affected patients present conflicting self-beliefs with discrepancies between their actual and desired self. Patients have an unrealistic ideal as to how they should look. Media-induced factors are considered to predispose to body dysmorphic disorder by establishing role models for beauty and attractiveness.

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The psychocutaneous manifestation of hypochondriacal disorder and body dysmorphic disorder on the scalp is usually imaginary hair loss (psychogenic pseudoef­fluvium).

Probably a variant of body dysmorphic disorder is the more recently proposed Dorian Gray syndrome in which patients wish to remain forever young and seek lifestyle drugs and surgery to deter the natural aging process, named after an Oscar Wilde novel, in which the protagonist, a beautiful young aesthete, exclaims in front of his portrait (Table 5.2):

Why should it keep what I must lose? Every moment that passes takes something from me, and gives something to it. Oh, if it were only the other way! If the picture could change, and I could be always what I am now! For that - for that - I would give everything! Yes, there is nothing in the whole world I would not give! I would give my soul for that!

Table 5.2

Criteria for the diagnosis of Dorian Gray syndrome

Signs of body dysmorphic disorder

Inability to mature and to progress in terms of psychological development

Use of at least two of following medical lifestyle treatments (different groups required):

1. Hair growth-promoting agents

2. Weight-reducing agents

3. Agents to treat erectile dysfunction

4. Mood-modifying agents

5. Minimal invasive cosmetic dermatologic procedures

6. Cosmetic surgery

From Brosig et al. (2001)

5.3 Tackling Side Effects

A side effect is an effect that is secondary to the one intended. The term is primarily used to describe unwanted or adverse effects.

In the broader sense, the term can also apply to unintended but beneficial effects from the use of the drug. An example is the hair growth-­promoting effect of minoxidil that was originally a drug intended to lower the blood pressure but proved to be a powerful trichotrophic agent.

As long as the drug is used for unapproved indications, that is, for their side effects, it is termed off-label use. An example is the use of oral finasteride for treatment of female androgenetic alopecia. Off-label use of drugs is legal, but its prescription is solely at the discretion of the prescriber. The promotion of drugs towards unapproved indications is illegal.

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Occurrence or fear of side effects is a major barrier to patient compliance. Therefore, it is of upmost importance to inform patients on potential side effects, their frequencies, and appropriate management.

Some side effects are directly related to the pharmacological effect of the drug, and others to a patient’s individual allergic or idiosyncratic disposition, to drug–drug interactions, or to simply not following instructions for proper use of the medication. Patients should be aware of possible allergies to active ingredients or additives and report other medical conditions and medications. Therefore, it is highly recommended, even when treatment can be purchased without a doctor’s prescription that the patient visits a physician for proper indication, exclusion of contraindications, instructions for proper use, and follow-up.

Table 5.3

Adverse reactions to 2 or 5 % topical minoxidil

Common:

Hair shedding (during initial 4–6 weeks of treatment)

Unwanted hair growth elsewhere on the body (usually facial, within 3–6 weeks of treatment)

Itching, redness, or irritation at the treated area (usually due to propylene glycol)

Changes in hair color or texture

Burning or irritation of the eye

Rare (treatment should be withheld immediately):

Severe allergic reactions: rash, hives, itching, difficulty breathing, tightness in the chest, and swelling of the mouth, face, lips, or tongue

Cardiovascular effects: chest pain, dizziness, fainting, increased heart rate, pounding heartbeat, sudden, unexplained weight gain, swollen hands or feet

Unexplained: breast tenderness, changes in vision or hearing

Thrombocytopenia and leukopenia (WBC  <  3,000/mm3) have very rarely been reported with oral minoxidil

Minoxidil solution and foam is used to promote hair growth in the treatment of androgenetic alopecia. It has originally been developed for treatment of patterned hair loss in men but proved to be more effective in women with thinning hair. For women, 2 % minoxidil solution is primarily used, but 5 % minoxidil solution is more effective, especially in the first 3 months of treatment, at the cost of more frequent side effects (Table 5.3).

Minoxidil is not used for alopecia areata or telogen effluvium. Efficacy and safety data are not available before the age of 18 years and after the age of 65 years. Nevertheless, minoxidil can be safely used before 18 or after 65 years at the discretion of the prescriber (off-label use). Before the age of 12 years, the dosage should be halved. Adverse cardiovascular effects have been reported in children.

Any of the following health problems should caution to the use of topical minoxidil: active diseases of the scalp, for example, eczema, infection, and cuts, as well as heart problems, for example, chest pain, heart attack, and heart failure. During pregnancy, minoxidil should be avoided, and during breast feeding, the use of minoxidil has been cleared on the occasion of the 2011 AAD meeting.

Before applying minoxidil to the scalp, the area should be clean and dry. The product may be applied to damp hair. To use the solution, the applicator is filled with 1 mL of medication. The hair in the area of thinning is parted, and the solution is applied evenly to the affected area of the scalp and gently rubbed in. Typically, the solution is applied twice a day, or, in the case of 5 % minoxidil, once daily as directed by the physician. The solution is allowed to dry completely before using other styling products, for example, gels or mousse, or before going to bed. If a dose is missed, the missed dose is to be skipped and the usual dosing schedule resumed. The dose should not be doubled to catch up.

If scalp irritation is a problem, a minoxidil compound should be used that is free of propylene glycol (Table 5.4).

Table 5.4

Prescription of a minoxidil compound free of propylene glycol

Rp.
Minoxidil	2.0, 3.0, or 5.0 g
Glycerine	10.0 g
Water	20.0 g
Ethanol 96 %	ad 100.0 g
M.D.S. Apply twice daily 1 mL to the affected area

Also, use of minoxidil should be avoided on the same days that hair is colored or permed. After applying minoxidil onto the scalp, exposure to the sun should be avoided, since may cause sunburns. Minoxidil should not be used on skin that is red, painful, irritated, scraped, cut, or infected. Doing so can may cause the drug to be absorbed into the body and result in systemic side effects. Hands should be thoroughly washed after application. Caution is to be given to avoiding getting the medication in eyes. If this occurs, eyes should be rinsed with large amounts of cool water.

Patients should be aware that it takes time for hair to regrow. Most people need to use this medication regularly for at least 8 weeks to see a benefit. Moreover, the medication must be used continuously to maintain hair growth. If the condition does not improve or worsens after using this medication for 3–6 months, the condition and treatment need to be reevaluated by the physician.

Seemingly ironic, upon initiation of treatment with topical minoxidil, patients frequently experience increased shedding of hair. Patients should be prepared and informed that this represents a physiological response to treatment, since minoxidil not only increases the duration of anagen in the hair cycle but triggers an immediate telogen release. The best thing to do is to treat through until the shedding stops and new hair growth is seen (usually at 3 months). The effect of minoxidil builds up until 12 months of treatment. Once it is established that minoxidil is effective, treatment should thereafter continue indefinitely since positive results will be reversed once treatment is stopped.

Another common side effect of minoxidil is elongation, thickening, and enhanced pigmentation of fine facial hair and rarely of body hair (hypertrichosis). This develops relatively early in the course of treatment (usually within 6 weeks after starting therapy). It is usually first noticed on the temples (Fig. 5.1a), between the hairline and the eyebrows, or in the sideburn area of the upper lateral cheek (Fig. 5.1b). Upon discontinuation of minoxidil, new hair growth stops but up to 12 months may be required for restoration to pretreatment appearance. Hair growth may be especially disturbing to women. Patients should therefore be carefully informed about this possible effect and that the risk is significantly higher with 5 % topical minoxidil before treatment is started. Disturbing hairs may be bleached, clipped, or waxed.

Fig. 5.1

Minoxidil-induced hypertrichosis. (a) Hyper­trichosis of the temple. (b) Hypertrichosis of the sideburn area and lateral cheek

We reported a case of minoxidil-induced trichostasis spinulosa in a 35-year-old female subject who had extended the application area of minoxidil to encompass the temporal and high frontal regions out of fear of hair loss in these areas. On examination, we observed multiple follicular blackish hair bristles the size of pinheads (0.5–1.0 mm) in the frontal region of the hairline and on both temples. Dermoscopic examination revealed tufts of pigmented terminal hair of varying diameters emerging from each hair follicle.

Itching, redness, or irritation at the treated area is far more frequently due to an irritant dermatitis to propylene glycol or the alcohol-based solution. Very few minoxidil users are truly allergic to the active ingredient. While irritant dermatitis usually develops early in the course of treatment, allergic reactions are usually acquired later. If an allergic reaction to minoxidil is suspected, this can be clarified by performing a repeated open application test (ROAT) to the forearm: Minoxidil is applied twice daily to an area of 5 × 5 cm on the inner aspect of the forearm for a duration of 7 days. In the event of a contact allergic reaction, an erythematous rash with papules will become apparent usually within 48–72 h (Fig. 5.2).

Fig. 5.2

Positive ROAT to minoxidil

Other side effects of topical minoxidil (severe allergic reactions, cardiovascular effects, and unexplained adverse reactions) are exceedingly rare.

For a comprehensive list of reported adverse reactions to other drugs, readers are encouraged to refer to the respective information for consumers and health-care professionals accompanying the drug.

The prescribing physician should always be aware that the off-label prescription of drugs occurs at the discretion of the prescriber.

This applies, for instance, for the use of oral tetracyclines, hydroxychloroquine, mycophenolate mofetil, cyclosporine A, or pioglitazone in the treatment of lichen planopilaris and related conditions (frontal fibrosing alopecia, fibrosing alopecia in a pattern distribution). The case of the oral antidiabetic pioglitazone that has recently been proposed for treatment of lichen planopilaris sheds light on the risks of liability issues: In 9 June 2011, the French Agency for the Safety of Health Products decided to withdraw pioglitazone in regard to high risk of bladder cancer; in 10 June 2011, Germany’s Federal Institute for Drugs and Medical Devices advised doctors not to prescribe the medication until further investigation of the cancer risk had been conducted; and ultimately, in 15 June 2011, the US FDA announced that pioglitazone use for more than 1 year may be associated with an increased risk of bladder cancer and that the information about this risk will be added to the warnings and ­precautions section of the label for pioglitazone-containing medicines.

For adverse effects of cosmetic hair treatments, refer to Sect. 6.​7.

5.3.1 Nocebo Effect

In a strict sense, a nocebo reaction refers to undesirable effects a subject experiences after receiving an inert dummy drug or placebo. Nocebo reactions are not chemically generated and are due only to the subject’s pessimistic belief and expectation that treatment will produce negative consequences. In a wider sense, the term is being increasingly used for unexpected negative reactions to an active drug.

The term nocebo (from Latin for I will harm) was originally coined in 1961 by W. Kennedy for the counterpart of placebo (from Latin for I will please), which refers to desirable effects a subject experiences after receiving an inert dummy drug. In both cases, there is no real pharmacologically active substance involved, but the actual negative or positive consequences, resp., of the administration of the drug, which may be physiological, behavioral, emotional, or cognitive, are nonetheless real. Kennedy emphasized that his specific usage of the term nocebo does not refer to the iatrogenic action of the drug but insisted that a nocebo reaction is subject centered and that the term nocebo reaction specifically refers to a ­quality inherent in the patient rather than in the drug. Kennedy was precisely speaking of an outcome that is totally generated by a subject’s negative expectation of a drug administration and is the exact counterpart of a placebo response that would be generated by a subject’s positive expectation.

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The influence of the prescribing physician should be kept in mind, since inspiring confidence versus skepticism and fear clearly impacts the outcome of treatment.

Finally, some patients with somatoform disorder and specific personality disorders, for example, anxious, negativistic, histrionic, or paranoid, are more prone to nocebo reactions and should be recognized as such.

5.4 Hair Prosthesis

A hair or cranial prosthesis is a custom-made wig specifically designed for patients who have lost their hair as a result of medical conditions or treatments, such as alopecia totalis, trichotillomania, chemotherapy, or any other clinical disease or treatment resulting in hair loss. The terminology is used when applying for medical insurance or tax deduction status.

Physicians have been prescribing these prostheses since the 1950s. Cranial prostheses do not only have the purpose to disguise hair loss but also help to protect the unprotected scalp from the sun and to regulate body temperature.

Many of the manufacturers today are designing excellent high-quality wigs that provide comfortable caps, high-quality synthetic fibers, durable human hair, and special materials to achieve a secure fit. Many of these products will be extremely light weight and have a very natural appearance.

While wigs cover the whole head, hair pieces (Fig. 5.3a–b) and hair integrations (Fig. 5.3c–e) intend to complement the proper hair.

Fig. 5.3

(a–e) Prosthesis. (a, b) Hair piece in a patient with frontal fibrosing alopecia. (c–e) Hair integration in a patient with vertex alopecia

Suggested Reading

Rawson E (1982) The life and death of Asclepiades of Bithynia. Class Q 32:358–370PubMedCrossRef

Listening to the Patient

Bergler R (2003) Haare und Psyche. In: Trüeb RM (ed) Haare. Praxis der Trichologie. Steinkopff, Darmstadt, p 11

Cash TF (1999) The psychosocial consequences of androgenetic alopecia: a review of the research literature. Br J Dermatol 141:398–405PubMedCrossRef

Cash TF, Price VH, Savin RC (1993) Psychological effects of androgenetic alopecia on women: comparisons with balding men and with female control ­subjects. J Am Acad Dermatol 29:569–575

Neumann M, Scheffer C, Tauschel D, Lutz G, Wirtz M, Edelhäuser F (2012) Physician empathy: definition, outcome-relevance and its measurement in patient care and medical education. GMS Z Med Ausbild 29:Doc11PubMedCentralPubMed

Teutsch C (2003) Patient-doctor communication. Med Clin North Am 87:1115–1145PubMedCrossRef

Adjustment Disorders

Brosig B, Kupfer J, Niemeier V et al (2001) The “Dorian Gray Syndrome”: psychodynamic need for hair growth restorers and, other “fountains of youth”. Int J Clin Pharmacol Ther 39:279–283PubMedCrossRef

Cash TF, Price VH, Savin RC (1993) Psychological effects of androgenetic alopecia on women: comparisons with balding men and with female control ­subjects. J Am Acad Dermatol 29:569–575

Cotterill JA (1996) Body dysmorphic disorder. Dermatol Clin 14:457–463PubMedCrossRef

Eckert G (1975) Diffuse hair loss and psychiatric disturbance. Acta Dermatol Venereol (Stockh) 55:147–149

Maffei C, Fossatti A, Rinaldi F et al (1994) Personality disorders and psychopathologic symptoms in patients with androgenetic alopecia. Arch Dermatol 130:868–872PubMedCrossRef

Tackling Side Effects

Baibergenova A, Walsh S (2012) Use of pioglitazone in patients with lichen planopilaris. J Cutan Med Surg 16:97–100PubMed

Georgala S, Befon A, Maniatopoulou E, Georgala C (2007) Topical use of minoxidil in children and systemic side effects. Dermatology 214:101–102PubMedCrossRef

Kennedy WP (1961) The nocebo reaction. Med World 95:203–205PubMed

Mirmirani P, Karnik P (2009) Lichen planopilaris treated with a peroxisome proliferator-activated receptor gamma agonist. Arch Dermatol 145:1363–1366PubMedCentralPubMedCrossRef

Navarini AA, Ziegler M, Kolm I et al (2010) Minoxidil-induced trichostasis spinulosa of terminal hair. Arch Dermatol 146:1434–1435PubMed

Hair Prosthesis

Delamere FM, Sladden MM, Dobbins HM, Leonardi-Bee J (2008) Interventions for alopecia areata. Cochrane Database Syst Rev. (2):CD004413

Vandegrift KV (1994) The development of an oncology alopecia wig program. J Intraven Nurs 17:78–82PubMed

[No authors listed] Wig madness (1970) N Engl J Med 282:567–568