Dr Ingrid Wilson explores the referral options available for aesthetic practitioners confronted with a patient seeking help for hair loss
A full head of hair contributes significantly to the perception of image. Consequently, patients experiencing hair loss can often experience psychological distress impacting significantly on their quality of life.1
Due to strains on the NHS, patients suffering with hair loss may present to aesthetic practitioners seeking a solution, or perhaps they are being treated for other cosmetic concerns but point out their hair loss to their aesthetic practitioner for guidance. The majority of aesthetic practitioners will be able to recognise the common conditions of male and female pattern balding. If the cause is known, and it is not associated with underlying medical conditions, the aesthetic practitioner may be in the ideal position to offer advice, as some hair loss approaches available are also used in skin rejuvenation.
However, there may sometimes be uncertainties in the diagnosis of other causes of hair loss. If the cause of the hair loss is not correctly identified, there is a potential to make the condition worse.2 The underlying causes could range from genetics, nutritional deficiency, disease process, or hair care practices, for example.3,4
Only a minority of aesthetic practitioners are likely to have received detailed training in the diagnosis and management of hair loss, so a point may therefore come when it is necessary to refer to another practitioner. In an ideal world, this practitioner could:
If the aesthetic practitioner has doubts about the diagnosis, there are a range of practitioners working in the private or public sector that are suitable for referral. However, it is very unlikely that all the above issues can be addressed by one type of practitioner. It is therefore important practitioners understand the professional background of each group to ensure that the patient gets the opportunity for correct diagnosis and management.
In the UK, a consultant dermatologist is best placed to diagnose and treat hair loss that is due to medical causes
The GP is in the best position to diagnose common causes of hair loss and should be considered first if you are in doubt about diagnosis. A GP can request investigations (blood tests and mycology for tinea capitis, for example) and diagnose and advise on the likely course of conditions, without a significant financial cost to the patient. They can also refer to dermatologists in the NHS or privately, particularly in cases of severe alopecia areata and potentially scarring (permanent) hair loss conditions.
A crucial role of the GP is recognising and responding to signs and symptoms of possible serious illness. As patients with hair loss are rarely acutely ill, unfortunately hair loss concerns may be considered cosmetic in the context of other diseases. In UK general practice, a typical consultation is scheduled for 10 minutes, and the emphasis would need to be on diagnosis, investigation if needed or referral to a dermatologist. There would simply not be enough time to cover all the practical advice that a patient may be seeking such as nutrition, psychological impact, how to cosmetically camouflage hair loss, what to think about when choosing a wig or discussing hair transplants (which is not routinely available on the NHS).
It’s important to note that although GPs are usually the first point of call, they receive very little training in diagnosing skin and hair loss conditions before they qualify.5,6 Within the current Royal College of General Practitioners’ curriculum for GPs in training, the hair loss competency is described as follows: ‘As a GP you should: identify symptoms that are within the range of normal and require no medical intervention, e.g. age-related changes such as dry skin/hair loss and innocent moles’.7 The curriculum does not refer to the recognition of potentially permanent or scarring forms of hair loss, which need urgent referral to a dermatologist.
At present, there is no subspecialty for hair accreditation for GPs with an extended role in dermatology (GPwER). Hair loss is specifically referred to in guidance for GPwERs as the recognition and holistic management of common dermatoses and their symptoms, including common hair and scalp conditions and recognising when to refer to a dermatologist.8 So, the key difference in basic competency between GPwERs and GPs appears to be recognition of scarring alopecias. GPs and GPwERs may find themselves seeing hair loss patients and as part of reflective practice that is required for appraisal and revalidation, may seek opportunities to learn more about diagnosing and treating hair loss conditions after they qualify.
In the UK, a consultant dermatologist is best placed to diagnose and treat hair loss that is due to medical causes. In the NHS, they receive referrals from GPs. In the private sector, paying patients can be referred to a private dermatologist. Dermatologists have the additional skills of dermoscopy and biopsy (for dermatohistopathology), which is particularly useful in the diagnosis of potentially permanent hair loss conditions (scarring). They are also in a position to prescribe potent medication for some forms of scarring hair loss such as hydroxychloroquine, which GPs are not able to.9 Dermatologists in the UK will treat cases of hair loss within their clinics, but there are currently only a handful of dedicated NHS hair loss clinics, so consequently waiting times can be long. Wigs may also be available from dermatologists, but provision can vary, according to an Alopecia UK report.10 Some of the NHS dermatologists specialising in hair loss can be found on the British Hair and Nail Society website.11 It should be noted that there is some evidence of a lack of confidence in managing ethnic hair among the dermatology community,12 and of delays in seeking the services of a dermatologist in this cohort.13
As waiting times for dermatologists (and GPs in some areas) can be long, patients can become anxious for explanations or solutions, so they may seek consultations with trichologists or other hair loss specialists like hair transplant surgeons.
Trichologists assess, diagnose and treat patients with common hair and scalp problems. These include alopecia (hair loss), dry or excessively greasy hair, head lice, hair breakage and scaly, flaking, greasy or itching scalps. The majority of trichologists in the UK do not have a medical or clinical background with the ability to prescribe, and are therefore not able to prescribe. Many trichologists supply patients with hair and scalp-care products such as medicated shampoos and conditioners as part of the treatment process. However, some controversies exist about the exact remit of their role.14 Some trichologists will also offer additional services such as advice on camouflaging hair loss cosmetically, wigs and hairpieces, or scalp micropigmentation to provide an overall service. Methods such as the use of ultraviolet light, infrared light, or high frequency electrotherapy may be used to assist in treatments. Many trichologists will have experience in hairdressing or wig making and others will even arrange for blood tests as part of their assessment.
The introduction of DNA testing for some forms of hair loss may be available to some trichologists, and this gives the potential to specifically tailor advice – some of which can be lifestyle related and not require a prescription.15 Trichology is also not currently statutorily regulated in the UK.16 That said, these professionals can be a useful resource for patients experiencing hair and scalp problems who may not be able to access a doctor, and importantly they are able to offer more time to discuss how the problem is impacting on the patient and offer clinic based treatments in some circumstances.
In the UK, trichology training is available from a variety of institutions including The Institute of Trichologists, International Association of Trichologists, The Trichological Society, and Trichocare. Each has its own curriculum and varies in the amount of face-to-face exposure with patients.
A market has developed for hair transplant surgery as an instant solution for hair loss, although it should be noted that not all patients are suitable. Hair transplant surgeons can come from a variety of backgrounds including general practice, general surgery and plastic surgery, for example. It is usually assumed that a hair transplant in the UK will be undertaken by a GMC-registered doctor.
However, sometimes it is not always the case. It is always wise to check whether the doctor associated with a hair transplant clinic is on the GMC register before referring.It appears that there are a variety of private providers for hair transplant training and there is not one standardised training route.
As with the cosmetic surgery and non-surgery fields, there is little regulation and oversight of the hair restoration surgery field in the UK.17 In England, hair restoration surgery (hair transplant surgery and prosthetic hair fibre implantation) is within the scope of the Care Quality Commission.18 However, this may not always mean that a medically qualified doctor is performing the surgery on a registered premises.
In Wales, Scotland and Northern Ireland a clinic can be registered but not yet inspected. I would suggest that practitioners refer to a hair transplant surgeon who is a member of associations such as the British Association of Hair Restoration Surgery (BAHRS) or the International Society of Hair Restoration Surgery (ISHRS). Even though being trained as a plastic surgeon isn’t required to be a hair transplant surgeon, the NHS website suggests that people interested should also check the British Association of Plastic Reconstruction and Aesthetic Surgeons (BAPRAS) website to see if the surgeon is a ‘full member’ on the specialist register for plastic surgery.19 Hair transplant surgery also falls under the remit of the Joint Council for Cosmetic Practitioners (JCCP), which has strict training requirements to join its register.20 They may also be registered with the British Association of Dermatologists (BAD) and the Royal College of Surgeons (RCS).
There are a range of partners to refer your patients to for diagnosing and treating hair loss conditions. It is important when choosing a referral partner to be aware of the nature of their training and their limitations to ensure the best care for your patients. Aesthetic practitioners should always refer if they are not trained or skilled in treating hair concerns, and refer before treating if they are not certain of the clinical diagnosis.