A Comment on Mercantilism in the Trichological Sciences

ABSTRACT

A quasi-scientific interest in hair loss and hair care originated in a London barbershop, and became known as trichology, with the Institute of Trichologists being founded. Other corporations successively followed, offering paid courses by home-study for training of initiates who desire more knowledge about hair. Trichologists are not medically qualified but are taught the practice of care and treatment of the hair and scalp in health and disease within their restricted but specialized role. With the advent of opportunities in the social media, and of epiluminiscence microscopy, a procedure practiced by the guild of trichologists long before its nominal introduction as trichoscopy into dermatologic practice, representatives of the medical profession are following the example of the trichologists in offering online courses, though with a better understanding of clinical-pathological correlations based on their academic learning. Despite the enthusiasm emerging with its establishment as a dermatologic tool in the diagnosis of hair and scalp disorders, caution is warranted not to elevate trichoscopy to something like a fetish status. As a diagnostic procedure, trichoscopy is to be understood as representing an integral part of a comprehensive dermatological examination. The Hippocratic Oath is one of the oldest binding documents in history, allegedly still held sacred by physicians: to treat the ill to the best of one’s ability, to preserve a patient’s privacy, and to teach the secrets of medicine to the next generation without fee. And yet, as in no other field of medicine, paid online courses on trichoscopy are flourishing and with a primary commercial aim. However, dermato-trichology, or trichiatry require the same due diligence as any other medical discipline, with respect to its practice and its ethics. Medical artistry is neither reducible to a single hand-held diagnostic technique nor is it negotiable.

INTRODUCTION

The first genuine scientific studies on hair probably began when English natural philosopher and polymath Robert Hooke (1635–1703) studied the hair shaft under the microscope, Italian biologist and physician Marcello Malphighi (1628–1694) described the anatomy of the hair follicle in his treatise “De pilis observationes” and German medical student Johann Dieffenbach (1792–1847) demonstrated that it was possible to transplant hair from a hair-bearing to a non-hair bearing area in his medical thesis “Nonnulla de regeneratione et transplantatione” (1822). However, the biology of hair growth was not understood at this time. In search of information to engage in the development of hair growth-promoting agents, makers of cosmetics turned to the medical faculty and received only vague indications. When questioned, doctors remained evasive. Meanwhile, snake oil vendors were as ineffectual as their physician colleagues but significantly more audacious. French chemist Antoine Laurent de Lavoisier (1743–1794) urged for some control but was ignored, and French doctor August Caron, who published in 1806 an “Encyclopedia of Beauty” (“Toilette des dames ou Encyclopédie de la beauté”), warned the women of his time against the risks of products of obscure origin after a wretched woman had been driven to madness after using a tonic called “Eau de Chine.”

In ca. 1860, a quasi-scientific interest in hair loss and hair care originated in a London barbershop under a self-styled Professor Wheeler and became known as trichology, with the Institute of Trichologists being founded. Other corporations successively followed internationally, offering paid courses by home-study for the training of initiates internationally who desire more knowledge about hair. Trichologists are not medically qualified but are taught the practice of care and treatment of the human hair and scalp in health and disease within their restricted but specialized role.[1] However, there have been criticisms regarding the role of trichologists who monopolize publicity and proliferate in the high street, versus the board-certified dermatologists following medical ethics in the practice and advertisement of their profession.

It was against this backdrop that in 2010, Professor Patrick Yesudian from India proposed the term dermato-trichologist for board-certified dermatologists dealing with the scientific study of the hair and scalp in health and disease, to distinguish them from the trichologists, who are not medically qualified and more involved with the cosmetic aspects of hair, and therefore basically ineffective in the treatment of medical conditions.[2]

Ultimately, the term trichiatry was proposed to designate the strictly medical professional dealing with the hair and scalp in health and disease. Trichiatrists differ from trichologists by virtue of being physicians. The quality and stringency of their graduate medical training as well as of their ethics of conduct are identical to that of other physicians.[3]

DEFINING THE PROBLEM

By definition, mercantilism refers to the belief in the benefits of profitable trading and represents the economic theory that trade generates wealth and is stimulated by the accumulation of profitable balances, which an administrative institution should encourage by means of protectionism.

The more the care and arrangement of an 18^th century Frenchwoman’s hair gained attention, the more impostors appeared on the scene whose exploits grew constantly more outrageous. In the late 18^th and early 19^th centuries, France held the monopoly for miraculous elixirs for hair growth and quality. It exported to America its “Eau de Ninon de L’enclos”, named after a beautiful courtesan whom had preserved her hair to the age of 85.

With the advent of opportunities in the social media, and of epiluminiscence microscopy, a procedure practiced by the guild of trichologists long before its nominal introduction by Rudnicka et al. as trichoscopy into dermatologic practice in 2006,[4] representatives of the medical profession are following the example of the trichologists in offering online courses, though with a better understanding of clinical-pathological correlations based on their academic learning.

REVISITING MEDICAL ETHICS

The Hippocratic Oath [Figure 1] is one of the oldest binding documents in history, allegedly still held sacred by physicians: To treat the ill to the best of one’s ability, to preserve a patient’s privacy, and to teach the secrets of medicine to the next generation without fee.[5]

Figure 1.

Hippocratic Oath. In ancient Greek, silverwork, contemporary. From the author’s desk

And yet, as in no other field of medicine, paid online courses on trichoscopy and on trichology are flourishing internationally and with a primary commercial aim, irrespective of medical ethics and principles. Short of peer-review, they disseminate eminence-based skills in public, not respecting the fact that these usually represent opinions of authorities based on their particular clinical experience and understanding rather than evidence-based medicine.

Ultimately, evidence-based medicine aims for the ideal that healthcare professionals should make conscientious, explicit, and judicious use of the best available evidence gained from the scientific method to clinical decision-making. It seeks to assess the strength of the evidence of risks and benefits of diagnostic tests and treatments, using techniques from science, engineering, and statistics, such as the systematic review of medical literature, meta-analysis, risk-benefit analysis, and randomized controlled trials.

Finally, as with any medical problem, a patient complaining of hair loss requires a comprehensive medical history, physical examination, and appropriate laboratory evaluation to identify the cause. By approaching the hair loss patient in a methodical way, commencing with the simplest and easiest to recognize objects, and ascending step by step to the knowledge of the more complex,[6] a final diagnosis can be made as prerequisite to a treatment that is appropriate for that specific condition.

Listening attentively is the most powerful diagnostic procedure in the diagnosis of hair growth disorders: A doctor who takes a careful history reaches a correct diagnosis in 70% of cases. This is far more efficient than all currently available tests and technologies. Touching is the oldest and most effective tool in doctoring. The doctor-patient relationship often changes dramatically with the physical examination (scalp, complete skin, nails, mucous membranes, assessment of the hair part width, hair pull, and hair feathering test). These skills can only be acquired through patient contact.

Particularly trichoscopy has gained popularity as a valuable tool in the differential diagnosis of hair and scalp disorders, but also as a profitable topic for online courses. Despite the enthusiasm emerging with its establishment as a dermatologic tool in the diagnosis of hair and scalp disorders, caution is warranted not to elevate trichoscopy to something like a fetish status within medical practice. As a diagnostic procedure, trichoscopy is to be understood as representing an integral part of a comprehensive dermatological examination. It is imprudent to replace well-tried dermatologic examination procedures with dermoscopy, such as the hair pluck, light microscopic hair shaft analysis, microbiological studies, and scalp biopsy for histopathological examination and direct immunofluorescence studies.[7]

CONCLUSION

In summary, medical trichology, dermato-trichology, or trichiatry requires the same due diligence as any other medical discipline, with respect to its practice and its ethics. Medical artistry is neither reducible to a single hand-held diagnostic technique nor is it negotiable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.