D o you have the ability to be part psychologist and part pathologist while at the same time being an extremely detail-oriented dermatologist? If so, then treating patients with hair disorders might just be the subspecialty for you. Detecting hair disorders can be tricky — often the presentation of hair loss can be subtle, and inflammation, if present, is not as obvious as in other parts of the skin. In addition, treating hair and scalp entities may be frustrating because the presence of hair in the affected area acts as a barrier, preventing adequate topical treatment. A person who decides to specialize in this area must have a strong interest in biology of hair growth and pathology of the hair follicle, and a desire to work with patients who are often distraught about their condition. The person who selects this field of practice must also be attentive to detail because clinical diagnoses often vary only minimally with regard to hair disorders. Emerging Subspecialty The discovery of the role of 5-alpha-reductase as a pivotal enzyme in the dihydrotestosterone pathway ignited the field of hair disorders in the early 1990s. The formulation of the 1-mg dosage of finasteride to treat male pattern hair loss and the release of 5% minoxidil solution allowed physicians to understand and treat large numbers of patients with androgenetic alopecia. Popularity of the subspecialty was carried further by advances in scalp biopsy techniques and surgical hair restoration techniques. Those clinicians with talents in these areas naturally gravitated to the field of hair disorders where so little was known. As the specialty developed, special interest groups of dermatologists and researchers within the specialty took shape. Groups particularly concerned with specific hair disorders (hair loss in non-scarring alopecia, alopecia areata, scarring hair loss, hair loss in patients of color, and research in these and other areas) were born and continue to gain momentum. As with many dermatologic subspecialties, the increased interest has led to a trickle-down interest in dermatologic residents and medical students who are taking the subspecialty to new heights. With all of this said, treating patients’ hair disorders is an exciting area of practice. Here’s what it takes to get involved in this subspecialty area. Gaining Expertise The training for those interested in hair diseases begins with a residency in dermatology. Those interested should be drawn to dermatopathology as hair disease primarily consists of scarring and non-scarring varieties. Most primary scarring diseases are inflammatory in origin and knowledge of pathology can be very useful. In fact, many hair specialists are board certified as dermatopathologists. Most hair specialists practice at academic medical centers in order to have access to the most current pathologic evaluations, important research on hair loss, and other dermatologic specialists with complementary interests (for example, rheumatologic disease and psoriasis to name a couple). The different avenues of specialty in hair disorders can be divided into two routes: clinical and basic research. For those interested in a clinical track and who have little exposure to hair diseases in their residency, higher levels of training are mandatory. A several month block after residency can be spent with one of the experts in the United States or internationally. Fellowship training is also an option for those who would like a more structured experience, though there are very few full year fellowships in the United States and there is no accreditation associated with these fellowships. Fellowships are usually 1 to 2 years long with a concentration on all clinical aspects of hair disorders, clinical and/or basic research, and often additional procedural specialties, such as laser hair removal or hair transplantation. If you have had significant exposure to these procedures in residency, elective rotations during the fourth year of residency may be all that is required as a means to supplement training. Most hair specialists also direct a research unit where clinical pharmaceutical studies are conducted. This usually begins as a natural process because of the easy access to patient bases in these practices. If you’re interested in this option, seek to gain a basic knowledge of epidemiology and statistical analysis as this helps in conducting research. Directing clinical studies may also be something that’s learned in a fellowship arrangement with extensive exposure to research or, if desired, this can be a separate course of formal study in a masters or doctorate program. Anoth-er aspect of training is in-volvement in national organizations that are focused on hair research. The main organization within the United States is the North American Hair Research Society. Other organizations that may provide research support include: American Society for Laser Medicine and Surgery, The Dermatology Foundation and the National Institutes of Health. Other hair research societies exist around the world in Australia, Europe and Asia, for example. Participation in the meetings and activities sponsored by these societies is useful in learning more about hair disease through presentation of the latest technologies and data. Another organization that supports hair disorder research is the National Alopecia Areata Foundation. This organization has many arms of interest in patient support and research, but one of the latest goals of the organization has been to establish a database of patients with alopecia areata, the Alopecia Areata Patient Registry, which is an effort to register affected patients across the nation to better understand the nature of the disease in a large cross-section of the country, and to potentially utilize the collected data to design clinical trials. This program heavily relies on dermatologists from all over the country to identify potential study participants and connect them with the registry. For those interested in basic science research, the individual should tour research departments with active research in the field of hair or the hair follicle or begin a basic science unit with a focus on hair research. Favorable aspects of a basic science department include a strong clinical department, which would support translational research. Possible options include, but are not limited to, the study of pathology of the hair follicle, pathophysiology of hair disease in animal models, genetic translational experiments, and cellular mechanism research. Advanced training in research theory via a masters or doctorate can be very useful in this path. Providing Services in a Clinical Setting Two possible options for working in the clinical hair specialty exist. The first involves clinic operation, and the second involves establishing a clinical research unit. The units are symbiotic and flow nicely for those who want the flexibility and variety of both clinical work and research challenges. Clinic Operations. The supplies needed are a camera to record the progression of disease, and a microscope to evaluate hair shaft abnormalities and perform routine microscopic staining procedures to diagnose fungal and bacterial diseases. Together, these equipment needs should cost less than $2,000. Another important aspect of successful clinic operations is access to the services of a good dermatopathologist for evaluating scalp biopsies. Access to electron microscopy services is also helpful for hair shaft abnormalities. The amount of personnel needed for a hair disorders clinic is the same as you’d need for the usual staff of an outpatient dermatology clinic. As for paperwork needed in clinic, an intake questionnaire is vital. This can be mailed to the patient before the appointment or given to the patient at the time of his or her first appointment. Historical data that are important to collect include haircare history, history of systemic illness, past medical history and personal and family hair histories. Additionally, it’s important to have brochures or patient literature available for patients to provide a quick review of the most common hair disorders and their treatments. These kinds of handouts often calm patients. Excellent patient brochures on select hair topics are available from the American Academy of Dermatology, the National Psoriasis Foundation and the National Alopecia Areata Foundation. Clinical Research Unit. The other option in the area of hair disease special interest is the establishment of a research unit that performs clinical pharmaceutical studies. These studies often focus on androgenetic alopecia, hirsutism, scalp psoriasis, seborrheic dermatitis and tinea capitis. In terms of personnel, at least one person in the role of clinical study coordinator is needed. This person focuses on the following aspects of running a clinical trial: recruitment, advertisement and the basic clinical organization of the research unit. A nurse is also needed for evaluating patients’ blood pressure, drawing blood and administering medications in the unit. To ensure that research activities don’t impinge on the clinical activities, a separate space is often useful for the research unit. The unit must be in a location where study participants can be easily recruited. This requirement would exclude extremely rural areas since the distance traveled for each research-related visit may prove prohibitive. As for supplies for the clinical research unit, computer software that collects patient and photographic data is important. A camera (digital or 35 mm) with the ability to take close-up and distant scalp and hair photos is a must. In addition, you’ll need a movable tripod fit for the camera. A small lab is also required where blood draws and urine can be centrifuged and then sent to a reference lab. At times, a microscope will be necessary to examine specimens for qualification of a study, such as potassium hydroxide prep. Reimbursement Issues As far as coding is concerned, the most common codes used for hair disorders are those for new and return patient visits, biopsies and corticosteroid injections. The diagnosis codes include the following: • 704.00 generalized hair loss • 704.01 alopecia areata • 704.09 scarring alopecia • 704.1 hirsutism and hypertrichiosis. Generally, the best advice is to use codes more specific than the one for generalized hair loss. For example, you should code for lichenplanopilaris using both the scarring hair loss and the lichen planus codes. Because many insurance companies tend to view dermatologic diagnoses as cosmetic, it’s best to document the details. Most hair specialists don’t bill for the microscopic exams they perform because a facility must be approved under the clinical laboratory improvement amendment (CLIA). This approval process can cost thousands of dollars and isn’t always worth the effort, as it is unlikely the practice will break-even on the investment without very large patient volumes. When laser hair removal and hair replacement are a part of the clinical endeavor, personal payment without a third-party payer is usually the norm. Many dermatologists use these cosmetic services as a way to complete their patients’ needs, to supplement research, or to pay for extra staff in order to keep the office running efficiently. If you choose to add these services, you’ll need to plan for extra, specific training for both of these procedures, although the residency programs with large cosmetic units may train residents to have baseline knowledge and first-hand experience. One weekend-long course for those not familiar with these procedures won’t suffice. If you’re going to add laser hair removal procedures, aim to learn about laser safety, develop hands-on experience, and have a knowledge of laser physics. Similarly, hair transplantation is an art that requires a number of hours of significant hands-on practice. Now that there are many freestanding laser hair removal clinics run by non-dermatologists, the market for each geographic area must be researched before making a large purchase like a laser. As for hair transplantation, special training will likely be necessary for staff as well. The procedure relies heavily on assistants, so at least one dedicated nurse with excellent dexterity is required to run a hair transplant unit. Laser equipment is usually expensive, so knowledge of the patient-base to be treated is imperative. For example, if you have a diverse patient population, you might consider buying two lasers for hair removal, one for treating patients with deeply pigmented skin and a separate one for patients with lighter complexions. You might want to hold off on these purchases until the clinic is up and running. Choosing this Area of Practice Treating patients with hair disorders can be a very rewarding area of practice. Patients are grateful to have practitioners available who are skilled in this field. If you have the interest in this area of practice, equipment requirements are minimal, specialized training is essential, and also important is to choose a place to practice in which you will find a high volume of patients who need your services.
Adding a Subspecialty with EaseSpotlight on: Hair Disorders
D o you have the ability to be part psychologist and part pathologist while at the same time being an extremely detail-oriented dermatologist? If so, then treating patients with hair disorders might just be the subspecialty for you. Detecting hair disorders can be tricky — often the presentation of hair loss can be subtle, and inflammation, if present, is not as obvious as in other parts of the skin. In addition, treating hair and scalp entities may be frustrating because the presence of hair in the affected area acts as a barrier, preventing adequate topical treatment. A person who decides to specialize in this area must have a strong interest in biology of hair growth and pathology of the hair follicle, and a desire to work with patients who are often distraught about their condition. The person who selects this field of practice must also be attentive to detail because clinical diagnoses often vary only minimally with regard to hair disorders. Emerging Subspecialty The discovery of the role of 5-alpha-reductase as a pivotal enzyme in the dihydrotestosterone pathway ignited the field of hair disorders in the early 1990s. The formulation of the 1-mg dosage of finasteride to treat male pattern hair loss and the release of 5% minoxidil solution allowed physicians to understand and treat large numbers of patients with androgenetic alopecia. Popularity of the subspecialty was carried further by advances in scalp biopsy techniques and surgical hair restoration techniques. Those clinicians with talents in these areas naturally gravitated to the field of hair disorders where so little was known. As the specialty developed, special interest groups of dermatologists and researchers within the specialty took shape. Groups particularly concerned with specific hair disorders (hair loss in non-scarring alopecia, alopecia areata, scarring hair loss, hair loss in patients of color, and research in these and other areas) were born and continue to gain momentum. As with many dermatologic subspecialties, the increased interest has led to a trickle-down interest in dermatologic residents and medical students who are taking the subspecialty to new heights. With all of this said, treating patients’ hair disorders is an exciting area of practice. Here’s what it takes to get involved in this subspecialty area. Gaining Expertise The training for those interested in hair diseases begins with a residency in dermatology. Those interested should be drawn to dermatopathology as hair disease primarily consists of scarring and non-scarring varieties. Most primary scarring diseases are inflammatory in origin and knowledge of pathology can be very useful. In fact, many hair specialists are board certified as dermatopathologists. Most hair specialists practice at academic medical centers in order to have access to the most current pathologic evaluations, important research on hair loss, and other dermatologic specialists with complementary interests (for example, rheumatologic disease and psoriasis to name a couple). The different avenues of specialty in hair disorders can be divided into two routes: clinical and basic research. For those interested in a clinical track and who have little exposure to hair diseases in their residency, higher levels of training are mandatory. A several month block after residency can be spent with one of the experts in the United States or internationally. Fellowship training is also an option for those who would like a more structured experience, though there are very few full year fellowships in the United States and there is no accreditation associated with these fellowships. Fellowships are usually 1 to 2 years long with a concentration on all clinical aspects of hair disorders, clinical and/or basic research, and often additional procedural specialties, such as laser hair removal or hair transplantation. If you have had significant exposure to these procedures in residency, elective rotations during the fourth year of residency may be all that is required as a means to supplement training. Most hair specialists also direct a research unit where clinical pharmaceutical studies are conducted. This usually begins as a natural process because of the easy access to patient bases in these practices. If you’re interested in this option, seek to gain a basic knowledge of epidemiology and statistical analysis as this helps in conducting research. Directing clinical studies may also be something that’s learned in a fellowship arrangement with extensive exposure to research or, if desired, this can be a separate course of formal study in a masters or doctorate program. Anoth-er aspect of training is in-volvement in national organizations that are focused on hair research. The main organization within the United States is the North American Hair Research Society. Other organizations that may provide research support include: American Society for Laser Medicine and Surgery, The Dermatology Foundation and the National Institutes of Health. Other hair research societies exist around the world in Australia, Europe and Asia, for example. Participation in the meetings and activities sponsored by these societies is useful in learning more about hair disease through presentation of the latest technologies and data. Another organization that supports hair disorder research is the National Alopecia Areata Foundation. This organization has many arms of interest in patient support and research, but one of the latest goals of the organization has been to establish a database of patients with alopecia areata, the Alopecia Areata Patient Registry, which is an effort to register affected patients across the nation to better understand the nature of the disease in a large cross-section of the country, and to potentially utilize the collected data to design clinical trials. This program heavily relies on dermatologists from all over the country to identify potential study participants and connect them with the registry. For those interested in basic science research, the individual should tour research departments with active research in the field of hair or the hair follicle or begin a basic science unit with a focus on hair research. Favorable aspects of a basic science department include a strong clinical department, which would support translational research. Possible options include, but are not limited to, the study of pathology of the hair follicle, pathophysiology of hair disease in animal models, genetic translational experiments, and cellular mechanism research. Advanced training in research theory via a masters or doctorate can be very useful in this path. Providing Services in a Clinical Setting Two possible options for working in the clinical hair specialty exist. The first involves clinic operation, and the second involves establishing a clinical research unit. The units are symbiotic and flow nicely for those who want the flexibility and variety of both clinical work and research challenges. Clinic Operations. The supplies needed are a camera to record the progression of disease, and a microscope to evaluate hair shaft abnormalities and perform routine microscopic staining procedures to diagnose fungal and bacterial diseases. Together, these equipment needs should cost less than $2,000. Another important aspect of successful clinic operations is access to the services of a good dermatopathologist for evaluating scalp biopsies. Access to electron microscopy services is also helpful for hair shaft abnormalities. The amount of personnel needed for a hair disorders clinic is the same as you’d need for the usual staff of an outpatient dermatology clinic. As for paperwork needed in clinic, an intake questionnaire is vital. This can be mailed to the patient before the appointment or given to the patient at the time of his or her first appointment. Historical data that are important to collect include haircare history, history of systemic illness, past medical history and personal and family hair histories. Additionally, it’s important to have brochures or patient literature available for patients to provide a quick review of the most common hair disorders and their treatments. These kinds of handouts often calm patients. Excellent patient brochures on select hair topics are available from the American Academy of Dermatology, the National Psoriasis Foundation and the National Alopecia Areata Foundation. Clinical Research Unit. The other option in the area of hair disease special interest is the establishment of a research unit that performs clinical pharmaceutical studies. These studies often focus on androgenetic alopecia, hirsutism, scalp psoriasis, seborrheic dermatitis and tinea capitis. In terms of personnel, at least one person in the role of clinical study coordinator is needed. This person focuses on the following aspects of running a clinical trial: recruitment, advertisement and the basic clinical organization of the research unit. A nurse is also needed for evaluating patients’ blood pressure, drawing blood and administering medications in the unit. To ensure that research activities don’t impinge on the clinical activities, a separate space is often useful for the research unit. The unit must be in a location where study participants can be easily recruited. This requirement would exclude extremely rural areas since the distance traveled for each research-related visit may prove prohibitive. As for supplies for the clinical research unit, computer software that collects patient and photographic data is important. A camera (digital or 35 mm) with the ability to take close-up and distant scalp and hair photos is a must. In addition, you’ll need a movable tripod fit for the camera. A small lab is also required where blood draws and urine can be centrifuged and then sent to a reference lab. At times, a microscope will be necessary to examine specimens for qualification of a study, such as potassium hydroxide prep. Reimbursement Issues As far as coding is concerned, the most common codes used for hair disorders are those for new and return patient visits, biopsies and corticosteroid injections. The diagnosis codes include the following: • 704.00 generalized hair loss • 704.01 alopecia areata • 704.09 scarring alopecia • 704.1 hirsutism and hypertrichiosis. Generally, the best advice is to use codes more specific than the one for generalized hair loss. For example, you should code for lichenplanopilaris using both the scarring hair loss and the lichen planus codes. Because many insurance companies tend to view dermatologic diagnoses as cosmetic, it’s best to document the details. Most hair specialists don’t bill for the microscopic exams they perform because a facility must be approved under the clinical laboratory improvement amendment (CLIA). This approval process can cost thousands of dollars and isn’t always worth the effort, as it is unlikely the practice will break-even on the investment without very large patient volumes. When laser hair removal and hair replacement are a part of the clinical endeavor, personal payment without a third-party payer is usually the norm. Many dermatologists use these cosmetic services as a way to complete their patients’ needs, to supplement research, or to pay for extra staff in order to keep the office running efficiently. If you choose to add these services, you’ll need to plan for extra, specific training for both of these procedures, although the residency programs with large cosmetic units may train residents to have baseline knowledge and first-hand experience. One weekend-long course for those not familiar with these procedures won’t suffice. If you’re going to add laser hair removal procedures, aim to learn about laser safety, develop hands-on experience, and have a knowledge of laser physics. Similarly, hair transplantation is an art that requires a number of hours of significant hands-on practice. Now that there are many freestanding laser hair removal clinics run by non-dermatologists, the market for each geographic area must be researched before making a large purchase like a laser. As for hair transplantation, special training will likely be necessary for staff as well. The procedure relies heavily on assistants, so at least one dedicated nurse with excellent dexterity is required to run a hair transplant unit. Laser equipment is usually expensive, so knowledge of the patient-base to be treated is imperative. For example, if you have a diverse patient population, you might consider buying two lasers for hair removal, one for treating patients with deeply pigmented skin and a separate one for patients with lighter complexions. You might want to hold off on these purchases until the clinic is up and running. Choosing this Area of Practice Treating patients with hair disorders can be a very rewarding area of practice. Patients are grateful to have practitioners available who are skilled in this field. If you have the interest in this area of practice, equipment requirements are minimal, specialized training is essential, and also important is to choose a place to practice in which you will find a high volume of patients who need your services.
D o you have the ability to be part psychologist and part pathologist while at the same time being an extremely detail-oriented dermatologist? If so, then treating patients with hair disorders might just be the subspecialty for you. Detecting hair disorders can be tricky — often the presentation of hair loss can be subtle, and inflammation, if present, is not as obvious as in other parts of the skin. In addition, treating hair and scalp entities may be frustrating because the presence of hair in the affected area acts as a barrier, preventing adequate topical treatment. A person who decides to specialize in this area must have a strong interest in biology of hair growth and pathology of the hair follicle, and a desire to work with patients who are often distraught about their condition. The person who selects this field of practice must also be attentive to detail because clinical diagnoses often vary only minimally with regard to hair disorders. Emerging Subspecialty The discovery of the role of 5-alpha-reductase as a pivotal enzyme in the dihydrotestosterone pathway ignited the field of hair disorders in the early 1990s. The formulation of the 1-mg dosage of finasteride to treat male pattern hair loss and the release of 5% minoxidil solution allowed physicians to understand and treat large numbers of patients with androgenetic alopecia. Popularity of the subspecialty was carried further by advances in scalp biopsy techniques and surgical hair restoration techniques. Those clinicians with talents in these areas naturally gravitated to the field of hair disorders where so little was known. As the specialty developed, special interest groups of dermatologists and researchers within the specialty took shape. Groups particularly concerned with specific hair disorders (hair loss in non-scarring alopecia, alopecia areata, scarring hair loss, hair loss in patients of color, and research in these and other areas) were born and continue to gain momentum. As with many dermatologic subspecialties, the increased interest has led to a trickle-down interest in dermatologic residents and medical students who are taking the subspecialty to new heights. With all of this said, treating patients’ hair disorders is an exciting area of practice. Here’s what it takes to get involved in this subspecialty area. Gaining Expertise The training for those interested in hair diseases begins with a residency in dermatology. Those interested should be drawn to dermatopathology as hair disease primarily consists of scarring and non-scarring varieties. Most primary scarring diseases are inflammatory in origin and knowledge of pathology can be very useful. In fact, many hair specialists are board certified as dermatopathologists. Most hair specialists practice at academic medical centers in order to have access to the most current pathologic evaluations, important research on hair loss, and other dermatologic specialists with complementary interests (for example, rheumatologic disease and psoriasis to name a couple). The different avenues of specialty in hair disorders can be divided into two routes: clinical and basic research. For those interested in a clinical track and who have little exposure to hair diseases in their residency, higher levels of training are mandatory. A several month block after residency can be spent with one of the experts in the United States or internationally. Fellowship training is also an option for those who would like a more structured experience, though there are very few full year fellowships in the United States and there is no accreditation associated with these fellowships. Fellowships are usually 1 to 2 years long with a concentration on all clinical aspects of hair disorders, clinical and/or basic research, and often additional procedural specialties, such as laser hair removal or hair transplantation. If you have had significant exposure to these procedures in residency, elective rotations during the fourth year of residency may be all that is required as a means to supplement training. Most hair specialists also direct a research unit where clinical pharmaceutical studies are conducted. This usually begins as a natural process because of the easy access to patient bases in these practices. If you’re interested in this option, seek to gain a basic knowledge of epidemiology and statistical analysis as this helps in conducting research. Directing clinical studies may also be something that’s learned in a fellowship arrangement with extensive exposure to research or, if desired, this can be a separate course of formal study in a masters or doctorate program. Anoth-er aspect of training is in-volvement in national organizations that are focused on hair research. The main organization within the United States is the North American Hair Research Society. Other organizations that may provide research support include: American Society for Laser Medicine and Surgery, The Dermatology Foundation and the National Institutes of Health. Other hair research societies exist around the world in Australia, Europe and Asia, for example. Participation in the meetings and activities sponsored by these societies is useful in learning more about hair disease through presentation of the latest technologies and data. Another organization that supports hair disorder research is the National Alopecia Areata Foundation. This organization has many arms of interest in patient support and research, but one of the latest goals of the organization has been to establish a database of patients with alopecia areata, the Alopecia Areata Patient Registry, which is an effort to register affected patients across the nation to better understand the nature of the disease in a large cross-section of the country, and to potentially utilize the collected data to design clinical trials. This program heavily relies on dermatologists from all over the country to identify potential study participants and connect them with the registry. For those interested in basic science research, the individual should tour research departments with active research in the field of hair or the hair follicle or begin a basic science unit with a focus on hair research. Favorable aspects of a basic science department include a strong clinical department, which would support translational research. Possible options include, but are not limited to, the study of pathology of the hair follicle, pathophysiology of hair disease in animal models, genetic translational experiments, and cellular mechanism research. Advanced training in research theory via a masters or doctorate can be very useful in this path. Providing Services in a Clinical Setting Two possible options for working in the clinical hair specialty exist. The first involves clinic operation, and the second involves establishing a clinical research unit. The units are symbiotic and flow nicely for those who want the flexibility and variety of both clinical work and research challenges. Clinic Operations. The supplies needed are a camera to record the progression of disease, and a microscope to evaluate hair shaft abnormalities and perform routine microscopic staining procedures to diagnose fungal and bacterial diseases. Together, these equipment needs should cost less than $2,000. Another important aspect of successful clinic operations is access to the services of a good dermatopathologist for evaluating scalp biopsies. Access to electron microscopy services is also helpful for hair shaft abnormalities. The amount of personnel needed for a hair disorders clinic is the same as you’d need for the usual staff of an outpatient dermatology clinic. As for paperwork needed in clinic, an intake questionnaire is vital. This can be mailed to the patient before the appointment or given to the patient at the time of his or her first appointment. Historical data that are important to collect include haircare history, history of systemic illness, past medical history and personal and family hair histories. Additionally, it’s important to have brochures or patient literature available for patients to provide a quick review of the most common hair disorders and their treatments. These kinds of handouts often calm patients. Excellent patient brochures on select hair topics are available from the American Academy of Dermatology, the National Psoriasis Foundation and the National Alopecia Areata Foundation. Clinical Research Unit. The other option in the area of hair disease special interest is the establishment of a research unit that performs clinical pharmaceutical studies. These studies often focus on androgenetic alopecia, hirsutism, scalp psoriasis, seborrheic dermatitis and tinea capitis. In terms of personnel, at least one person in the role of clinical study coordinator is needed. This person focuses on the following aspects of running a clinical trial: recruitment, advertisement and the basic clinical organization of the research unit. A nurse is also needed for evaluating patients’ blood pressure, drawing blood and administering medications in the unit. To ensure that research activities don’t impinge on the clinical activities, a separate space is often useful for the research unit. The unit must be in a location where study participants can be easily recruited. This requirement would exclude extremely rural areas since the distance traveled for each research-related visit may prove prohibitive. As for supplies for the clinical research unit, computer software that collects patient and photographic data is important. A camera (digital or 35 mm) with the ability to take close-up and distant scalp and hair photos is a must. In addition, you’ll need a movable tripod fit for the camera. A small lab is also required where blood draws and urine can be centrifuged and then sent to a reference lab. At times, a microscope will be necessary to examine specimens for qualification of a study, such as potassium hydroxide prep. Reimbursement Issues As far as coding is concerned, the most common codes used for hair disorders are those for new and return patient visits, biopsies and corticosteroid injections. The diagnosis codes include the following: • 704.00 generalized hair loss • 704.01 alopecia areata • 704.09 scarring alopecia • 704.1 hirsutism and hypertrichiosis. Generally, the best advice is to use codes more specific than the one for generalized hair loss. For example, you should code for lichenplanopilaris using both the scarring hair loss and the lichen planus codes. Because many insurance companies tend to view dermatologic diagnoses as cosmetic, it’s best to document the details. Most hair specialists don’t bill for the microscopic exams they perform because a facility must be approved under the clinical laboratory improvement amendment (CLIA). This approval process can cost thousands of dollars and isn’t always worth the effort, as it is unlikely the practice will break-even on the investment without very large patient volumes. When laser hair removal and hair replacement are a part of the clinical endeavor, personal payment without a third-party payer is usually the norm. Many dermatologists use these cosmetic services as a way to complete their patients’ needs, to supplement research, or to pay for extra staff in order to keep the office running efficiently. If you choose to add these services, you’ll need to plan for extra, specific training for both of these procedures, although the residency programs with large cosmetic units may train residents to have baseline knowledge and first-hand experience. One weekend-long course for those not familiar with these procedures won’t suffice. If you’re going to add laser hair removal procedures, aim to learn about laser safety, develop hands-on experience, and have a knowledge of laser physics. Similarly, hair transplantation is an art that requires a number of hours of significant hands-on practice. Now that there are many freestanding laser hair removal clinics run by non-dermatologists, the market for each geographic area must be researched before making a large purchase like a laser. As for hair transplantation, special training will likely be necessary for staff as well. The procedure relies heavily on assistants, so at least one dedicated nurse with excellent dexterity is required to run a hair transplant unit. Laser equipment is usually expensive, so knowledge of the patient-base to be treated is imperative. For example, if you have a diverse patient population, you might consider buying two lasers for hair removal, one for treating patients with deeply pigmented skin and a separate one for patients with lighter complexions. You might want to hold off on these purchases until the clinic is up and running. Choosing this Area of Practice Treating patients with hair disorders can be a very rewarding area of practice. Patients are grateful to have practitioners available who are skilled in this field. If you have the interest in this area of practice, equipment requirements are minimal, specialized training is essential, and also important is to choose a place to practice in which you will find a high volume of patients who need your services.
