15.Miss L told us the Practice refused to refer her to specialists for hair loss. Miss L said she approached the Practice on multiple occasions for help and asked for a specialist referral, but the GP did not provide the appropriate treatment. Miss L said the lack of treatment or referral to specialists led to worsening hair loss and caused her significant distress and anxiety. We are very sorry to learn of how the events have impacted Miss L and understand the importance of her complaint.
16.In the complaint response, the Practice evidenced the different medications it gave Miss L to try and treat the hair loss. It also explained it carried out blood tests to try and clarify what was causing the hair loss. The Practice said that it planned to refer Miss L to specialists if the treatment options in primary care were not having an effect after six months.
17.The Practice explained that the clinicians involved in Miss L’s care had given realistic treatment, timeframes and adhered to all clinical guidelines. It confirmed that it did refer Miss L to specialists in February 2024 following her complaint but documented this was at Miss L’s insistence and the referral could have been rejected as not all primary care treatment options had been exhausted.
18.We obtained Miss L’s medical records from the time of the events. These records show Miss L first approached the Practice with hair loss concerns in September 2023. Miss L’s GP documented that she was suffering from alopecia areata (autoimmune condition) and advised her to use minoxidil for four months to see if the condition improved. The GP also prescribed a steroid cream.
19.As set out above, there are two types of hair loss in women. The relevant NICE guidance on alopecia areata says:
‘Referral to a paediatric dermatologist or dermatologist should be arranged (or specialist advice sought) if:
The diagnosis is uncertain.
The affected person is a child.
The affected person is pregnant or breast-feeding.
The affected person wishes for treatment which requires specialist input, or prefers to have their treatment under specialist advice.
Hair loss does not respond to treatment in primary care.’
20.Miss L first asked for a referral to specialists in October 2023. The Practice advised her that before she could be referred, all primary care options needed to be exhausted.
21.Our adviser told us that a patient diagnosed with alopecia areata, should be referred to specialists if they ask for this, in line with the above quoted guidance.
22.The medical records state Miss L has alopecia areata. Retrospectively, the Practice has explained this was incorrectly coded and the GP was working on the assumption Miss L had female pattern hair loss (androgenetic alopecia). We consider the GP was treating Miss L for female pattern hair loss and we have therefore investigated this complaint on the basis that Miss L had been diagnosed and treated for female pattern hair loss. We are sorry to learn that the wrong coding was used in Miss L’s records. This has caused confusion for Mrs L during the complaints process.
23.NICE Clinical Knowledge Summary: Female pattern hair covers the drug treatments that are available in the management of androgenetic alopecia. It says:
Consider minoxidil 2% topical solution or 5% foam (Regaine for Women Once a Day® 5% scalp foam).
Topical minoxidil 2% solution is not available to prescribe on the NHS but can be bought over-the-counter (OTC) or prescribed privately for women aged 18–65 years.’
24.During Miss L’s first consultation about hair loss in September 2023, the GP advised her that over-the-counter minoxidil could be used to treat her condition. Because the GP believed she had androgenetic alopecia, we have found the GP was acting in line with the above quoted guidance.
25.When Miss L attended the Practice again in November 2023, she informed the GP that she had already been using minoxidil for one year, and steroid cream for one month but there had been no improvement to the hair loss. The GP prescribed Miss L with spironolactone and explained that before a referral to specialists could be considered, all options in primary care should be exhausted first.
26.The relevant BAD guidance on androgenetic alopecia says:
‘Other oral treatments include spironolactone, cyproterone acetate, flutamide, and bicalutamide. These medicines can block the action of androgens (hormones) on the scalp, which may lead to some improvement in hair loss.’
27.The above guidance clearly suggests spironolactone as an oral treatment which may lead to improvement in hair loss. Our adviser told us that the prescription of spironolactone was appropriate if Miss L was being treated for androgenetic alopecia. As we accept the GP was treating Mrs L for androgenetic alopecia, we have found that the prescription of spironolactone given to Miss L in November was in line with guidance.
28.We have found the Practice offered treatment options to Miss L in line with relevant guidance. We do acknowledge how difficult this period was for Miss L given the hair loss was not improving despite her trying multiple treatment options. We understand she was keen for specialist referral.
29.The relevant NICE guidance on the management of androgenetic alopecia also says:
‘Assess the response to treatment at 6 months.
If successful, continue treatment indefinitely. Stopping treatment will lead to loss of all results within 3–6 months, and the rebound shedding may be severe.
If there is no response after 1 year, discontinue treatment and consider referral to a dermatologist, depending on clinical judgement and the woman's wishes.’
30.At Miss L’s first consultation with the Practice, the GP explained to her that if there was no improvement after six months, or Miss L suffered from any scarring, then she could be referred to a dermatologist. The above quoted guidance suggests a referral to a dermatologist should be considered after one year. We do not consider the GP did anything wrong in offering this referral after six months as this actually would have been sooner than the relevant guidance suggests.
31.After multiple requests from Miss L, the Practice referred her to a dermatologist in February 2024 (this was about five months after she first went to the Practice about this issue). The Practice explained this referral might be rejected as Miss L had not yet exhausted all treatment options in primary care. We have seen no evidence to suggest that the Practice should have referred Miss L to specialists sooner than it did. We understand that Miss L has since had an appointment with a dermatologist who recommended a cream that could be bought over-the-counter.
32.In summary, we acknowledge the importance of Miss L’s complaint, and we are sorry to learn how the events have impacted her. We thank her for giving us the opportunity to look into her complaint. We have found that the Practice offered multiple treatment options for androgenetic alopecia in line with guidance. We also consider the Practice responded to Miss L’s request for specialist referral and did this sooner than the guidance states. For these reasons, we have decided not to uphold this complaint.