|Year : 2021 | Volume
| Issue : 1 | Page : 59-64
Hair loss severity and its impact on quality of life in patients suffering from androgenic alopecia: A one-year cross-sectional study
Kriti Lohia, Bhavana Ravindra Doshi, BS Manjunathswamy
Department of Dermatology, KLE Academy of Higher Education and Research's, JNMC, Belagavi, Karnataka, India
|Date of Submission||19-Feb-2020|
|Date of Decision||03-Jun-2020|
|Date of Acceptance||05-Jun-2020|
|Date of Web Publication||19-Feb-2021|
Bhavana Ravindra Doshi
Department of Dermatology, KLE Academy of Higher Education and Research's, JNMC, Belagavi - 590 010 Karnataka
Source of Support: None, Conflict of Interest: None
Background: Androgenic alopecia (AGA) is a common form of nonscarring alopecia encountered in daily dermatology practice. Both apparent and imperceptible AGA has a significant impact on an individual's personality, where physical appearance plays an important role in the probable prospects for marriage as well as other social aspects. Hair loss, thus, can severely hamper them for both men and women with clinical severity of alopecia not necessarily correlating with the quality of life (QoL) of the patient. Objectives: The objective is to assess the QoL in patients with AGA attending a tertiary care hospital in western India and compare QoL with hair loss severity (HLS), rated by both dermatologist and patient. Materials and Methods: One hundred and four patients, clinically diagnosed with AGA, consenting for the study over a period of 1 year were included. Demographic data of the patients were recorded. QoL was assessed using skindex-16 questionnaire; HLS was assessed through self-administered questionnaires completed by patients and dermatologists. Data were analyzed using Wilcoxon signed-rank test, Kendall's tau correlation coefficients, and Chi-square test. Results: The mean global score of Skindex–16 was 45.75 ± 16.90, with highest scores from emotions (64.93 ± 23.26). A positive correlation was found between the patients' HLS rating (r = 0.33, P < 0.0001) and the clinical HLS rating. However, patient rated the extent of their hair loss as more severe than the dermatologist. Patient-related HLS significantly correlated with the mean global score of Skindex–16 (P < 0.0001) as well as with all the subdomain scores (P < 0.0001), whereas dermatologist-rated HLS only significantly correlated with the global score of Skindex–16 (P = 0.04) but not with the subdomain scores. Limitations: As Skindex-16 is a self-reported questionnaire, there may be a recall bias. Another limitation of our study is the sample size; a study with a bigger sample size is required to vindicate our findings. Conclusion: The study demonstrates that AGA patients perceived their HLS as more severe than the dermatologist. Both patient-related HLS and dermatologist-rated HLS showed statistical correlation with the total global Skindex-16 score. Hence, dermatologists need to be more alert and should address the psychosocial and QOL issues, when treating patients with AGA.
Keywords: Androgenic alopecia, hair loss severity, hair loss, quality of life, skindex-16
|How to cite this article:|
Lohia K, Doshi BR, Manjunathswamy B S. Hair loss severity and its impact on quality of life in patients suffering from androgenic alopecia: A one-year cross-sectional study. Clin Dermatol Rev 2021;5:59-64
|How to cite this URL:|
Lohia K, Doshi BR, Manjunathswamy B S. Hair loss severity and its impact on quality of life in patients suffering from androgenic alopecia: A one-year cross-sectional study. Clin Dermatol Rev [serial online] 2021 [cited 2022 Dec 3];5:59-64. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/1/59/309770
| Introduction|| |
Androgenic alopecia (AGA) is one of the leading causes of hair loss in the world with an incidence of up to 70% in men and 10% in females., Genetic, hormonal, and environmental factors are some of the causes in its evolution which affect both men and women. Some studies also indicate an impactful role of psychological factors in the development of alopecia.
The first change noticed in men is a bi-temporal recession in 96% of sexually mature Caucasian males beginning at the time of puberty up to the fourth decade of life. Whereas, in women, most commonly a progressive centrifugal pattern of hair loss over the scalp is seen with two main peaks of onset; first in the third decade and the second peak starts from the age of 40 years until menopause, associated with more severe hair loss if onset is earlier., Although the clinical presentation varies, pathogenesis is quite alike in both the genders.
Previous studies reveal that patients who have either clinically imperceptible or clinically apparent hair loss can have significantly decreased quality of life (QoL)., This may lead to emotional changes such as feeling upset, angry, and worried about their condition. As the medical therapies in the treatment of AGA are still are not curative, and with the advent of wide spread social media and the need to define oneself using them, these adverse effects due to hair loss are not unexpected. Specific psychosocial findings in those with hair loss include loss of self-confidence, low self-esteem, and heightened self-consciousness.
Different questionnaires and instruments are used to assess QoL in dermatologic patients., However, skindex–16 is one of the best dermatological instruments to measure dermatology-specific, health-related QoL, which in turn can also assess patients' experiences.,
As clinically imperceptible alopecia too has detrimental effects on QoL in both men and women, it can be inferred that clinical assessment of hair loss severity (HLS) cannot accurately predict its psychosocial impact. The objective of this study, thus, was to assess the QoL in patients' with AGA and compare QoL with HLS as rated by both dermatologist and patient.
| Materials and Methods|| |
Patients clinically diagnosed with AGA attending the outpatient department of our tertiary care institute over 1-year period between May 1, 2018, and April 31, 2019, were included in the study after the institutional ethics committee clearance. A total of 104 consenting patients with AGA were included in the study after obtaining a written informed consent. The patients presenting with other co-existing hair disorders such as cicatricial alopecia, telogen effluvium, and/or alopecia areata (AA) were excluded from the study. Demographic data and clinical characteristics such as age, gender, onset/symptoms, duration of hair loss, family history, drug history, treatment history, and other comorbidities of the patient were recorded. The clinical severity of AGA was assessed using Norwood–Hamilton scale for men and Ludwig scale for women. All patients completed the skindex-16 questionnaire [Table 1] (which is dermatology-specific QoL instrument with a 100-point scale where high scores indicate poor QoL) by answering questions with respect to their hair loss. Further, patients completed another author devised questionnaire [Table 2] to evaluate their perceived HLS that was documented by a single dermatologist.
|Table 2: Author devised questionnaire to evaluate the perceived hair loss severity by patients|
Click here to view
Assessment of quality of life using skindex-16
A self-reported dermatology-specific QoL measurement tool, Skindex-16, was used after obtaining due permission from Mapi Research Trust. This instrument consists of 16 questions, with three kinds of scales: A symptom scale (4 items), a function scale (5 items), and emotion scale (7 items) that are related to the effects of dermatologic disorders on QoL. This tool is a validated, sensitive, reliable, and specific measure of the extent to which the dermatologic conditions of patients' bothers them. Every question inquired about the degree to which the patients' had been bothered by their dermatologic disorder 1 week before the administration of this questionnaire. Patients answered every question with a number that ranged from 0 (never bothered) to 6 (always bothered). After completion of skindex-16, the responses to each item were transformed to a linear scale ranging from 0 (never bothered) to 100 (always bothered), thus higher values reflect a lower QoL. Mean global skindex-16 score and subdomain scores (symptoms, emotions, and function) were converted to a linear, 100-point scale as well.
Assessment of hair loss severity using participant questionnaire
Participants completed a self-administered HLS questionnaire that indicated the visually perceived severity of their diagnosis of AGA on a 5-point scale (where 5 = very severe hair loss, 4 = severe hair loss, 3 = moderate hair loss, 2 = mild hair loss, and 1 = very mild hair loss).
Assessment of hair loss severity using dermatologist questionnaire
A self-administered questionnaire to clinically assess HLS was completed by a single dermatologist who was blinded to the patient's response, using Norwood–Hamilton scale (ranging from Grade I-VIII) for males and Ludwig scale for women (ranging from no hair loss – Ludwig III). The association between the clinical grading and the patient's own assessment of their HLS was then assessed as per [Table 3].
|Table 3: Co-relating parameters used for hair loss severity as rated by patient with dermatologist using Norwood-Hamilton scale in males and Ludwig scale in females|
Click here to view
R I 3184.108.40.206 was used to analyze the data. The Wilcoxon signed-rank test was used to compare hair loss ratings between patient and dermatologist. Kendall's tau correlation coefficient was used to determine whether patient-rated hair loss (from patients' questionnaire) was at variance with the clinical assessment of hair loss (from the dermatologist's questionnaire) and to assess whether patient and/or dermatologist-rated hair loss correlated with QoL. Chi-square test was used to assess the significance of QoL. Ordinal logistic regression analysis was performed to study the effect of gender and education status on HLS. P < 0.05 was considered as statistically significant.
| Results|| |
A total of 104 patients participated in the study where 26.9% (28) were female and 73.1% (76) were male. The mean age of the study population was 29.68 ± 8.88 years with nearly three-fourth of the patients ranging between the ages of 21 and 30 years (67.3%), indicative of early age of manifesting with AGA. The onset of disease was insidious in 98.1% of the patients. Majority of the participants in the study were graduates (85.57%). For most of the patients (75%), the duration of hair loss was between 1 and 5 years with a mean of 3.71 ± 3.77 years. However, only 37.5% of the patients had a history of having undergone/actively receiving treatment for the same. Family history of similar complaints was found to be present in 62.5% of the patients. Clinically, majority of the male patients were diagnosed with Grade 3 as per Norwood–Hamilton scale followed by Grade 4 and 2 respectively in males and Ludwig Grade 2 severity followed by Ludwig Grade 1 in females [Table 4].
|Table 4: Demographic including clinical characteristics of the study patients|
Click here to view
Dermatology-related quality of life
Replies to the skindex-16 were indexed from 0 (never bothered) to 100 (always bothered). The skindex-16 questionnaire was studied under three subscales, i.e., symptoms, emotions, and functions and also evaluated for overall mean global score. The mean Global Skindex-16 score was 45.75 (standard deviation [SD] = 16.90, n = 104) [Table 5]. Highest scores were recorded from the emotions domain, indicating lowest QoL (mean = 64.93 ± 23.26). This was followed by function domain (mean = 43.08 ± 21.14) and then the symptom domain (mean = 15.54 ± 13.02).
|Table 5: Skindex-16 quality of life: Subscale domain scores and global score|
Click here to view
Patient-rated hair loss severity compared with clinical hair loss severity
A positive correlation was found between the patients and dermatologists clinical HLS rating (r = 0.33, P < 0.0001). However, 77.63% (76) male and 82.14% (23) female patients' clinical assessment score was not matching their own perception of HLS. The data indicate that a patient rates the extent of their hair loss as more severe (mean = 4) than does a dermatologist (mean = 3, P < 0.0001) implying that there are significant differences between the classification of HLS between the patient and dermatologist [Table 6]. By considering Ludwig score “3” as severe and Norwood Hamilton score “5–7” as severe. Furthermore, Skinde × 16 score “4–5” taken as severe. We observed that, 63 (60.58%) subjects think that they have severe AGA problem. While using clinical scale assessment, we found that 13 (12.5%) had severe AGA problem. Using cross tables, we found that out of 104 subjects, 22 (21.2%) are correctly matched with clinical scale assessment, whereas 74 (71.1%) responders thought that they had severity more than the clinical scale while 8 (7.7%) thought to have less severity than clinical assessment scale.
|Table 6: Comparison of hair loss severity as rated by the patient and by the dermatologist|
Click here to view
Using ordinal logistic regression analysis, it was found that gender did not significantly influence (odds ratio 2.04; 95% confidence interval 0.84–4.97; P = 0.12) HLS assessed by the patients.
Quality of life and hair loss severity rated by both patient and dermatologist
Patient-related HLS significantly correlated with the mean global Skindex-16 score (P < 0.0001) under the subscale of symptoms (P = 0.25), emotions (P = 0.0005), and function (P < 0.0001) subscales [Table 7]. This indicates that Skindex-16 is a reliable predictor of QoL of a patient with alopecia and correctly represents the impact of hair loss on the various aspects of a patient's life. Dermatologist-rated HLS also significantly correlated with the total global Skindex-16 score (P = 0.04), but it did not show statistical correlation with the subscale scores signifying that dermatologist-rated HLS may predict the overall QoL, but it is a weak predictor of the impact the disease has on a patient's psychology and emotions.
|Table 7: Correlation between hair loss severity and global score of Skindex-16|
Click here to view
| Discussion|| |
Although AGA is one of the most common hair loss disorders, it can significantly affect a patient's QoL.,,, It may be regarded clinically as a mild disorder; however, it often leads to serious distress in everyday lives of both men and women.
Demographic data, including age and gender of patients affected with AGA in our study were comparable to other similar studies. The mean duration of hair loss (3.71 ± 3.77 years) in our study was near to the study conducted by Zhang et al. (4.49 years). Reports suggest the prevalence of AGA to be more severe in patients with positive family history, which was comparable to our study. Similar to our study, it was reported that acne was the major problem in patients with AGA., It has been reported that treatment or drug-induced hair loss is difficult to confirm. However, in our study, most of the patients had neither the drug history nor the treatment history.
A study conducted by Gonul et al. reported that Ludwig Grade 2 (38 patients) and Hamilton Grade 3 (12 patients) were the most common types in women and men, respectively, which was in accordance to the findings in our study.
A study by Reid et al. included 104 patients having either AGA, telogen effluvium, or AA where QoL was evaluated using Skindex-16 and HLS severity was compared as rated by the patient with the dermatologist. Their findings were nearly similar to our study with a mean global score of 57.3 (SD ± 16.2) in their study, which was 45.75 in our study and lowest QoL reflected on the emotion domain subscale. The study also confirms their findings, which state that a patient's perception of their disease is usually more severe than is clinically perceived and that a dermatologist-rated HLS, is in fact a poor indicator of the emotional and functional consequences of the disease. Overall in our study, the patient's HLS rating correlated more strongly with QoL.
Zhang and Zhang conducted a study with a total of 178 participants with either AA or AGA using dermatology life quality index (DLQI) to evaluate their perception regarding their symptoms, feelings, work, hobbies, social, and personal relationships as well as treatment dimensions of life. The mean duration of hair loss (3.71 ± 3.77 years) in our study was near to their study (4.49 years). Although their study showed similar findings when comparing QoL that was lower in patients with AGA, however, they reported no changes in QoL with respect to the severity of hair loss, gender or educational level. Although our study made similar inferences to that of Zhang et al. with respect to educational status and gender, other studies have shown conflicting results.
Another study conducted by Jankovic et al. on Siberian patients with AA using DLQI demonstrated that alopecia negatively influences QoL; however, the results are not comparable as study population included cases of hair loss due to AA.
Literature also has reported that hair follicle disorders significantly impacts emotion domain rather than other domains. Likewise, in our study, it was found that emotion subdomain of Skindex–16 was more adversely affected in AGA patients followed by functions and symptoms subdomain. It is notable that the present study, scores reported for emotional, functional, and symptom subdomain were 64.93, 43.08, and 13.02, respectively; these findings were nearly matched with the study conducted by Alsaiariand Fatani, in which scores reported for emotional, functional, and symptom subdomain were 54.2, 32.2, and 37.7, respectively. However, an Indian study by Gupta et al. reported the symptom (62.87%) domain to be affected more than the emotion domain (55.46%). In our study under the emotion domain, the highest response was for the question 6 regarding worsening/spread of the alopecia whereas in the function domain; maximal response was to the question 13 regarding the effect of alopecia affecting their desire to be with people. Hence, it implies that the dermatologist should provide relevant treatment, not just for hair loss, but also tend to the emotional anguish faced by them in their daily lives.
Many of AGA patients have been identified to have underlying associated medical conditions which can make the hair loss worse, for example, seborrheic dermatitis, polycystic ovary disease, metabolic syndrome, and thyroid dysfunction making it essential to first address them.
Since skindex-16 was a self-reported questionnaire there may be a recall bias. Furthermore, factors such as duration of hair loss, reasons behind loss of hair such as family history, treatment history, and knowledge of disease spectrum, which may affect the patients' QoL, are not considered in skindex-16.
| Conclusion|| |
In our study, we found that differences in illness perception can lead to significant influence on the disease outcome with respect to a patient's QoL, their psychological and emotional status. Counseling regarding the probable causes, chronicity and importance in treatment compliance and coping strategies can significantly reduce the psychological stress faced by such patients. Our findings emphasize the need for dermatologists understand the impact of hair loss of the patient's life, the contrary perception of HLS between dermatologists and patients and to individualize the treatment protocol accordingly.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We would like to acknowledge Dr. Mary-Margaret Chren and MAPI for permitting us to use Skindex-16.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yu NL, Tan H, Song ZQ, Yang XC. Illness perception in patients with androgenetic alopecia and alopecia areata in China. J Psychosom Res 2016;86:1-6.
Norwood OT, Lehr B. Female androgenetic alopecia: A separate entity. Dermatol Surg 2000;26:679-82.
Dhurat R, Sukesh MS. Hair and scalp disorders. In: Sacchianand S, editor. IADVL Textbook of Dermatology. 4th
ed. Mumbai: Bhala?ni Publishing House; 2015. p. 1489-501.
Reid EE, Haley AC, Borovicka JH, Rademaker A, West DP, Colavincenzo M, et al
. Clinical severity does not reliably predict quality of life in women with alopecia areata, telogen effluvium, or androgenic alopecia. J Am Acad Dermatol 2012;66:e97-102.
Olsen EA. Female pattern hair loss. J Am Acad Dermatol 2001;45:S70-80.
Salman KE, Altunay IK, Kucukunal NA, Cerman AA. Frequency, severity and related factors of androgenetic alopecia in dermatology outpatient clinic: Hospital-based cross-sectional study in Turkey. An Bras Dermatol 2017;92:35-40.
Zhang M, Zhang N. Quality of life assessment in patients with alopecia areata and androgenetic alopecia in the People's Republic of China. Patient Prefer Adherence 2017;11:151-5.
Han SH, Byun JW, Lee WS, Kang H, Kye YC, Kim KH, et al
. Quality of life assessment in male patients with androgenetic alopecia: Result of a prospective, multicenter study. Ann Dermatol 2012;24:311-8.
Williamson D, Gonzalez M, Finlay AY. The effect of hair loss on quality of life. J Eur Acad Dermatol Venereol 2001;15:137-9.
Al-Mutairi N, Eldin ON. Clinical profile and impact on quality of life: Seven years experience with patients of alopecia areata. Indian J Dermatol Venereol Leprol 2011;77:489-93.
] [Full text]
He Z, Lu C, Chren MM, Zhang Z, Li Y, Ni X, et al
. Development and psychometric validation of the Chinese version of Skindex-29 and Skindex-16. Health Qual Life Outcomes 2014;12:190.
Babu M, Raghu MT. Assessing quality of life in patients with skin diseases using skindex 16 questionnaire. World J Pharm Res 2016;5:1513-21.
Hamilton JB. Patterned loss of hair in man; types and incidence. Ann N Y Acad Sci 1951;53:708-28.
Ludwig E. Classification of the types of androgenetic alopecia (common bladness) occuring in the female sex. Br J Dermatol 1977;97:247-54.
Chren MM, Lasek RJ, Sahay AP, Sands LP. Measurement properties of Skindex-16: A brief quality-of-life measure for patients with skin diseases. J Cutan Med Surg 2001;5:105-10.
Su LH, Chen TH. Association of androgenetic alopecia with smoking and its prevalence among Asian men: A community-based survey. Arch Dermatol 2007;143:1401-6.
Tandon S, Arora P, Gautam RK, Bhardwaj M, Garga U, Sharma N. Correlation between clinical features, biochemical parameters, and histopathological findings in women with patterned baldness: A study from North India. J Cutan Aesthet Surg 2019;12:42-8.
] [Full text]
Garg T, Yadav P, Agarwal S, Mendiratta V. Drug-induced diffuse hair loss in females: An observational study. Astrocyte 2014;1:80-3. [Full text]
Gonul M, Cemil BC, Ayvaz HH, Cankurtaran E, Ergin C, Gurel MS. Comparison of quality of life in patients with androgenetic alopecia and alopecia areata. An Bras Dermatol 2018;93:651-8.
Jankovic S, Peric J, Maksimovic N, Cirkovic A, Marinkovic J, Jankovic J, et al
. Quality of life in patients with alopecia areata: A hospital-based cross-sectional study. J Eur Acad Dermatol Venereol 2016;30:840-6.
Abolfotouh MA, Al-Khowailed MS, Suliman WE, Al-Turaif DA, Al-Bluwi E, Al-Kahtani HS. Quality of life in patients with skin diseases in central Saudi Arabia. Int J Gen Med 2012;5:633-42.
Alsaiari S, Fatani MI. Demographic and clinical profile of alopecia areata in Makkah, Saudi Arabia and its impact of quality of life. Int J Med Health Res 2018;4:61-7.
Gupta S, Goyal I, Mahendra A. Quality of life assessment in patients with androgenetic alopecia. Int J Trichology 2019;11:147-52.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]