Journal of Clinical & Experimental Dermatology Research
Open Access

Psychological Impact of Alopecia Areata on Egyptian Patients

Doaa AE Abou-Taleb^1*, Omnia H Abd El Hameed² and Alaa EA Moubasher^{1 *}Correspondence: Doaa AE Abou-Taleb, Department of Dermatology, Venereology and Andrology, Assiut University Hospital, Assiut, Egypt, Email:

Author info »

Introduction

AA is a common chronic autoimmune condition characterized with sudden onset of hair loss in a clear circular area. Alopecia means ‘baldness or loss of hair’ and areata means ‘occurring in patches’ [1]. It may affect the pilosebaceous unit in both males and females and has no racial predilection. It usually affects the scalp, but any hair-bearing area can be involved. The clinical picture may vary from a single patch of non-scarring hair loss, to multiple patches or loss of hair on the entire scalp (alopecia totalis), or the whole body (alopecia universalis) [2]. The skin of the affected patches appears usually normal and smooth; rarely a slightly pinkish color can be observed [3].

One of the most common anxiety disorders in AA patients is generalized anxiety disorder (GAD), which occurs in 39% of patients suffering from AA. Patients with GAD frequently report constant feeling of nervousness, anxiety and muscle tension, heart palpitations and dizziness. Patients with GAD often express fear of the disease or its recurrence [4].

Since hair is a vital part of the body, hair loss might have negative effects on patients’ quality of life. The different look, usually in patients with visible bald patches, may cause low self-esteem and body disfigurement. As a chronic disease, it can affect social activity, self-perception and emotional well-being [5]. The frequent occurrence of extensive alopecia may lead to significant mental disorders caused by social isolation and also the lack of acceptance of one’s own appearance [6].

Patients with AA feel social neglect and rejection, often do not accept their disease, and are tired of continuous discomfort associated with chronic dermatological condition [7]. Personal and social problems are frequent among AA patients. Chronic course of AA is associated with exposure to chronic stress. Patients with AA often confirm the negative impact of stressful life events on the course of the disease [7,8]. Emotional stress is one of the risk factors of AA and is associated with either actual or symbolic hair loss [8].

The aim of this study was to assess the psychological impact of AA among Egyptian patients by using the Arabic version of DASS-42.

Patients and Methods

This cross-sectional study was conducted at the department of Dermatology, Venereology and Andrology, Assiut University Hospitals, Assiut, Egypt. The study was approved by the Assiut University Medical Ethics committee and was carried out in accordance with the guidelines of the Helsinki Declaration. All patients signed informed consent prior to the study.

A total of 100 Egyptian patients with AA were randomly recruited from the outpatient clinics of the department. They were enrolled in the study after signing an informed consent. Inclusion criteria included Egyptian patients with AA aged ≥ 16 years old, both sex and all clinical types of AA (monolocularis, multilocularis, totalis and universalis). Exclusion criteria included patients with any associated chronic dermatological diseases such as psoriasis, vitiligo, pemphigus and systemic lupus erythematosus and non- cooperative patients.

A detailed history was taken from all patients regarding age, sex, occupation, marital status, residence, educational status, special habits as smoking, duration of the complaints, site of the lesions, onset, course, possible causes, precipitating factors, family history and other associated diseases. Observation for the presence or absence of veil, head cover or cap. A full dermatologic examination was performed to determine the number, site, shape, extension of the sites affected by AA, and the type of AA; And to assess the percentage of scalp hair loss and the severity of AA by SALT score (the Severity of Alopecia Tool) [9]. All the data were filled in specific designed sheets. All patients were face to face interviewed, they were asked to describe the impact of AA on their life by filling in the Arabic version of DASS-42 [10,11].

Statistical analysis

All analyses were carried out using using SPSS version 21. Simple frequencies were used for data checking and cleaning. Data were presented as number, percentage, mean and standard deviation. The mean, standard deviation for the DASS-42 score were estimated. A P-value ≤ 0.05 was considered statistically significant.

Results

Patients’ demographics

The demographic data of a total 100 Egyptian patients with AA were summarized in Table 1. The age of patients ranged from 16 to 59 years with a mean ± SD=27.58 ± 9.7 years and (71%) of the patients were males. The majority of the patients (56%) were unmarried, (57%) were residents in rural areas of Assiut, and (58%) were workers. Regarding their education, (47%) of the patients with lower education and (46%) with higher education.

Table 1: Socio-demographic data of the studied cases.

The clinical characteristics of the studied cases are presented on Table 2. The family history of AA was positive only in 12% of the patients. The majority of the patients had acute (sudden) onset of AA (85%) and progressive course (69%). (59%) of patients wear a head cover. Stress as an exacerbation factor of the disease was positive in (83%) of the patients. It was found that the most common type of AA in our patients was AA multilocularis (59%) followed by AA monolocularis (36%). The severity of AA was assessed by the SALT score as shown in Table 3. The mean of SALT score was 14.43 ± 24.9.

Table 2: Clinical characteristics of the studied cases.

Table 3: Distribution of the studied cases into SALT score subclasses according to the percentage of hair loss.

Assessment of the psychological impact of AA among egyptian patients by using the arabic version of DASS-42

According to the Arabic version of DASS-42, the patients of AA who had depression were 90 patients (26% with extreme depression, 22% with severe depression, 29% with moderate depression and 13% with mild depression). Also, anxiety was present in 85% of patients (38% with extreme anxiety, 24% with severe anxiety, 18% with moderate anxiety and 5% with mild anxiety). Regarding stress, it was present in 95% of patients (35% with extreme stress, 23% with severe stress, 32% with moderate stress and 5% with mild stress) as shown in Tables 4.

Table 4: Assessment of the psychological impact of AA among Egyptian patients by using the Arabic version of DASS-42.

The mean of the DASS-42 score was higher in female patients (58.38 ± 12.3) than males (56.03 ± 13.8) with a significant statistical difference (P-value=0.024), and was also higher in rural (71.63 ± 24.6) than urban (60.14 ± 24.6) with a significant statistical difference (P-value=0.019) as shown in Table 5.

Table 5: Socio-demographic characteristics and DASS-42.

The mean of the DASS-42 score was higher in patients with head cover (76.47 ± 21.9) than without head cover (52.61 ± 22.5), in stressed patients (70.55 ± 24.1) than non-stressed (47.82 ± 21.4) with significant statistical differences (P-value<0.001). Moreover, it was higher with disease duration ≥ 6 months (72.72 ± 24.2) than in disease duration <6 months (59.89 ± 24.5) with a significant statistical difference (P-value<0.001).

Moreover, it was higher with disease duration ≥ 6 months (72.72 ± 24.2) than in disease duration <6 months (59.89 ± 24.5) with a significant statistical difference (P-value<0.001).

Discussion

Hair represents an important sign of health and vitality. Long time ago dermatologists searched for etiology and treatment for alopecia [12]. AA is a common chronic autoimmune condition presented with sudden onset of loss of hair in a clear circular area [1,2]. It is a common cause of non-scarring alopecia that occurs in a patchy, confluent or diffuse pattern. It involves loss of hair from any hairy areas of the body, usually from the scalp [13].

Hair is a vital part of the body; hair loss might have negative effects on patients’ quality of life. The different look, in patients with AA may cause low self-esteem and cosmetic disfigurement. AA as a chronic disease, it may affect social activity, self -perception, economic state and feelings [5-7]. Moreover, AA can have psychosocial complications, including depression, low self-esteem, altered self- image, and less frequent and enjoyable social engagements. To assess the severity of AA, quality of life seems to be a more relevant criterion than clinical evaluation such as AA extension because the perception of patients may differ significantly from those of their health-care providers [14].

AA has been linked to negative psychosocial consequences such as emotional pain and suffering, negative effects on daily lifestyle, functions and physical symptoms brought on by the condition or caused by treatments which may result in distressing side- effects. Isolation and withdrawal may lead to increased feelings of depression, stress and anxietyin patients with AA [15,16].

In our study despite of the number of patients with AA was higher in males than females (71%), the mean of DASS-42 was higher in females (75.48 ± 22.4) than males (63.10 ± 25.3) with a statistically significant difference (p-value=0.024). This indicates that the affection of depression, anxiety, and stress were more predominant in female patients with AA. This may be due to the importance of hair loss to them and the impact of hair loss on their appearance.

We recommend that patients with AA should be encouraged to discuss their psychological complaints at clinic visits. Certain interventions such as: Counseling, psycho-education, and psychotherapeutic interventions to reduce the psychological impact of AA should be considered in their treatment.

Conclusion

The Arabic version of DASS-42 assesses the psychological impact of AA on Arab patients. It is very important that dermatologists improve the relations with their patients and re-evaluate their management of AA and take in consideration the patients’ counseling and psychological management that can help to improve the clinical outcomes of AA.

Conflict of Interest

There is no conflict of interest to be reported by any of the authors.

References

1. Alexis AF, Dudda-Subramanya R, Sinha AA. Alopecia areata: Autoimmune basis of hair loss. Eur J Dermatol. 2004;14(6): 364-370.
2. Alkhalifah A, Alsantali A, Wang E, McElwee KJ, Shapiro J. Alopecia areata update: Part 1-clinical picture, histopathology and pathogenesis. J Am Acad Dermat. 2010;62(2): 178-88.
3. Finner A. Alopecia areata: Clinical presentation, diagnosis, and unusual cases. Dermatol Ther. 2011;24(3): 348-354.
4. Han SH, Byun JW, Lee WS. Quality of life assessment in male patients with androgenetic alopecia: Result of a prospective, multicenter study. Ann Dermatol. 2012;24(3): 311-318.
5. Firooz A, Firoozabadi MR, Ghazisaidi B, Dowlati Y. Concepts of Patients with alopecia areata about their disease. BMC Dermatol. 2005;5: 1-251.
6. Rocha de HT, Sodré CT, Brasil MA, Silva MR. Quality of life in alopecia areata: A case control study. Int J Trichology. 2014;6(1): 8-12.
7. Kuty-Pachecka M. Psychological and psychopathological factors in alopecia areata. Psychiatr Pol. 2015;49(5): 955-964.
8. Ghanizadeh A, Ayoobzadehshirazi A. A review of psychiatric disorders comorbidities in patients with alopecia areata. Int J Trichology. 2014;6(1): 2-4.
9. Olsen EA, Hordinski MK, Price VH. Alopecia areata investigational assessment guidelines- part II. National Alopecia Areata Foundation. J Am Acad Dermatol. 2004;51(3): 440-447.
10. Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. (2nd. Ed.) Sydney: Psychology foundation. 1995.
11. Taouk M, Lovibond PF, Laub R. Psychometric properties of an arabic version of the depression anxiety stress scale (DASS). Res Social Work Pract. 2016;27(3): 375-386.
12. Martinez-Mir A, Zlotogorski A, Gordon D, Petukhova L, Mo J, Gilliam TC, et al. Genomewide scan for linkage reveals evidence of several susceptibility loci for alopecia areata. Am J Hum Genet. 2007;80(2): 316-328.
13. Wasserman D, Guzman-Sanchez DA, Scott K, McMichael A. Alopecia areata. Int J Dermatol. 2007;46(2): 121-131.
14. Hunt N, McHale S. The psychological impact of alopecia. Brit Med J. 2005; 331(7522): 951-953.
15. Chu SY, Chen YJ, Tseng WC, Lin MW, Chen TJ, Hwang CY, et al. Psychiatric comorbidities in patients with alopecia areata in Taiwan: A case control study. Br J Dermatol. 2012;166(3): 525-531.
16. Alfani S, Antinone V, Mozzetta A, Di Pietro C, Mazzanti C, Stella P, et al. Psychological status of patients with alopecia areata. Acta Derm Venereol. 2012;92(3): 304-306.