Factors Affecting the Psychosocial Distress of Patients with Alopecia Areata: A Nationwide Study in Korea
2018; Elsevier BV; Volume: 139; Issue: 3 Linguagem: Inglês
10.1016/j.jid.2018.09.024
ISSN1523-1747
AutoresHee Seong Yoon, Jung Min Bae, Seung Dohn Yeom, Woo‐Young Sim, Won Soo Lee, Hoon Kang, Yang Won Lee, Ki‐Ho Kim, Do-Won Kim, Moon Bum Kim, Seong‐Jin Kim, Bark‐Lynn Lew, Oh Sang Kwon, Chang‐Hun Huh, Dong‐Youn Lee, Byung In Ro, Jin Park, Beom Joon Kim, Young Lee, Gwang Seong Choi,
Tópico(s)Acne and Rosacea Treatments and Effects
ResumoAlopecia areata (AA) is an autoimmune skin disease characterized by one or more alopecic patches, with a lifetime risk of 2.1% (Mirzoyev et al., 2014Mirzoyev S.A. Schrum A.G. Davis M.D.P. Torgerson R.R. Lifetime incidence risk of alopecia areata estimated at 2.1% by Rochester Epidemiology Project, 1990–2009.J Invest Dermatol. 2014; 134: 1141-1142Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar). Hair loss evokes not only a cosmetic problem but also significant psychosocial distress in affected patients (Dubois et al., 2010Dubois M. Baumstarck-Barrau K. Gaudy-Marqueste C. Richard M.A. Loundou A. Auquier P. et al.Quality of life in alopecia areata: a study of 60 cases.J Invest Dermatol. 2010; 130: 2830-2833Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, Liu et al., 2016Liu L.Y. King B.A. Craiglow B.G. Health-related quality of life (HRQoL) among patients with alopecia areata (AA): a systematic review.J Am Acad Dermatol. 2016; 75: 806-812Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar). Several studies have shown that patients with AA had poor self-confidence, had increased rates of depression, and were subject to stigmatization (Aghaei et al., 2014Aghaei S. Saki N. Daneshmand E. Kardeh B. Prevalence of psychological disorders in patients with alopecia areata in comparison with normal subjects.ISRN Dermatol. 2014; 2014: 304370Crossref PubMed Google Scholar, Alfani et al., 2012Alfani 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: 304-306Crossref PubMed Scopus (42) Google Scholar, Back et al., 2008Back S.J. Park Y.O. Kim K.J. Kim C.D. Seo Y.J. Lee J.H. et al.Quality of life of alopecia areata patients.Korean J Dermatol. 2008; 46: 578-586Google Scholar). However, large scale, in-depth clinical studies on the various factors affecting psychosocial status and quality of life (QOL) in AA patients have rarely been reported. We performed a nationwide questionnaire-based survey to investigate anxiety, depression, and QOL in AA patients and to identify the factors associated with each category. We enrolled patients with AA (≥ 20 years old) diagnosed by a dermatologist between January 2015 and February 2016. We recorded demographic characteristics including age, sex, marital status, educational background, age of onset, disease duration, treatment history (duration of treatment, degree of improvement, satisfaction, recurrence, and adverse effects), associated diseases, medications, and past medical history. Disease severity was assessed using the Severity of Alopecia Tool (i.e., SALT) score based on the percentage of the involved scalp area (S1 = 0%–25%, S2 = 26%–50%, S3 = 51%–75%, S4 = 76%–99%, S5 = 100%). We assessed anxiety and depression using the Beck Anxiety Inventory and Beck Depression Inventory (Beck et al., 1961Beck A.T. Ward C.H. Mendelson M. Mock J. Erbaugh J. An inventory for measuring depression.Arch Gen Psychiatry. 1961; 4: 561-571Crossref PubMed Scopus (28335) Google Scholar, Beck et al., 1988Beck A.T. Epstein N. Brown G. Steer R.A. An inventory for measuring clinical anxiety: psychometric properties.J Consult Clin Psychol. 1988; 56: 893-897Crossref PubMed Scopus (9159) Google Scholar), respectively. QOL was assessed using the hair-specific Skindex-29 questionnaire, as modified by Han et al., 2012Han S.H. Byun J.W. Lee W.S. Kang H. Kye Y.C. Kim K.H. et al.Quality of life assessment in male patients with androgenetic alopecia: result of a prospective, multicenter study.Ann Dermatol. 2012; 24: 311-318Crossref PubMed Scopus (96) Google Scholar. Anxiety, depression, and QOL impairment were categorized as mild, moderate, or severe, based on the score. Univariable and multivariable logistic regression analyses were sequentially performed to identify independent factors associated with anxiety, depression, and QOL impairment, respectively. Pearson correlation analyses were conducted between each item. All analyses were performed using R 3.3.1 (R Foundation for Statistical Computing, Vienna, Austria). The study protocol was designed in accordance with the Declaration of Helsinki and was approved by the institutional review board of each participating hospital, and all participants gave written informed consent. A total of 1,203 AA patients from 15 hospitals participated in this study (see Supplementary Table S1 online). As measured by the Beck Anxiety Inventory, 10.1% of patients had anxiety, and 4.2% had severe anxiety (Table 1). For the Beck Depression Inventory, 40.9% of patients had depression, and 9.4% had severe depression. In the symptoms domain of the hair-specific Skindex-29, 30.3% of patients had impaired QOL, and 9.9% had severely impaired QOL (Table 2). In the functioning domain, 71.3% of patients had impaired QOL, and 48.7% had severely impaired QOL. In the emotions domain, 81.7% of patients had impaired QOL, and 60.2% had severely impaired QOL. In addition, anxiety and depression were positively correlated with each other, and they were also correlated with impairment in symptoms, functioning, and emotions (Figure 1).Table 1Anxiety and depression and associated factors in patients with alopecia areataScaleAnxietySevere Anxietyn%Odds Ratio (95% CI)P-Valuen%Odds Ratio (95% CI)P-ValueBAI1The BAI has 21 items; a score of 0 indicates the lowest and 63 the highest level of anxiety. A score of 22-26 points indicates the individual requires observation and intervention, 27–31 points indicates severe anxiety, and 32 points or greater indicates extreme anxiety (Beck et al., 1988). Total122/1,20310.150/1,2034.2 SexMale36/5766.3Reference11/5761.9ReferenceFemale86/62713.72.526 (1.683–3.863)<0.00139/6276.23.578 (1.864–7.447)<0.001 SeverityS142/6876.1Reference15/6872.2ReferenceS228/24211.62.157 (1.286–3.571)0.00312/2425.02.519 (1.134–5.483)0.020S317/10715.93.039 (1.611–5.529)<0.0014/1073.71.813 (0.507–5.146)0.301S421/10819.43.844 (2.127–6.787)<0.00113/10812.06.392 (2.886–14.010)<0.001S514/5923.74.836 (2.363–9.495)<0.0016/5910.25.270 (1.800–13.744)0.001ScaleDepressionSevere Depressionn%Odds Ratio (95% CI)P-Valuen%Odds Ratio (95% CI)P-ValueBDI2The BDI has 21 items; a score of 0 indicates the lowest and 63 the highest level of depression. A score of 0–9 points indicates no depression; 10–15 points, mild depression; 16–23 points, moderate depression; and 24 points or greater, severe depression (Beck et al., 1961). Total492/1,20340.9113/1,2039.4 SexMale205/57635.6Reference36/5766.3ReferenceFemale287/62745.81.626 (1.279–2.070)<0.00177/62712.32.259 (1.491–3.482)<0.001 SeverityS1223/68732.5Reference31/6874.5ReferenceS2102/24242.11.603 (1.181–2.174)0.00231/24212.83.295 (1.944–5.589)<0.001S366/10761.73.531 (2.314–5.446)<0.00117/10715.94.171 (2.167–7.807)<0.001S468/10863.03.652 (2.396–5.633)<0.00125/10823.16.604 (3.676–11.798)<0.001S533/5955.92.614 (1.520–4.540)<0.0019/5915.33.906 (1.663–8.430)<0.001Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck depression inventory; CI, confidence interval; S, severity.1 The BAI has 21 items; a score of 0 indicates the lowest and 63 the highest level of anxiety. A score of 22-26 points indicates the individual requires observation and intervention, 27–31 points indicates severe anxiety, and 32 points or greater indicates extreme anxiety (Beck et al., 1988Beck A.T. Epstein N. Brown G. Steer R.A. An inventory for measuring clinical anxiety: psychometric properties.J Consult Clin Psychol. 1988; 56: 893-897Crossref PubMed Scopus (9159) Google Scholar).2 The BDI has 21 items; a score of 0 indicates the lowest and 63 the highest level of depression. A score of 0–9 points indicates no depression; 10–15 points, mild depression; 16–23 points, moderate depression; and 24 points or greater, severe depression (Beck et al., 1961Beck A.T. Ward C.H. Mendelson M. Mock J. Erbaugh J. An inventory for measuring depression.Arch Gen Psychiatry. 1961; 4: 561-571Crossref PubMed Scopus (28335) Google Scholar). Open table in a new tab Table 2Factors associated with impaired quality of life in patients with alopecia areata according to each hair-specific Skindex-29 domainDomains and FactorsImpaired QOLSeverely Impaired QOLn%Odds Ratio (95% CI)P-Valuen%Odds Ratio (95% CI)P-ValueSymptoms365/1,20330.3119/1,2039.9 SexMale148/57625.7Reference48/5768.3ReferenceFemale217/62734.61.568 (1.216–2.027)<0.00171/62711.31.434 (0.968–2.140)0.075 SeverityS1174/68725.3Reference42/6876.1ReferenceS274/24230.61.291 (0.927–1.788)0.12723/2429.51.596 (0.922–2.702)0.087S344/10741.11.872 (1.210–2.874)0.00415/10714.02.255 (1.156–4.200)0.013S455/10850.92.803 (1.833–4.294)<0.00128/10825.94.955 (2.852–8.531)<0.001S518/5930.51.108 (0.598–1.982)0.73511/5918.63.174 (1.446–6.528)0.002Functioning873/1,20371.3604/1,20350.2 SeverityS1459/68765.2Reference277/68739.0ReferenceS2178/24272.91.351 (0.976–1.888)0.074130/24251.11.676 (1.244–2.262)<0.001S392/10786.42.850 (1.655–5.238)<0.00175/10768.63.206 (2.071–5.063)<0.001S492/10883.62.680 (1.574–4.844)<0.00182/10875.04.321 (2.733–7.036)<0.001S552/5983.13.200 (1.515–7.867)0.00540/5963.62.658 (1.514–4.815)<0.001 Disease duration in years<1369/54567.1231/54541.6Reference1–5307/41072.6226/41052.31.458 (1.114–1.909)0.0065–10118/15376.184/15353.41.423 (0.978–2.072)0.065≥1079/9582.463/9566.72.172 (1.360–3.520)0.001Emotions983/1,20381.7724/1,20360.2 SexMale522/62783.3394/62762.8ReferenceFemale461/57680.0330/57657.31.314 (1.032–1.673)0.027 Age in years20–39530/62984.3Reference411/62965.3Reference40–59393/49779.10.632 (0.458–0.869)0.004260/49752.30.680 (0.529–0.873)0.003≥6060/7777.90.641 (0.356–1.202)0.15036/7746.80.816 (0.496–1.355)0.427 SeverityS1521/68775.8Reference355/68751.7ReferenceS2207/24285.51.802 (1.211–2.742)0.004154/24263.61.643 (1.211–2.240)0.002S3102/10795.35.221 (2.281–15.096)<0.00181/10775.72.775 (1.750–4.532)<0.001S4100/10892.63.084 (1.533–7.096)0.00490/10883.34.502 (2.700–7.905)<0.001S553/5989.81.899 (0.841–5.098)0.15644/5974.62.320 (1.279–4.425)0.007 Disease duration in years<1412/54575.6294/54553.9Reference1–5350/41085.4253/41061.71.232 (0.939–1.618)0.1325–10132/15386.3104/15368.01.598 (1.084–2.377)0.019≥1089/9593.773/9576.82.295 (1.384–3.934)0.002Abbreviations: CI, confidence interval; QOL, quality of life; S, severity.The hair-specific Skindex-29 includes domains of symptoms (7 items), emotions (10 items), and functioning (12 items). A 5-point scale is used for scoring: 0 (never), 1 (rarely), 2 (sometimes), 3 (often), and 4 (all the time). The responses were transformed into linear scores ranging from 0 (no effect) to 100 (effect always experienced). The cutoff score proposed by Prinsen et al., 2011Prinsen C.A. Lindeboom R. de Korte J. Interpretation of Skindex-29 scores: cutoffs for mild, moderate, and severe impairment of health-related quality of life.J Invest Dermatol. 2011; 131: 1945-1947Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar was used as the standard for patient grouping: ≥39 (mild), ≥42 (moderate), and ≥52 (severe) for symptoms; ≥24 (mild), ≥35 (moderate), and ≥39 (severe) for emotions; and ≥21 (mild), ≥32 (moderate), and ≥37 (severe) for functioning. Open table in a new tab Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck depression inventory; CI, confidence interval; S, severity. Abbreviations: CI, confidence interval; QOL, quality of life; S, severity. The hair-specific Skindex-29 includes domains of symptoms (7 items), emotions (10 items), and functioning (12 items). A 5-point scale is used for scoring: 0 (never), 1 (rarely), 2 (sometimes), 3 (often), and 4 (all the time). The responses were transformed into linear scores ranging from 0 (no effect) to 100 (effect always experienced). The cutoff score proposed by Prinsen et al., 2011Prinsen C.A. Lindeboom R. de Korte J. Interpretation of Skindex-29 scores: cutoffs for mild, moderate, and severe impairment of health-related quality of life.J Invest Dermatol. 2011; 131: 1945-1947Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar was used as the standard for patient grouping: ≥39 (mild), ≥42 (moderate), and ≥52 (severe) for symptoms; ≥24 (mild), ≥35 (moderate), and ≥39 (severe) for emotions; and ≥21 (mild), ≥32 (moderate), and ≥37 (severe) for functioning. In this nationwide survey, we found that AA patients had psychosocial comorbidities, including anxiety and depression. These findings have been described in previous studies using various instruments (Alfani et al., 2012Alfani 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: 304-306Crossref PubMed Scopus (42) Google Scholar, Colon et al., 1991Colon E.A. Popkin M.K. Callies A.L. Dessert N.J. Hordinsky M.K. Lifetime prevalence of psychiatric disorders in patients with alopecia areata.Compr Psychiatry. 1991; 32: 245-251Crossref PubMed Scopus (159) Google Scholar). Colon et al. performed psychiatric interviews and found that AA patients had elevated rates of generalized anxiety disorder (39%) and major depressive disorder (39%). A study using the Minnesota Multiphasic Personality Inventory showed that depression and anxiety scores in AA patients were significantly higher than in control individuals (Alfani et al., 2012Alfani 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: 304-306Crossref PubMed Scopus (42) Google Scholar). In this study, we also showed that the involvement of more than 50% (S3, S4, and S5) of the scalp and female sex were both independent factors affecting both anxiety and depression. We confirmed that AA patients have markedly impaired QOL in all aspects of symptoms, functioning, and emotions. Our results suggested that AA could affect patients’ QOL more than vitiligo or androgenetic alopecia, compared with the previous studies using the similar study protocol in Korea (Bae et al., 2018Bae J.M. Lee S.C. Kim T.H. Yeom S.D. Shin J.H. Lee W.J. et al.Factors affecting quality of life in patients with vitiligo: a nationwide study.Br J Dermatol. 2018; 178: 238-244Crossref PubMed Scopus (42) Google Scholar, Han et al., 2012Han S.H. Byun J.W. Lee W.S. Kang H. Kye Y.C. Kim K.H. et al.Quality of life assessment in male patients with androgenetic alopecia: result of a prospective, multicenter study.Ann Dermatol. 2012; 24: 311-318Crossref PubMed Scopus (96) Google Scholar). More patients with AA have impaired QOL than patients with vitiligo (symptoms: 30.3% vs. 14.6%, functioning: 71.3% vs. 48.8%, and emotions: 81.7% vs. 65.0%) (Bae et al., 2018Bae J.M. Lee S.C. Kim T.H. Yeom S.D. Shin J.H. Lee W.J. et al.Factors affecting quality of life in patients with vitiligo: a nationwide study.Br J Dermatol. 2018; 178: 238-244Crossref PubMed Scopus (42) Google Scholar). For hair-specific Skindex-29, the mean score of each domain was higher in AA patients than androgenetic alopecia patients (symptoms: 27.4 vs. 27.3, functioning: 38.7 vs. 24.0, and emotions: 48.7 vs. 32.1) (Han et al., 2012Han S.H. Byun J.W. Lee W.S. Kang H. Kye Y.C. Kim K.H. et al.Quality of life assessment in male patients with androgenetic alopecia: result of a prospective, multicenter study.Ann Dermatol. 2012; 24: 311-318Crossref PubMed Scopus (96) Google Scholar). We also found that sex, age, disease severity, and longer duration were associated with QOL impairment in AA patients. However, linear correlations between severity and these impairments were not obvious. Previously, a Serbian study also showed that disease severity was not associated with the symptoms and emotions domains of the Skindex-29 in AA patients (Jankovic et al., 2016Jankovic 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: 840-846Crossref PubMed Scopus (20) Google Scholar). Moreover, a US study pointed out that patients rated their hair loss as more severe than did the dermatologist, and clinical hair loss severity did not reliably predict the degree of subjective distress (Reid et al., 2012Reid E.E. Haley A.C. Borovicka J.H. Rademaker A. West D.P. 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-e102Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar). A Brazilian study reported that disease severity did not influence the mental health subscale score (de Hollanda et al., 2014de Hollanda T.R. Sodre C.T. Brasil M.A. Ramos E.S.M. Quality of life in alopecia areata: a case-control study.Int J Trichology. 2014; 6: 8-12Crossref PubMed Scopus (24) Google Scholar). Our findings are in line with those of previous studies, which do not seem to be related to race or cultural background. The Severity of Alopecia Tool score would not be sufficient to assess the severity of AA, and other factors more than clinical hair loss severity should be considered in treating AA patients. There are some limitations to our study. First, we included only adult patients to use uniform, validated instruments. Second, there could be selection bias, because only patients who visited the hospital were included in the study. Third, all participants were Korean. Fourth, we did not consider the specific location or distribution pattern of alopecic patches. However, our study was performed throughout the country, and dermatologists conducted both the physical examination and the survey process. Therefore, the results should be highly reliable. In conclusion, we found that AA patients would have psychosocial problems including anxiety, depression, and impaired QOL in the domains of symptoms, functioning, and emotions. Also, we determined the independent factors influencing anxiety, depression, and QOL. The involvement of more than 50% of the scalp markedly affects anxiety, depression, and QOL; however, the clinical severity was not linearly correlated with those impairments. Therefore, dermatologists should consider these psychosocial aspects when treating AA patients. Hee Seong Yoon: http://orcid.org/0000-0001-8997-9697 Oh Sang Kwon: http://orcid.org/0000-0003-0464-5124 Jung Min Bae: https://orcid.org/0000-0001-5975-8519 The authors state no conflict of interest. We thank all patients who participated in this study. This study was supported by the Korean Hair Research Society of the Korean Dermatological Association. 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