Quality of Life Assessment in Patients with Androgenetic Alopecia.

BACKGROUND: Male-pattern alopecia (MPA) or androgenetic alopecia (AGA) is a commonly encountered dermatological condition present in males and is less common among females. Although AGA is a physiological condition, its impact on person's self-esteem is so great that it cannot be ignored. It has a significant affect over a variety of physiological and social aspects of one's life and even on the individual's overall quality of life (QOL). AIMS AND
OBJECTIVES: The aim of this study is to study the clinical profile of 200 male patients having MPA and to access its impact on QOL using the Dermatology Life Quality Index (DLQI) and hair-specific Skindex-29.
MATERIALS AND METHODS: Clinical profiles of 200 patients were studied, and QOL assessment was done using the DLQI and hair-specific Skindex-29 scales.
RESULTS: Of 200 cases of MPA, majority (41.5%) of the patients belonged to the age group of 21-30 years. Smoking, alcoholism, dietary habits, nature of work, and seasonal variation did not seem to affect the incidence of MPA. Positive family history of MPA was observed in 50% of patients. A mean DLQI score of 13.52 was recorded in the study. The main affected parameter was personal relations with mean score of 2.3. Maximum number of patients had DLQI score between 11 and 20. MPA was observed in 50% of patients. In the study, the mean hair-specific Skindex-29 score was found to be 75.62. The different subscale parameters in Skindex-29 were symptoms, functions, emotions; with respective score of 22.1 ± 5.025, 25.89 ± 4.814, and 27.73 ± 5.942. The major subscales affected were symptoms with a mean score of 3.14. Both hair-specific Skindex-29 and DLQI had a significant correlation, thereby suggesting that AGA significantly affects patient's QOL.
CONCLUSION: AGA harmfully affected the patient's QOL which warns the physicians to pay more attention to QOL impairment in patients of AGA for the better understanding of the disease burden on individual patients.

INTRODUCTION

Hair is one of the defining characteristics of mammals. All through the ages, it has sociological and psychological importance in making appearance and personality of a person. The cultural origin of humankind is reflected in different hair styles and different hair-shaving patterns. It also reflects the person's status and his distinct personality. Due to hair hype by public and media advertisement, hair excess or loss is socially and cosmetically unacceptable as in hirsutism and alopecia. The genetically determined progressive process that causes a gradual conversion of terminal hair into vellus hair is known as androgenetic alopecia (AGA), which is the most common type of hair loss affecting over 70% of adult males and 50% of women.[1] AGA is a benign condition and can have significant psychological impact on a person and involves both hormonal and genetic factors. Some studies conducted in the past also signify that AGA can have psychosocial complications, including depression, low self-esteem altered self-image, and less frequent and enjoyable social engagements. In patients with AGA due to continuous disease progression, quality of life (QOL) gets impaired. Therefore, treatment and counseling is very important in these cases. There are not many studies on the QOL in patients of AGA. Therefore, this study was carried out to know the psychosocial aspects affecting the patient's life due to disease progression and its prospects in the future population.

MATERIALS AND METHODS

This prospective study was conducted in the outpatient department of dermatology in a tertiary care center in North India. A total of 200 male patients in the age group of 18–60 years with AGA Grade I–VII of the Hamilton–Norwood classification were enrolled in the study. The participation was totally voluntary, and informed consent was obtained from all the patients willing to participate in the study. Patients with any other dermatological disease were excluded from the study. The study had ethical approval from the institute.

All the demographic parameters including age, duration of alopecia, detailed family history, occupation, education, marital status, and history of onset were recorded in the pro forma designed. All patients were classified according to BG Prasad classification for socioeconomic status. QOL in all patients was assessed using the Dermatology Life Quality Index (DLQI) scale and the hair-specific Skindex-29 scale. The DLQI questionnaire was used to know the hair and scalp problems for the past week. The DLQI score consisted of maximum of 3 and minimum of 0 values against a total of 30 score for each patient. The Hairdex scale consisted of three subscales, i.e., emotion, function, and symptom. The pro forma consisted of 29 questionnaires with a maximum score of 5 and minimum score of 1 for each questionnaire. The total minimum score was 29 and maximum score was 145 for each patient. Each score was recorded on the pro forma and the total score was calculated.

RESULTS

The minimum age group belong to 18 years and maximum age group to 60 years in all 200 patients of AGA. Table 1 shows the maximum number of patients, i.e., 44.5% belong to the age group of 21–30 years. The mean age was found to be 32 years. Distribution of the study patients was done according to socioeconomic status based on the modified BG Prasad classification.

Table 1

Different demographic variables with patient distribution

Demographic variables	Total patients (%)
Age (years)
18-20	22 (11.0)
21-30	89 (44.5)
31-40	49 (24.5)
41-50	33 (16.5)
51-60 and above	7 (3.5)
Marital status
Married	94 (47)
Unmarried	106 (53)
Urban/rural
Rural	78 (39)
Urban	122 (61)
Occupation
Businessman	12 (6)
Driver	4 (2)
Electrician	2 (1)
Farmer	17 (8.5)
Laborer	19 (9.5)
Office job	46 (23)
Shopkeeper	33 (16.5)
Student	51 (25.5)
Others	16 (8)
Education
Illiterate	2 (1)
8th	10 (5)
10th	37 (18.5)
12th	32 (16)
Graduate	107 (53.5)
Postgraduate	12 (6)
Socioeconomic status
Class I upper	33 (16.5)
Class II upper middle	47 (23.5)
Class III middle	76 (38)
Class IV lower middle	29 (14.5)
Class V lower	15 (7.5)
Duration of hair fall (years)
0-5	100 (50)
5-10	75 (37.5)
11-15	17 (8.5)
16-20	8 (4)
Nature of work
Outdoor work	75 (37.5)
Indoor work	99 (49.5)
Outdoor work and indoor work	26 (13)
Family history
Positive	100 (50)
Negative	100 (50)
Alcoholic/nonalcoholic
Alcoholic	70 (35.5)
Nonalcoholic	130 (65.5)
Treatment history of
No treatment	154 (77)
Hair oil	29 (14.5)
Minoxidil	9 (4.5)
Vitamin	5 (2.5)
Topical steroid	3 (1.5)

Table 1 also shows the distribution of patients according to the socioeconomic status. Maximum (76) number of patients belonged to middle class (Class III). Most (53%) of the patients in total were unmarried. Majority (61%) of the patients affected were from urban background.

The total duration of hair fall in 50% of patients was between 0 and 5 years. Most of the study patients were from younger age group and, therefore, had a short duration of history of hair fall. The mean duration of disease was 5.8 years of age.

Table 1 also shows the distribution of educational status. Majority (107) of the patients were graduates. They were followed by 37 patients who completed their 10th standard and 32 patients who studied till the 12th standard. Only 12 patients were postgraduates. Five patients studied till the 8th standard and two patients were illiterate. In the total study population, most (49.5%) of the patients were engaged in indoor work, 104 patients were vegetarian, 130 patients were nonalcoholics, and 145 patients were nonsmokers. Majority (92.5%) of the patients did not have any associated disease. Only 7% of patients had a history of diabetes or hypertension. Maximum (77%) number of patients sought medical advice for the first time for male-pattern alopecia (MPA). Only nine patients sought minoxidil as a treatment option.

Table 2 shows the distribution of study patients based on the Hamilton–Norwood scale. The total patients with Grade III presentation were 60 which were the most affected group, followed by Grade II and IIA which were 22 patients in each group. Grade VII was the least affected group among the others with only four patients. The age group of 21–30 years had most number of patients with maximum patients belonging to Grade IIA.

Table 2

Patient distribution according to the Hamilton-Norwood scale

Hamilton-Norwood	Age groups (years)					Total
	18-20	21-30	31-40	41-50	>50
Grade 1	9	4	0	0	0	13
Grade 2	10	12	0	0	0	22
Grade 2 anterior	3	18	1	0	0	22
Grade 3	0	15	4	2	0	21
Grade 3 anterior	0	12	6	2	0	20
Grade 3 vertex	0	10	5	4	0	19
Grade 4	0	9	11	3	1	24
Grade 4 anterior	0	3	9	4	1	17
Grade 5	0	2	6	5	0	13
Grade 5 anterior	0	3	4	6	2	15
Grade 6	0	1	3	5	1	10
Grade 7	0	0	0	2	2	4
Total (%)	22 (11)	89 (44.5)	49 (24.5)	33 (16.5)	7 (3.5)	200

Table 3 shows that the total mean of DLQI score was 13.52 with the standard deviation of 3.15. The mean percentage obtained in the present study was 45.1%. The total mean of Hairdex-29 score was 75.62 with a standard deviation of 13.78. The mean percentage obtained was 52.2%. The different subscale parameters in Skindex-29 were symptoms, functions, emotions; with respective score of 22.1 ± 5.025, 25.89 ± 4.814, and 27.73 ± 5.942. The most common presentation in symptom subscale was “water bothers my scalp” with a mean score of 3.265, whereas the least effected symptom was”my scalp itches.” The highest affected emotion questionnaire was “I am humiliated by my alopecia” with a mean of 3.045. In function subscale, the highest mean (2.58) was of decreased desire to be with people.

Table 3

Scoring according to dermatology life quality index and hair-specific Skindex-29 scales

Descriptive statistics	Mean±SD	Median	Maximum	Minimum	Range	Mean (%)
DLQI score	13.52±3.15	13.00	22	6	16	45.1
Hairdex-29 score	75.62±13.78	77.00	104	39	65	52.2
Symptom	22.01±5.025	24	31	8	23	62.87
Function	25.89±4.814	26	40	15	25	43.14
Emotion	27.73±5.942	28	40	13	27	55.46

SD - Standard deviation; Hairdex-29 - Hair-specific Skindex-29; DLQI - Dermatology life quality index

DISCUSSION

In today's world, dermatologists treat patients with a wide range of diseases (many of them severe or life-threatening) that it may be hard to take the effect of male-pattern hair loss (also known as AGA) seriously on the QOL of those affected by it.[2]

It should be specified that hair growth and hair style are important elements of an individual's identity: hair strongly influences whether or not a person is seen as physically attractive,[3] and there are consistent advantages of being perceived as attractive,[4] such as better personal relations, better emotional and psychological strength, and priority in employment practices. Girman et al.[5] showed that men with greater hair loss had more concern about getting older, perceived noticeability to others and greater dissatisfaction with their hair appearance than men with less hair loss.

Given the psychological and symbolic importance of hair, it is not surprising that hair loss may have a potentially adverse impact on a person's QOL. Unfortunately, this impact is often ignored by those not affected by it. It has been proven difficult to convince the public and medical practitioners that male-pattern hair loss has any significant effect on QOL. Even the history of the treatment of AGA has more than its fair share of “trichoquackery,” and medical practitioners are reluctant about any claims to treat AGA, and thus, QOL is totally ignored.[1]

Thus, this study was conducted to assess the effects on QOL of AGA patients, by DLQI and Skindex-29 scales. We chose two scales to better out the assessment process of QOL owing to the importance of knowing all the aspects that are affected after hair loss: emotional, functional, and symptomatic.

The current study found that the effect of AGA on QOL was comparable to other studies.[567] Consistent with previous findings,[56] young adults were more affected in our study. Although negative effects due to hair loss were reported across all age groups, they were more apparent in younger men.

Goldberg–Huxley suggested that the group which suffers most in terms of QOL are those who are under specialist treatment and consult their general practitioner, as compared to those who “cope” with their disease.[8] This is illustrated in our study where >50% of participants reported a diagnosis more than 5 years previously and yet were still seeking medical consultation, suggestive of the continuous psychological impact of alopecia and its role in shaping identity.

Most of the patients were from middle class, urban settled, and unmarried. Stressful environment – pertaining to the urban standards of living in a nuclear family – and anxiety of losing hair are the key triggering factors in the progression of AGA. These changes were more perceived in younger population with an increase in stressful conditions in an urban setup.

In line with the previous findings regarding the psychological consequences of alopecia,[91011] patients reported increased symptoms such as scalp irritation, always bothered, burning, and itchy sensation. Patients experienced loss of desire to meet people and preferred staying at home and did not even want to interact with close ones. Emotionally, patients experienced embarrassment, humiliation, and depression due to MPHL (Male pattern hair loss) which was in accordance with Wells et al.[12] Alfonso et al.[13] also reported negative effects on social life and feeling of depression which were similar to our study.

Clinical symptoms, functional behavior, and emotional stability in addition to anxiety and worry about hair loss all affect the QOL of an individual. Patients showed deterioration at all levels. The mean DLQI score was high and comparable with Tahir et al.[14] The impaired DLQI score suggested that AGA has a negative impact over the individual's life. The altered feelings due to acceptance of hair loss, thereby reducing daily leisure and outdoor activities to avoid negative emotions from their surroundings and decreasing social outgoings, led to a cycle of depression and anxiety. The increased stress created due to all the factors forced patients to opt for alternate means such as wearing hats or wigs to prevent psychosocial discomfort. Such means increase the financial pressure and decrease the self-esteem of the patients.

The symptom scale was most deranged in our study out of symptoms, functions, and emotions in hair-specific Skindex-29, accounting for more focus of the patients on the itching and burning scalp before accepting and knowing the fact that it is a continuing progressive condition termed AGA. Most of the patients in our study had Grade III baldness which may be considered a normal process in today's lifestyle, limiting their response in terms of emotional and functional setbacks. The emotional and functional side effects of AGA arise after the partial or complete acceptance of the condition and understanding the fact that this may progress to complete baldness. The most important illness perceptions were illness identity, illness consequences and a strong emotional response to the condition. Both identity and consequences have consistently been shown to be strong predictors of outcomes in other studies with chronic illness,[151617] and emotional representations are emerging as an important predictor of QOL.[1819]

Accounting for the unpredictable condition, uncertain etiology, and limited treatment, patients later felt helpless. The current study suggests that practitioners need to move the focus away from symptoms and to help people to deal with their emotional responses to AGA. In addition, other studies show that people with high-grade alopecia want greater attention given to psychological issues arising from the condition [Table 4].[9142021222324] Thus, it is important that practitioners recognize the long-term psychological impact of alopecia such as depression and anxiety and start addressing patients' perceptions of their illness and concerns about the future.

Table 4

The demographic parameters present in different studies of androgenetic alopecia

Parameters	Present study	Williamson D et al.	Neena Sawant et al.	Kehkshan Tahir et al.	Sung-Hyub Han et al.	Rahul Bade et al.
Hairdex-29	75.63±13.78	Not studied	Not available	Not studied	Not available	83.05±15.68
Symptom	22.01±5.025	Not studied	24.05±15.24	Not studied	26.3±19.5	14.93±2.87
Function	25.89±4.814	Not studied	7.73±5.53	Not studied	24.0±20.1	28.09±8.31
Emotion	27.73±5.942	Not studied	12.31±12.61	Not studied	32.1±21.8	39.14±9.93
DLQI	13.52±3.15	8.3±5.6	Not studied	11.87±3.35	Not studied	13.5±4.4

Hairdex-29 - Hair-specific Skindex-29; DLQI - Dermatology life quality index

Dermatologists can help in better emotional adjustment by illness coherence, proper diagnosis, and suggestions with newer treatment options and convincing them to judiciously continue treatment.

Recent advancements have led to the introduction of DNA testing of androgen receptor gene to diagnose the condition and relate the future probability of baldness and relative prognosis. The newer treatment options such as platelet-rich plasma (PRP) therapy and low-level laser light therapy (LLLT), in addition to standard drug treatments such as minoxidil and finasteride, have opened gates for better control of AGA. However, the limited treatment options can only delay the process but cannot reverse it completely. PRP and LLLT therapy can help in increasing 30% thickness of hair if continued regularly, but the effects reverse if discontinued. Studies are needed to assess whether such interventions are effective in improving patient outcomes and reducing psychological disorders among those with alopecia.

Various limitations of the study should, however, be considered when evaluating the findings. Despite the strong relationships between illness and QOL, the use of a cross-sectional design restricts the causality of these relationships. Prospective longitudinal studies are needed to assess how people's perception of alopecia is affected with time. Long-term studies are needed to note the treatment outcomes particularly related to hair loss itself and psychological support to overcome the stress of AGA. It would be interesting to examine psychological response both during periods of hair loss and during periods of remission.

CONCLUSION

AGA is a common dermatological condition, with potentially adverse psychosocial sequelae. Research confirms a negative moderate effect of visible hair loss on symptomatic, emotional, social, and psychological state. More importantly, AGA is typically experienced as a moderately stressful condition that diminishes body image satisfaction. The medical practitioners can play a role in improvement of patients' QOL, by recognizing and addressing the psychological impact of alopecia. However, further research will be needed to know the QOL improvement with the newer behavioral PRP and LLLT therapies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.