Identity and psychological distress in alopecia areata.

In this issue of the BJD, Macbeth and her seven coauthors provide a timely article regarding mental health conditions associated with alopecia areata (AA). In the past, this area has been neglected by many dermatologists and others when considering the treatment of AA, a problem we discussed nearly 20 years ago. Focusing specifically on depression and anxiety, as these are probably the most likely mental health concomitants of AA, this large‐scale study found that both conditions are more common among people diagnosed with AA than among controls.

This is not a surprising finding. Hair is of fundamental importance in projecting the self‐image, and a dramatic change in appearance can profoundly affect the way people see themselves. In this sense AA is similar to other forms of disfigurement. We have long acknowledged the importance of the psychosocial aspects of, for example, facial disfigurement, but hair has similarities because it can be just as important for self‐esteem as any other part of appearance. Many women (in particular) see their hair as their ‘crowning glory’, so the loss of hair can be particularly distressful for women. Macbeth et al. did not compare sex differences. It would have been helpful to see whether previous findings regarding sex differences are repeated, or whether cultural change has altered the pattern of psychosocial problems experienced by men and women.

One important finding from the study of Macbeth et al. is not just that people with AA were more likely to experience depression and anxiety, but that they were also more likely to be issued time off work certificates and be recorded as unemployed. We know that hair loss can affect whether people take part in social activities such as sport or sexual activity, so this adds to the evidence regarding the inability of many people with AA to take part in normal social activities, presumably directly because of their hair loss.

The authors do recognize some of the limitations of their study. In addition to this, one problem may be the focus on medications as the main indicators of depression and anxiety. While this provides a reasonable measure of the classification of depression and anxiety, it is not without its faults. Many people experiencing symptoms of depression and anxiety do not go to their doctor and obtain medication. On the other hand, some people may be prescribed medication without a full assessment of their mental health. These issues are not likely to change the overall picture that many people with AA experience psychosocial problems.

Perhaps the most important point made by Macbeth et al. is that people with AA who experience psychological distress should be provided with appropriate support, and that we need to develop and test appropriate psychological therapies for use with AA. Psychologists do have appropriate therapies available. We must recognize the need for these among people with AA.