The lived experience of alopecia areata: a qualitative study

Estimation of health utility values for alopecia areata

PURPOSE

Alopecia areata (AA) is an autoimmune-mediated inflammatory dermatological disease characterised by non-scarring hair loss affecting the scalp and sometimes other hair-bearing sites. This study aimed to elicit health state utility values (HSUVs) from the UK general population for AA using time trade off (TTO) interviews.

METHODS

Vignette descriptions of health states defined by the extent of hair loss were developed (as well as one describing caregiver burden). These were developed using data from standardised patient reported outcome (PRO) measures, a literature review and qualitative interviews. Health states were defined based on the severity of alopecia tool (SALT), which assesses extensiveness of scalp hair loss. HSUVs were then elicited for each health state in TTO interviews with the UK public.

RESULTS

One caregiver and five patient health states were developed based on the literature review findings, clinical trial PRO (Hospital Anxiety and Depression Scale and Alopecia Areata Patient Priority Outcomes Questionnaire) data and qualitative interviews with patients (N = 11), clinical experts (N = 4) and caregivers of adolescents with AA (N = 10). These data showed a more severe impact among patients with more extensive hair loss. One hundred and twenty participants evaluated the vignettes in TTO interviews. Patient HSUVs ranged from 0.502 for the most extensive hair loss health state (SALT 50-100 + eyebrow and eyelash loss) to 0.919 (SALT 0-10) for the mildest health state. The caregiver HSUV was 0.882.

CONCLUSION

Quantitative and qualitative data sources were used to develop and validate vignettes describing different AA health states. Patient and caregiver HSUVs demonstrate a large impact associated with AA, especially for states defined by more extensive hair loss.

Establishing the financial burden of alopecia areata and its predictors

Background

Alopecia areata (AA) can have a significant impact on wellbeing. Consequently, individuals with AA often seek treatments or products to promote hair regrowth or camouflage their hair loss that incur a financial cost to the individual.

Objectives

The current study aimed to examine the direct financial burden of AA to understand the wider impact of the condition and the factors which influence spending on products and services.

Methods

A total of 829 United Kingdom based participants completed an online survey. Demographic and condition-specific data were collected, alongside spending on AA-related products and services. Participants were asked about their use of products and services, the associated costs, how they financed these costs, and their household income to determine what percentage of income they spent on products and services.

Results

Participants predominantly identified as female (85.9%), white (92.7%) with a mean age of 42.7 years and a median AA duration of 10.94 years. Female gender, Asian ethnicity, lower income, and worse AA symptoms predicted higher spend from income. Wigs were the most common product used and incurred the greatest cost (median £700). The highest cost for men was private dermatology services (median = £550). On average people spent 3% of their disposable income (prior to housing costs) on AA-related products and services.

Conclusions

This study outlines the risk factors associated with higher financial burden from managing AA which require consideration by health providers, commissioners, and policy makers when designing services to support the wellbeing of people living with AA.

"Hair is your crown and glory" - Black women's experiences of living with alopecia and the role of social support

BACKGROUND

Alopecia is an autoimmune condition that results in hair loss, mainly from the scalp. There are three specific types of autoimmune alopecia: alopecia areata (AA; small patches of hair loss), alopecia totalis (AT; total hair loss from the scalp) and alopecia universalis (AU; total hair loss from the scalp and body). Whilst research has explored the experiences of White women living with alopecia, there is a lack of research exploring the impact of alopecia on women in the Black community. The current study aimed to explore Black women's experience of living with autoimmune types of alopecia with a focus on the cultural importance of hair within the Black community and the impact of social support.

PARTICIPANTS AND PROCEDURE

Seven Black women (age range: 37-68 years; mean age: 51 years) were recruited purposively through alopecia support group organisations and social media to participate in a semi-structured interview; four participants were diagnosed with AA, two participants were diagnosed with AU, and one participant was diagnosed with AT. One-to-one interviews were conducted online, and interpretative phenomenological analysis was used to guide data collection and analysis.

RESULTS

Participants discussed the significance of hair specifically within the Black community and the complex relationship between psychological wellbeing, coping and seeking support.

CONCLUSIONS

This novel area, specific to Black women's psychological experience of alopecia, acknowledges the influence of cultural and ethnic differences. The findings suggest that proactive awareness from health professionals and social support groups are needed due to the nuances of Black women's alopecia experience to provide better support and to enhance the quality of life for Black women to manage their alopecia.

Out-of-Pocket Costs in Alopecia Areata: A Cross-Sectional Study in German-speaking Countries

Alopecia areata is a common skin disease which is associated with psychosocial and financial burden. No curative therapy exists and, hence, affected persons resort to self-financed cosmetic solutions. However, studies on the economic impact of alopecia areata on individuals are limited. To estimate annual individual out-of-pocket costs in persons with alopecia areata, a cross-sectional study using a standardized online questionnaire was performed in Germany, Austria and Switzerland. A total of 346 individuals (95.1% women, mean age: 38.5 ± 11.6 years) with alopecia areata participated between April and August 2020. Mean additional spending on everyday necessities was 1,248€ per person per year, which was significantly influenced by the duration of the illness, the treatment provider, and disease severity. Hair replacement products and cosmetics accounted for the highest monthly costs, followed by costs for physician visits, hospital treatments, and medication. Most participants (n = 255, 73.7%) were currently not undergoing treatment, due to lack of efficacy, side-effects, costs and acceptance of the disease. Sex differences in expenses were observed, with women having higher expenditures. Alopecia areata-related out-of-pocket costs place a considerable financial burden on affected individuals, are higher compared with those of other chronic diseases, and should be considered in economic assessments of the impact of this disease.

Anxiety, depression, and quality of life in children and adults with alopecia areata: A systematic review and meta-analysis

Introduction

Alopecia areata (AA) is a non-scarring hair loss condition, subclassified into AA, alopecia universalis, and alopecia totalis. There are indications that people with AA experience adverse psychosocial outcomes, but previous studies have not included a thorough meta-analysis and did not compare people with AA to people with other dermatological diagnoses. Therefore, the aim of this systematic review and meta-analysis was to update and expand previous systematic reviews, as well as describing and quantifying levels of anxiety, depression, and quality of life (QoL) in children and adults with AA.

Methods

A search was conducted, yielding 1,249 unique records of which 93 were included.

Results

Review results showed that people with AA have higher chances of being diagnosed with anxiety and/or depression and experience impaired QoL. Their psychosocial outcomes are often similar to other people with a dermatological condition. Meta-analytic results showed significantly more symptoms of anxiety and depression in adults with AA compared to healthy controls. Results also showed a moderate impact on QoL. These results further highlight that AA, despite causing little physical impairments, can have a significant amount on patients' well-being.

Discussion

Future studies should examine the influence of disease severity, disease duration, remission and relapse, and medication use to shed light on at-risk groups in need of referral to psychological care.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022323174].

Men’s experiences of alopecia areata: A qualitative study

Alopecia areata (AA) affects men at similar rates to women, yet comparatively little is known about men’s experience of the condition. We interviewed a demographically diverse group of 18 men with AA to explore this gap. From qualitative thematic analysis, participants’ accounts described a profound yet often-minimised impact of AA on their lives, in the context of poor public awareness and misguided assumptions about AA in men. Conversely, this adversity appeared to facilitate personal growth for many. These findings can help health professionals better understand men’s gendered experience of AA, which we discuss through the lens of masculinities theory.

A qualitative interview study to explore adolescents' experience of alopecia areata and the content validity of sign/symptom patient-reported outcome (PRO) measures

BACKGROUND

The content validity (appropriateness and acceptability) of patient-reported outcome (PRO) measures for scalp hair loss, eyebrow loss, eyelash loss, nail damage and eye irritation has been demonstrated in adults with alopecia areata (AA) but not adolescents.

OBJECTIVE

To explore the content validity of the suite of AA PRO measures and accompanying photoguides in an adolescent sample.

METHODS

Semi-structured, 90-minute, combined concept elicitation and cognitive interviews were conducted face-to-face with adolescents who experienced ≥50% AA-related scalp hair loss. Transcripts underwent thematic and framework analysis.

RESULTS

Eleven adolescents (age 12-17 years, 55% female, 45% non-Caucasian/white) diagnosed with AA for 5.9 years (mean) participated. Participants had 69.6% scalp hair (mean) and current eyebrow (82%), eyelash loss (82%) and/or nail involvement (36%). Adolescents reported scalp, eyebrow and eyelash hair loss as their top three most bothersome signs/symptoms. Despite mostly accepting their AA, impacts related to visible areas of hair loss were prominent. Participants demonstrated good understanding and appropriate use of the PRO measures, and advocated including hair loss percentages alongside descriptive categories in the Scalp Hair Assessment PRO™. Results confirmed treatment success thresholds established with adults: achievement of ≤20% scalp hair loss, no/minimal eyebrow and eyelash loss, no/a little nail damage and eye irritation (PRO categories 0 or 1).

CONCLUSIONS

The Scalp Hair Assessment PRO™, PRO Measure for Eyebrows™, PRO Measure for Eyelashes™, PRO Measure for Nail Appearance™ and PRO Measure for Eye Irritation™ and accompanying photoguides are fit-for-purpose self-reported measures of AA signs/symptoms that are impactful to adolescents with AA.

Characterizing the willingness to undergo treatment in patients with alopecia areata

Alopecia areata is an autoimmune disease that results in partial or total balding of the scalp and/or body. Treatments available are minimally effective, have severe side effects, and are often painful. Given these burdens, patients may not feel undergoing treatment is worthwhile. The purpose of this study is to characterize the willingness of patients with alopecia areata to undergo treatment. We found that few patients are willing to undergo treatment at the risk of severe health side effects. The most acceptable form of treatment administration was topical and the least acceptable was injection at the site of hair loss. A majority of patients would only undergo treatment for hair growth that is cosmetically acceptable and the most important site of hair regrowth was the scalp. The willingness to undergo treatment differed significantly by gender, age, time since disease onset, and disease severity. This study offers insight into the preferences of patients with alopecia areata and characteristics that would make treatment widely acceptable. Institutions conducting research on treatment for alopecia areata can use the results of this study to better understand the needs of their target population.

Effects of the new COVID-19 normal on customer satisfaction: Can facemasks level off the playing field between average-looking and attractive-looking employees?

The attractiveness of service employees can have a significant impact on customer attitudes and behaviors. While frontline employees can reduce the risk of the COVID-19 transmission and infection by wearing facemasks, doing so can also influence customers' perceptions of employees' attractiveness and thus affect customer satisfaction. Based on the Gestalt theory, this study explores the impact of hotel employees' facemask-wearing on customer satisfaction through two experimental studies. The results indicate that average-looking frontline employees who wear facemasks induce high levels of customer satisfaction. However, while the impact of wearing facemasks on customer satisfaction is not significant for attractive-looking male frontline employees, attractive-looking female frontline employees who wear facemasks induce lower customer satisfaction. Customers' perception of employees' physical attractiveness fully mediates the effects of wearing facemasks on customer satisfaction in the case of average-looking employees. Customers' self-perceived physical attractiveness moderates the mediated effects. Implications that can help hotel managers improve customers' service evaluations during the COVID-19 pandemic are provided.

Patient Perspectives of the Social, Emotional and Functional Impact of Alopecia Areata: A Systematic Literature Review

Introduction

Alopecia areata (AA) is a chronic, autoimmune disease of hair loss, which can significantly affect the emotional and psychological well-being of patients. A systematic literature review was conducted to better understand the burden of AA from the patient perspective.

Methods

Embase, MEDLINE and Cochrane databases were searched for published studies (2008–2018) reporting on assessments of health-related quality of life (HRQoL) for patients with AA. Qualitative, and quantitative data were collected.

Results

The review included 37 studies encompassing a range of clinical outcome assessment (COA) tools. None of the COA tools were specific for AA, and only one study used the Hairdex scale, which was designed to evaluate HRQoL in patients with disorders of the hair and scalp. All studies reported substantial impact on HRQoL due to AA, both overall and in domains related to personality (i.e. temperament and character), emotions and social functioning. Acute stress was also noted, and several studies identified lack of emotional awareness (alexithymia) in 23–50% of the patients with AA.

Conclusions

Although it is well-established that patients with AA experience anxiety and depression, they also experience a decrease in HRQoL in many other areas, including personality, emotions, behaviors and social functioning, and these changes may be accompanied by acute stress and alexithymia. There is a need to achieve consensus on a core set of measures for AA and to develop and validate AA-specific measurement tools for use in future studies, to attain a clearer understanding of the impact of AA on patients.

Trial Registration

PROSPERO registration number; CRD42019118646.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00512-0.

Alopecia areata (AA) is a disease in which a person’s immune system attacks their hair follicles, from which hairs grow, causing hair loss. Studies have shown that people with AA may have a lower quality of life, and studies have reported higher rates of depression and anxiety in people with AA than in people without AA. Study design: We reviewed published studies to better understand how AA affected people socially, emotionally and in their day-to-day functioning. We also looked at how healthcare providers measured these social, emotional and day-to-day effects on people with AA. Our review included 37 published studies that used several evaluation tools to measure the impacts of AA. These included a variety of questionnaires that were answered by people with AA. Results: The studies reported that AA negatively affected the personality, emotions, behaviors and/or social functioning of many people with AA. However, none of the evaluation tools that were used in those studies were specific for AA, and most of the evaluation tools did not include questions about the hair or scalp. Conclusions: We recommend that a group of people familiar with AA (practitioners, researchers and patients) work together to develop an evaluation tool that is designed specifically for people with AA. This evaluation tool can then be used in future studies to better understand how AA affects people socially, emotionally and in their day-to-day functioning.

'My face in someone else's hands': a qualitative study of medical tattooing in women with hair loss

The psychological and social impact of hair loss and its ongoing treatment can be considerable. Medical treatments are not always successful, and alternative treatments, such as medical tattooing, are growing in popularity. The aims of this study were to explore adults' motivations, experiences, and self-perceived outcomes in relation to medical tattooing. Individual telephone interviews were conducted with 22 women from the United Kingdom aged 26-67 years who had undergone medical tattooing in the past 5 years related to hair loss. Interviews were transcribed and inductive thematic analysis was performed. Appearance concerns, loss of self-confidence/identity, and the practicalities of daily upkeep were cited as reasons for seeking a semi-permanent solution. Trust in the practitioner and the ongoing costs of tattoo maintenance were important considerations in participants' decision-making process and their overall satisfaction with treatment outcomes. Participants felt the emotional impact of hair loss and the subsequent need for appearance-restoring treatment remains unrecognised. This study provides insight into participants' perceptions of an under-researched and unregulated but widely accessible treatment. Implications for the decision-making process are discussed, and suggestions for health professionals are offered.

Therapeutic implications of psychological state in patients with alopecia areata: A qualitative study

Hair loss can significantly impact an individual's psychological state, self-image, and can lead to numerous personal, social, and occupational problems. Although these impairments are well documented in primary studies and reviews, and the need for appropriate psychological help is emphasized, there is still a lack of knowledge for a broader and specific picture. The patient's perspective is vital while seeking to understand the content of the variables like "impaired body image" or "low self-esteem." This article advocates the need for studies involving methodologies allowing to explore the complexity and depth of experience. A better understanding of patients' states, reactions, and needs might contribute to the practice of healthcare professionals seeking the best possible help. This study aimed to explore the lived experience of people with alopecia areata in Lithuania using a phenomenological approach. Experiences of six patients with varying degrees of alopecia areata, four women and two men (mean age 27 years), were explored. Data were obtained using an unstructured interview and were analyzed based on Colaizzi's phenomenological approach. This article explores findings related to patient's psychological state covering two superordinate themes: (a) devastating loss of perceived self and (b) grieving and the process of acceptance. The insights for the appropriate therapeutic intervention were formulated.

"'You lose your hair, what's the big deal?' I was so embarrassed, I was so self-conscious, I was so depressed:" a qualitative interview study to understand the psychosocial burden of alopecia areata

Background

Alopecia areata (AA) is characterized by hair loss that can affect the scalp and body. This study describes the psychosocial burden of AA.

Methods

Participants diagnosed with AA who had experienced ≥50% scalp hair loss according to the Severity of Alopecia Tool (SALT) were identified by clinicians. A semi-structured interview guide, developed with expert clinician input, included open-ended questions to explore patients’ experiences of living with AA. Data were thematically analyzed to identify concepts and relationships.

Results

Participants (n = 45, 58% female, mean age 33.3 years [range 15–72], mean SALT 67.2 [range 0–100]) described the AA diagnosis as “devastating”. Both males and females reported emotional and psychological impacts of AA including feeling sad/depressed (n = 21), embarrassed/ashamed (n = 10) and angry/frustrated (n = 3). Patients felt helpless (n = 5) due to the unpredictability of disease recurrence, and anxious (n = 19) about judgement from others. Many patients avoided social situations (n = 18), which impaired relationships and increased isolation. Coping strategies included concealment of hair loss through wigs or make-up, although fear of the displacement of these coverings also caused anxiety and the avoidance of activities that could result in scalp exposure (n = 22). Some patients became more accepting of AA over time, which lessened the emotional impact, though efficacious treatment was still desired. A conceptual framework was developed, and a conceptual model was created to depict the relationship between the physical signs/symptoms and the associated psychosocial effects of AA.

Conclusion

AA impairs patients’ emotional and psychological wellbeing, relationships and lifestyles. Greater disease awareness and effective treatments are needed.

Psychosocial and psychiatric comorbidities and health-related quality of life in alopecia areata: A systematic review

BACKGROUND

Alopecia areata (AA) is an immune-mediated disease resulting in nonscarring hair loss. Systematic reviews on the psychosocial and psychiatric comorbidities, health-related quality of life, and interventions targeting psychosocial well-being are limited.

OBJECTIVE

To conduct a systematic review of the psychosocial comorbidities, health-related quality of life, and treatment options targeting psychosocial well-being in adult and pediatric AA patients.

METHODS

A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines within the PubMed database. Specific search terms included, but were not limited to, alopecia areata, psychosocial, psychiatry, and quality of life. Studies were then evaluated for their design and categorized into corresponding levels of evidence according to the guidelines adapted from the Oxford Center for Evidence Based Medicine.

FINDINGS

Seventy-three reports met inclusion criteria, involving approximately 414,319 unique participants. AA patients were found to have psychiatric comorbidities, particularly anxiety and depression. Health-related quality of life is reduced in AA patients, but data on pediatric AA quality of life are limited. Psychotherapy is often recommended as adjuvant treatment.

CONCLUSION

AA has substantial psychosocial impact on patients and results in reduced health-related quality of life. Addressing this should be an active part of treatment.

Investigating the beneficial experiences of online peer support for those affected by alopecia: an interpretative phenomenological analysis using online interviews

BACKGROUND

Those affected by alopecia are at risk of experiencing a range of psychosocial consequences. Alopecia UK provides online peer support via facilitated Facebook pages. Online peer support has been found to provide a variety of benefits in other long-term conditions, such as providing information and emotional support.

OBJECTIVES

This study sought to gain an experiential account as to how online support provides benefit to people living with alopecia.

METHODS

A purposive sample of 12 participants was recruited directly from Alopecia UK's Facebook group. A total of 11 were diagnosed with alopecia and one participant was a family member of someone with alopecia. The qualitative approach of Interpretative Phenomenological Analysis was used to guide data collection and analysis. Participants took part in online synchronous interviews, which drew on review of participant-selected screenshots of online activity.

RESULTS

Four themes were identified, including 'gradual healing', 'image concern', 'belonging' and 'new identity and self-acceptance'. The participants made use of the group through expressing emotion, finding practical advice, and also as a place to connect and share experiences. Participants also reported that the online support facilitated the return of social confidence.

CONCLUSIONS

This study provides a detailed understanding as to how online peer support groups can be beneficial. Online groups have the potential to create a feeling of belonging, which can develop a sense of being accepted and understood and as such can be important in maintaining psychological well-being. The findings indicate that online groups have the potential to be used as a platform for assisting people in developing both effective coping styles and feeling understood, and such platforms warrant further investment by healthcare professionals. What's already known about this topic? Alopecia may be associated with psychosocial distress due to both the individual impact and the reactions of others. Online peer support is known to be a beneficial method of providing psychosocial support for people living with a range of health conditions. What does this study add? An in-depth view of the benefits experienced through belonging to an online peer support group for those diagnosed with alopecia, in addressing the psychosocial effects experienced with the condition. This research highlights the need for further investigation of the utility of supporting the development of online peer support for people living with skin conditions. Online peer support groups could be highly effective to use in combination with existing psychological therapies to connect others with shared experience. What are the clinical implications of this work? People living with alopecia can benefit from peer support, and healthcare professionals should ensure that patients know where they can gain access to both psychological support and peer support.

Living with alopecia areata: an online qualitative survey study

BACKGROUND

Living with alopecia areata (AA) totalis and universalis (collectively referred to here as AA) involves unpredictable, sometimes rapid hair loss. There is currently no effective treatment and patients describe feelings of shock, loss, trauma and disrupted identity. Cultural meanings attached to hair and hair loss, including associations between hair and femininity, and hair loss and cancer may exacerbate distress. Consequently, wigs and make-up are frequently used as camouflage, but this can produce feelings of inauthenticity, shame and anxiety.

OBJECTIVES

This article explores how meanings associated with hair and hair loss influence experiences of living with AA. We also aim to identify how this understanding might inform practice by healthcare professionals to best support patients to cope with the condition.

METHODS

A total of 95 participants with AA completed an online qualitative survey about their experiences of living with the condition. Data were subjected to thematic analysis within a critical realist theoretical framework.

RESULTS

The following four themes were identified: (i) It's (not) only hair; (ii) A restricted life; (iii) Abandon hope all ye who lose their hair and (iv) Seeking support in 'a highly personal journey'.

CONCLUSIONS

Findings suggest that negative cultural meanings of hair and hair loss are pervasive and may drive social avoidance and camouflage behaviours in people with AA. Normalizing social interactions with healthcare practitioners, significant others and peers were cited as pivotal to positive adjustment. Support groups and online forums were highly valued particularly as few had been offered specialist psychological support. Future research should develop and evaluate psychological support in order to address the specific challenges of living with AA.

Alopecia Areata: Factors That Impact Children and Adolescents

Research suggests that several factors affect children and adolescents with alopecia areata (AA). While hair loss is mostly associated with individuals undergoing chemotherapy, AA also causes individuals to lose the hair on their scalp and elsewhere on the body. This loss can be particularly devastating to children and adolescents, and can affect them socially, as well as psychologically. A mixed method research design was used to combine survey data with interview transcripts and field notes to capture a more detailed picture of AA and its effect on children and adolescents. The data reported here were extracted from a larger study utilizing nine demographic items, four independent variable items (gender, age, duration of diagnosis, age of onset), and 27 dependent variable items regarding impact factors. Subsequently, six follow-up interview questions were used with a small group for additional context. An exploratory factor analysis revealed five impact factors: Confidence/Self-Esteem, Psychological Effects, Appearance/Acceptance, Socialization, and Communication. Female participants reported significantly greater difficulty adjusting and managing AA than did their male counterparts. While most participants revealed a positive attitude about themselves, the majority were affected psychologically by this condition. Open communication with family and friends gave comfort and support to the vast majority.

A mixed methods survey of social anxiety, anxiety, depression and wig use in alopecia

OBJECTIVES

This study aimed to examine levels of social anxiety, anxiety and depression reported by people with alopecia as a result of a dermatological condition and associations with wig use. The study also sought to report on experiences of wearing wigs in social situations and the relationship with social confidence.

DESIGN

A cross-sectional survey was sent by email to the Alopecia UK charity mailing list and advertised on social media.

PARTICIPANTS

Inclusion criteria were a diagnosis of alopecia, aged 13 or above and sufficient English to complete the survey. Exclusion criteria included experiencing hair loss as a result of chemotherapy treatment or psychological disorder. Participants (n=338) were predominantly female (97.3%), Caucasian (93.5%) and aged between 35 and 54 years (49.4%) with a diagnosis of alopecia areata (82.6%).

MAIN OUTCOME MEASURES

The Social Phobia Inventory measured symptoms of social anxiety, and the Hospital Anxiety and Depression Scale was used to measure symptoms of anxiety and depression. Survey questions were designed to measure the use of wigs. Open-ended questions enabled participants to comment on their experiences of wearing wigs.

RESULTS

Clinically significant levels of social anxiety (47.5%), anxiety (35.5%) and depression (29%) were reported. Participants who reported worries about not wearing a wig reported significantly higher levels of depression: t(103)=3.40, p≤0.001; anxiety: t(109)=4.80, p≤0.001; and social anxiety: t(294)=3.89, p≤0.001. Wearing wigs was reported as increasing social confidence; however, the concealment it afforded was also reported as both reducing fear of negative evaluation and maintaining anxiety.

DISCUSSION

Overall, 46% of participants reported that wearing a wig had a positive impact on their everyday life with negative experiences related to fears of the wig being noticed. Psychological interventions alongside wig provision would be beneficial for people living with alopecia.

The importance of mindfulness in psychosocial distress and quality of life in dermatology patients

BACKGROUND

Mindfulness, defined as purposively and nonjudgementally paying attention in the present moment, could be used within psychosocial interventions to reduce the distress associated with social anxiety and avoidance found in many skin conditions. However, little is known about the relationship between naturally occurring levels of mindfulness and distress in dermatology patients.

OBJECTIVES

To examine the relationship between mindfulness and psychosocial distress in a dermatological population. It was hypothesized that higher levels of mindfulness would be associated with lower levels of social anxiety, anxiety, depression and skin shame, and with better quality of life.

METHODS

Adult dermatology outpatients (n = 120) from one hospital completed items assessing subjective severity, skin shame, fear of negative evaluation, anxiety and depression, quality of life, and levels of mindfulness.

RESULTS

Considering depression, 14% reported mild, 5% moderate and 2·5% severe symptoms. For anxiety, 22% reported mild, 23% moderate and 6% severe symptoms. In addition, 33·4% reported clinically significant social anxiety. After controlling for subjective severity, mindfulness explained an additional 19% of the variance in depression, 39% in anxiety, 41% in social anxiety, 13% in skin shame and 6% in dermatological quality of life. One specific facet of mindfulness (acting with awareness) was found to be the most consistent predictor of distress.

CONCLUSIONS

The findings indicate that higher levels of mindfulness are associated with lower distress. This suggests that facilitating mindfulness may be helpful in reducing distress in dermatology patients, and the use of mindfulness techniques warrants further investigation.

The Perceived Stigma in Patients with Alopecia and Mental Disorder: A Comparative Study

Aim:

We aimed to measure the perceived stigma, especially in patients with alopecia areata (AA) and to compare the results with patients with mental disorder (MD).

Materials and Methods:

This study included forty patients with AA who were consecutively recruited from dermatology outpatient clinic and 42 patients with MD who were consecutively recruited from psychiatric outpatient clinic. The presence of a MD was assessed by the Diagnostic and Statistical Manual of Mental Disorder Fourth Edition. All participants were asked to complete the 28 items modified stigmatization questionnaire.

Results:

Total and all subscale scores of stigmatization questionnaire scale were higher in the group of patients with AA than in the patients with MD.

Conclusion:

AA is a condition that leads to more self-stigmatization than MD.

Alopecia areata and health-related quality of life: a systematic review and meta-analysis

BACKGROUND

No systematic review has yet evaluated the available evidence on health-related quality of life (HRQOL) in alopecia areata (AA).

OBJECTIVES

To conduct a systematic review and meta-analysis of HRQOL studies among patients diagnosed with AA.

METHODS

A systematic search was performed for papers published between 1946 and 15 December 2014 in Medline, Embase, Web of Science, CINAHL, PsycINFO and the Cochrane Library. Random-effects meta-analyses were conducted to pool data.

RESULTS

Twenty-one studies were included, representing a total of 2530 adult patients with AA. Of the 14 different HRQOL measures used in the studies, Dermatology Life Quality Index (DLQI; n = 8) and SF-36 (n = 7) were the most common. Three AA-specific HRQOL instruments were identified: Alopecia Areata Quality of Life Index, Alopecia Areata Quality of Life and Alopecia Areata Symptom Impact Scale. The mean pooled DLQI score of patients with AA was 6·3 (95% confidence interval 5·6-7·1). Comparing age- and sex-matched controls, the meta-analysis of SF-36 studies revealed significantly reduced HRQOL across the role-emotional, mental health and vitality domains (P < 0·001). Wearing a wig had a positive impact, while scalp involvement, anxiety and depression had a negative impact on HRQOL. Conflicting results were found regarding the association between HRQOL and age, sex, marital status and disease duration.

CONCLUSIONS

Patients with AA experience significant impairment in HRQOL, especially in the area of mental health. Several generic and dermatology-specific HRQOL instruments have been used, but no validation studies have confirmed their applicability in AA. The newly developed AA-specific measures seem very promising; however, a more extensive assessment of validity and reliability is needed.

Psycho-emotional conditions of patients with non-cicatrazing alopecia (circumsribed, androgenetic)

Most common psycho-emotional disorders are described with patients with circumsribed, androgenetic alopecia. Main identification methods presented. It was shown based on analysis of literary data and in order to upgrade the quality of medical help for this group of patients how important it is to identify the preoccupying, depressive and other pathological psychogenic conditions of patients chronic alopecia.

The relationship between alopecia areata and alexithymia, anxiety and depression: a case-control study

BACKGROUND

Alopecia areata (AA) is a skin disease characterized by the sudden appearance of areas of hair loss on the scalp and other hair-bearing areas, but its aesthetic repercussions can lead to profound changes in patient's psychological status and relationships.

AIM

The goal was to investigate a possible relationship between AA and alexithymia as well as two other emotional dimensions, anxiety and depression.

MATERIALS AND METHODS

Fifty patients with AA seen in the Department of Dermatology of Hedi Chaker University Hospital, Sfax were included in this study. Anxiety and depression were evaluated by Hospital Anxiety and Depression scale questionnaire, alexithymia was assessed by Toronto Alexithymia scale 20, and severity of AA was measured by Severity of Alopecia Tool.

RESULTS

Patient's mean age was 32.92 years. 52% of patients were females. Depression and anxiety were detected respectively in 38% and 62% of patients. There was statistically significant difference between patients and control group in terms of depression (P = 0.047) and anxiety (P = 0.005). Forty-two percent of patients scored positive for alexithymia. No significant difference was found between patient and control groups (P = 0.683) in terms of alexithymia. Anxiety was responsible for 14.7% of variation in alexithymia (P = 0.047).

CONCLUSIONS

Our study shows a high prevalence of anxiety and depressive symptoms in AA patients. Dermatologists should be aware of the psychological impact of AA, especially as current treatments have limited effectiveness.

Can you pull it off? Appearance modifying behaviours adopted by wig users with alopecia in social interactions

In the academic and medical literature on alopecia, wigs (hair prostheses) are typically recommended as a coping strategy: a device to camouflage, conceal, or cover hair loss, and cope with the psychological impact of a dramatic change in body image. This paper used Goffman's (1959) theory of impression management to demonstrate (a) the social significance of self-presentation, and (b) how adults with alopecia managed their wig use in their daily lives. Data from 14 interviews, two focus groups and six video diaries with 22 Caucasian adults (19 females, 3 males; 29-74 years, SD=13.75) with alopecia in Scotland were analysed using discursive psychology. The analysis detailed how participants managed their wig use and behaviours in relation to social interaction with different categories of people. The paper raises concerns about health and medical discourse about wigs as a coping mechanism, and provides practical suggestions for wig users in social settings.