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Health-Related Quality of Life (Hrqol) Among Patients With Alopecia Areata (Aa) : A Systematic Review
Health-Related Quality of Life (Hrqol) Among Patients With Alopecia Areata (Aa) : A Systematic Review
Alopecia areata (AA) is a common skin disease that is frequently emotionally devastating. Several studies
have examined the effect of AA on health-related quality of life (HRQoL). We performed a systematic
review of all published studies of HRQoL in patients with AA. Eleven studies met inclusion criteria,
incorporating data from 1986 patients. Patients with AA consistently demonstrate poor HRQoL scores, with
greater extent of scalp involvement associated with lower HRQoL. HRQoL experienced by patients with AA
is similar to that seen in patients with other chronic skin diseases including atopic dermatitis and psoriasis.
( J Am Acad Dermatol http://dx.doi.org/10.1016/j.jaad.2016.04.035.)
Key words: alopecia areata; alopecia totalis; alopecia universalis; health-related quality of life; quality of
life; review.
From the Departments of Dermatologya and Pediatrics,b Yale 208059, New Haven, CT 06520. E-mail: brittany.craiglow@yale.
University School of Medicine.c edu.
Funding sources: None. Published online July 16, 2016.
Conflicts of interest: None declared. 0190-9622/$36.00
Accepted for publication April 12, 2016. Ó 2016 by the American Academy of Dermatology, Inc.
Reprint requests: Brittany G. Craiglow, MD, Department of http://dx.doi.org/10.1016/j.jaad.2016.04.035
Dermatology, Yale University School of Medicine, PO Box
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Table I. Health-related quality of life and disease severity indices for evaluating patients with alopecia areata
Severity of AA
Severity of Alopecia Tool42
Developed by the National AA Foundation Working Committee, evaluating both the density and extent of hair loss,
ranging from S0 (0% hair loss) to S5 (100% hair loss).
HRQoL measures and score ranges
Dermatology Life Quality Index18
Self-reported questionnaire composed of 10 questions, assessing effect of skin condition on various aspects of life. Scores
range from 0 (no effect on patient’s life, high HRQoL) to 30 (extremely large effect on patient’s life, poor HRQoL).
Skindex19
Self-reported questionnaire composed of various number of questions, assessing the degree to which an individual is
bothered because of various aspects of skin condition. Scores range from 0 (never bothered, high HRQoL) to 100
(always bothered, poor HRQoL). Three dimensions are assessed: symptoms, emotions, function.
impacted both the psychological health and the HRQoL in the pediatric population
social life of patients.30 Only 1 study specifically evaluated children and
adolescents.21 The Pediatric Quality of Life (PedsQL)
Inventory, Parent and Child versions, was adminis-
HRQoL of patients with AA versus control tered to both the patient and the caregiver, most often
groups the mother. In patients, the mean PedsQL scores were
Only 1 study using DLQI included an age- and sex- 74.0 overall, 73.4 in physical health, and 74.3 in
matched control group for comparison. In this study, psychosocial. Compared with control subjects, lower
DLQI scores were significantly higher in patients with HRQoL was observed in pediatric patients (P = .048).
severe AA than in control subjects, indicating a lower Pediatric patients’ separate physical health and
HRQoL in patients with AA.30 No control groups for psychosocial HRQoL scores were not significantly
comparison were available in studies using Skindex. different from that of control subjects (P = .062 and
Three studies included separate SF-36 scores with P = .082, respectively). In parents, PedsQL scores were
control groups,24,27,28 and 1 study used control group 70.3 overall, 68.5 in physical health, and 70.0 in
data extracted from the literature.25 The results of psychosocial. Compared with control subjects,
these studies are shown in Table II. parents’ physical health, psychosocial, and overall
Patients with AA had poorer HRQoL in role HRQoL were poor (P = .039, P \ .001, and P = .001,
emotional, mental health, and vitality aspects of respectively).
SF-36 compared with control groups, indicating
poor social functioning, higher psychological
distress, and diminished energy levels as a result of Factors affecting HRQoL
disease.24,25,27,28 Although 3 studies found that The factors affecting HRQoL are conflicting
patients with AA had poorer HRQoL in social among the studies and include severity of scalp
functioning compared with control subjects, 1 involvement, concomitant depression, and female
study found the opposite result.24 The authors gender.
attributed this finding to the fact that their control Several studies showed that increased scalp
group comprised staff from an extremely busy involvement was associated with lower
hospital and that, as a result, it was possible the HRQoL.21,22,27,30,31 In contrast, 2 studies found that
group had less time available to participate in social severity of scalp involvement did not correlate with
activities. poor HRQoL.26,28 Jankovic et al29 found that severity
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Fig 1. Mean Short Form Health Survey (SF-36) scores, overall and for each domain, for patients
with alopecia areata. HRQoL, Health-related quality of life.
of disease only correlated with certain aspects of Two studies found that female patients with AA
HRQoL, including the personal relationship had lower HRQoL than male patients22,27; however,
dimension of DLQI and social functioning other studies found no significant correlation
dimension of Skindex; however, they reported no between impaired HRQoL and gender.25,29,30 Other
correlation with any dimension of the SF-36 measure. factors found to correlate with impaired HRQoL
Table III depicts DLQI scores for studies that stratified include young age22,27,31 and unmarried status.27
HRQoL scores based on severity of AA and variants.
Three studies found depression to be associated DISCUSSION
with poor HRQoL.21,23,29 Although it is unclear Loss of hair occurring in any disease negatively
whether these patients were depressed before the impacts QoL and is often associated with loss of self-
onset of AA, a study in Iran found that depression esteem and psychosocial problems.32 In this review,
was the highest predicting factor of significant we specifically examined HRQoL in patients with AA
impairment of HRQoL in patients with AA.23 In the and variants. Patients with AA consistently demon-
pediatric study, both anxiety and depression were strate poorer HRQoL than control patients, with
found to negatively predict psychosocial HRQoL realms such as vitality, mental health, emotion, and
scores in the child and parent groups, but not the social functioning most negatively affected. Somatic
adolescent group.21 This group suggested that pre- symptoms such as physical functioning and bodily
adolescent children may be too immature for skills to pain were least affected. Pediatric patients and their
cope with the burden of diseases. In addition, the caretakers also reported poorer HRQoL.
third study found that patients with depression had The impact of AA on HRQoL is comparable with
significantly worse AA-related HRQoL scores in other chronic, relapsing skin conditions such as
multiple areas of life, including relationships, psoriasis and atopic dermatitis. DLQI scores of
emotions, daily activities, and social functioning.29 patients with AA were 5.3 to 13.54,22,23,29-31 which is
J AM ACAD DERMATOL Liu, King, and Craiglow 5
VOLUME jj, NUMBER j
73.3 vs 87.0*
64.3 vs 72.2*
58.9 vs 84.1*
64.1 vs 86.3*
49.3 vs 69.7*
54.5 vs 62.4*
88.2 vs 90.3
77.2 vs 77.9
Fig 2. Mean Skindex scores in function, symptoms, and
emotion. HRQoL, Health-related quality of life.
70.608 vs 86.034*
70.270 vs 85.034*
63.892 vs 78.939*
88.514 vs 96.429
87.500 vs 91.122
77.865 vs 83.408
74.297 vs 80.388
61.757 vs 70.102
Masmoudi et al,27 2013
AA vs control (N = 50)
58.17 vs 71.62*
54.60 vs 82.20*
33.33 vs 83.06*
63.64 vs 77.14*
62.40 vs 77.00*
95.50 vs 90.20
93.10 vs 88.30
95.40 vs 89.80
Scores range from 0 (poor health-related quality of life) to 100 (high health-related quality of life).
71.83 vs 55.48*
55.69 vs 67.23*
51.35 vs 59.71*
83.17 vs 78.37
90.19 vs 88.85
65.04 vs 68.14
76.31 vs 77.23
59.83 vs 76.96
Social functioning
Table III. Comparison of Dermatology Life Quality here will serve to increase appreciation for the
Index scores stratified by severity of alopecia areata burden of disease of AA and give further meaning
Jankovic Al-Mutairi and
and importance to emerging progress in treatment.
et al,29 2016 Eldin,30 2011 Qi et al,31 2015
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2004 areata and the impact of the disease on the Mean age = 31.53 6 12.61 y
Turkey quality of life’’ N = 52 Non-AA patients - Vitality: 51.35 6 20.68
Mean age = 31.90 6 12.33 y - Mental health: 55.69 6 17.85
- Role emotional: 59.83 6 42.22
- Social functioning: 71.83 6 24.47
Bodily pain: 76.31 6 22.85
n 2016
-
- General health: 65.04 6 19.99
- Physical functioning: 90.19 6 17.15
- Role physical: 83.17 6 29.59
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Dubois et al25 Letter to the editor: ‘‘Quality of life in alopecia N = 60 SF-36 SF-36:
2010 areata: a study of 60 cases’’ Mean age = 40.1 6 15.2 y Skindex-29 - Vitality: 54.5 6 20.4
France Non-AA population provided - Mental health: 49.3 6 20.4
by literature search - Role emotional: 64.1 6 39.1
- Social functioning: 58.9 6 29.5
- Bodily pain: 77.2 6 20.7
- General health: 64.3 6 22.7
- Physical functioning: 88.2 6 22.5
- Role physical: 73.3 6 35.0
Skindex-29:
- Emotions: 48.9 6 27.8
- Symptoms: 18.3 6 19.7
- Functioning: 28.0 6 24.6
Reid et al26 ‘‘Clinical severity does not reliably predict N = 23 Female patients with AA Skindex-16 Skindex-16: 58.56 6 3.44 (SEM, not SD)
2012 quality of life in women with alopecia Mean age = NR - Emotions: 82.09 6 3.28
United States areata, telogen effluvium, or androgenic - Symptoms: 25.36 6 3.98
alopecia’’ - Functioning: 52.17 6 6.34
Bilgiç et al21 ‘‘Psychiatric symptomatology and health- N = 74 PedsQL-P and -C PedsQL-C: 78.5 6 10.0
2014 related quality of life in children and Mean age: 12.1 6 2.8 y - Physical health: 78.3 6 14.4
Turkey adolescents with alopecia areata’’ - Psychosocial: 78.6 6 10.5
PedsQL-P: 77.6 6 11.9
- Physical health: 74.9 6 17.7
- Psychosocial: 79.0 6 11.3
Shi et al22 ‘‘Health-related quality of life (HRQoL) in N = 532 DLQI DLQI: 6.8 6 4.7
2013 alopecia areata patientsea secondary No mean age reported Skindex-16 Skindex-16:
United States analysis of the National Alopecia Areata - Emotions: 43.3 6 33.3
Registry Data’’ - Symptoms: 18.8 6 24.2
- Functioning: 30.2 6 30.8
Jankovic et al29 ‘‘Quality of life in patients with alopecia areata: N = 60 Patients DLQI DLQI: 5.3 6 5.5
2016 a hospital-based cross-sectional study’’ Mean age = 37.3 6 14.3 y SF-36 SF-36:
Serbia Skindex-29 - Vitality: 59.3 6 12.4
AA, Alopecia areata; DLQI, Dermatology Life Quality Index; HRQoL, health-related quality of life; NR, not recorded; Peds QL-C, Pediatric Quality of Life Inventory - Child Version; PedsQL-P, Pediatric
Quality of Life Inventory - Parent Version; SD, standard deviation; SF-36: Short Form Health Survey.