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Quality of Life in Alopecia Areata: A Study of 60 Cases

      Abbreviations

      AA
      alopecia areata
      Qol
      quality of life
      SF36
      short form 36
      TO THE EDITOR
      Alopecia areata (AA) is a chronically relapsing skin disorder characterized by a sudden loss of hair. Because the perception of patients may differ significantly from those of their health-care providers, quality of life (Qol) appears to be a more relevant criterion to assess the severity of this disease than clinical evaluation such as AA extension. To our knowledge, only one Turkish study investigated the impact of AA on Qol using short form 36 (SF36), indicating lower Qol levels compared with sex-matched individuals (
      • Gulec A.T.
      • Tanriverdi N.
      • Duru C.
      • et al.
      The role of psychological factors in alopecia areata and the impact of the disease on the quality of life.
      ). In this study, Qol was assessed using a generic instrument. Because only three dimensions were affected and results may be linked to the specific culture, a confirmation was needed. We used an approach combining generic and specific measures to assess the impact of AA on French patients' Qol, to compare Qol levels with those observed in the general population and in other dermatological conditions, and finally to determine the impact of clinical characteristics and sociodemographic factors on Qol.
      Subjects were aged over 16 years, presenting with a minimum of 8 weeks AA history, having given informed consent to participate, and having the French language as their native language. Sociodemographic data and characteristics of the disease (duration and course, treatments in the recent period, affected surfaces on the scalp and other areas involved) were recorded. The severity of each AA was reported using visual analogical scales (0–10) by reference to (i) all the AA cases seen in daily practice; (ii) all cases of all skin disorders. Three self-administered questionnaires were used to assess Qol: the generic and worldwide-used SF36 (
      • Leplege A.
      • Ecosse E.
      • Verdier A.
      • et al.
      The French SF-36 Health Survey: translation, cultural adaptation and preliminary psychometric evaluation.
      ,
      • Leplege A.
      • Ecosse E.
      • Pouchot J.
      • et al.
      ;
      • Coste J.
      ), and two “chronic skin disorders”-specific Qol instruments with French validated available versions, the VQ-Dermato (
      • Grob J.J.
      • Auquier P.
      • Martin S.
      • et al.
      Development and validation of a quality of life measurement for chronic skin disorders in french: VQ-Dermato.The Reseau d' Epidemiolo gie en Dermatologie.
      ,
      • Grob J.J.
      • Auquier P.
      • Dreyfus I.
      • et al.
      How to prescribe antihistamines for chronic idiopathic urticaria: desloratadine daily versus PRN and quality of life.
      ) and the Skindex (
      • Chren M.M.
      • Lasek R.J.
      • Quinn L.M.
      • et al.
      Skindex, a quality-of-life measure for patients with skin disease: reliability, validity, and responsiveness.
      ,
      • Chren M.M.
      • Lasek R.J.
      • Flocke S.A.
      • et al.
      Improved discriminative and evaluative capability of a refined version of Skindex, a quality-of-life instrument for patients with skin diseases.
      ;
      • Leplege A.
      • Ecosse E.
      • Zeller J.
      • et al.
      The French version of Skindex (Skindex-France). Adaptation and assessment of psychometric properties.
      ). To better figure out the level of QoL in AA, we compared AA scores with those available in literature related to the French population: (1) rare dermatological diseases including hidradenitis suppurativa (
      • Wolkenstein P.
      • Loundou A.
      • Barrau K.
      • et al.
      Quality of life impairment in hidradenitis suppurativa: a study of 61 cases.
      ) and neurofibromatosis type 1 (
      • Wolkenstein P.
      • Zeller J.
      • Revuz J.
      • et al.
      Quality-of-life impairment in neurofibromatosis type 1: a cross-sectional study of 128 cases.
      ); (2) chronic/frequent dermatological diseases including psoriasis, chronic idiopathic urticaria, and atopic dermatitis (
      • Grob J.J.
      • Revuz J.
      • Ortonne J.P.
      • et al.
      Comparative study of the impact of chronic urticaria, psoriasis and atopic dermatitis on the quality of life.
      ); (3) general population: French age- and sex-matched controls (
      • Leplege A.
      • Ecosse E.
      • Pouchot J.
      • et al.
      ). This study was conducted in adherence to the Helsinki guidelines. Institutional approval was not required for experiments. After having given their inform consent, 60 patients were included (39 women and 21 men); their mean age was 40.1 years (SD 15.2) and median AA duration was 6 years (2 months to 60 years). Course of the disease was stable in 25 subjects and unstable in 35. The median of the scalp surface involved was 77%. The median of severity score was 6.5 (range 4.0–9.0) by reference to the AA patients and 3.5 (range 2.0–6.0) by reference to the patients presenting any skin disorder.
      Mental health and vitality were the most altered SF36 dimensions, whereas physical functioning, role physical and body pain were the least ones. Regarding VQ-Dermato, daily life, leisure activity, and physical discomfort were the least altered dimensions. For Skindex, emotions dimension was the most affected and symptoms the least one. Compared with the general population and with patients suffering from other dermatological conditions (Table 1), AA patients presented significantly altered Qol for almost all the SF36 dimensions. For VQ-Dermato, AA patients reported (i) significantly better (mood state, leisure activity, daily life, and physical discomfort) or worse scores (self-perception) than psoriasis, chronic idiopathic urticaria, and atopic dermatitis patients; (ii) being less bothered to treatment-induced restrictions than psoriasis, but more than chronic idiopathic urticaria patients. AA patients reported significantly better Qol than did hidradenitis suppurativa patients, except for social functioning and mental health dimensions of SF36 and self-perception, mood state, and treatment restriction dimensions of VQ-Dermato.
      Table 1Quality-of-life indicative comparisons between AA patients and other dermatological conditions, and French age- and sex-matched controls
      From Leplege et al., (2001), Wolkenstein et al., (2001), Grob et al., (2005), and Wolkenstein et al., (2007).
      AA, N=60HS, N=61PNF1, N=128PPSO, N=408PCU, N=367PAD, N=386PControlsP
      SF36
      SF36, 36 items, eight dimensions (range (0–100), 0 lowest and 100 highest level of Qol; Leplege et al., 1998; Coste, 2001; Leplege et al., 2001).
       Physical functioning88.2±22.571.3±27.4<0.00176.8±26.40.00490.3±7.00.506
       Role—physical73.3±35.043.6±39.0<0.00172.8±39.10.93287.0±6.70.006
       Bodily pain77.2±20.744.5±24.4<0.00165.3±29.60.00577.9±6.30.865
       General health64.3±22.743.3±22.4<0.00158.4±23.00.10172.2±5.30.011
       Vitality54.5±20.440.4±20.4<0.00149.7±21.30.14662.4±3.20.005
       Social functioning58.9±29.552.5±25.80.20670.4±25.70.00784.1±3.5<0.001
       Role—emotional64.1±39.142.9±42.00.00469.4±39.40.39086.3±5.1<0.001
       Mental health49.3±20.443.0±18.40.07756.4±22.00.03669.7±2.7<0.001
      VQ-Dermato
      VQ-Dermato, 28 items, seven domains and one overall score (range (0–100), 0 highest and 100 lowest level of Qol; Grob et al., 1999, 2009).
       Self-perception51,4±26.252.2±26.70.86837.4±24.7<0.00123.8±21.8<0.00134.2±24.6<0.001
       Daily life13.9±17.746.9±28.7<0.00119.3±19.40.14536.2±20.4<0.00135.5±21.3<0.001
       Mood state34.2±24.137.9±26.40.42249.3±25.2<0.00150.3±25.5<0.00150.1±25.5<0.001
       Social functioning31.8±25.147.6±29.70.00231.3±23.70.88027.5±22.90.18434.1±23.50.485
       Leisure activity23.9±28.452.1±31.3<0.00147.2±29.3<0.00136.7±28.1<0.00146.7±27.9<0.001
       Treatment restrictions30.3±30.235.8±34.00.34938.6±26.00.02417.0±20.7<0.00132.5±26.40.556
       Physical discomfort25.0±26.966.1±26.5<0.00144.4±28.2<0.00161.4±23.7<0.00169.8±21.3<0.001
      Skindex
      Skindex, 29 items, three domains (range (0–100), 0 highest and 100 lowest level of Qol; Chren et al., 1996, 1997; Leplege et al., 2003). Bold values P<0.05.
       Emotions48.9±27.859.2±23.40.02931.6±26.7<0.001
       Symptoms18.3±19.752.2±22.3<0.00121.4±19.70.315
       Functioning28.0±24.648.8±25.5<0.00122.3±23.30.126
      Abbreviations: AA, alopecia areata; AD, atopic dermatitis; CU, chronic urticaria; HS, hidradenitis suppurativa; NF1, neurofibromatosis type 1; PSO, psoriasis; SF36, short form 36.
      1 From
      • Leplege A.
      • Ecosse E.
      • Pouchot J.
      • et al.
      ,
      • Wolkenstein P.
      • Zeller J.
      • Revuz J.
      • et al.
      Quality-of-life impairment in neurofibromatosis type 1: a cross-sectional study of 128 cases.
      ,
      • Grob J.J.
      • Revuz J.
      • Ortonne J.P.
      • et al.
      Comparative study of the impact of chronic urticaria, psoriasis and atopic dermatitis on the quality of life.
      , and
      • Wolkenstein P.
      • Loundou A.
      • Barrau K.
      • et al.
      Quality of life impairment in hidradenitis suppurativa: a study of 61 cases.
      .
      2 SF36, 36 items, eight dimensions (range (0–100), 0 lowest and 100 highest level of Qol;
      • Leplege A.
      • Ecosse E.
      • Verdier A.
      • et al.
      The French SF-36 Health Survey: translation, cultural adaptation and preliminary psychometric evaluation.
      ;
      • Coste J.
      ;
      • Leplege A.
      • Ecosse E.
      • Pouchot J.
      • et al.
      ).
      3 VQ-Dermato, 28 items, seven domains and one overall score (range (0–100), 0 highest and 100 lowest level of Qol;
      • Grob J.J.
      • Auquier P.
      • Martin S.
      • et al.
      Development and validation of a quality of life measurement for chronic skin disorders in french: VQ-Dermato.The Reseau d' Epidemiolo gie en Dermatologie.
      ,
      • Grob J.J.
      • Auquier P.
      • Dreyfus I.
      • et al.
      How to prescribe antihistamines for chronic idiopathic urticaria: desloratadine daily versus PRN and quality of life.
      ).
      4 Skindex, 29 items, three domains (range (0–100), 0 highest and 100 lowest level of Qol;
      • Chren M.M.
      • Lasek R.J.
      • Quinn L.M.
      • et al.
      Skindex, a quality-of-life measure for patients with skin disease: reliability, validity, and responsiveness.
      ,
      • Chren M.M.
      • Lasek R.J.
      • Flocke S.A.
      • et al.
      Improved discriminative and evaluative capability of a refined version of Skindex, a quality-of-life instrument for patients with skin diseases.
      ;
      • Leplege A.
      • Ecosse E.
      • Zeller J.
      • et al.
      The French version of Skindex (Skindex-France). Adaptation and assessment of psychometric properties.
      ).
      Bold values P<0.05.
      Skindex and SF36 were not statistically linked to sociodemographic and clinical parameters (data not shown). Only the VQ-Dermato global score indicated a significantly better Qol in older subjects (Table 2). Disease severity, extrascalp involvement, and scalp surface involved were related with altered VQ-dermato dimensions (Table 2).
      Table 2Associations between VQ-Dermato dimension scores and global score, and sociodemographic/clinical characteristics in 60 alopecia areata (AA) patients
      Self-perceptionDaily lifeMood stateSocial functioningLeisure activityTreatment restrictionsPhysical discomfortGlobal score
      Gender
      Mean ± SD, P: P-value Mann–Whitney test.
       Men42.28±21.5410.24±15.0432.74±21.2827.40±18.0013.10±17.9830.47±26.9919.05±25.1925.88±15.04
       Women53.66±28.4716.05±18.9435.02±25.7834.29±28.2330.07±31.5130.15±32.0028.38±27.5832.30±21.83
      P0.1960.3410.8390.4990.0420.6940.1610.406
      Educational level
      Mean ± SD, P: P-value Mann–Whitney test.
       <12 Years48.58±28.4813.75±18.5727.08±23.9926.09±25.1821.21±29.0626.14±29.6124.46±27.3027.02±21.57
       ≥12 Years53.18±24.8914.02±17.3638.54±23.4135.51±24.7425.58±28.3133.48±30.8225.36±27.0332.40±18.69
      P0.4090.6700.0590.1030.4290.3800.9340.149
      Marital status
      Mean ± SD, P: P-value Mann–Whitney test.
       Single59.16±22.6114.87±17.8836.61±25.7238.65±28.6230.95±32.0735.16±38.5226.25±30.0534.71±24.22
       Couple47.09±27.3313.43±17.8232.83±23.3628.07±22.4919.93±25.7427.94±25.7624.34±25.4927.88±17.33
      P0.1090.5830.6140.1410.2100.8150.9520.457
      Occupational status
      Mean ± SD, P: P-value Mann–Whitney test.
       Not working43.63±26.978.51±12.4128.08±23.7929.62±25.4923.02±28.2527.63±31.6221.59±27.8727.43±21.63
       Working56.00±24.9717.06±19.6337.67±23.8733.15±25.1624.44±28.9031.85±29.7327.08±26.4731.66±19.09
      P0.0750.1190.1590.6030.9730.5540.4030.371
      Disease course
      Mean ± SD, P: P-value Mann–Whitney test.
      ,
      Course of the disease was defined as “unstable” if there was alternation of worsening and improvement phases in the last 2 years, and “stable” otherwise.
       Stable51.37±30.2615.95±20.0038.28±26.4135.27±27.7529.34±29.8840.48±35.3327.60±31.2734.88±23.31
       Unstable51.40±23.2612.42±15.9631.31±22.2529.31±23.1120.10±27.1522.84±23.8723.16±23.6627.07±17.04
      P0.7010.6300.3400.4740.1380.0930.7920.174
      Scalp surface involved
      Mean ± SD, P: P-value Mann–Whitney test.
       <80%47.35±24.2011.96±14.5929.22±22.3729.91±23.6915.48±22.8820.97±22.2225.35±27.1425.34±16.81
       ≥80%57.70±28.4717.01±21.7642.33±25.0734.86±27.4936.78±31.6045.39±35.6524.43±27.1338.20±22.43
      P0.0650.6930.0640.5120.0060.0160.8870.023
      Extrascalp involvement
      Mean ± SD, P: P-value Mann–Whitney test.
       No48.82±24.2511.68±14.8430.34±21.3929.53±22.8017.32±24.4623.11±24.4324.68±26.9826.08±16.15
       Yes56.40±29.6718.38±22.1342.11±27.7836.33±29.2436.46±31.7344.12±35.9425.66±27.4738.32±24.39
      P0.1780.4050.1130.4840.0160.0430.8900.049
      Alopecia universalis
      Mean ± SD, P: P-value Mann–Whitney test.
       No50.55±25.3014.86±17.4632.82±22.9731.16±24.1621.85±27.4829.38±30.1626.63±27.2130.30±19.16
       Yes54.35±30.1010.35±18.8938.94±28.0834.23±29.2231.09±31.5833.75±31.7618.75±25.8429.65±23.64
      P0.4580.2600.4870.8400.3090.6560.3270.970
      Age
      Spearman's correlation coefficient, P: P-value Spearman's test.
      -0.099-0.134-0.236-0.149-0.173-0.120-0.059-0.294
      P0.4560.3220.0750.2600.1950.4060.6610.042
      Disease duration
      Spearman's correlation coefficient, P: P-value Spearman's test.
      -0.118-0.0900.073-0.1570.084-0.095-0.145-0.039
      P0.3760.5110.5890.2390.5360.5180.2810.793
      Severity 1
      Spearman's correlation coefficient, P: P-value Spearman's test.
      ,
      Severity 1: visual analog scale by reference to the cases of AA seen in daily practice; 0 “patient among the least affected” and 100 “patient among the most affected”.
      0.2470.0270.3190.1800.3590.396-0.0570.348
      P0.0590.8440.0150.1730.0060.0040.6730.015
      Severity 2
      Spearman's correlation coefficient, P: P-value Spearman's test.
      ,
      Severity 2: visual analog scale by reference to the cases of all skin disorders seen in daily practice; 0 “patient among the least affected” and 100 “patient among the most affected”. Bold values: P<0.05.
      0.2160.0560.3340.1870.3830.3770.0380.390
      P0.1010.6790.0100.1560.0030.0070.7770.006
      1 Mean ± SD, P: P-value Mann–Whitney test.
      2 Spearman's correlation coefficient, P: P-value Spearman's test.
      3 Course of the disease was defined as “unstable” if there was alternation of worsening and improvement phases in the last 2 years, and “stable” otherwise.
      4 Severity 1: visual analog scale by reference to the cases of AA seen in daily practice; 0 “patient among the least affected” and 100 “patient among the most affected”.
      5 Severity 2: visual analog scale by reference to the cases of all skin disorders seen in daily practice; 0 “patient among the least affected” and 100 “patient among the most affected”.Bold values: P<0.05.
      Our results show that (1) Qol is impaired in AA, the most influenced domains being self-perception, such as in the
      • Gulec A.T.
      • Tanriverdi N.
      • Duru C.
      • et al.
      The role of psychological factors in alopecia areata and the impact of the disease on the quality of life.
      study, and also mental health and social life. It may be because of the special importance of hair in appearance (
      • Cash T.F.
      The psychosocial consequences of androgenetic alopecia: a review of the research literature.
      ;
      • Firooz A.
      • Firoozabadi M.R.
      • Ghazisaidi B.
      • et al.
      Concepts of patients with alopecia areata about their disease.
      ); (2) social life is impaired in AA at the same level as in psoriasis, atopic dermatitis, and chronic idiopathic urticaria. On the dimensions dealing with mental health and social life, AA also compares very well with hidradenitis suppurativa, one of the rare skin disorders with the highest impact on most dimensions of Qol (
      • Wolkenstein P.
      • Loundou A.
      • Barrau K.
      • et al.
      Quality of life impairment in hidradenitis suppurativa: a study of 61 cases.
      ). Similarly, social life and mental comfort of patients seem to be more affected in AA than in neurofibromatosis type 1; (3) sociodemographic parameters did not impact Qol, except for leisure activities, with women appearing to be more affected; (4) clinical severity of AA appears to be poorly linked to Qol, even when assessed with a sensitive dermatology-specific Qol tool (VQ-Dermato). Furthermore, the dimension of self-perception, which seems to be particularly involved in AA, is not significantly linked to the clinical severity of the disorder.
      Some limitations must be mentioned. The sample size did not allow a multivariate approach, and moderate associations were possibly missed owing to low power. We were unable to confirm the impact of anxiety or depression on Qol (
      • Gulec A.T.
      • Tanriverdi N.
      • Duru C.
      • et al.
      The role of psychological factors in alopecia areata and the impact of the disease on the quality of life.
      ) because these parameters were not collected. One must be cautious while generalizing the study findings to minor cases seen in everyday care because our hospital-based series of AA was probably not representative of community cases. Although we did not systematically search for other health disorders in our patients, none of them declared to have one.
      Although AA is a perfectly benign disorder, this work confirms the initial hypothesis that AA seriously impairs Qol, mainly by altering self-perception and self-esteem, both of which interfere with social life. From a practical point of view, these results can (i) help doctors to realize that they probably strongly underestimate the severity of AA and encourage them to give patients the treatments and the psychological help they require; (ii) help patients by showing that their suffering is understood by others; (iii) help health-care decision-makers to promote therapeutic trials in this orphan disorder.

      ACKNOWLEDGMENTS

      This work was supported by institutional grants from the PHRC 2005 (Program Hospitalier Recherche Clinique National).

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