Accepted Manuscript

Psychosomatic aspects of alopecia areata

Fabiane Mulinari-Brenner

PII: S0738-081X(18)30182-2
DOI: doi:10.1016/j.clindermatol.2018.08.011
Reference: CID 7279
To appear in: Clinics in Dermatology

Please cite this article as: Fabiane Mulinari-Brenner , Psychosomatic aspects of alopecia
areata. Cid (2018), doi:10.1016/j.clindermatol.2018.08.011

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• Title. Psychosomatic aspects of alopecia areata

• Author names and affiliations. Fabiane Mulinari-Brenner, MD

From the Department of Internal Medicine, Division of Dermatology, Universidade Federal do Parana, Hospital

de Clinicas, Parana - Brazil

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• Corresponding author.

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Fabiane Mulinari-Brenner, MD

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Av. Vicente Machado,1907 NU
Curitiba – PR – Brazil

80440-020
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fmbrenner@ufpr.br
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Phone # 55-41-33523293
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55-41-988011818
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Conflict of interest

The author has no conflict of interest to declare

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Psychosomatic aspects of alopecia areata

Abstract

Psychologic and social impact of scalp hair is more important than its biologic significance. Etiology of

alopecia areata (AA) suggests a predominantly autoimmune reaction. Correlation between AA and psychologic

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disorders is reciprocal. Psychiatric disorders can trigger the onset of AA and its negative impacts may develop or

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exacerbate psychologic problems. The high incidence of a neurotic personality, depression, anxiety, and

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deficiency in coping with stress strengthen the role of psychic factors in the pathogenesis of AA.

Strategies to assess these patients are often not apparent for the clinician and identifying patients in
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need of extra psychologic support should be a mainstay for successful treatment. Women, young patients and
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those with significant AA or previous psychiatric disorders are at greater risk, requiring careful following. Proper

awareness and consciousness about the close relationship between AA and psychologic factors are essential.
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Keywords: Alopecia, depression, anxiety, quality of life

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Introduction
The psychologic and social impact of scalp hair can be more important than its biologic significance.

Etiology of alopecia areata (AA) is unknown, and the majority of evidence suggests that genetically predisposed

individuals, when exposed to an unknown trigger, develop a predominantly autoimmune reaction, leading to

acute hair loss.

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Environmental triggers, including viral or bacterial infections, along with autoimmune disorders, seem to

play a major role in the development of AA.1,2 Some observers consider stressful life events as being significant

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factors. Greater number of emotionally stressful events was seen in AA patients.3 Considering the theory of

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unity of body and mind, a correlation between AA and psychologic disorders is important. Additionally,
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psychiatric disorders may provide a trigger for initiation and exacerbation of the disease. Negative impacts of

the disease on the patient’s life, may develop or exacerbate existing psychologic problems.
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Effects of AA on social and emotional well-being, along with the patient’s mental health, can be found in

various cultures worldwide. Referring to the problem as ‘‘it’s just hair’’, especially by health care professionals,
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contributes to a poor health-related quality of life (HRQoL).

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Clinical Aspects of Alopecia Areata

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Hair loss in AA may range from a circumscribed area or areas, involvement of the entire scalp (totalis), to

development of complete body hair loss (universalis). Considering there are 7.5 billion people on the globe and
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0.2% of them are estimated to have AA, around 15 million people are afflicted.4 Over 127 million people (1.7%

of the population) will experience an episode of AA during their lifetime.4 The course of the disease is not

predictable, with periods of hair loss and regrowth, without scarring. AA can occur at any age, although 60% of

patients develop their first episode of hair loss before the age of 20.4 Family history of AA is observed in 20% of

cases, indicating a genetic basis.1

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Spontaneous hair regrowth in AA may occur in 80% of the patients within a year.4 Alopecia totalis (AT),

alopecia universalis (AU), and ophiasis pattern (hair loss around the periphery of the scalp) are considerably

more treatment resistant.2 A poor prognosis is found in long term hair loss, as well as in cases with nail

dystrophy, onset in childhood, atopic background, autoimmune disorders and a family history of AA.5

Quantitative hair loss and regrowth can be assessed with the Severity of Alopecia Tool (SALT) score,

which is a mathematic approach to the determination of hair loss and hair regrowth.6 The scalp is divided into

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four areas:

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1. vertex - 40% of scalp surface area;

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2. right profile of scalp - 18% of scalp surface area;

3. left profile of scalp - 18% of scalp surface area;

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4. posterior aspect of scalp - 24% of scalp surface area.
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The percentage of hair loss in any of these areas is calculated by multiplying the percentage of hair loss by the

percentage surface area of the scalp in that area. The accurate determination of hair loss is important for
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following the regrowth on each visit.

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The SBN (scalp-body-nail) index grades hair loss in different areas of the body.6 Scalp hair loss (S) is graded:
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 S0 = no hair loss,
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 S1 = 25% hair loss,

 S2 = 25–49% hair loss,

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 S3 = 50–74% hair loss,

 S4a = 75–95%,

 S4b = 96–99% hair loss,

 S5 = 100% hair loss.

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Body hair loss may be rated as none, some, or 100% (B0, B1, and B2, respectively), and nail involvement as

none or some (N0 and N1) with a subcategory N1a for 20 nail dystrophy. This index is the mainstay for grouping

different cases in clinical studies.

A high incidence of atopic dermatitis, vitiligo, lichen planus, psoriasis, asthma, thyroid conditions, vitamin D

deficiency, and anemia may be found in patients with AA.1,2,4

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Health Status and Quality of Life in Alopecia Areata

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Although AA is a medically benign disorder, its emotional and psychologic distress impacts on the HRQoL
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in extensive and chronic disease. Patients often report being harassed, stared at, or assumed to be undergoing

chemotherapy due to their hair loss.7 More than half of patients believe that their illness has major
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consequences on their lives.8 Understanding HRQoL is essential in recognizing all aspects of this ‘‘cosmetic’’

disorder and motivates good patient care. Patient self-image, interpersonal relationships, work, or school
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activities can be affected, even in patients with localized hair loss. Simple decisions, such as wearing a wig, may
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improve the quality of life.7

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A specific stressful life event is reported as the trigger for AA in up to 77% of the patients. 8 AA patients
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seem to have experienced more stressful life events than their healthy siblings and control patients. 3 Loss of a
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family member during childhood and emotional neglect by relatives are sources of higher scores on the

Traumatic Events Questionnaire (TEQ).3 Accidents, bad news, and physical or sexual abuse are evaluated by this

tool. Stressful life events may influence immune responses related to neuropeptides, such as cells migration

and microvascular endothelium feedbacks.9 Most AA patients believe that stress is the cause of their disease.8

The association between severity of AA and HRQoL is uncertain, because the studies have used different

combinations of HRQoL questionnaires and disease severity measures.10 Several reports have suggested lower
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HRQoL in adults in children with AA.11-15 The detrimental effect on quality of life is similar to other chronic

dermatologic diseases, including atopic dermatitis and psoriasis;11,13 however, AA leads to more self-

stigmatization than mental disorders.12

A wide range of HRQoL instruments are available to evaluate AA. Only three have been validated in the

AA population.10 Dermatology Life Quality Index (DLQI), Skindex and Short Form Health Survey (SF- 36) goals

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and findings in AA are reviewed in Table 1. The most affected aspects of DLQI in AA are symptoms, feelings, and

daily activities.10,13 Skindex emotions and SF-36 role-emotional, mental health, and vitality are also severely

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affected.10,16 Female gender, young age, unmarried status, severity of scalp involvement, and concomitant

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psychiatric disorders are more often associated with a lower HRQoL in AA.7,10,13
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Psychiatric aspects of Alopecia Areata
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Stressful events, trauma, and acute anxiety are the most common triggers of AA.18 Patients with AA

more often suffer from anxiety and depression than the general population. Hair loss, however, can also be
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considered as an initiating factor in anxiety and depression.19,20 Psychiatric diagnoses, such as substantial
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depression, generalized anxiety disorder, adjustment disorder and paranoid disorders, have been observed in
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up to 78% of patients with AA.19-21 Women, young patients, and those with extensive disease are more
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affected.20,22

Recognizing depression, along with underlining the profound impact the extensive hair loss, chronic
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nature of AA and frequent recurrences can have on the body image of such patients is not an easy task.

Psychiatric evaluation is often required. In fact, AA is the second most referred dermatosis to psychiatrists from

dermatologists, surpassed only by psoriasis.23 Results vary, but 1/3 up to 3/4 of AA patients have psychiatric

disorders after structured psychiatric evaluation.19,24,25 Unfortunately, concomitant systemic disorders, such as

hypothyroidism, may delay the correct psychiatric diagnosis.

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One of the most common diseases in all ages is depression. It is predicted to be the second most

prevalent disease by the year 2025.26 Dermatologic diseases are considered one of the most important

predisposing factors for depression and suicidal ideation. Some patients do not seek help or even carry out

treatment, as they consider their condition to be hopeless. A small number may even commit suicide due to

significant depression and hopelessness.27,28

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A variety of questionnaires can be applied in the clinical evaluation of these patients. A complete

medical history should be taken before considering these tools. Psychiatric hospitalization, a background of

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cognitive disorders, brain damage or epilepsy, alcohol abuse, and use of narcotics can lead to incorrect

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evaluation. Table 2 review the most widely used psychometric tests that can evaluate the severity of psychiatric
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damage in AA.20-23 In pediatric patients, family members should also be observed and specific scales may be

helpful.19,29
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Ophiasis, AU, and diffuse AA are more often affected by depression.26 Depressed AA patients are more

likely to mention stress as the cause of the disease.30 Prevalence of a death wish and suicidal ideation among
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alopecia patients varies in different groups from zero to 25%.21,26 Women are more often affected by
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depression, with feeling loss of love from family and friends.28 Beyond the generally higher rate of depression
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among women, chronic skin manifestations are usually associated with a greater psychologic burden and a

feeling of loss.24 Facial involvement is more often associated with depression, anxiety, and neurosis.31
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Neurosis is a class of mental disorders involving distress, without delusions or hallucinations. Neurosis

should not be mistaken for psychosis which refers to a loss of touch with reality. There is no difference in AA

patients and the control group in psychosis and lying.31 Neuroticism, a fundamental trait, and a neurotic

personality type are predominant in AA patients.31 The neurotic personality found in a high percentage of the

patients may be an additional element in the group of psychologic factors that possibly have some influence on

the development of the disease.

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Glutamate is the main excitatory neurotransmitter in the normal brain, perturbations of glutamate

homeostasis may be expected to have consequences beyond the modulation of excitatory communication

between neurons. High concentration of glutamate is found in anxiety and obsessive-compulsive disorder

which is the neurosis more often identified in AA in children and adolescents.29 Low levels of glutamate in

schizophrenia may explain the low rates of this disorder in AA group. 30,31

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All of these psychologic morbidities may lead to suicide; however, depression plays a crucial role. Half

of those who commit suicide are depressed.26 As might be expected, suicide attempts are highest among

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patients with AU and diffuse AA.26 Suicidal ideation is reported in 60% of AU patients, more than three times

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the 18% of patients with localized alopecia.26 NU
Difficulty in expressing emotions, as in alexithymia, is often reported in patients with AA, adding to the

complex evaluation of these patients. Alexithymia can be assessed by the Toronto Alexithymia scale; however,
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the difference between the alexithymia incidence among AA and control patients is controversial.22,32-33 Some

alexithymic characteristics are associated with AA.32,33

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Despite the evidence provided above for proving the association of AA with psychiatric disorders, the
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efficacy of antidepressants, psychotherapy, relaxation techniques, individual or group therapy, and hypnosis in
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AA treatment has not been evaluated by appropriate clinical trials.10,34,35 Trials with hypnotherapy suggest

possible hair growth and improvement in HRQOL, although clinical responses varied and relapse rates were
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high.10,34

Coping with Alopecia Areata

The onset of a chronic condition brings with it a range of difficulties that may show considerable

variation in their nature and severity as perceived by the patient. More than 60% of AA patients believe their
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behavior could determine improvement or worsening of their illness.9 To respond to the difficulties that a

chronic illness presents, patients construct their own common-sense cognitive model of their condition. Such a

model is based on information received from a range of sources including physicians, family members, friends,

internet, and existing social concepts. Cultural cosmetic appeal, current life status, and stage of development all

may interfere with the effects of a skin disease on body self-image. Unfortunately, inaccurate interpretation of

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the given information may lead to poor compliance and treatment leave.

Negative psychologic issues in patients with AA, particularly regarding self-esteem, body image, and self-

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confidence lead to three coping steps:

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 avoidance
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 appearance fixing
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 acceptance.36

Interpretative Phenomenological Analysis (IPA), an approach to psychologic qualitative research, can offer
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insights into how the patient makes sense of AA. It can be used to provide a holistic perspective of four key
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themes:
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 loss (self/social)

 concerns (physical/future)
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 negative (emotions/thoughts)

 coping styles (adaptive/maladaptive).37

Initial intropunitive maladaptive forms of coping behaviors in AA are later replaced by more adaptive forms of

coping, such as treatment and support seeking, religious coping, and acceptance. Women experience greater
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feelings of loss and report more negative thoughts and emotions.37 Adolescents are known to have more

difficulties in coping with beauty problems developing from dermatologic diseases.37

Support groups may play a definite role in the coping framework of AA. Sharing experiences with others

and gaining support from others with the same or similar diseases can be a definite link to the treatment. There

is a stronger deficiency in coping with stress in AA patients, when compared to androgenetic alopecia

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patients.38 Parents should always be the focus in pediatric AA, as they may send the message that the child is

not “normal.” Support groups help parents learn to communicate with their child, adding to the influence and

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information health care providers can give during the regular visits.38 Patients can derive emotional support and

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information that can improve quality of life and increase treatment compliance. An excellent source is the
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National Alopecia Areata Foundation web site (www.naaf.org), which provides patients, parents, and

physicians, guides and links to support groups.39

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Conclusions
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Proper awareness and consciousness about the close relationship between AA and psychologic factors is

essential for a desirable management of AA. The high incidence of neurotic personality, depression, anxiety,
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and deficiency in coping with stress strengthens the role of psychic factors in the etiopathogenesis of AA.
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Strategies to assess these patients are often not part of the armamentarium for many dermatologists.

Identifying patients in need of extra psychologic support is the mainstay for successful treatment. Women,

young patients, and those with extensive disease or previous psychiatric disorders are at greater risk and

require careful follow-up.

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of alopecia areata and psoriasis. Ind Psychiatry J. 2015;24:125-128.

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33. Sellami R, Masmoudi J, Ouali U, et al. The relationship between alopecia areata and alexithymia, anxiety

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34. Willemsen R, Vanderlinden J, Deconinck A, et al. Hypnotherapeutic management of alopecia areata. J Am

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35. Abedini H, Farshi S, Mirabzadeh A, et al. Antidepressant effects of citalopram on treatment

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36. Tucker P. Bald is beautiful?: the psychosocial impact of alopecia areata. J Health Psychol. 2009;14:142-151.
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an interpretative phenomenological analysis. Int J Qual Stud Health Well-being. 2015;10:26039.

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2011;24:302-304.

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Appendices:

Table 1. Health-related quality of life indices for evaluating patients with alopecia areata

Dermatology Life Quality Index (DLQI) Results for AA

Self-reported questionnaire composed of 10 questions,  The percentage of body hair loss was
assessing effect of skin condition on various aspects of related to poor DLQI14
life. Scores range from 0 (no effect on patient’s life, high  Concomitant depression in AA is
HRQoL) to 30 (extremely large effect on patient’s life, associated with poor DLQI13,15

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poor HRQoL).  Scores range from 5.3 to 137
Skindex

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Self-reported questionnaire composed of 61-item  Related to severity of disease14
survey, assessing the degree to which an individual is  Pronounced symptoms in older

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bothered in various aspects of skin condition. Scores patients14
range from 0 (never bothered, high HRQoL) to 100
(always bothered, poor HRQoL). Dimensions assessed
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are symptoms, emotions and function.16

Short Form Health Survey (SF-36)

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Original constructed for use in the Medical Outcomes  No correlation with AA severity14
Study, not specific to skin. Scores range from 0 (poor  Poorer HRQoL in role emotional,
HRQoL) to 100 (high HRQoL). Evaluates 8 dimensions of mental health, and vitality17
HRQoL, including physical functioning, role physical, role 
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Somatic symptoms such as physical

emotional, bodily pain, social functioning, general health, functioning and bodily pain were least
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vitality, and mental health. affected14

 Unmarried patients scored lower14
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AA, Alopecia areata; HRQoL, health-related quality of life.

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Table 2. Psychometric Tests for Alopecia Areata
Age Test
Adults Beck Depression Inventory
Fear of Negative Evaluation Scale
The Holmes and Rahe Stress Scale
(Social Readjustment Rating Scale)
Hospital Anxiety and Depression
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Scale
Toronto Alexithymia scale
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Traumatic Events Questionnaire
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Children Children’s Depression Inventory
State-Trait Anxiety Inventories for
Children
Kiddie-Schedule for Affective
Disorders and Schizophrenia for
Goals
A multiple choice self-report inventory with three different
versions to help health care and researchers on the
diagnosis of depression for adults and adolescents 13 years
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old and over.
The brief version is most often used to measure social
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anxiety, evaluating on how the patient self identifies in 12
different social situations
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The number of "Life Change Units" apply to events in the
past year of a patient's life are added and the final score
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will give a rough estimate of how stress affects health.
A fourteen-item-scale is used by medical doctors to
evaluate levels of anxiety and depression in people with
physical health problems.
A 20-item instrument to measure alexithymia: people who
have trouble identifying and describing emotions and who
tend to minimize emotional experience and focus attention
externally.
The 11-item questionnaire with a 7 points scale that
evaluates frequency, age at the time, degree of injury, life
threat, and how traumatizing the event was at the time
and currently
A 27-item self-rated and symptom-oriented scale to assess
the severity of symptoms related to depression and
dysthymic disorders in children and adolescents.
Two 20-item scales that measure state and trait anxiety in
children between the ages of 6 and 14, that could measure
anxiety at both poles of the normal affect curve.
A collection of psychiatric diagnostic criteria and symptom
rating, organized as a semi-structured diagnostic interview
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anxiety and depression for school-aged children (6 to 18 years).

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