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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 31  |  Issue : 4  |  Page : 455-461

Androgenetic alopecia: What impact does it have on the quality of Life?


1 Department of Dermatology and Venereology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
2 Department of Dermatology and Venereology, Obafemi Awolowo University Teaching Hospitals Complex; Department of Dermatology and Venereology, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria

Date of Submission17-May-2022
Date of Decision21-Jun-2022
Date of Acceptance14-Jul-2022
Date of Web Publication27-Aug-2022

Correspondence Address:
Dr. Ademola Olusegun Enitan
Department of Dermatology and Venereology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_61_22

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  Abstract 


Background: Androgenetic alopecia (AGA) is a common hair disorder resulting from a combination of genetic, hormonal, and nutritional factors. It may be associated with psychological, social, and emotional disturbances in the affected individuals and this may lead to a significant reduction in the quality of life (QoL). Aim: This study determined the impacts of AGA on the QoL among a Nigerian population. Patients, Materials and Methods: This was a hospital-based cross-sectional study involving 110 adults with AGA. Adult patients with AGA attending dermatology clinic were consecutively recruited after obtaining an informed consent. The QoL was assessed with Hairdex questionnaire. Results: The mean age of the study participants was 43.45 ± 11.72 years (age range of 23–82 years) with male-to-female ratio of 14.7:1. The AGA duration ranged from 2 to 38 years, with a mean duration of 11.5 ± 4.2 years. Significant impairment in QoL was observed among the subjects in the Hairdex domains of symptoms, functioning, emotion, stigmatization, and self-confidence. Subjects who have previously been treated were more affected compared to those who were new and were yet to receive any treatment. Conclusion: Significant proportion of individuals with AGA experience enormous impairment in the QoL, indicating the need for psychosocial support while managing such patients.

Keywords: Androgenetic alopecia, pattern hair loss, quality of life, Nigeria


How to cite this article:
Enitan AO, Olasode OA, Onayemi OE, Ajani AA, Oninla OA, Olanrewaju FO, Oripelaye MM. Androgenetic alopecia: What impact does it have on the quality of Life?. Niger J Med 2022;31:455-61

How to cite this URL:
Enitan AO, Olasode OA, Onayemi OE, Ajani AA, Oninla OA, Olanrewaju FO, Oripelaye MM. Androgenetic alopecia: What impact does it have on the quality of Life?. Niger J Med [serial online] 2022 [cited 2022 Oct 5];31:455-61. Available from: http://www.njmonline.org/text.asp?2022/31/4/455/354858




  Introduction Top


Androgenetic alopecia (AGA), also called pattern alopecia, pattern hair loss, or pattern baldness, is the most common form of alopecia, characterized by progressive decline in hair growth or the presence of nonfunctional or dead hair follicles on the scalp in a specified pattern.[1] It is referred to as female pattern baldness in females, and male pattern baldness in males.[2] AGA results from excessive action of androgen in genetically susceptible men and women with polygenic inheritance pattern, causing thinning of hair which usually begins between ages 12 and 40 years.[3] The classical history of AGA is a gradual thinning of hairs followed by hair loss in a well-defined pattern. This commonly starts in the temporal areas in men but in women, the process often begins from the vertex.[4],[5] The process continues gradually following the Hamilton–Norwood classification in men but in women, the frontal hairline is usually retained.[6] AGA is seen in 50% of adult men and perhaps as many women worldwide.[4],[7] Up to 13% of premenopausal women reportedly have some evidence of AGA.[5] The incidence of AGA increases greatly in women following menopause and may affect up to 75% of women older than 65 years.[5] The prevalence of AGA (male and female) in a study by Oiwoh et al.[8] in South-Western Nigeria is 29.95% but a higher prevalence of 65% is seen among the male adult population in the Northern Nigeria.[9]

The quality of life (QoL) is defined by the World Health Organization as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns.[10] It is a broad-ranging concept affected in a complex way by the person's physical health, psychological state, personal belief, social relationship, and their relationship to salient features of their environment.[10] Individuals with AGA experience both psychological and emotional stress, leading to a significant reduction in the QoL and secondary morbidities.[7],[11] In total, 88% of women with mild-to-moderate alopecia have reported change in daily activities and 72% have reported loss of self-esteem.[12] According to Wells et al.,[13] very low self-esteem occurs in men with increasing hair loss regardless of their age. However, these disturbances are worse in women with higher levels of societal anxiety, possibly because of the cosmetic importance of hair. Davis and Callender[14] noted that though alopecia is not life-threatening and considered cosmetic in many cases, the effects on patients' QoL are real. This is because the perception of hair as an agent of beauty, youthfulness and health, with the provision of sense of self-identity and self-esteem is lost in patients with alopecia. For women, hair portrays femininity and self-confidence.[14]

The aim of this study is to assess the impacts of AGA on QoL of the affected individuals in South-Western Nigeria. The psychological disturbance as well as impairment in the QoL among individuals with AGA are usually not given the deserved attention.[15] For instance, while there is a paucity of data on the QoL among individuals with AGA in Nigeria, there are treatment protocols and many published articles on holistic management of skin diseases, including AGA, in some other climes. In view of the interconnection between the body and mind (physical and psychological health), QoL has become a major part of medical evaluation in patients with skin diseases as improvement in the QoL is also considered when evaluating the efficacy of medical interventions, hence this study.

Patients, Materials and Methods

This was a hospital-based cross-sectional study involving 110 adults (103 males and 7 females) with AGA. Adult patients with AGA attending dermatology clinic were consecutively recruited after obtaining an informed consent. Patients who had other forms of alopecia, in addition to AGA, were excluded from the study. Ethical approval was obtained from the Ethics and Research Committee of the institution, where the study was conducted (Ethical clearance certificate number ERC/2018/06/13). Male AGA (MAGA) and female AGA (FAGA) were graded using the Hamilton–Norwood classification and Ludwig classification, respectively. The details of each grading system are given below.

Hamilton–Norwood grading of male androgenetic alopecia

  • Type I: No or very minimal hairline recession along the anterior border in the frontotemporal region [Figure 1][16]
  • Type II: The anterior border of the hair in the frontotemporal region has symmetric triangular areas of recession which extend no further posteriorly than 2 cm anterior to a line drawn in a coronal plane at the level of the external auditory meatus [Figure 1]
  • Type III: The triangular areas in Type II extend posterior to the coronal plane, which is 2 cm anterior to the external auditory meatus. This is the minimal level considered to represent baldness [Figure 1]
  • Type III Vertex: Most of the hair loss is seen on the vertex. Frontal hair loss may be similar to Types I or II but should not exceed Type III. This type is most commonly seen with advancing age [Figure 1]
  • Type IV: Hair loss on the vertex is associated with frontal loss more severe than Type III, but the frontal and vertex areas are separated by a distinct band of hair [Figure 1]
  • Type V: Greater hair loss than Type IV with only a sparse band of hair separating the frontal and vertex areas. The hair left on the occipital and parietal areas begins to form the shape of a horseshoe when viewed from above [also true for Types VI and VII, [Figure 1]]
  • Type VI: The frontal and vertex areas of hair loss are contiguous with greater lateral and posterior areas of denudation [Figure 1]
  • Type VII: The most severe form of male pattern baldness. Only a narrow sparse horseshoe-shaped band of hair is left extending from the ears posteriorly to the occiput [Figure 1].
Figure 1: Hamilton–Norwood classification of MPHL

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In addition, Types II through V can also be designated with a type A variant. The major features of the Type A variant are: (1) the entire anterior hairline border recedes in unison without leaving the mid-frontal peninsula of hair and (2) there is no simultaneous balding of the vertex. The two minor features are: (1) scattered sparse hairs frequently persisting in the entire area of balding and (2) the horseshoe-shaped fringe of hair that remains on the sides and back tends to be wider and reaches higher on the head. These variants exist only in about 3% of the population.[17]

Ludwig grading of female androgenetic alopecia

  • Grade I: Perceptible thinning of the hair on the crown, limited in the front by a line situated 1–3 cm behind the frontal hairline [Figure 2][18]
  • Grade II: Pronounced rarefaction of the hair on the crown within the area seen in Grade I [Figure 2]
  • Grade III: Full baldness (total denudation) within the area seen in Grades I and II [Figure 2].[6]
Figure 2: Ludwig classification of FPHL

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Hairdex questionnaire, a hair-specific questionnaire which has been validated in Nigeria for use in both English and Yoruba language,[19] was used to assess the QoL of the study participants. The English or Yoruba version of the questionnaire, depending on the preferred language of each subject, was administered to the subjects by the same researcher to ensure uniformity of information. Hairdex assesses 5 domains of QoL which include the symptoms, emotion, functioning, stigmatization, and self-confidence and it contains a total of 48 questions. AGA occurring before 30 years of age was considered premature.[20] MAGA was subdivided into mild (Hamilton–Norwood class I to III), moderate (Hamilton–Norwood class IV and V), and severe (Hamilton–Norwood class VI and VII). IBM SPSS Statistics (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp) was used for data analysis. Numerical variables were expressed as means ± standard deviation (SD) for normally distributed data and the outcome variables expressed in mean for two groups were compared using independent (Student's) t-test or analysis of variance, where there are more than two groups. The level of statistical significance was set at 0.05.


  Results Top


The mean age of the study participants was 43.45 ± 11.72 years (age range of 23–82 years) with male-to-female ratio of 14.7:1. The AGA duration ranged from 2 to 38 years, with a mean duration of 11.5 ± 4.2 years. There is no significant difference in the duration of symptoms between the male and female subjects with AGA (Student's t-test = −0.869, P = 0.382). Family history of AGA was present in 88 (80%) of the subjects. All the seven (100%) female patients with AGA had received one form of treatment or the other before presentation at the dermatology clinic. Meanwhile, only 15 (14.6%) out of the one hundred and three male patients with AGA had received treatment previously. While none of the 22 patients (male and female) who had received previous treatment for AGA was satisfied with the treatment outcome, the females were 6 times more likely to seek treatment for AGA than males and this was statistically significant (χ2 = 10.291, P = 0.003).

Five of the female subjects had Ludwig class II (moderate) AGA, one had Ludwig class I (mild), and another female had Ludwig class III AGA. All the 103 male subjects had AGA ranging from class III to VII on the Hamilton–Norwood system. Class III MAGA had the highest frequency, accounting for 47 (45.6%) of the subjects followed by MAGA class IV (30.1%). There were two cases of MAGA class VII (1.9%). Mild, moderate, and severe MAGA accounted for 47.4%, 43.6%, and 9.%, respectively. The images of some of these classes are captured below [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8].
Figure 3: Ludwig class III Female androgenetic alopecia

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Figure 4: Hamilton–Norwood Class IIIa male androgenetic alopecia

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Figure 5: Hamilton–Norwood Class IV male androgenetic alopecia

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Figure 6: Hamilton–Norwood Class IVa male androgenetic alopecia

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Figure 7: Hamilton–Norwood Class V male androgenetic alopecia

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Figure 8: Hamilton–Norwood Class Va male androgenetic alopecia

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Each of the five domains of the Hairdex questionnaire was assessed and the scores obtained among the study participants are shown in [Table 1]. The mean ± SD scores for symptom, emotion, functioning, stigmatization, and self-confidence among the subjects were 8.75 ± 1.18, 21.88 ± 7.93, 21.25 ± 6.73, 16.18 ± 4.8, and 19.42 ± 3.85, respectively. For symptom, emotion, functioning and stigmatization, the higher the score, the higher the negative impacts of AGA on the QoL. However, the self-confidence score has an inverse relationship with AGA's impact on QoL, which means the higher the self-confidence score, the lower the negative impacts of AGA on QoL. The subjects with premature AGA (AGA before the age of 30 years) had higher scores in the total Hairdex and subgroups of symptom, emotion, functioning, and stigmatization. There is a significant difference in the Hairdex symptom subgroup between patients with premature AGA and those with adult-onset AGA (t = 2.582, P = 0.018). Although the mean scores in all the domains for Hairdex except self-confidence were higher in the females with AGA than their male counterparts, these were not statistically significant as shown in [Table 1]. Similarly, there is no significant difference in the QoL with respect to other socio-demographic data [Table 1].
Table 1: Relationship between sociodemographic status and quality of life among the Subjects

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There is no statistically significant difference in QoL between the male patients with mild, moderate, and severe AGA [Table 2]. Conversely, patients who had one form of treatment or the other for their AGA had a more impaired QoL in all the five domains and in total Hairdex score when compared to those who had never sought or received any form of treatment (P < 0.05) as shown in [Table 2].
Table 2: Relationship between severity of male androgenetic alopecia, previous treatment for androgenetic alopecia, and quality of life among the subjects

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  Discussion Top


The mean total Hairdex score among the study participants is comparable to what was obtained by Gonul et al.[21] in their study. However, the mean subtotal Hairdex scores are slightly higher than the findings by Sawant et al.[22] in India but Bade et al.[23] in India and Schmidt et al.[24] in Germany found higher mean scores for total and subtotal Hairdex in their studies. This variation in the Hairdex scores from these studies is likely attributable to differences in the ability to cope with events of life by people in different geographical parts of the world. This study showed that individuals with AGA have significant impairment in their QoL in all domains of Hairdex and this suggests that subjects with AGA suffer emotional and psychological disturbances in addition to impaired functioning, stigmatization and low self-esteem.[13],[18],[25] Many of the male patients (55.6%) in this study were worried the hair loss may get worse and the females shared the same view. Almost half of the male patients visit salon weekly to ensure the remaining hairs are cut to the level of the scalp and all the women in the study constantly use camouflage to ensure the bald area is not seen by a nonmember of their household. These varying degrees of impairment in QoL suffered by AGA patients are corroborated by many other studies. For instance, in a local study by Ekpudu[25] on pattern of alopecia and effects of alopecia on QoL of patients, majority of the patients (54%) had a moderate to extremely large impairment in QoL; female patients having more impairment in QoL than male patients. Studies by Oiwoh[18] in South-Western part of Nigeria and Dlova et al.[11], in their study on QoL in South African women with alopecia, also corroborated these findings. While Oiwoh et al.[18] used Hairdex questionnaire, Ekpudu[25] and Dlova et al.[11] used the Dermatology Life Quality Index and alopecia QoL indicators questionnaire respectively to assess QoL in AGA. These observations among African patients with AGA have also been reported in similar studies in Asia, America, Europe, and Australia.[7],[12],[15],[16],[17],[18],[19],[20],[21],[22],[24],[26],[27] In fact, the QoL of AGA patients is affected more than previously thought.[21] According to Wells et al.,[13] very low self-esteem occurs in men with increasing hair loss regardless of their age. These disturbances are worse in women with higher levels of societal anxiety, possibly because of the cosmetic importance of hair. For women, hair portrays femininity and self-confidence.[14] Davis and Callender[14] noted that even though alopecia is not life threatening and considered cosmetic in many cases, the effects on patients' QoL are real. This is because the perception of hair as an agent of beauty, youthfulness, and health with provision of sense of self-identity and self-esteem is lost in patients with AGA.

The mean total and subtotal Hairdex scores, with exception of self-confidence, were higher among the female patients with AGA compared to their male counterparts. The lower score in self-confidence among the females shows females with AGA are less confident compared to their male counterparts. These differences in the Hairdex scores among the male and female subjects are comparable to the findings in the previous studies, where females with AGA had higher scores in domains of symptoms, emotion, functioning, stigmatization, and total Hairdex score but a lower score in self-confidence compared to their male counterpart.[21],[25],[28],[29] Although the mean scores in all the domains of Hairdex, except self-confidence, were higher in the females with AGA than their male counterparts, these were not significant. Similar studies also found no statistical difference in the QoL in both genders.[18],[30]

There was no significant difference in the QoL among the subjects with premature AGA and adult-onset AGA, except in the symptom subgroup of Hairdex, but the QoL is significantly impaired in all the age groups. Similarly, marital status, ethnicity, religion, educational qualification, and employment status have no significant impact on the QoL among individuals with AGA. This is similar to the findings by Zhang et al.[30] in China and Gonul et al.[21] in Turkey. Oiwoh,[18] however, discovered patients with AGA who had secondary and tertiary education scored higher in emotion, functioning, and stigmatization with Hairdex subscales and in total Hairdex score. Similar to this study, Gonul et al.[21] found no significant difference in total Hairdex or Hairdex subgroups based on the employment status in patients with AGA.

All the patients who had sought or received treatment for AGA previously had more impairment in the QoL compared to their counterparts who had never sought or received treatment. They reported more symptoms (P = 0.004), emotional disturbance (P = 0.023), impaired functioning (P = 0.002), stigmatization (P = 0.006), and lower self-confidence (P = 0.027). These results are consistent with the findings by Han et al.[31] in South Korea, Guptal et al.[15] in India and Goldberg and Huxley[32] in London, who all reported the group of AGA patients who suffer most in terms of QoL were those who were under specialist treatment and consult their general practitioner, as compared to those who “cope” with their disease.[32] The highly impaired QoL in this group of people may be the reason for their continued presentation in the hospital in an attempt to get a satisfactory care for their hair loss.


  Conclusion Top


AGA is not a physical disorder only; it also has enormous negative psychological impacts with impairment in the QoL among the sufferers. Patients with AGA experience higher symptoms, emotional disturbances, impaired functioning, stigmatization, and lower self-esteem compared to their counterparts without the disorder. It is therefore important to include QoL in the evaluation of patients with AGA and offer them psychosocial support in addition to medical therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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