The Quality of Life and Psychosocial Impact on Female Pattern Hair Loss

Abstract

Background

Alopecia, a benign dermatologic condition affecting both genders, particularly harms female patients due to psychosocial effects. Female pattern hair loss (FPHL), the primary cause of hair loss in women, lacks sufficient Korean epidemiological studies examining its psychosocial aspects.

Objective

This study aimed to explore FPHL’s psychosocial impacts, including quality of life (QoL), depression, anxiety, medical consumption, and hair loss factors in Korean women.

Methods

A total of 202 patients with FPHL were interviewed using a validated questionnaire to assess the QoL, psychological impact, and pattern of medical consumption. The severity of hair loss was evaluated using the “basic and specific (BASP) classification” by dermatologists. The Hair-Specific Skindex-29 (HSS29) was used to assess the QoL and Beck depression inventory (BDI), Beck anxiety inventory (BAI) to evaluate psychological aspects, and medical expenses and the number of clinic visits to determine medical consumption.

Results

The global HSS29 score of FPHL was 40.97±18.92, indicating a notable impact on QoL. The mean BDI and BAI scores were 14.47 and 10.06, respectively. In multivariable regression analysis, HSS29, BDI, and BAI scores were most affected by the severity of hair loss (p<0.001).

Conclusion

FPHL damages the psychosocial aspects of patients, such as QoL, depression, and medical consumption, according to the severity of hair loss.

INTRODUCTION

Hair, especially scalp hair, has more social and psychological significance than biological importance¹. For many people, the shape of their hair is central to their attractiveness and self-esteem². Throughout history, luxuriant hair has symbolized health, youth, and potency³. Notably, even clinically inconspicuous hair loss is correlated with a reduced quality of life (QoL), and patients may rate their hair loss as more severe than dermatologists⁴,⁵. The most common type of hair loss is androgenetic alopecia (AGA), and it is called male pattern hair loss (MPHL) in men and female pattern hair loss (FPHL) in women². FPHL starts with a specific diffuse loss of hair of the parietal or frontovertical regions (“in the crown”), maintaining the frontal hairline⁶.

Patients with hair loss suffer psychosocial stress due to undesirable appearance and subjective symptoms. Because hair loss is less common in women than men, women may suffer more from the subjective symptom of hair loss. Several studies have been published on the psychosocial problems related to hair loss, and some of them focused on female patients⁷,⁸,⁹,¹⁰.

Dermatology Life Quality Index (DLQI) and Skindex-29 are mainly used to measure the QoL of patients with skin diseases, and one study reported better sensitivity with Skindex-29¹¹,¹²,¹³,¹⁴. The Skindex-29 is modified for hair loss as Hair-Specific Skindex-29 (HSS29) and many studies have investigated the QoL for patients with pattern hair loss using HSS29 so far¹⁵,¹⁶.

Understanding the effects of FPHL on psychosocial states is essential to providing comprehensive assistance to female patients. Several studies reported the impact of FPHL on QoL using standardized self-report and DLQI, but few studies have used hair-specific questionnaires such as HSS29 for FPHL so far⁹,¹⁰,¹⁷. Our study was designed to investigate the relationship between QoL using hair-specific and psychological stress questionnaires among Korean female patients with FPHL.

MATERIALS AND METHODS

Patients

A total of 202 Korean female patients over 13 years of age were enrolled in our research from the Department of Dermatology, Inha University Hospital in South Korea. Participants in this research were diagnosed with FPHL by dermatologists from June 2020 to November 2022. The patients who visited the hospital for treatment of alopecia and other skin diseases and showed sufficient clinical hair loss to diagnose with FPHL were included. Patients with severe seborrheic dermatitis, alopecic disease except for FPHL, and scalp disorders such as psoriasis and infection were excluded. Patients taking specific drugs that could cause alopecia, such as corticosteroids and cyclosporines over the previous six months, were also excluded. Additionally, patients with psychological disorders or chronic debilitating diseases, as well as those taking systemic medications like antidepressants that could potentially affect the study results, were not included.

Classification of FPHL using the basic and specific (BASP) classification

The classification system used in this study was the basic and specific classification system introduced by Lee et al.¹⁸ The BASP classification is appropriate for examining the hair loss found in Asians and can be applied to both female and male patients. Two board-certified dermatologists completed a classification of severity, and the patients were classified into three groups: ‘mild,’ ‘moderate,’ and ‘severe.’ The BASP scale L, M0, M1, C1, V1, and F1 were classified as ‘mild’, the BASP scale M2, C2, V2, and F2 as ‘moderate,’ and the BASP scale M3, C3, U1, U2, U3, V3, and F3 as ‘severe.’ Then the severity of patient hair loss was rated on a 3-point scale (1=mild, 2=moderate, and 3=severe) with clinically apparent hair loss. Representative pictures for each severity classification are shown in Supplementary Fig. 1.

Assessment of quality of life (QoL)

The QoL was assessed by using HSS29 questionnaires¹⁵,¹⁹,²⁰,²¹,²²,²³. This questionnaire consisted of three types of dimensions: a symptom (Sx) dimension (seven items), a functional (Fx) dimension (12 items), and an emotional (Em) dimension (10 items). Patients answered each question with a number ranging from zero (never bothered) to four (always bothered), and the answers were summed and transformed to a linear scale ranging from zero (never bothered) to 100 (always bothered). A global HSS29 score is the mean of three dimensions. A high score indicates severely impaired QoL, and a low score reflects mild damage in the QoL.

Assessment of psychological aspects

To understand the effects of FPHL on psychological states, the Beck depression inventory (BDI) and Beck anxiety inventory (BAI) were utilized²⁴. The BDI is a 21-item inventory assessing symptoms of depression. The items in the BDI were scored on a four-point scale ranging from zero (absent) to three (severe), and the total score ranged from zero to 63. The BAI is a 21-item inventory; each item was answered on a 4-point scale based on the severity of the question quantifying the psychological aspect of anxiety.

Assessment of medical consumption

The medical consumption for FPHL was measured by medical expenses and the number of clinic visits. The medical expenses were scaled by eight points, where 1-point was noted for spending less than $10 (US dollars) a year for hair loss, 2-points for $10-40, 3-points for $40–80, 4-points for $80–400, 5-points for $400–800, 6-points for $800–4,000, 7-points for $4,000–8,000, and 8-points for over $8,000, respectively. The number of clinic visits was scaled by eight points as well, where 1-point was scored for less than one visit to clinics a year for hair loss, 2-points for 2–5 visits, 3-points for 6–10 visits, 4-points for 11–20 visits, 5-points for 21–30 visits, 6-points for 31–40 visits, 7-points for 41–50 visits, and 8-points for over 51 visits, respectively.

Investigation of factors that affect the psychosocial aspects of FPHL

We acquired information about the participants to discover the association between the factors and the psychosocial aspects of FPHL. Patients were instructed to answer questions such as age at the time of the survey, age at diagnosis, duration of hair loss (in months), previous experience of medical treatment, marital status, educational level, and family history of pattern hair loss. The educational level was categorized into four groups, the elementary school level, the middle school level, the high school level, and over the bachelor’s level. The family members described in the immediate family history only included parents and grandparents with pattern hair loss.

Statistical analysis

Several statistical analysis methods were used to evaluate the correlation between the factors and psychosocial effects. The Shapiro-Wilk test was used to test for normal distribution. The Wilcoxon rank-sum test was performed to assess the impact of previous treatment experience, marital status, and family history on HSS29, BDI, and BAI. The correlations among the factors such as educational level, the severity of hair loss, and psychosocial effects (HSS29, BDI, and BAI) were analyzed by the Kruskal-Wallis test. The Spearman’s rank correlation test evaluated the correlation among three factors such as age at the time of the survey, age at diagnosis, and duration of hair loss, which are continuous variables, and the psychosocial impacts such as HSS29, BDI, BAI, medical expenses and the number of clinic visits. The multivariate regression analysis was performed to find factors that affected the psychosocial aspect of FPHL, and the final models were chosen using the stepwise method with the direction “both.”

All statistical analyses were conducted in R software (version 4.2.1, R Core Team 2022, Vienna, Austria), and only p-values less than 0.05 were considered statistically significant. The values are mainly presented as mean ± standard deviation.

Ethics statement

All participants in this study provided their informed consent in writing prior to participation. The research was carried out in strict accordance with the principles of the Declaration of Helsinki and received full approval from the Ethics Committee of the Institutional Review Board of Inha University Hospital (Approval No: INH-IRB 2020-06-011).

RESULTS

Clinical characteristics of FPHL patients

This study included 202 Korean patients with FPHL to investigate the psychosocial impacts of FPHL (Table 1). The mean age of participants was 37.48 years, including eight (3.96%) pediatric patients younger than 19 years old, and the youngest patient was 15 years old. Among them, 111 patients (54.95%) had a family history of hair loss, 28 patients had a paternal history of hair loss, 28 had maternal history, and nine had a both-sided hair loss history. For the duration of hair loss, 97 patients (48.02%) were over 60 months, and the most extended duration was 420 months, with patients with a severe degree of hair loss diagnosed at 24 years old. A total of 155 patients (76.73%) were classified into mild severity, 35 patients (17.33%) were moderate, and 12 patients (5.94%) were severe. The representative clinical photographs for each severity classification are shown in Supplementary Fig. 1. A total of 161 (79.7%) patients had a history of treatment. Among them, only one patient had a history of hair transplant, and the rest were treated with topical agents with or without oral medication.

Table 1. Demographics and clinical characteristics of patients with female pattern hair loss.

Characteristics		Values
Total number of patients		202 (100)
Age at the time of the survey (yr)		37.48±13.30
	<20	8 (3.96)
	20–29	63 (31.19)
	30–39	48 (23.76)
	40–49	45 (22.28)
	50–59	24 (11.88)
	≥ 60	14 (6.93)
Family history of hair loss
	Yes	111 (54.95)
	No	90 (44.55)
	Non-response	1 (0.50)
Marital status
	Married	113 (55.94)
	Single	87 (43.07)
	Non-response	2 (0.99)
Duration of hair loss (mo)
	≤12	20 (9.90)
	13–60	85 (42.08)
	>60	97 (48.02)
Educational level
	Elementary school level	1 (0.50)
	Middle school level	5 (2.48)
	High school level	48 (23.76)
	Bachelor’s level	147 (72.77)
	Non-response	1 (0.05)
The severity of hair loss
	Mild	155 (76.73)
	Moderate	35 (17.33)
	Severe	12 (5.94)
Treatment history
	Yes	161 (79.70)
	No	41 (20.30)
	Non-response	0 (0)

Values are presented as numbers of patients (%) or mean ± standard deviation.

HSS29 scores

The global HSS29 score of the FPHL patients was 40.97±18.92. The symptom dimension score was 31.86±19.82, the functional dimension 37.84±22.85, and the emotional dimension 53.21±22.4 (Fig. 1A). The Wilcoxon rank-sum test and Kruskal-Wallis test are shown in Fig. 2 with boxplots and p-values. The results indicated that the global HSS29 score was high (poor QoL) in patients with a treatment history and with a more severe degree of hair loss (green and red colored plots on the top panel in Fig. 2A, respectively). Regarding the functional dimensions of HSS29, it was related to previous treatment experience and severity (green and red colored plots on the third panel in Fig. 2A). The Spearman’s correlation test results are displayed in Fig. 3 with the Spearman correlation coefficient. The functional dimension was related to age at the time of the survey, and duration with Spearman correlation coefficients of 0.217 and 0.24, respectively.

Fig. 1. (A) The boxplot of the HSS29 score with the global, symptom, function, and emotional dimensions and (B) the BDI and BAI scores. The bar plot of (C) medical expenses and (D) the number of clinic visits.

HSS29: Hair-Specific Skindex-29, BDI: Beck depression inventory, BAI: Beck anxiety inventory.

Fig. 2. The boxplot of (A) the HSS29 score, (B) psychological (BDI and BAI) scores, and (C) medical expenses (Med Exp) and the number of clinic visits (Clin Vis) points are presented. The four plots are displayed: the factors such as the family history of hair loss (Fm Hx), marital status, treatment history (Tx Hx), educational level, and the severity of hair loss. The Wilcoxon rank=sum test and Kruskal-Wallis test are also shown with the color (red: p-value <0.001; blue: p-value <0.01, and green: p-value <0.05).

HSS29: Hair-Specific Skindex-29, BDI: Beck depression inventory, BAI: Beck anxiety inventory.

Fig. 3. The Spearman’s correlation coefficient among the clinical factors such as age at the survey (age), age at diagnosis, and duration and the psychosocial aspects of HSS29, BDI, BAI scores, and medical consumption.

HSS29: Hair-Specific Skindex-29, BDI: Beck depression inventory, BAI: Beck anxiety inventory, Med Exp: medical expenses, Clin Vis: clinic visits.

The p-value <0.05 is represented with ^*; p<0.01 with ^**, and p<0.001 with ^***. The grey cell means the p-value >0.05.

As a result of the multivariable regression shown in Table 2, the global HSS29 was associated with severity and BDI with an adjusted R-square of 0.39, meaning that the severity and BDI explain 39% of the global HSS29 score. Most of the HSS29 scores, except for symptom dimension, were correlated with the severity of hair loss with standardized β over 5. The function dimension was associated with severity, BDI, and duration with an adjusted R-square of 0.46. The emotional dimension was associated with severity, medical expenses, BDI, and age with an adjusted R-square of 0.41.

Table 2. Results of multivariable regression analysis among the factors of psychosocial aspects of female pattern hair loss.

Measurement with the clinical factors		Standardized β	Standard error	Adjusted R-square	p-value
Global HSS29 score				0.39	<0.001
	Severity	5.07	1.86
	BDI score	1.08	0.10
Symptom score				0.12	<0.001
	BDI score	0.68	0.13
Function score				0.46	<0.001
	Severity	7.51	2.18
	BDI score	1.29	0.12
	Duration	−0.72	0.36
Emotion score				0.41	<0.001
	Severity	7.27	2.10
	Medical expenses	2.23	0.93
	BDI score	1.29	0.12
	Age	−0.23	0.10
BDI score				0.57	<0.001
	Severity	2.06	0.87
	Medical expenses	−0.72	0.36
	BAI score	0.54	0.06
	Global HSS29 score	0.20	0.03
BAI score				0.46	<0.001
	Severity	−2.71	0.89
	Medical expenses	0.91	0.38
	BDI score	0.64	0.05
Medical expenses				0.29	<0.001
	Treatment history	0.76	0.20
	The number of clinic visits	0.58	0.08
Number of clinic visits				0.28	<0.001
	Medical expenses	0.36	0.05
	Age	0.14	0.00*

HSS29: Hair-Specific skindex-29, BDI: Beck depression inventory, BAI: Beck anxiety inventory.

^*This value actually represents a measurement of 0.005.

Psychological scores in patients with FPHL

The BDI and BAI measure the psychological effects of FPHL. The BDI score was 14.47±10.21, and the BAI score was 10.06±9.53 (Fig. 1B). As shown in Figs. 2B and 3, the poor BDI score was related to the severity of hair loss, age, and duration and the poor BAI score was associated with a married person and the age at the survey and diagnosis. In regression analysis (Table 2), the BDI was affected by severity, medical expenses, BAI, and global HSS29 with an adjusted R-square of 0.57. The BAI was negatively correlated with severity and positively correlated with medical expenses, and the BDI with an adjusted R-square of 0.46.

Medical consumption in patients with FPHL

Medical consumption was measured by medical expenses and the number of clinic visits per year. The median point of medical expenses was four ($80–400 spending per year) with a standard deviation of 1.32, the maximum point was six, and the minimum point was one, which is $800-4,000 and less than $10 a year, respectively (Fig. 1C). Medical expense was correlated with treatment history (Fig. 2C) and global HSS29, symptom, and emotional dimensions, and the number of clinic visits (Fig. 3).

The median point of clinic visits was two with a standard deviation of 0.99, meaning 2 to 5 times clinic visits a year (Fig. 1D). The number of clinic visits was correlated with a married person, the presence of a treatment history (Fig. 2C), and medical expenses (Fig. 3).

DISCUSSION

The QoL of patients with FPHL has been moderately investigated. Cash et al.²⁵ surveyed 60 men and 96 women with MPHL and FPHL, respectively, to assess the psychological impact of hair loss using a series of standardized inventories. Five percent of women ranked their emotional stress due to FPHL as very-to-extremely upsetting. They also reported increased social anxiety, poor self-esteem, a negative body image, and a sense of powerlessness²⁶. Another study described the QoL of 125 patients with FPHL measured by the DLQI correlated with the severity of hair loss⁸. Guerra-Tapia et al.¹⁰ studied the QoL of 170 FPHL patients using the Spanish HSS29 questionnaire and Sadiq et al.¹⁷ used the HSS29 in Pakistani FPHL patients and both noted that it is a valuable tool for assessing QoL. However, no study has cohesively analyzed QoL and psychologic stress to investigate their effect on patients with FPHL. Through an integrated analysis of QoL, psychological stress, and medical consumption, this study revealed that FPHL has markedly detrimental psychosocial effects in patients.

As shown in Fig. 1A, the emotional dimension scored higher than the symptom and functional dimensions, which exhibited a better mean global HSS29 score. In a meta-analysis for patients with AGA, the emotional dimension showed a poorer score of 29.22 than the symptom score of 21.95 and the functional score of 18.52, which is consistent with our results¹⁶. Therefore, we assert that pattern hair loss has much more influence on the emotional aspects than the symptom or functional characteristics.

As presented in Fig. 4, the QoL was remarkably impaired in FPHL patients compared to that of patients with MPHL¹⁵. The mean global HSS29 score was 27.3 for MPHL patients but 40.97 for FPHL patients. The emotional dimension was the most affected aspect in both males and females, even though the mean value was much poorer in females at 53.21 as compared with the score of males at 32.1. The symptom dimension was more affected by hair loss than the function dimension in MPHL patients, but the function dimension was more affected than the symptom dimension in females. We postulate that the poor QoL of female patients is related to the fact that male patients’ psychosocial aspects are less affected by subjective hair loss symptoms. In other studies, 170 Spanish FPHL patients showed a global HSS29 score of 26.42±18.90, and 150 Pakistani FPHL patients scored 35.95±14.10, indicating a better QoL than our results (Supplementary Table 1)¹⁰,¹⁷. This signifies regional and cultural differences in the psychological effects of female pattern alopecia, such that treatment should be performed with consideration of the sociocultural situation of the patient.

Fig. 4. The comparison of the HSS29 scores between males and females.

HSS29: Hair-Specific Skindex-29.

Among many factors, the FPHL patient group with the greatest severity showed the poorest global HSS29 score, 54.53±16.88, with a high score of 74.15. In the symptom dimension, the patients with a treatment history exhibited the worst score (33.19±19.52), with a high score was 85.71, who had a treatment history of mild severity. The mean functional score was worse in the severe-degree FPHL group (59.72±22.98), and the worst was 97.92. Lastly, the mean emotional score was worse in the severe-degree FPHL group (59.72±19.78), with the worst score being 100 in two patients. Both patients were in their thirties with moderate severity, treatment history, and family history, and were married.

It is challenging to compare Skindex-29, BDI, and BAI scores between FPHL and other skin disease patients due to the difference between groups. However, considering the simple comparison with the mean score (Supplementary Table 2), the HSS29 score of FPHL patients was noticeably poorer than that of vitiligo, with the global skindex-29 score ranging from 20.8 to 33.1, and female acne patients with a score of 34.27²⁷,²⁸. The patients with FPHL showed the almost equal HSS29 scores of psoriasis and atopic dermatitis patients with scores of 39.34 and 39.68, respectively²⁹,³⁰. Also, because the HSS29 score of FPHL patients was much higher than that of MPHL patients, the difference might be more significant than expected in females. In addition, the average BDI score for vitiligo was 8.97, psoriasis 11.0, and alopecia areata (AA) 10.0, respectively, which are slightly lower than the BDI score of this study, but all were classified as mildly depressed status³¹,³².

More psychosocial problems can be expected in women than men because a smaller proportion of women are affected by FPHL, which emphasizes their deviation from the normal. Venning and Dawber³³ demonstrated that 13% of 564 premenopausal women showed hair loss on the scalp, whereas it was about 45% in men. Another reason why more psychosocial problems are expected in patients with FPHL is that our cultural normative emphasize the relevance of women’s physical attractiveness³⁴. According to Cash et al.²⁵, FPHL patients displayed more negative perceptions of themselves and complained of psychological disturbances more than MPHL patients or females without FPHL. One study explained the psychosexual effects of AGA with female BDI of 14.74±4.44 and female BAI of 11.93±4.85, which are very similar to our research²⁴. They asserted that the psychologic measurement scores were significantly higher in females than in males (BDI of 8.82±5.07 and BAI of 5.95±3.83).

Our study indicated that medical expenditures were related to the treatment experience and the number of clinic visits (Table 2). This can be logically explained because treatment and visiting clinics require costs. Kim and Kwon³⁵ reported that the average monthly expenditure and QoL were significantly correlated in both MPHL and FPHL patients. Of note, 90 patients with FPHL revealed that the expenditure was related to QoL, which is the same findings as our study. Choi et al.³⁶ indicated the medical consumption of pediatric AA patients. Two-thirds of severe AA patients spent more than $1,000 a year, and the number of clinic visits increased as the severity of AA increased.

In conclusion, our study illustrated that FPHL damages the psychosocial aspects of patients, such as QoL, depression, anxiety, and medical consumption. Among them, QoL and depression were most affected by the severity of hair loss. We observed that the psychosocial deterioration was more severe in FPHL than in MPHL patients. This study provides evidence of FPHL patients’ QoL, helps others to understand the patients’ psychological stress, and contributes to the enhancement of hair loss treatment in the future.

SUPPLEMENTARY MATERIALS

Supplementary Table 1

Comparison of Hair-Specific Skindex-29 scores of female pattern hair loss patients with other studies

Supplementary Table 2

Comparison of HSS29, BDI, and BAI scores among other skin diseases

Supplementary Fig. 1

Clinical photographs of (A) mild, (B) moderate, and (C) severe degrees of female pattern hair loss.