Impact of male androgenetic alopecia on a Jordanian cohort measured using the Dermatology Life Quality Index

Abstract

Objectives

This study aimed to assess the impact of androgenetic alopecia on the quality of life of individuals in a Jordanian cohort using the Dermatology Life Quality Index and compare it with that in other communities.

Methods

This cross-sectional study recruited men from different age groups with varying extent of androgenetic alopecia. The participants’ demographics were documented using the Dermatology Life Quality Index questionnaire. The severity of androgenetic alopecia was assessed using the Hamilton–Norwood scale.

Results

A total of 522 participants were included in this study. The mean Dermatology Life Quality Index of the cohort was 1.5. The main burden was a feeling of embarrassment. A greater impact of androgenetic alopecia was noted in younger age groups than in older age groups, while participants who had had the disease for a longer duration (>10 years) showed significantly milder effects.

Conclusion

Our study found a minor impact of androgenetic alopecia on the quality of life of individuals in a Jordanian cohort. This could be attributed to the high prevalence of the condition and its cultural tolerance. This result should be interpreted with caution, as our study was conducted on the general population, whereas other studies have focused on individuals seeking treatment for androgenetic alopecia.

Introduction

Androgenetic alopecia (AGA) is a common disorder involving hair loss, which is believed to be related to genetic factors and circulating androgen levels in the blood. ¹ This condition can affect multiple aspects of an individual’s life, including their psychological well-being. The physical appearance of an individual greatly affects their personality, self-esteem, and social interactions. First impressions are usually based on facial features and overall appearance, with hair being an important aspect of a person’s self-image. Both excessive hair growth and hair loss can influence an individual’s quality of life. ² AGA can affect both sexes; however, men are affected to a greater extent. The clinical presentation of AGA varies between men and women. In men, it usually involves both temporal regions and the vertex, whereas in women, it tends to be more diffuse. Hair loss starts after puberty and progresses with aging, with a mean onset between the third and fourth decades of life.^3–5

Although male pattern alopecia is very common, it affects people’s self-esteem and confidence and can cause depression, in addition to social anxiety. Men with AGA commonly report a low quality of life, especially in younger age groups. Understanding how dermatological conditions can negatively affect an individual is essential because this can help improve the treatment and care given to the patient, thus enhancing the outcome.^1–2

Previous studies have shown that patients and dermatologists have conflicting views on alopecia severity. Dermatologists usually grade AGA severity according to clinical signs and symptoms rather than considering its psychosocial impact.^6–7

This study used the Dermatology Life Quality Index (DLQI) questionnaire to evaluate the impact of AGA on men in a Jordanian cohort. The main objective was to determine the impact of AGA on their social and emotional well-being, which will help provide appropriate support and counseling for them to lead normal lives.

Methods

Study design

This was an observational cross-sectional study conducted between February and September 2023. Randomly selected men from Jordan’s north and middle regions who considered themselves to have AGA were asked to complete an anonymous three-part questionnaire, where all patient details were de-identified.

The first part of the questionnaire inquired about the participants’ demographics, including age, height, weight, education level, occupation, marital status, income, smoking status, and medical history (diabetes, hypertension, and any dermatological conditions such as eczema, psoriasis, vitiligo, and seborrheic dermatitis). It also inquired about the participants’ thoughts, experiences, and plans related to AGA.

The second part was the Arabic version of the DLQI questionnaire. In the third part, the participants used the Hamilton–Norwood scale to choose a grade that reflected their hair loss.

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki (1975) and its subsequent revisions, including the 2013 version. The study was approved by the Institutional Review Board of the Ethics Committee of the Jordan University of Science and Technology, with approval number (260/2022), and the date of approval was 10 May 2022. Informed consent was obtained from all participants. The reporting of this cross-sectional study conforms to The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. ⁸

Study population and sample

The inclusion criterion for our sample was adult men with AGA, and we aimed to enroll patients from different age groups who had varying grades of AGA. A total of 522 questionnaires were collected in this study; questionnaires with missing data were excluded.

Measurements

The participants’ AGA grade was assessed using the Hamilton–Norwood scale. ⁹ The body mass index (BMI) of each participant was calculated by dividing their weight (kg) by the square of their height (m). The BMI categories were interpreted as follows: (a) less than 18.5 kg/m², underweight; (b) 18.5–24.9 kg/m², normal weight; (c) 25.0–29.9 kg/m², overweight; and (d) >30 kg/m², obese.

The DLQI questionnaire consisted of 10 questions regarding symptoms and feelings, daily activities, leisure, work and school, personal relationships, and treatment as dimensions of life. Each item was scored on a scale of 0–3 points. The summation of all points yielded a DLQI score of 0–30. The DLQI scores were interpreted as follows: (a) 0–1, no effect on patient life; (b) 2–5, small effect on patient life; (c) 6–10, moderate effect on patient life; (d) 11–20, very large effect on patient life; and (e) 21–30, extremely large effect on patient life. ¹⁰

Statistical methods

Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS v21; IBM Corporation, Armonk, NY, USA). Continuous variables were represented as means and standard deviations. Frequency and percentage values were used to represent categorical variables. Spearman correlation was used to test the hypotheses. Differences were considered statistically significant if the P-value was <0.05 and highly significant if the P-value was <0.01.

Results

Characteristics of the participants

This study included 522 men who completed the questionnaire. Their mean (±standard deviation (SD)) age was 40.6 ± 13.0 (range: 18–85) years; approximately 50% of them were aged >40 years, and only 3% were aged <20 years. Among them, 151 (28.9%) were obese, 245 (46.9%) were overweight, and 123 (23.6%) were of normal weight. The educational level varied from high school to PhD, with the majority (78.6%) holding university degrees and 21.4% having completed a diploma or high school. Furthermore, approximately 84% of the participants were employed in various sectors, while 11.5% were students, 3.1% were retired, and 1.3% were unemployed. Moreover, 67.2% of the participants were married. The monthly income of the participants varied, with 34.5% earning less than US$700, 36% earning US$700–1400, and 26% earning more than US$1500 per month. Approximately 35% of the participants had chronic medical illnesses, such as hypertension, diabetes mellitus, or ischemic heart disease. Moreover, 23.4% reported suffering from other dermatological diseases, including eczema, psoriasis, vitiligo, and seborrheic dermatitis. Most participants (91.6%) reported a family history of AGA; 41.8% cases were from both maternal and paternal sides, 36.6% were from the paternal side, and 13.2% were from the maternal side. The demographics of participants are detailed in Table 1.

Table 1.

Demographic characteristics of the participants.

Variables	Frequency	Percentage (%)
Age (years)
Mean ± SD	41 ± 13
18–20	16	3.1
21–30	131	25.1
31–40	105	20.1
41–50	152	29.1
51–60 and above	118	22.6
BMI
Underweight	3	0.6
Normal weight	123	23.6
Overweight	245	46.9
Obese	151	28.9
Educational level
High school	59	11.2
Diploma	53	10.2
Bachelor’s degree	301	57.7
Master’s degree‎/PhD	109	20.9
Occupation
Health sector	65	12.5
Education sector	104	19.9
Trade and agriculture sector	27	5.2
Judicial sector	38	7.3
Professional crafts sector	22	4.2
Military and security sector	57	10.9
Business sector	55	10.5
Engineering sector	71	13.6
Student	60	11.5
Retired	16	3.1
Unemployed	7	1.3
Marital status
Married	351	67.2
Single	171	32.8
Monthly income (US$)
<700	180	34.5
700–1400	205	39.3
≥1500	137	26.2
Smoking
Yes	341	65.3
No	181	34.7
Chronic disease (HTN, DM)
Yes	186	35.6
No	336	64.4
Dermatological diseases (psoriasis, seborrheic dermatitis, vitiligo)
Yes	122	23.4
No	400	76.6
Family history of AGA
Yes‎/paternal	191	36.6
Yes‎/maternal	69	13.2
Yes‎/both	218	41.8
No	44	8.4

BMI: body mass index; PhD: doctor of philosophy; HTN: hypertension; DM: diabetes mellitus; AGA: androgenetic alopecia; SD: standard deviation.

Features of AGA

Regarding AGA duration, 196 (37.5%) participants had AGA for <5 years, 116 (22.2%) for 5–10 years, and 210 (40.3%) for >10 years. Approximately 85% of the men reported grades III–VII AGA based on the Hamilton–Norwood scale, with 117 (22.4%) of them reporting grade V AGA. The AGA features of the participants are shown in Table 2.

Table 2.

AGA duration, AGA grade, and DLQI findings.

Variables	Frequency	Percentage (%)
Duration of AGA
≤5 years	196	37.5
5–10 years	116	22.2
≥10 years	210	40.3
Hamilton–Norwood scale
I	28	5.4
II	46	8.8
III	85	16.3
IV	99	19.0
V	117	22.4
VI	91	17.4
VII	56	10.7
DLQI
Mean ± SD	1.5 ± 0.11
No effect on patient’s quality of life (0–1)	354	67.8
Mild effect on patient’s quality of life (2–5)	133	25.5
Moderate effect on patient’s quality of life (6–10)	22	4.2
Severe effect on patient’s quality of life (11–20)	12	2.3
Very severe effect on patient’s quality of life (21–30)	1	0.2

AGA: androgenetic alopecia; DLQI: Dermatology Life Quality Index; SD: standard deviation.

DLQI

According to the analysis of participants’ DLQI, AGA did not affect the quality of life of 354 (67.8%) participants, with a small effect on 133 (25.5%) participants and a moderate–to-severe effect on 35 (6.7%) participants. The minimum recorded DLQI was 0, the maximum was 21, and the mean DLQI (±SD) was 1.5 ± 0.11. The number of participants within each DLQI severity grade is shown in Table 2.

A feeling of embarrassment or self-consciousness about AGA was the main domain affected, with 183/522 participants feeling embarrassed because of AGA; 131 participants were mildly embarrassed, and 52 were embarrassed to a greater extent. The second domain affected was the associated symptom of itching, as 117 participants reported little itching and 27 complained of moderate itchiness. Problems with AGA therapy was the third domain affected, with 48 participants indicating minor issues; a similar number of participants reported minor problems with their partners and friends because of AGA; 28 and 22 participants believed that AGA influenced the choice of clothing and leisure activities, respectively. In total, 18 participants had sexual difficulties; 15 of these cases were mild and three were assumed to be severe. A minor impact was observed on daily activity, sports, and studying or working, as reported by 11, 13, and 10 participants, respectively. Figure 1 shows the number of individuals and their responses regarding the impact of AGA on their quality of life within each DLQI domain.

Figure 1.

Number of participants and their corresponding responses regarding the influence of AGA on their quality of life within each DLQI domain. AGA: androgenetic alopecia; DLQI: Dermatology Life Quality Index.

Perception, thoughts, and experiences of the participants about AGA

Inquiring about the participants’ thoughts and experiences of AGA revealed the following. Most participants (68%) believed that AGA was a normal trait, whereas 32% considered it to be a disease. Approximately 18% (97/522) of the participants believed that AGA negatively affected their job opportunities, and 19.9% of them recalled being bullied and criticized by others due to AGA. Only 11% of the participants sought therapy for AGA, and 170 (32.6%) had considered a hair transplant. The thoughts and experiences of our participants are summarized in Supplementary Table 1.

Effect of demographics, AGA features, and participants’ perception on DLQI

While assessing the demographics of participants with the highest DLQI, we found a significant association between age and the impact of the disease; those aged between 18 and 40 years had the highest DLQI (correlation coefficient = 0.273, P = 0.000). Detailed results are displayed in Supplementary Figure 1. In addition, the DLQI was lower among participants with AGA duration of >10 years than among other AGA duration groups (P = 0.018), as illustrated in Supplementary Figure 2. Furthermore, participants with other dermatological diseases had higher DLQI than those with other diseases (P = 0.001). However, there was no correlation between DLQI and other demographics such as BMI, smoking, having chronic diseases, and family history of AGA. In addition, there was no correlation between DLQI and AGA grade, as determined by the Hamilton–Norwood scale (P = 0.345).

There was a correlation between the DLQI and negative thoughts and experiences of participants. For instance, AGA negatively affected the participants’ job opportunities, and the participants recalled being bullied or criticized. Moreover, there was a correlation between the DLQI and seeking therapy or hair transplant (P = 0.000). Table 3 illustrates the correlation between the DLQI and the participants’ demographics, AGA features, perceptions, and thoughts.

Table 3.

Correlation between DLQI and participants’ demographics, AGA duration and grade, and participants’ thoughts and experiences.

		Correlation coefficient	Spearman correlation
			P-value
DLQI	- Age	0.273	0.000
	- BMI	0.161	0.921
	- Smoking	0.330	0.897
	- Chronic disease (HTN, DM)	0.047	0.362
	- Dermatological diseases	0.129	0.001
	- Hamilton–Norwood scale	0.105	0.345
	- Duration of AGA	0.179	0.018
	- Family history of AGA	0.109	0.172
	- People’s thoughts about AGA (disease vs. normal trait)	0.015	0.458
	- Decreases job opportunities due to AG	0.236	0.000
	- I was bullied or criticized due to AGA	0.495	0.000
	- Considering a hair transplant	0.397	0.000
	- Seeking therapy for AGA	0.368	0.000

DLQI: Dermatology Life Quality Index; BMI: body mass index; HTN: hypertension; DM: diabetes mellitus; AGA: androgenetic alopecia.

Discussion

This study revealed that AGA is well-tolerated by those affected in our society. It did not affect most of our participants, as shown by their low mean DLQI, and many of them believed that it was a normal trait. Only a quarter of the participants experienced a slight influence, primarily with regard to their psychological and social aspects.

Various studies conducted worldwide have revealed at least a moderate impact of AGA on the quality of life of individuals using multiple instruments^{2–6,11–16}; the DLQI was the most frequently employed instrument. A recent meta-analysis revealed a combined DLQI of 8.16, ¹⁷ which was significantly greater than the mean score of 1.5 observed in the present study. We reviewed several studies utilizing DLQI and compared them with regard to the country of studies as well as the number, mean DLQI, and sex of the participants; the results are shown in Table 4.^{6,11–13,15,18–26} Multiple potential factors could account for this disparity. First, although the psychological distress caused by AGA is more pronounced among women, we included only men in our study.^3,16,19 Second, it is assumed that patients in regions with lower AGA prevalence, such as Asia, experience greater psychological burden than those in places with higher AGA prevalence, such as Europe. ¹ According to Table 4, most studies reporting high DLQI were conducted in Asian countries. Our study found a minor impact of AGA on the quality of life of individuals from a Jordanian cohort, possibly due to its high prevalence and cultural acceptance. This suggests that societal norms and familiarity with AGA influence individual experiences. The lower DLQI in our study is contradictory to findings from Asian and European populations, where hair loss may be less socially normalized and thus more distressing. Cultural perceptions of hair loss vary considerably worldwide. In some societies, baldness is associated with aging or negative self-image, whereas in others, it is seen as a common or even socially acceptable trait. This variation may explain the observed differences in DLQI across different countries. In addition, our sample enrolled participants from the general population rather than the clinical population, whereas the studies specified in Table 4 mostly included hospital-based participants.

Table 4.

Comparison of the participant number, participant sex, and country of studies that used DLQI to assess participants’ quality of life.

Study	Country	Participant number and sex	Mean DLQI
The current study	General population in Jordan	522 men	1.5
Zhang et al.2017 6	Hospital-based population in China	123 patients	5.5
Gupta et al.2019 11	Tertiary hospital-based population in North India	200 menAged 18–60 years	13.52 ± 3.15
Yu et al.2016 12	Hospital-based population in China	212 patients, 133 men and 79 women	8.3
Lan et al.2015 13	Hospital-based population in China	165 men	5.50 ± 4.44
Tahir et al.2013 16	Hospital-based population in Lahore, Pakistan	125 patients, 53 men and 72 womenAged ≥18 years	Overall score: 12.80 ± 3.76. The mean DLQI was 11.87 ± 3.35 in men and 13.49 ± 3.91 in women.
Zhuang et al.2013 18	Hospital-based population in Northern China	125 womenAged 32.21 ± 10.35 years	8.94 ± 5.65
Russo et al.2015 19	Hospital-based population in Italy	80 patients ,56 women and 24 men	5.93
Katoulis et al.2020 20	Hospital-based population in Greece	41 patients, 18 men and 23 women	4.0 at baseline
Katoulis et al.2018 21	Hospital-based population in Greece	40 women with AGA	4.0 at baseline
Ghimire et al.2018 22	Hair transplantation surgery population in Nepal	120 menAged 19–49 years	2.79
Chyi et al.2019 23	Private clinic population in Cheras, Selangor, Malaysia	125 patients (84 men and 41 women) (aged ≥20 years)	3.94
Yamazaki et al.2011 24	Hospital-based population in Japan	27 men with AGA aged 19–76  (average: 33.8) years	5.74
Zac et al.2021 25	Hospital-based population in Brazil	31 women on minoxidil	4.0 ± 3.5
Titeca et al.2020 26	European countries	20 patients	2.5

DLQI: Dermatology Life Quality Index.

A cross-sectional online survey conducted in Saudi Arabia assessed the psychosocial burden of AGA among 1230 patients. The findings revealed that 78% of the participants felt embarrassed by their condition. However, the overall psychosocial impact was considered low, with a median burden score of 10%. ²⁷

In our study, the main burden of AGA on the participants’ quality of life was the feeling of embarrassment and self-consciousness, followed by itching, problems related to AGA treatment, and personal relationships; this generally concurs with several studies from other communities. However, limited impairment in work, leisure activities, choice of clothing, and sexual difficulties were reported among our participants. The studies on other communities have reported more significant impairment in these domains.^6,11,16,22

Our findings also indicated that AGA had a greater impact on younger age groups than on older age groups, aligning with most previous studies.^2,11,13–15 In contrast, a study found that younger people deal psychologically better with AGA than older people. ²⁸ Our study also revealed a lower impact of AGA on those with a longer disease duration (>10 years), possibly due to improved tolerance and acceptance of the condition; this contradicts the findings of other studies.^4,16 In addition, there was a correlation between DLQI and having other dermatological diseases, probably due to a heightened perception of alopecia or an additive effect of the two conditions. Previous studies have mostly excluded patients with coexisting dermatological diseases. Other demographics assessed in this study, such as BMI, smoking, income, marital status, and educational level, did not impact the participants’ quality of life. Similarly, the grade of alopecia, as determined by the Hamilton–Norwood scale, did not affect the participants’ quality of life. A previous study reported similar findings, ⁶ whereas numerous studies have shown that severe grades are correlated with poor quality of life.^1,5,15,16,28 Our finding may be elucidated by the participants’ acceptance that evolves with the chronicity of the condition, as individuals tend to have more severe grades of alopecia at stages when they are more established in their professional and familial lives. ²⁹

Less than 20% of the participants in our study expressed negative experiences related to AGA, such as decreased job opportunities and being bullied or criticized. Approximately 10% of them sought medical help, and 30% considered hair transplantation. These experiences and thoughts are correlated with higher DLQI, indicating the usefulness of DLQI in identifying individuals most affected by this condition.

Our study was the first to evaluate the impact of AGA in a Jordanian cohort and recruited participants from the general population. However, it had limitations related to its cross-sectional design; it was also based on a self-reported response survey, which may have introduced response bias. Additionally, our recruitment method may have introduced selection bias, as individuals visiting barbershops may have different perspectives on AGA compared with those seeking clinical treatment or those who do not visit barbershops regularly. Furthermore, a self-selection bias may exist, as participants less affected by the condition are expected to be more eager to participate in the survey. Another limitation of our study is the exclusion of women. We assumed that the reliance on self-diagnosis of AGA in women may be inappropriate and that diagnosis needs clinical confirmation. Previous research has indicated that women experience a higher psychological burden due to AGA, revealing that our findings may not fully capture the impact of the condition. However, we enrolled a relatively large number of participants and used the DLQI questionnaire, which allowed comparison with other studies. Combining the results of this study with future studies involving people seeking treatment from both sexes will help us better determine the burden of AGA in our community.

Conclusion

Our study indicated that AGA is better tolerated in our society compared with other parts of the world. Nonetheless, the impact of this condition on people affected should always be addressed, especially for those seeking medical help and young individuals who may be more vulnerable to this disease. Slowing the progression of AGA may be a realistic option, as most people with a longer duration of the condition are often less impacted and cope better. This study provides novel insights into the AGA-related quality of life of men in a Jordanian cohort, helping to fill a gap in Middle Eastern dermatology research. Future studies should explore female AGA and clinical populations to further expand the understanding of this topic.

Data availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Patient consent statement

Written informed consent was obtained from the participants for the publication of their photographs and medical information in print and online.

Supplementary material

Supplemental material for this article is available online.