ABSTRACT
Background:
Hair loss is a general condition that can occur in many cases.
Normal hair has three stages:
growth, resting, and shedding. These stages can be interrupted by many factors, such as stress. Stress is a CNS phenomenon that responds to physiological and psychological conditions. The prevalence of hair fall among the general population is highly shown in different ages, genders, and races. It focuses on a specific portion of the population, university students, who face stress during their studying periods for several reasons. Our study aimed to evaluate the prevalence of stress-induced hair loss among undergraduate students at a public university in Riyadh, Saudi Arabia.
Methods:
A cross-sectional study was carried out at Imam Mohammad Ibn Saud Islamic University in Riyadh using a self-report questionnaire Google form with 928 participants, including males and females from various colleges.
Results:
The study revealed that 627 students had moderate stress (67.6%), and 277 students had high stress (29.8%), with females exhibiting a higher proportion of high-stress levels (34.6%) compared to males (19.7%). Also, 410 (44.2%) of participants reported experiencing hair loss, with females showing a higher prevalence of 330 (80.5%) compared to males.
Conclusion:
This study sheds light on stress-induced hair loss among university students and provides insights into the factors associated with stress levels in this population. The findings underscore the importance of addressing stress as a significant concern for students’ wellbeing and academic success.
Keywords: Hair loss, perceived stress scale, Saudi Arabia, stress, telogen effluvium, university students
Introduction
Stress is a neurological phenomenon that responds to physiological and psychological conditions. It manifests as a group of apparent symptoms, including anger, a sense of incompetence, worthlessness, and even wrongdoings.[1,2] Stress interferes with body functions and affects various body systems.[3] Hair is highly significant to an individual’s personality. An average individual has a range of 100,000 to 150,000 strands of hair on his head.[4,5] Physiologically, hair follows a predetermined life cycle consisting of three stages: a growth stage (anagen), a resting stage (catagen), and a shedding stage (telogen).[5] Hair loss is a natural occurrence, meaning approximately 50 to 100 strands of hair are lost daily without being noticed due to concurrent new hair growth.[5,6] Regardless of average hair loss, any cause that disturbs the growth-loss cycle leads to abnormal hair shedding (alopecia or baldness).[5,7] Various factors play a role in unusual hair fall “Alopecia,” including hormonal fluctuations, scalp infections, skin diseases, family history, and stress-induced hair loss.[4,8] Several stress-related mechanisms lead to unusual hair loss, such as increased cytokine secretion influenced by stress-induced adaptive immunity disturbance. As a result, the fate of hair’s epithelial cells will be determined.[9,10,11] Moreover, prolonged exposure to stress worsens the condition by attracting a normal growth cycle and preventing hair follicles from growing.[12,13] Another picture of stress-induced hair shedding is a higher cortisol release.[14] In addition, the correlation between elevated cortisol secretion and stress makes cortisol a hallmark of physiological stress.[15,16] The prevalence of hair loss among the general population is high, demonstrated across different ages, genders, and races.[17,18] Focusing on a specific portion of the population, university students face stress during their studying periods for several reasons: Academic pressure is one of the most significant factors. In addition to academic stress, economic and social challenges also have an effect. Stress exists due to these factors, which induces undesirable hair-shedding consequences.[19,20,21,22] Stress-induced hair loss, primarily depicted as telogen effluvium (TE), is a widely acknowledged phenomenon that can be initiated by significant mental or physical stress stimuli, including intense medical conditions like COVID-19. In a cross-sectional study done in the Asir territory of Saudi Arabia, the incidence of heightened thinning hair following COVID-19 infection, a classic stress catalyst, was 73.3% among persons with no prior TE history, with more cases recorded in females (77.3% vs. 43.3% in males).[23] Understanding the relationship between stress and hair loss among university students can help healthcare practitioners, and mental-health counselors recognize early psychosomatic manifestations of stress and provide timely interventions. For patients, awareness of this link encourages early consultation, lifestyle modifications, and stress-management practices that can mitigate preventable hair loss and its psychological consequences. More research is needed to assess the prevalence of stress-induced hair loss among university students in Riyadh, Saudi Arabia. Our study aimed to evaluate the prevalence of stress-induced hair loss among undergraduate students at Imam Mohammad Ibn Saud Islamic University in Riyadh, Saudi Arabia.
Methods
Study design
A cross-sectional study was conducted at Riyadh’s public university (Imam Mohammad Ibn Saud Islamic University). The sample size was calculated using Raosoft (Raosoft Inc., Seattle, Washington, USA)[24] based on a confidence level of 95% and a 5% margin of error. Therefore, the estimated sample size was around 385.
Study population and sampling
Students from various colleges at Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia, were invited to complete the questionnaire, ensuring a representative sample. Participants were explicitly informed that communication would be solely for scientific purposes and that their identities would be kept confidential. The selection of participants will involve random sampling.
Study questionnaire
The questionnaire was made by using bilingual languages (Arabic and English) and designed as a Google Form Survey; an online survey was distributed to participants, who were requested to provide demographic information such as age, gender, GPA, and name of the college that they are affiliated with. The survey encompassed inquiries about Stress-Induced Hair Loss. Specific questions were addressed regarding Stress, the Hair Pull Test, its relation to stress, and other factors that trigger hair loss.
Reliability and validity of the questionnaire
We employed the Perceived Stress Scale (PSS-10) to evaluate the extent to which respondents perceived their lives as stressful over the previous month. Participants provided ratings on a 4-point scale, with responses ranging from 0, signifying “never,” to 4, indicating “very often.” The total scores on this scale fell from 0 to 40, with higher scores reflecting a more substantial perception of stress. Categorizations were established based on the PSS scores: Scores between 0 and 13 were classified as low stress, scores from 14 to 26 indicated moderate stress, and scores spanning 27-40 were associated with high stress.
Statistical analysis
Data analysis was implemented using RStudio (R version 4.3.1). We used frequencies and percentages to express categorical variables. The relationships between students’ characteristics, stress levels, and hair test categories were assessed using Pearson’s Chi-squared or Fisher’s exact test whenever applicable. Multivariable Linear Regression analysis was applied to participants to determine the statistical significance of predictors influencing stress-induced hair loss. We used the significantly associated variables with positive hair fall testing as independent variables in a multivariable logistic regression model, and the result of the hair fall test was used as a dependent variable. Results were presented as odds ratio (OR) and 95% confidence interval (95% CIs). Statistical significance was considered at P < 0.05.
Results
Initially, we received records from 946 respondents. However, we excluded 18 responses from those who declined to participate. Therefore, a total of 928 responses were analyzed. As demonstrated in Table 1, the majority of participants were female (68.2%), and those between 21 and 23 occupied the most significant portion of students’ ages (51.0%). The College of Economics and Administrative Sciences exhibited the highest enrolment, constituting 21.9% of the participants. In terms of GPA, the majority of students reported a GPA greater than 4.5 (42.6%).
Table 1.
Demographic and academic characteristics
| Characteristic | n=928 |
|---|---|
| Gender | |
| Male | 295 (31.8%) |
| Female | 633 (68.2%) |
| Age | |
| 18 to 20 | 338 (36.4%) |
| 21 to 23 | 473 (51.0%) |
| More than 24 | 117 (12.6%) |
| College Name | |
| College of Arabic Language | 20 (2.2%) |
| College of Computer and Information Sciences | 189 (20.4%) |
| College of Continuing Education and Community Services | 2 (0.2%) |
| College of Economics and Administrative Sciences | 203 (21.9%) |
| College of Education | 10 (1.1%) |
| College of Engineering | 38 (4.1%) |
| College of Languages and Translation | 54 (5.8%) |
| College of Media and Communication | 57 (6.1%) |
| College of Medicine | 109 (11.7%) |
| College of Sciences | 57 (6.1%) |
| College of Sharia | 88 (9.5%) |
| College of Social Sciences | 33 (3.6%) |
| College of the Fundamentals of Religion | 27 (2.9%) |
| Other | 41 (4.4%) |
| GPA | |
| <3 | 64 (6.9%) |
| 3 to 3.49 | 101 (10.9%) |
| 3.5 to 3.99 | 143 (15.4%) |
| 4 to 4.5 | 225 (24.2%) |
| >4.5 | 395 (42.6%) |
n (%)
The most common disease among students was iron deficiency (86.9%), followed by zinc deficiency (27.2%), Figure 1, whereas the most commonly received medications were antibiotics (38.3%), then, antidepressants, and mood stabilizers (30.9%), Figure 2.
Figure 1.
The proportions of diseases among a subgroup of participants who had diseases (n=320)
Figure 2.
The proportions of medication users among a subgroup of participants using medications (n=94)
Stress levels and the associated factors
The majority of students had moderate stress (67.6%), 277 students had high stress (29.8%), and 24 students had low stress (2.6%). Table 2 presents the association between stress levels and various demographic and academic characteristics among the participants. A significant association was found between gender and stress levels (P < 0.001, Figure 3). Females exhibited a higher proportion of high stress levels (34.6%) than males (19.7%), Figure 4.
Table 2.
The association between stress levels and the demographic and academic characteristics
| Characteristic | Stress level | P | ||
|---|---|---|---|---|
|
| ||||
| Low n=24 | Moderate n=627 | High n=277 | ||
| Gender | <0.001 | |||
| Male | 14 (4.7%) | 223 (75.6%) | 58 (19.7%) | |
| Female | 10 (1.6%) | 404 (63.8%) | 219 (34.6%) | |
| Age | 0.255 | |||
| 18 to 20 | 10 (3.0%) | 232 (68.6%) | 96 (28.4%) | |
| 21 to 23 | 8 (1.7%) | 317 (67.0%) | 148 (31.3%) | |
| More than 24 | 6 (5.1%) | 78 (66.7%) | 33 (28.2%) | |
| GPA | 0.498 | |||
| < 3 | 1 (1.6%) | 42 (65.6%) | 21 (32.8%) | |
| 3 to 3.49 | 4 (4.0%) | 67 (66.3%) | 30 (29.7%) | |
| 3.5 to 3.99 | 6 (4.2%) | 94 (65.7%) | 43 (30.1%) | |
| 4 to 4.5 | 5 (2.2%) | 143 (63.6%) | 77 (34.2%) | |
| > 4.5 | 8 (2.0%) | 281 (71.1%) | 106 (26.8%) | |
| College Name | ||||
| College of Arabic Language | 0.417 | |||
| No | 23 (2.5%) | 615 (67.7%) | 270 (29.7%) | |
| Yes | 1 (5.0%) | 12 (60.0%) | 7 (35.0%) | |
| College of Computer and Information Sciences | 0.032 | |||
| No | 19 (2.6%) | 514 (69.6%) | 206 (27.9%) | |
| Yes | 5 (2.6%) | 113 (59.8%) | 71 (37.6%) | |
| College of Continuing Education and Community Services | >0.999 | |||
| No | 24 (2.6%) | 625 (67.5%) | 277 (29.9%) | |
| Yes | 0 (0.0%) | 2 (100.0%) | 0 (0.0%) | |
| College of Economics and Administrative Sciences | 0.966 | |||
| No | 19 (2.6%) | 491 (67.7%) | 215 (29.7%) | |
| Yes | 5 (2.5%) | 136 (67.0%) | 62 (30.5%) | |
| College of Education | 0.620 | |||
| No | 24 (2.6%) | 621 (67.6%) | 273 (29.7%) | |
| Yes | 0 (0.0%) | 6 (60.0%) | 4 (40.0%) | |
| College of Engineering | 0.032 | |||
| No | 22 (2.5%) | 596 (67.0%) | 272 (30.6%) | |
| Yes | 2 (5.3%) | 31 (81.6%) | 5 (13.2%) | |
| College of Languages and Translation | 0.432 | |||
| No | 24 (2.7%) | 592 (67.7%) | 258 (29.5%) | |
| Yes | 0 (0.0%) | 35 (64.8%) | 19 (35.2%) | |
| College of Media and Communication | 0.846 | |||
| No | 23 (2.6%) | 586 (67.3%) | 262 (30.1%) | |
| Yes | 1 (1.8%) | 41 (71.9%) | 15 (26.3%) | |
| College of Medicine | <0.001 | |||
| No | 21 (2.6%) | 537 (65.6%) | 261 (31.9%) | |
| Yes | 3 (2.8%) | 90 (82.6%) | 16 (14.7%) | |
| College of Sciences | >0.999 | |||
| No | 23 (2.6%) | 588 (67.5%) | 260 (29.9%) | |
| Yes | 1 (1.8%) | 39 (68.4%) | 17 (29.8%) | |
| College of Sharia | 0.063 | |||
| No | 21 (2.5%) | 577 (68.7%) | 242 (28.8%) | |
| Yes | 3 (3.4%) | 50 (56.8%) | 35 (39.8%) | |
| College of Social Sciences | 0.606 | |||
| No | 23 (2.6%) | 603 (67.4%) | 269 (30.1%) | |
| Yes | 1 (3.0%) | 24 (72.7%) | 8 (24.2%) | |
| College of the Fundamentals of Religion | 0.647 | |||
| No | 23 (2.6%) | 608 (67.5%) | 270 (30.0%) | |
| Yes | 1 (3.7%) | 19 (70.4%) | 7 (25.9%) | |
| Other | 0.897 | |||
| No | 23 (2.6%) | 598 (67.4%) | 266 (30.0%) | |
| Yes | 1 (2.4%) | 29 (70.7%) | 11 (26.8%) | |
n (%). Pearson’s Chi-squared test; Fisher’s exact test
Figure 3.
The distribution of hair fall and stress among males and females
Figure 4.
(a-b) Participants’ categories based on the number of hairs found in their hands based on the hair pull test
High-stress levels were significantly higher among College of Computer and Information Sciences students (37.6% vs. 27.9%, P = 0.032) and significantly lower among students of the College of Engineering (13.2% vs. 30.6%, P = 0.032) and College of Medicine (14.7% vs. 31.9%, P < 0.001, Table 2).
Focusing on males, the prevalence of high stress was significantly higher among students who enrolled in the College of Sharia (51.7% vs. 16.2%, P < 0.001) and significantly lower among College of Medicine students (9.3% vs. 23.2%, P = 0.019). Regarding females, high stress levels were considerably higher in the College of Computer and Information Sciences (44.1% vs. 32.0%, P = 0.015, Table 3).
Table 3.
The association between stress levels and the demographic and academic characteristics
| Characteristic | Stress levels among males | Stress levels among females | ||||||
|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||
| Low n=14 | Moderate n=223 | High n=58 | P | Low n=10 | Moderate n=404 | High n=219 | P | |
| Age | 0.248 | 0.516 | ||||||
| 18 to 20 | 4 (5.0%) | 63 (78.8%) | 13 (16.3%) | 6 (2.3%) | 169 (65.5%) | 83 (32.2%) | ||
| 21 to 23 | 5 (3.0%) | 127 (76.5%) | 34 (20.5%) | 3 (1.0%) | 190 (61.9%) | 114 (37.1%) | ||
| More than 24 | 5 (10.2%) | 33 (67.3%) | 11 (22.4%) | 1 (1.5%) | 45 (66.2%) | 22 (32.4%) | ||
| GPA | 0.524 | 0.388 | ||||||
| <3 | 0 (0.0%) | 24 (75.0%) | 8 (25.0%) | 1 (3.1%) | 18 (56.3%) | 13 (40.6%) | ||
| 3 to 3.49 | 3 (7.1%) | 30 (71.4%) | 9 (21.4%) | 1 (1.7%) | 37 (62.7%) | 21 (35.6%) | ||
| 3.5 to 3.99 | 2 (4.5%) | 34 (77.3%) | 8 (18.2%) | 4 (4.0%) | 60 (60.6%) | 35 (35.4%) | ||
| 4 to 4.5 | 3 (5.5%) | 37 (67.3%) | 15 (27.3%) | 2 (1.2%) | 106 (62.4%) | 62 (36.5%) | ||
| >4.5 | 6 (4.9%) | 98 (80.3%) | 18 (14.8%) | 2 (0.7%) | 183 (67.0%) | 88 (32.2%) | ||
| College Name | ||||||||
| College of Arabic Language | 0.201 | 0.688 | ||||||
| No | 13 (4.5%) | 220 (75.6%) | 58 (19.9%) | 10 (1.6%) | 395 (64.0%) | 212 (34.4%) | ||
| Yes | 1 (25.0%) | 3 (75.0%) | 0 (0.0%) | 0 (0.0%) | 9 (56.3%) | 7 (43.8%) | ||
| College of Computer and Information Sciences | 0.958 | 0.015 | ||||||
| No | 12 (5.0%) | 183 (75.6%) | 47 (19.4%) | 7 (1.4%) | 331 (66.6%) | 159 (32.0%) | ||
| Yes | 2 (3.8%) | 40 (75.5%) | 11 (20.8%) | 3 (2.2%) | 73 (53.7%) | 60 (44.1%) | ||
| College of Continuing Education and Community Services | >0.999 | >0.999 | ||||||
| No | 14 (4.8%) | 222 (75.5%) | 58 (19.7%) | 10 (1.6%) | 403 (63.8%) | 219 (34.7%) | ||
| Yes | 0 (0.0%) | 1 (100.0%) | 0 (0.0%) | 0 (0.0%) | 1 (100.0%) | 0 (0.0%) | ||
| College of Economics and Administrative Sciences | >0.999 | 0.838 | ||||||
| No | 12 (4.8%) | 190 (75.4%) | 50 (19.8%) | 7 (1.5%) | 301 (63.6%) | 165 (34.9%) | ||
| Yes | 2 (4.7%) | 33 (76.7%) | 8 (18.6%) | 3 (1.9%) | 103 (64.4%) | 54 (33.8%) | ||
| College of Education | >0.999 | 0.526 | ||||||
| No | 14 (4.8%) | 221 (75.4%) | 58 (19.8%) | 10 (1.6%) | 400 (64.0%) | 215 (34.4%) | ||
| Yes | 0 (0.0%) | 2 (100.0%) | 0 (0.0%) | 0 (0.0%) | 4 (50.0%) | 4 (50.0%) | ||
| College of Engineering | 0.630 | |||||||
| No | 12 (4.7%) | 192 (74.7%) | 53 (20.6%) | 10 (1.6%) | 404 (63.8%) | 219 (34.6%) | ||
| Yes | 2 (5.3%) | 31 (81.6%) | 5 (13.2%) | |||||
| College of Languages and Translation | 0.433 | >0.999 | ||||||
| No | 14 (4.8%) | 220 (75.9%) | 56 (19.3%) | 10 (1.7%) | 372 (63.7%) | 202 (34.6%) | ||
| Yes | 0 (0.0%) | 3 (60.0%) | 2 (40.0%) | 0 (0.0%) | 32 (65.3%) | 17 (34.7%) | ||
| College of Media and Communication | 0.813 | 0.519 | ||||||
| No | 14 (4.9%) | 214 (75.1%) | 57 (20.0%) | 9 (1.5%) | 372 (63.5%) | 205 (35.0%) | ||
| Yes | 0 (0.0%) | 9 (90.0%) | 1 (10.0%) | 1 (2.1%) | 32 (68.1%) | 14 (29.8%) | ||
| College of Medicine | 0.019 | 0.631 | ||||||
| No | 11 (5.0%) | 158 (71.8%) | 51 (23.2%) | 10 (1.7%) | 379 (63.3%) | 210 (35.1%) | ||
| Yes | 3 (4.0%) | 65 (86.7%) | 7 (9.3%) | 0 (0.0%) | 25 (73.5%) | 9 (26.5%) | ||
| College of Sciences | 0.169 | 0.446 | ||||||
| No | 14 (4.8%) | 220 (76.1%) | 55 (19.0%) | 9 (1.5%) | 368 (63.2%) | 205 (35.2%) | ||
| Yes | 0 (0.0%) | 3 (50.0%) | 3 (50.0%) | 1 (2.0%) | 36 (70.6%) | 14 (27.5%) | ||
| College of Sharia | <0.001 | >0.999 | ||||||
| No | 12 (4.5%) | 211 (79.3%) | 43 (16.2%) | 9 (1.6%) | 366 (63.8%) | 199 (34.7%) | ||
| Yes | 2 (6.9%) | 12 (41.4%) | 15 (51.7%) | 1 (1.7%) | 38 (64.4%) | 20 (33.9%) | ||
| College of Social Sciences | 0.658 | 0.340 | ||||||
| No | 14 (4.8%) | 219 (75.3%) | 58 (19.9%) | 9 (1.5%) | 384 (63.6%) | 211 (34.9%) | ||
| Yes | 0 (0.0%) | 4 (100.0%) | 0 (0.0%) | 1 (3.4%) | 20 (69.0%) | 8 (27.6%) | ||
| College of the Fundamentals of Religion | 0.520 | 0.795 | ||||||
| No | 13 (4.7%) | 212 (76.0%) | 54 (19.4%) | 10 (1.6%) | 396 (63.7%) | 216 (34.7%) | ||
| Yes | 1 (6.3%) | 11 (68.8%) | 4 (25.0%) | 0 (0.0%) | 8 (72.7%) | 3 (27.3%) | ||
| Other | 0.397 | 0.675 | ||||||
| No | 13 (4.5%) | 217 (75.9%) | 56 (19.6%) | 10 (1.7%) | 381 (63.4%) | 210 (34.9%) | ||
| Yes | 1 (11.1%) | 6 (66.7%) | 2 (22.2%) | 0 (0.0%) | 23 (71.9%) | 9 (28.1%) | ||
n (%). Fisher’s exact test
Characteristics of hair fall
When participants passed their fingers through their hair and pulled it upward, 410 participants (44.2%) reported finding six or more hairs in their hands, while 518 participants (55.8%) found five or fewer. This indicated a positive hair fall test among 44.2% [Figure 5]. Most of those with a positive test were females (80.5%, Figure 6). Table 4 outlines the characteristics of hair fall among participants who tested positive for hair loss (n = 410). When participants first noticed their hair falling, the majority (69.0%) reported it occurring after entering the university, whereas 29.8% noticed it before entering. Additionally, 57.8% of participants affirmed that their hair fall increased during stressful days, 37.1% were unsure (maybe), and 5.1% reported no increase. When asked about their parents’ hair loss, the majority (53.7%) reported none, followed by 20.7% for mothers, 13.9% for fathers, and 11.7% for both parents experiencing hair loss.
Figure 5.
Gender distribution among a subgroup of participants with a positive hair pull test
Figure 6.
The distribution of hair fall and stress among males and females
Table 4.
Characteristics of hair fall among participants with a positive hair fall test (n=410)
| Characteristic | n (%) |
|---|---|
| When have you noticed that your hair has started to fall? | |
| Before entering the university | 122 (29.8%) |
| After entering the university | 283 (69.0%) |
| I do not notice any hair loss | 5 (1.2%) |
| Does your hair fall increase during stressful days? | |
| No | 21 (5.1%) |
| Maybe | 152 (37.1%) |
| Yes | 237 (57.8%) |
| Do your parents suffer from hair loss? | |
| None | 220 (53.7%) |
| Father | 57 (13.9%) |
| Mother | 85 (20.7%) |
| Both | 48 (11.7%) |
Factors associated with having a positive hair fall test
Gender demonstrated a significant association with positive hair fall tests (P < 0.001), with a higher proportion of females (52.1%) testing positive compared to males (27.1%). Colleges with significant associations include the College of Economics and Administrative Sciences (P = 0.006), the College of Engineering (P = 0.024), and the College of Medicine (P < 0.001). Importantly, stress levels showed a significant association (P < 0.001), with participants reporting high-stress levels having a higher prevalence of positive hair fall tests (55.2%) compared to those with moderate and low stress (39.6% and 37.5%, respectively). Additionally, aggressive hair brushing (29.4% vs 46.5%, P < 0.001) and taking hot showers or using any heating tools for hair (40.9% vs 48.5%, P = 0.021) were significantly associated with lower rates of positive hair fall tests. Moreover, the weekly frequency of washing hair showed a significant difference for hair fall testing (P = 0.022, Table 5).
Table 5.
The association between having a positive hair pull test and the participants’ demographic, academic, and lifestyle characteristics
| Characteristic | Hair fall test | P | |
|---|---|---|---|
|
| |||
| Negative n=518 | Positive n=410 | ||
| Gender | <0.001 | ||
| Male | 215 (72.9%) | 80 (27.1%) | |
| Female | 303 (47.9%) | 330 (52.1%) | |
| Age | 0.553 | ||
| 18 to 20 | 184 (54.4%) | 154 (45.6%) | |
| 21 to 23 | 272 (57.5%) | 201 (42.5%) | |
| More than 24 | 62 (53.0%) | 55 (47.0%) | |
| GPA | 0.067 | ||
| <3 | 27 (42.2%) | 37 (57.8%) | |
| 3 to 3.49 | 56 (55.4%) | 45 (44.6%) | |
| 3.5 to 3.99 | 76 (53.1%) | 67 (46.9%) | |
| 4 to 4.5 | 121 (53.8%) | 104 (46.2%) | |
| >4.5 | 238 (60.3%) | 157 (39.7%) | |
| College Name | |||
| College of Arabic Language | 0.941 | ||
| No | 507 (55.8%) | 401 (44.2%) | |
| Yes | 11 (55.0%) | 9 (45.0%) | |
| College of Computer and Information Sciences | 0.682 | ||
| No | 415 (56.2%) | 324 (43.8%) | |
| Yes | 103 (54.5%) | 86 (45.5%) | |
| College of Continuing Education and Community Services | >0.999 | ||
| No | 517 (55.8%) | 409 (44.2%) | |
| Yes | 1 (50.0%) | 1 (50.0%) | |
| College of Economics and Administrative Sciences | 0.006 | ||
| No | 422 (58.2%) | 303 (41.8%) | |
| Yes | 96 (47.3%) | 107 (52.7%) | |
| College of Education | 0.117 | ||
| No | 515 (56.1%) | 403 (43.9%) | |
| Yes | 3 (30.0%) | 7 (70.0%) | |
| College of Engineering | 0.024 | ||
| No | 490 (55.1%) | 400 (44.9%) | |
| Yes | 28 (73.7%) | 10 (26.3%) | |
| College of Languages and Translation | 0.968 | ||
| No | 488 (55.8%) | 386 (44.2%) | |
| Yes | 30 (55.6%) | 24 (44.4%) | |
| College of Media and Communication | 0.822 | ||
| No | 487 (55.9%) | 384 (44.1%) | |
| Yes | 31 (54.4%) | 26 (45.6%) | |
| College of Medicine | <0.001 | ||
| No | 437 (53.4%) | 382 (46.6%) | |
| Yes | 81 (74.3%) | 28 (25.7%) | |
| College of Sciences | 0.109 | ||
| No | 492 (56.5%) | 379 (43.5%) | |
| Yes | 26 (45.6%) | 31 (54.4%) | |
| College of Sharia | 0.843 | ||
| No | 468 (55.7%) | 372 (44.3%) | |
| Yes | 50 (56.8%) | 38 (43.2%) | |
| College of Social Sciences | 0.357 | ||
| No | 497 (55.5%) | 398 (44.5%) | |
| Yes | 21 (63.6%) | 12 (36.4%) | |
| College of the Fundamentals of Religion | 0.715 | ||
| No | 502 (55.7%) | 399 (44.3%) | |
| Yes | 16 (59.3%) | 11 (40.7%) | |
| Other | 0.544 | ||
| No | 497 (56.0%) | 390 (44.0%) | |
| Yes | 21 (51.2%) | 20 (48.8%) | |
| Stress | <0.001 | ||
| Low | 15 (62.5%) | 9 (37.5%) | |
| Moderate | 379 (60.4%) | 248 (39.6%) | |
| High | 124 (44.8%) | 153 (55.2%) | |
| How many times do you wash your hair per week? | 0.022 | ||
| Less than twice | 47 (59.5%) | 32 (40.5%) | |
| 2 to 3 Times | 277 (52.0%) | 256 (48.0%) | |
| More than 3 Times | 194 (61.4%) | 122 (38.6%) | |
| Do you brush your hair aggressively? | <0.001 | ||
| No | 429 (53.5%) | 373 (46.5%) | |
| Yes | 89 (70.6%) | 37 (29.4%) | |
| Do you usually take hot showers or use heating tools for your hair? | 0.021 | ||
| No | 206 (51.5%) | 194 (48.5%) | |
| Yes | 312 (59.1%) | 216 (40.9%) | |
| How many hours do you sleep per night? | 0.522 | ||
| Less than 7 Hours | 267 (54.8%) | 220 (45.2%) | |
| 7 Hours or More | 251 (56.9%) | 190 (43.1%) | |
| Are you a smoker (cigarette, e-cigarette, or shisha)? | 0.759 | ||
| No | 463 (55.6%) | 369 (44.4%) | |
| Yes | 55 (57.3%) | 41 (42.7%) | |
| Do you eat three meals per day? | 0.439 | ||
| No | 331 (54.9%) | 272 (45.1%) | |
| Yes | 187 (57.5%) | 138 (42.5%) | |
n (%). Pearson’s Chi-squared test; Fisher’s exact test
Regarding diseases, participants reporting deficiencies in iron (52.5% vs. 40.6%, P < 0.001), zinc (57.5% vs. 42.8%, P = 0.009), biotin (88.9% vs 43.7%, P = 0.013), and protein (59.5% vs 43.5%, P = 0.040) had a higher prevalence of positive hair fall tests. Additionally, participants who have not been diagnosed with any diseases exhibited a lower prevalence of having a positive hair pull test (39.8% vs 52.5%, P < 0.001). Among medications, antibiotics (61.1% vs 43.5%, P = 0.037) and weight loss drugs (15.4% vs 44.6%, P = 0.035) were significantly associated with positive hair fall tests. Notably, those using any medications for hair loss prevention had a higher prevalence of positive hair pull tests (54.1%) compared to those not using preventive measures (41.4%, P = 0.001, Table 6).
Table 6.
The association between positive hair pull tests, disease reporting, and medication use
| Characteristic | Hair fall test | P | |
|---|---|---|---|
|
| |||
| Negative n=518 | Positive n=410 | ||
| Diseases | |||
| Deficiency in iron | <0.001 | ||
| No | 386 (59.4%) | 264 (40.6%) | |
| Yes | 132 (47.5%) | 146 (52.5%) | |
| Deficiency in zinc | 0.009 | ||
| No | 481 (57.2%) | 360 (42.8%) | |
| Yes | 37 (42.5%) | 50 (57.5%) | |
| Deficiency in biotin | 0.013 | ||
| No | 517 (56.3%) | 402 (43.7%) | |
| Yes | 1 (11.1%) | 8 (88.9%) | |
| Deficiency in protein | 0.040 | ||
| No | 501 (56.5%) | 385 (43.5%) | |
| Yes | 17 (40.5%) | 25 (59.5%) | |
| Haven’t been diagnosed with any of the diseases | <0.001 | ||
| No | 152 (47.5%) | 168 (52.5%) | |
| Yes | 366 (60.2%) | 242 (39.8%) | |
| Hyperthyroidism | 0.194 | ||
| No | 515 (56.0%) | 404 (44.0%) | |
| Yes | 3 (33.3%) | 6 (66.7%) | |
| Hypothyroidism | 0.067 | ||
| No | 509 (56.3%) | 395 (43.7%) | |
| Yes | 9 (37.5%) | 15 (62.5%) | |
| Syphilis | 0.506 | ||
| No | 516 (55.7%) | 410 (44.3%) | |
| Yes | 2 (100.0%) | 0 (0.0%) | |
| Systemic lupus | >0.999 | ||
| No | 516 (55.8%) | 409 (44.2%) | |
| Yes | 2 (66.7%) | 1 (33.3%) | |
| Medications | |||
| Anticlotting drugs | 0.195 | ||
| No | 518 (55.9%) | 408 (44.1%) | |
| Yes | 0 (0.0%) | 2 (100.0%) | |
| Antibiotics | 0.037 | ||
| No | 504 (56.5%) | 388 (43.5%) | |
| Yes | 14 (38.9%) | 22 (61.1%) | |
| Antifungals | 0.699 | ||
| No | 514 (55.7%) | 408 (44.3%) | |
| Yes | 4 (66.7%) | 2 (33.3%) | |
| Chemotherapy | >0.999 | ||
| No | 517 (55.8%) | 409 (44.2%) | |
| Yes | 1 (50.0%) | 1 (50.0%) | |
| Cholesterol-lowering drugs | 0.391 | ||
| No | 514 (55.7%) | 409 (44.3%) | |
| Yes | 4 (80.0%) | 1 (20.0%) | |
| Weight loss drugs | 0.035 | ||
| No | 507 (55.4%) | 408 (44.6%) | |
| Yes | 11 (84.6%) | 2 (15.4%) | |
| Anticonvulsants | >0.999 | ||
| No | 514 (55.8%) | 407 (44.2%) | |
| Yes | 4 (57.1%) | 3 (42.9%) | |
| Antidepressants and mood stabilizers | 0.943 | ||
| No | 502 (55.8%) | 397 (44.2%) | |
| Yes | 16 (55.2%) | 13 (44.8%) | |
| Blood pressure medications | >0.999 | ||
| No | 515 (55.8%) | 408 (44.2%) | |
| Yes | 3 (60.0%) | 2 (40.0%) | |
| I am not using any of these medications. | 0.588 | ||
| No | 50 (53.2%) | 44 (46.8%) | |
| Yes | 468 (56.1%) | 366 (43.9%) | |
| Immunosuppressants | 0.442 | ||
| No | 518 (55.9%) | 409 (44.1%) | |
| Yes | 0 (0.0%) | 1 (100.0%) | |
| Do you use oral, topical medications, or clinically required techniques to prevent hair loss? | 0.001 | ||
| No | 424 (58.6%) | 299 (41.4%) | |
| Yes | 94 (45.9%) | 111 (54.1%) | |
n (%). Pearson’s Chi-squared test; Fisher’s exact test
Risk factors for having a positive hair fall test
Table 7 presents the logistic regression analysis results identifying risk factors for having a positive hair fall test among participants. Female gender was significantly associated with a higher likelihood of a positive hair pull test (OR = 2.29, 95% CI: 1.58 to 3.33, P < 0.001). Aggressive hair brushing emerged as a significant protective factor, with participants reporting aggressive brushing showing lower odds of a positive hair fall test (OR = 0.53, 95% CI: 0.34 to 0.81, P = 0.004). The other variables, including college affiliation, stress levels, hair washing frequency, use of hot showers or heating tools for hair, and various reported diseases and medications, did not significantly correlate with the likelihood of a positive hair fall test.
Table 7.
Risk factors for having a positive hair fall test
| Characteristic | OR1 | 95% CI | P |
|---|---|---|---|
| Gender | |||
| Male | Reference | Reference | |
| Female | 2.29 | 1.58, 3.33 | <0.001 |
| College Name | |||
| College of Economics and Administrative Sciences | 1.34 | 0.96, 1.88 | 0.090 |
| College of Engineering | 0.91 | 0.39, 1.98 | 0.824 |
| College of Medicine | 0.64 | 0.39, 1.05 | 0.082 |
| Stress | |||
| Low | Reference | Reference | |
| Moderate | 0.78 | 0.32, 1.98 | 0.588 |
| High | 1.26 | 0.51, 3.26 | 0.622 |
| How many times do you wash your hair per week? | |||
| Less than twice | Reference | Reference | |
| 2 to 3 times | 1.22 | 0.73, 2.04 | 0.454 |
| More than 3 times | 1.34 | 0.78, 2.34 | 0.294 |
| Do you brush your hair aggressively? | |||
| No | Reference | Reference | |
| Yes | 0.53 | 0.34, 0.81 | 0.004 |
| Do you usually take hot showers or use heating tools for your hair? | |||
| No | Reference | Reference | |
| Yes | 0.76 | 0.58, 1.01 | 0.063 |
| Diseases | |||
| Deficiency in iron | 0.92 | 0.45, 1.86 | 0.810 |
| Deficiency in zinc | 0.96 | 0.56, 1.65 | 0.879 |
| Deficiency in biotin | 5.26 | 0.85, 102 | 0.133 |
| Deficiency in protein | 1.13 | 0.54, 2.36 | 0.748 |
| Haven’t been diagnosed with any of the diseases | 0.76 | 0.37, 1.55 | 0.448 |
| Medications | |||
| Antibiotics | 1.96 | 0.95, 4.21 | 0.075 |
| Weight loss drugs | 0.22 | 0.03, 0.90 | 0.061 |
| Do you use any oral, topical medications, or clinically required techniques to prevent hair loss? | |||
| No | Reference | Reference | |
| Yes | 1.39 | 1.00, 1.94 | 0.051 |
OR=Odds Ratio, CI=Confidence Interval
Discussion
The present study examined the association between stress levels and hair loss among Imam Mohammad Ibn Saud Islamic University college students. The results revealed that the majority of students experienced moderate stress (67.6%), while 29.8% reported high-stress levels, and only 2.6% reported low-stress levels. These results indicate that a significant proportion of college students experience considerable stress. Comparing our findings with previous studies, our results align with the existing literature on the prevalence of stress among college students. Several studies have reported high levels of stress among college students, highlighting the need for interventions and support services to address this issue.[1,25] Our study further contributes to this body of knowledge by examining the association between stress levels and demographic and academic characteristics.
In comparison with previous studies, our findings are largely consistent with earlier investigations conducted in various settings. For example, Barbayannis et al. (2022)[6] reported that over two-thirds of college students experienced moderate to severe stress during the COVID-19 pandemic, underscoring the widespread nature of academic stress and its adverse psychological impact. Similarly, Walli et al. (2013)[29] found that 60% of female medical students in Pakistan experienced significant stress accompanied by hair fall, linking high academic pressure and emotional strain to telogen effluvium. Fatima et al. (2018)[11] also observed a high prevalence of stress-induced hair loss among medical students, emphasizing the influence of long study hours and examination-related anxiety. These prior studies align with our results showing a strong relationship between stress and hair fall among university students. However, the slightly higher rates of moderate stress observed in our sample (67.6%) may reflect persistent academic and lifestyle stressors even beyond the postpandemic period, highlighting the ongoing burden among Saudi university students.
Gender emerged as a significant factor associated with stress levels among college students. Females exhibited a higher proportion of high-stress levels (34.6%) than males (19.7%). This finding is consistent with previous research that has consistently identified gender differences in stress levels among college students.[26] The higher prevalence of stress among females may be attributed to various factors, including academic pressure, social expectations, and hormonal differences.
Furthermore, our study revealed significant differences in stress levels among students from different colleges. College of Computer and Information Sciences students reported significantly higher stress levels (37.6%) than other colleges. In comparison, students from the College of Engineering (13.2%) and College of Medicine (14.7%) reported significantly lower stress levels. These findings suggest that the academic demands and specific challenges within different disciplines may contribute to variations in stress levels among college students. Similar findings have been reported in previous studies, highlighting the role of academic factors in stress levels among students.[27]
Regarding the timing of hair loss, most participants reported experiencing hair fall after entering the university, indicating that the transition to university life and associated stressors may contribute to hair loss.[9,28,29] Additionally, participants noted an increase in hair fall during stressful periods, suggesting a direct relationship between psychological stress and hair loss.
The study also explored the influence of other factors on hair loss. For instance, medication usage, particularly antibiotics and weight loss drugs, showed significant associations with positive hair fall tests, suggesting that certain medications may contribute to hair loss as a side effect.[30,31] It is important to note that several variables, such as college affiliation, hair washing frequency, use of hot showers or heating tools for hair, and reported diseases, did not exhibit significant associations with hair fall. This suggests that factors other than those examined in this study may contribute to hair loss among university students.
Distinctly, our study differs from previous research in several important aspects. While earlier studies such as those by Walli et al. (2013)[29] and Fatima et al. (2018)[11] focused primarily on medical students or single-gender samples, our investigation included a diverse group of both male and female students from multiple academic disciplines within a large Saudi public university. This broader representation enhances the generalizability of our findings to a wider student population. Additionally, our study integrated both psychological (Perceived Stress Scale scores) and behavioral (hair-pull test outcomes) assessments, allowing for a more objective evaluation of stress-related hair loss compared to prior research that relied solely on self-reported measures. The contextual emphasis on cultural, academic, and environmental factors within Saudi Arabia also provides a novel contribution to the global understanding of stress-induced hair loss patterns.
Overall, these findings highlight the detrimental impact of stress on hair health, particularly among female university students. The results underscore the importance of implementing stress management strategies and providing support mechanisms to minimize the adverse effects of stress on hair loss. Further research is warranted to explore additional factors contributing to hair loss and to develop targeted interventions for individuals experiencing stress-induced hair loss.
Limitations
The present study has several limitations. First, the study was cross-sectional, so it cannot be used to determine whether stress causes hair loss. Second, the study relied on self-reported measures of stress and hair loss, which may be subject to bias. Third, the study was conducted in a specific population of university students in Saudi Arabia, so the findings may need to be more generalizable to other populations.
Despite these limitations, our study provides important insights into the association between stress, hair loss, and demographic and academic characteristics among university students. The findings suggest that stress is a significant risk factor for hair loss and that gender and college affiliation may also play a role.
Conclusion
This study sheds light on stress-induced hair loss among university students and provides insights into the factors associated with stress levels in this population. The findings underscore the importance of addressing stress as a significant concern for students’ wellbeing and academic success. Future research should explore effective stress management interventions and develop targeted support services to enhance university students’ mental health and overall wellbeing.
Ethical approval
The Institutional Review Board (IRB) committee at Al-Imam Mohammad Ibn Saud Islamic University has reviewed and approved this research with project number 587/2023, dated 09-01-2024.
Author contributions
All authors participated in the concept, design, analysis, interpretation of data, writing, and manuscript review. They have seen and approved the final version of the manuscript.
Informed consent statement
Informed consent was obtained from all subjects involved in the study.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
- 1.Alanazi AS, Alsalhi WA, Alghuyaythat WK, Almutairi AN, Almazrou MA, Alabdulminaim JA, et al. Stress-related hair loss among the general population in Al Majma’ ah, Saudi Arabia: A cross-sectional study. Cureus. 2023;15:e46517. doi: 10.7759/cureus.46517. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ahn D, Kim H, Lee B, Hahm DH. Psychological stress-induced pathogenesis of alopecia areata: Autoimmune and apoptotic pathways. Int J Mol Sci. 2023;24:11711. doi: 10.3390/ijms241411711. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Aldahish A, Vasudevan R, Salem H, Alqahtani A, AlQasim S, Alqhatani A, et al. Telogen effluvium and COVID-19: A cross-sectional study. Eur Rev Med Pharmacol Sci. 2023;27:7823–33. doi: 10.26355/eurrev_202308_33437. [DOI] [PubMed] [Google Scholar]
- 4.Almohanna HM, Ahmed AA, Tsatalis JP, Tosti A. The role of vitamins and minerals in hair loss: A review. Dermatol Ther (Heidelb) 2018;9:51–70. doi: 10.1007/s13555-018-0278-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Alomaish AR, Gosadi IM, Dallak FH, Durayb AA, Dallak AH, Hakami JA, et al. Prevalence of alopecia and its contributing factors among primary healthcare attendees in the Jazan region, Saudi Arabia. J Family Med Prim Care. 2021;10:3851–6. doi: 10.4103/jfmpc.jfmpc_1070_21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Barbayannis G, Bandari M, Zheng X, Baquerizo H, Pecor KW, Ming X. Academic stress and mental well-being in college students: Correlations, affected groups, and COVID-19. Front Psychol. 2022;13:886344. doi: 10.3389/fpsyg.2022.886344. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Botchkarev VA. Stress and the hair follicle: Exploring the connections. Am J Pathol. 2003;162:709–12. doi: 10.1016/S0002-9440(10)63866-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Chen L, Wang L, Qiu XH, Yang XX, Qiao ZX, Yang YJ, et al. Depression among Chinese university students: Prevalence and socio-demographic correlates. PLoS One. 2013;8:e58379. doi: 10.1371/journal.pone.0058379. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Chu B, Marwaha K, Sanvictores T, Awosika AO, Ayers D. StatPearls. Treasure Island (FL): StatPearls Publishing; 2025. Physiology, Stress Reaction. [PubMed] [Google Scholar]
- 10.Deng Y, Cherian J, Khan NUN, Kumari K, Sial MS, Comite U, et al. Family and academic stress and their impact on students’ depression level and academic performance. Front Psychiatry. 2022;13:869337. doi: 10.3389/fpsyt.2022.869337. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Fatima A, Ali MD, Safdar M. Stress related hairloss in medical. J Univ Med Dent Coll. 2018;9:68–73. [Google Scholar]
- 12.Gokce N, Basgoz N, Kenanoglu S, Akalin H, Ozkul Y, Ergoren MC, et al. An overview of the genetic aspects of hair loss and its connection with nutrition. J Prev Med Hyg. 2022;63:E228–38. doi: 10.15167/2421-4248/jpmh2022.63.2S3.2765. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Hadshiew IM, Foitzik K, Arck PC, Paus R. Burden of hair loss: Stress and the underestimated psychosocial impact of telogen effluvium and androgenetic alopecia. J Invest Dermatol. 2004;123:455–7. doi: 10.1111/j.0022-202X.2004.23237.x. [DOI] [PubMed] [Google Scholar]
- 14.Harrison S, Bergfeld W. Diffuse hair loss: Its triggers and management. Cleve Clin J Med. 2009;76:361–7. doi: 10.3949/ccjm.76a.08080. [DOI] [PubMed] [Google Scholar]
- 15.Jones A, Rice N, Rosa Dias P. Long-term effects of cognitive skills, social adjustment and schooling on health and lifestyle: Evidence from a reform of selective schooling. Health, Econometrics and Data Group (HEDG) Working Papers. 2010 [Google Scholar]
- 16.Knezevic E, Nenic K, Milanovic V, Knezevic NN. The role of cortisol in chronic stress, neurodegenerative diseases, and psychological disorders. Cells. 2023;12:2726. doi: 10.3390/cells12232726. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Liu N, Wang LH, Guo LL, Wang GQ, Zhou XP, Jiang Y, et al. Chronic restraint stress inhibits hair growth via substance P mediated by reactive oxygen species in mice. PLoS One. 2013;8:e61574. doi: 10.1371/journal.pone.0061574. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Maajida Aafreen M, Vishnu Priya V, Gayathri R. Effect of stress on academic performance of students in different streams. Drug Invent Today. 2018;10:1776. Available from: https://openurl.ebsco.com/contentitem/gcd:131123674 . [Google Scholar]
- 19.Maymone MBC, Laughter M, Pollock S, Khan I, Marques T, Abdat R, et al. Hair aging in different races and ethnicities. J Clin Aesthet Dermatol. 2021;14:38–44. [PMC free article] [PubMed] [Google Scholar]
- 20.Mounessa J, Caravaglio JV, Domozych R, Chapman S, Dellavalle RP, Dunnick CA, et al. Commonly prescribed medications associated with alopecia. J Am Acad Dermatol. 2023;88:1326–33.e2. doi: 10.1016/j.jaad.2017.01.060. [DOI] [PubMed] [Google Scholar]
- 21.Natarelli N, Gahoonia N, Sivamani RK. Integrative and mechanistic approach to the hair growth cycle and hair loss. J Clin Med. 2023;12:893. doi: 10.3390/jcm12030893. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Patel M, Harrison S, Sinclair R. Drugs and hair loss. Dermatol Clin. 2013;31:67–73. doi: 10.1016/j.det.2012.08.002. [DOI] [PubMed] [Google Scholar]
- 23.Peters EMJ, Müller Y, Snaga W, Fliege H, Reißhauer A, Schmidt-Rose T, et al. Hair and stress: A pilot study of hair and cytokine balance alteration in healthy young women under major exam stress. PLoS One. 2017;12:e0175904. doi: 10.1371/journal.pone.0175904. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Sample Size Calculator. Raosoft, Inc. Available from: http://www.raosoft.com/samplesize.html .
- 25.Scribner M, Sasso P, Puchner L. Stress management and coping strategies in undergraduate students at a Midwestern State University. N Y J Student Aff. 2020;20:4–32. [Google Scholar]
- 26.Shimizu Y, Ntege EH, Sunami H, Inoue Y. Regenerative medicine strategies for hair growth and regeneration: A narrative review of literature. Regen Ther. 2022;21:527–39. doi: 10.1016/j.reth.2022.10.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Soorih Shaikh, Sarwan Shaikh, Sarees Shaikh Aijaz Ali Shaikh and Syed Ghazanfar Saleem. (2016);Prevalence of hair loss and stress as the cause;A cross-sectional study. Int J of Adv Res. 2016:327–33. [Google Scholar]
- 28.Van Uum SHM, Sauvé B, Fraser LA, Morley-Forster P, Paul TL, Koren G. Elevated content of cortisol in hair of patients with severe chronic pain: A novel biomarker for stress. Stress. 2008;11:483–8. doi: 10.1080/10253890801887388. [DOI] [PubMed] [Google Scholar]
- 29.Walli H, Ghazal H, German S, Ali M, Zuberi BF. Prevalence of stress and its relation to hair fall in female medical students. J Pioneering Med Sci. 2013;3:205–7. [Google Scholar]
- 30.Wosu AC, Valdimarsdóttir U, Shields AE, Williams DR, Williams MA. Correlates of cortisol in human hair: Implications for epidemiologic studies on health effects of chronic stress. Ann Epidemiol. 2013;23:797–802.e2. doi: 10.1016/j.annepidem.2013.09.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Yaribeygi H, Panahi Y, Sahraei H, Johnston TP, Sahebkar A. The impact of stress on body function: A review. EXCLI J. 2017;16:Doc1057. doi: 10.17179/excli2017-480. [DOI] [PMC free article] [PubMed] [Google Scholar]