Abstract
This cohort study evaluates the association between frontal fibrosing alopecia and health-related quality of life.
Alopecia has a negative association with health-related quality of life (HRQOL). To our knowledge, there are no large studies focusing on HRQOL in patients with frontal fibrosing alopecia (FFA). The aim of our study was to describe the association between HRQOL, psychological distress, and perception of disease in a large series of patients with FFA.
Methods
We designed a descriptive cross-sectional study including patients diagnosed with FFA in our center from January 1, 2016, to February 28, 2017. The institutional review board at Ramon y Cajal University Hospital approved the study, and participants provided oral informed consent. Calculations determined a total sample size of 80 patients to provide 80% power with a type I error of .05. Demographic and clinical characteristics were collected. We used the following questionnaires: the Dermatology Life Quality Index (DLQI), the Hospital Anxiety and Depression Scale (HADS), and the Revised Illness Perception Questionnaire (IPQ-R). All 3 tools are validated methods for evaluating dermatology-specific HRQOL, self-reported measure of anxiety and depression, and perception of disease, respectively. Scoring for the measures is described in the Table. For comparison between groups, we used the Pearson correlation coefficient or χ2 test, as appropriate. All given P values are 2-tailed and P <.05 indicates statistical significance. Statistical analysis was conducted with SPSS, version 19.0 (SPSS Inc).
Table. Clinical of Characteristics of 82 Patients With Frontal Fibrosing Alopecia.
| Clinical Characteristics | No. (%) |
|---|---|
| Age, mean (SD), y | 59.3 (7.6) |
| Age at onset, mean (SD), y | 55.7 (8.9) |
| Grade of severity (n = 67)a | |
| I (<1.0 cm) | 10 (15) |
| II (1.0-2.99 cm) | 29 (43) |
| III (3.0-4.99 cm) | 19 (28) |
| IV (5.0-6.99 cm) | 6 (9) |
| V (>7.0 cm) | 3 (5) |
| Loss of eyebrows (n = 67) | |
| No | 2 (3) |
| Partial | 38 (57) |
| Total | 27 (40) |
| Symptoms | |
| Pruritus (n = 41) | |
| No | 5 (12) |
| Mild | 21 (51) |
| Severe | 15 (37) |
| Trichodynia (n = 41) | |
| No | 31 (76) |
| Mild | 7 (17) |
| Severe | 3 (7) |
| Inflammation | |
| Erythema (n = 41) | |
| No | 28 (68) |
| Mild | 10 (24) |
| Severe | 3 (7) |
| Hyperkeratosis (n = 41) | |
| No | 20 (48) |
| Mild | 19 (46) |
| Severe | 2 (5) |
| DLQI score, mean (SD) | |
| 0-1 (No impairment) | 34 (42) |
| 2-5 (Mild impairment) | 34 (42) |
| 6-10 (Moderate impairment) | 10 (12) |
| 11-30 (Severe impairment) | 4 (5) |
| HADS score, mean (SD) (n = 80) | |
| Anxiety | |
| ≤7 (Normal level) | 45 (56) |
| 8-10 (Mild alteration) | 20 (25) |
| 11-15 (Moderate alteration) | 12 (15) |
| ≥16 (Severe alteration) | 3 (4) |
| Depression | |
| ≤7 (Normal level) | 63 (79) |
| 8-10 (Mild alteration) | 12 (15) |
| 11-15 (Moderate alteration) | 5 (6) |
| ≥16 (Severe alteration) | 0 |
Abbreviations: DLQI, Dermatology Life Quality Index; HADS, Hospital Anxiety and Depression Scale.
Grade of frontal fibrosing alopecia severity was classified according to the scale of Vañó-Galván et al.
Results
Eighty-two patients completed at least 1 questionnaire (DLQI, n = 82; HADS, n = 80; IPQ-R, n = 75). All patients were women; their demographic and clinical features are represented in the Table. The DLQI showed a slight association between alopecia and HRQOL (median total DLQI score, 2; range, 0-22), although 48 (58.5%) of patients had some degree of association with their HRQOL that was severe in 4 (4.9%) of them. Regarding HADS, the mean (SD) levels of psychological distress were low (HADS total score, 5.8 [3.6]), but 18.8% and 6.3% of the patients had moderate to severe anxiety and depression symptoms, respectively.
Scores on the IPQ-R questionnaire indicated that patients perceived FFA as a chronic disease (IPQ-R timeline, 22.3 [4.7]) with an unpredictable course (IPQ-R timeline cyclical, 9.9 [3.6]). The women considered that their alopecia had significant consequences on their lives (IPQ-R consequences, 16.8, [4.5]). Participants believed that they could control the alopecia progression by their own treatment (IPQ-R personal control, 17.8 [4.9]) and with medical treatment (IPQ-R treatment control, 16.2 [3.7]). The patients considered stress (33 [44.6%]), altered immunity (33 [44.4%]), aging (27 [36.5%]), and bad luck (25 [31.9%]) as the most common causes of the disease.
Rates of DLQI, HADS, and IPQ-R were correlated with demographic and clinical variables. There was a negative correlation between age of onset of FFA and HADS (r = −0.393, P = .03). A negative correlation between the grade of severity and personal control of the disease was also detected (r = −0.34, P = .008). Patients presenting with trichodynia had a higher impairment of HRQOL (χ2 = 0.508, P = .04); the rest of the clinical variables demonstrated no significant association with the total DLQI score. Patients with low levels of HRQOL had higher levels of anxiety (r = 0.336, P = .01), and those with more anxiety had more depression symptoms (r = 0.624, P = .007).
Discussion
Although a negative association between HRQOL and FFA exists, our study did not find any association with severity of the alopecia, as previous studies described. Older patients with FFA may be more likely to have anxiety or depression and patients with severe alopecia might feel powerless to control their illness. Trichodynia was the only clinical feature related to impaired HRQOL; despite its infrequency in FFA, approximately 20% of the patients may have trichodynia. Control of this symptom might help to improve FFA patients’ HRQOL and prevent psychological distress. A limitation of the study is that data about the duration of the disease and treatments received were not collected. In conclusion, our study shows that FFA may be negatively associated with HRQOL and induce psychological distress.
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