Beyond hair loss: The psychosocial toll of AA

Alopecia areata (AA) is painless and non-life threatening, yet it can have a profound impact on the psychosocial wellbeing of people with the condition. Indeed, people with AA describe a sense of grief and loss of identity associated with the loss of their hair.^1,2

“To feel like that part of me was taken really affected me.” Nikki Vontaya describes the cultural significance of hair, the impact of AA, and how redefining beauty can inspire personal empowerment. View transcript.

How does AA affect psychosocial wellbeing?

The sudden and unpredictable hair loss in AA causes significant emotional distress.³ On top of this, the visible nature of the disease can cause people with AA to feel judged and lose confidence in their appearance; negative self-perception is common among people with AA.^3,4

Of note, psychological burden is not directly proportional to volume of hair lost. A 2023 study (N=547) found that people with 21–49% or 50–94% scalp hair loss reported greater psychological impact and a lower quality of life (QoL) than those with 95–100% scalp hair loss.⁴

The limited effectiveness of treatments and lack of a cure also contribute to the emotional distress of people with AA.²

Addressing the psychological impacts of AA begins with assessment.

Given this large emotional impact, it is perhaps not surprising that people with AA have an increased risk of developing anxiety and depression.¹ In a 2022 study of 5,435 people with AA, patients with AA had a 30–38% higher risk of new-onset depression or anxiety than population controls.⁵ Children and adolescents with AA experience higher rates of psychiatric disorder, with up to 78% having at least one psychiatric disorder and up to 50% experiencing depression.⁶

In the case of depression, the association with AA seems to go both ways.⁷ Depression increases the risk of subsequent AA by 90%, and AA increases the risk of subsequent depression by 34%.⁷

“This is huge.” Dr. Yolanda Lenzy (Lenzy Dermatology, Chicopee, Massachusetts, USA) discusses the surprisingly large psychosocial impact of hair loss, including needs for children in school and the perils of windy weather. View transcript.

Healthcare providers also need to be on the lookout for less common psychosocial comorbidities; AA has been linked to conditions including obsessive compulsive disorder, post-traumatic stress disorder, and alexithymia.^7-9

The psychological impacts and emotional burdens of AA can negatively impact all aspects of life. People with AA report often feeling isolated, worrying about the future, and struggling with a negative self-image.⁴ These feelings and the psychological impact of AA can have far-reaching negative consequences, even impacting work productivity and social lives.¹⁰

People with AA (n=5,435) were 82% more likely to be unemployed when compared with a matched control population in the year after diagnosis (n=21,740), at 1.3% versus 0.6%, potentially exacerbating the economic burden of AA.⁵

Thus, there is a clear need for evidence-based mental health treatment for people with AA that addresses the psychological burdens associated with the condition beyond anxiety and depression.^4,5,11

How can the psychosocial impacts of AA be addressed?

There are a number of promising treatments for AA-caused hair loss, but even the promise of recovery with optimal pharmacologic intervention is not enough to fully address the psychological impacts of this disease.¹¹

“Huge, huge, huge…” Vontaya highlights the psychological and emotional challenges she faced after diagnoses and the ways in which family and healthcare professionals supported her wellbeing. View transcript.

Addressing the psychological impacts of AA begins with assessment. By incorporating mental health screening into dermatological practice or referring patients to a psychological health service, medical professionals can help patients navigate the complex emotional burden and potential psychiatric comorbidities associated with AA.¹¹ The integration of dermatological and psychological care in this way is known as psychodermatology.¹²

Psychotherapy, cognitive behavioral therapy, and hypnotherapy may be helpful treatment options for people managing the emotional burden of AA, with as needed use of psychopharmacologic treatments, such as antidepressants for people with AA-related depression.^6,11,12 Patients may even achieve better hair regrowth outcomes when treatments such as antidepressants and hypnotherapy are used in conjunction with dermatologic treatments. ⁶ This implies an overlap between the underlying mechanisms of depression and AA.⁶

Wigs can also be helpful, by helping to address aesthetic concerns and improving emotional wellbeing, acting as a type of coping mechanism while healthcare teams address the physical and psychologic symptoms of AA.¹³

“We try to serve as a resource to make sure patients are aware of these great things that are out there.” Dr. Lenzy outlines the support that is available for people struggling with the psychosocial impact of AA. View transcript.

Taking action: Multidisciplinary care

Treating AA is a collaborative, multidisciplinary effort that should involve dermatology, psychology, and pharmacologic therapy.¹⁴ This ensures that the mental burden of AA is assessed and addressed, minimizing the negative impact on the individual’s health-related QoL and outcomes.¹⁴

There is also a clear need for further research to better inform contemporary practices.^4,5,11 This is especially true for often overlooked groups affected by AA, including skin of color populations, adolescents, and children.^4,5,11,15.