American Journal of Clinical Dermatology

, Volume 20, Issue 2, pp 195–200 | Cite as

The Medical and Psychosocial Associations of Alopecia: Recognizing Hair Loss as More Than a Cosmetic Concern

  • Dustin H. Marks
  • Lauren R. Penzi
  • Erin Ibler
  • Athena Manatis-Lornell
  • Dina Hagigeorges
  • Mariko Yasuda
  • Lynn A. Drake
  • Maryanne M. SennaEmail author
Current Opinion


Alopecia encompasses a broad range of hair loss disorders, generally categorized into scarring and non-scarring forms. Depending on the specific pathogenesis of hair loss and geographic location, a number of psychiatric and medical comorbidities, including but not limited to thyroid disease, lupus erythematosus, diabetes mellitus, atopic dermatitis, sinusitis, coronary artery disease, anxiety, depression, and suicidality, have been identified in association with alopecia. In addition to the numerous associated comorbid conditions, patients with alopecia report decreased quality-of-life measures across symptomatic, functional, and global domains. While alopecia can affect patients of all ages, genders, and ethnicities, hair loss may more significantly impact women as hair represents an essential element of femininity, fertility, and female attractiveness in society. Individuals of lower socioeconomic status may also face health disparities in the context of alopecia as a majority of hair loss treatments are considered cosmetic in nature and accordingly are not covered by third-party insurance providers. Although traditionally thought of as a merely aesthetic concern, alopecia encompasses a significant burden of disease with well-defined comorbid associations and genuine psychosocial implications, and thus should be assessed and managed within a proper medical paradigm.


Compliance with Ethical Standards


No funding was received for the preparation of this article.

Conflict of interest

Mr. Dustin Marks, Dr. Lauren Penzi, Dr. Erin Ibler, Ms. Athena Manatis-Lornell, Ms. Dina Hagigeorges, Dr. Mariko Yasuda, Dr. Lynn Drake, and Dr. Maryanne Senna have no conflicts of interest to report.


  1. 1.
    Otberg N, Shapiro J. Chapter 88: hair growth disorders. Fitzpatrick’s Dermatology in General Medicine, 8th ed. AccessMedicine, McGraw-Hill Medical. New York: The McGraw-Hill Companies; 2012. Available at: Accessed 6 Sept 2018.
  2. 2.
    Korta DZ, Christiano AM, Bergfeld W, et al. Alopecia areata is a medical disease. J Am Acad Dermatol. 2018;78(4):832–4.Google Scholar
  3. 3.
    Hordinsky M, Ericson M. Autoimmunity: alopecia areata. J Investig Dermatol Symp Proc. 2004;9(1):73–8.Google Scholar
  4. 4.
    Banka N, Mubki T, Bunagan MJK, McElwee K, Shapiro J. Frontal fibrosing alopecia: a retrospective clinical review of 62 patients with treatment outcome and long-term follow-up. Int J Dermatol. 2014;53(11):1324–30.Google Scholar
  5. 5.
    Schmidt TH, Khanijow K, Cedars MI, et al. Cutaneous findings and systemic associations in women with polycystic ovary syndrome. JAMA Dermatol. 2016;152(4):391–8.Google Scholar
  6. 6.
    Arias-Santiago S, Gutiérrez-Salmerón MT, Castellote-Caballero L, Buendía-Eisman A, Naranjo-Sintes R. Androgenetic alopecia and cardiovascular risk factors in men and women: a comparative study. J Am Acad Dermatol. 2010;63(3):420–9.Google Scholar
  7. 7.
    Hunt N, McHale S. The psychological impact of alopecia. BMJ. 2005;331(7522):951–3.Google Scholar
  8. 8.
    Zhang M, Zhang N. Quality of life assessment in patients with alopecia areata and androgenetic alopecia in the People’s Republic of China. Patient Prefer Adherence. 2017;11:151–5.Google Scholar
  9. 9.
    Singam V, Patel KR, Lee HH, Rastogi S, Silverberg JI. Association of alopecia areata with hospitalization for mental health disorders in US adults. J Am Acad Dermatol. 2018. (epub 6 August 2018).
  10. 10.
    Wang X, Xiong C, Zhang L, et al. Psychological assessment in 355 Chinese college students with androgenetic alopecia. Medicine (Baltimore). 2018;97(31):e11315.Google Scholar
  11. 11.
    Huang KP, Mullangi S, Guo Y, Qureshi AA. Autoimmune, atopic, and mental health comorbid conditions associated with alopecia areata in the United States. JAMA Dermatol. 2013;149(7):789–94.Google Scholar
  12. 12.
    Ghanizadeh A, Ayoobzadehshirazi A. A review of psychiatric disorders comorbidities in patients with alopecia areata. Int J Trichology. 2014;6(1):2–4.Google Scholar
  13. 13.
    Mardones F, Shapiro J. Lichen planopilaris in a Latin American (Chilean) population: demographics, clinical profile and treatment experience. Clin Exp Dermatol. 2017;42(7):755–9.Google Scholar
  14. 14.
    Cash TF. The psychosocial consequences of androgenetic alopecia: a review of the research literature. Br J Dermatol. 1999;141(3):398–405.Google Scholar
  15. 15.
    Chu S-Y, Chen Y-J, Tseng W-C, et al. Psychiatric comorbidities in patients with alopecia areata in Taiwan: a case-control study. Br J Dermatol. 2012;166(3):525–31.Google Scholar
  16. 16.
    Brankov N, Conic RZ, Atanaskova-Mesinkovska N, Piliang M, Bergfeld WF. Comorbid conditions in lichen planopilaris: a retrospective data analysis of 334 patients. Int J Womens Dermatol. 2018;4(3):180–4.Google Scholar
  17. 17.
    Pratt CH, King LE, Messenger AG, Christiano AM, Sundberg JP. Alopecia areata. Nat Rev Dis Primer. 2017;3:17011.Google Scholar
  18. 18.
    Cevasco NC, Bergfeld WF, Remzi BK, de Knott HR. A case-series of 29 patients with lichen planopilaris: the Cleveland Clinic Foundation experience on evaluation, diagnosis, and treatment. J Am Acad Dermatol. 2007;57(1):47–53.Google Scholar
  19. 19.
    Schmidt TH, Shinkai K. Evidence-based approach to cutaneous hyperandrogenism in women. J Am Acad Dermatol. 2015;73(4):672–90.Google Scholar
  20. 20.
    Matilainen V, Laakso M, Hirsso P, Koskela P, Rajala U, Keinänen-Kiukaanniemi S. Hair loss, insulin resistance, and heredity in middle-aged women. A population-based study. J Cardiovasc Risk. 2003;10(3):227–31.Google Scholar
  21. 21.
    Matilainen VA, Mäkinen PK, Keinänen-Kiukaanniemi SM. Early onset of androgenetic alopecia associated with early severe coronary heart disease: a population-based, case-control study. J Cardiovasc Risk. 2001;8(3):147–51.Google Scholar
  22. 22.
    Yang C-C, Hsieh F-N, Lin L-Y, Hsu C-K, Sheu H-M, Chen W. Higher body mass index is associated with greater severity of alopecia in men with male-pattern androgenetic alopecia in Taiwan: a cross-sectional study. J Am Acad Dermatol. 2014;70(2):297–302.e1.Google Scholar
  23. 23.
    Trieu N, Eslick GD. Alopecia and its association with coronary heart disease and cardiovascular risk factors: a meta-analysis. Int J Cardiol. 2014;176(3):687–95.Google Scholar
  24. 24.
    Christoffersen M, Frikke-Schmidt R, Schnohr P, Jensen GB, Nordestgaard BG, Tybjærg-Hansen A. Visible age-related signs and risk of ischemic heart disease in the general population: a prospective cohort study. Circulation. 2014;129(9):990–8.Google Scholar
  25. 25.
    Wang EH, Santos L, Li XY, et al. Alopecia areata is associated with increased expression of heart disease biomarker cardiac troponin I. Acta Derm Venereol. 2018;98(8):776–82.Google Scholar
  26. 26.
    Katoulis AC, Christodoulou C, Liakou AI, et al. Quality of life and psychosocial impact of scarring and non-scarring alopecia in women. J Dtsch Dermatol Ges. 2015;13(2):137–42.Google Scholar
  27. 27.
    Han S-H, Byun J-W, Lee W-S, et al. Quality of life assessment in male patients with androgenetic alopecia: result of a prospective, multicenter study. Ann Dermatol. 2012;24(3):311–8.Google Scholar
  28. 28.
    Chiang YZ, Bundy C, Griffiths CEM, Paus R, Harries MJ. The role of beliefs: lessons from a pilot study on illness perception, psychological distress and quality of life in patients with primary cicatricial alopecia. Br J Dermatol. 2015;172(1):130–7.Google Scholar
  29. 29.
    Pradhan P, D’Souza M, Bade BA, Thappa DM, Chandrashekar L. Psychosocial impact of cicatricial alopecias. Indian J Dermatol. 2011;56(6):684–8.Google Scholar
  30. 30.
    Haskin A, Aguh C, Okoye GA. Understanding patient experiences with scarring alopecia: a qualitative study with management implications. J Dermatol Treat. 2017;28(4):318–21.Google Scholar
  31. 31.
    Liu LY, Craiglow BG, King BA. Successful treatment of moderate-to-severe alopecia areata improves health-related quality of life. J Am Acad Dermatol. 2018;78(3):597–599.e2.Google Scholar
  32. 32.
    Jabbari A, Sansaricq F, Cerise J, et al. An open-label pilot study to evaluate the efficacy of tofacitinib in moderate to severe patch-type alopecia areata, totalis, and universalis. J Invest Dermatol. 2018;138(7):1539–45.Google Scholar
  33. 33.
    Alfonso M, Richter-Appelt H, Tosti A, Viera MS, García M. The psychosocial impact of hair loss among men: a multinational European study. Curr Med Res Opin. 2005;21(11):1829–36.Google Scholar
  34. 34.
    Weitz R. Rapunzel’s daughters: what women’s hair tells us about women’s lives. New York: Farrar, Straus and Giroux; 2004.Google Scholar
  35. 35.
    Cash TF, Price VH, Savin RC. Psychological effects of androgenetic alopecia on women: comparisons with balding men and with female control subjects. J Am Acad Dermatol. 1993;29(4):568–75.Google Scholar
  36. 36.
    van der Donk J, Passchier J, Knegt-Junk C, et al. Psychological characteristics of women with androgenetic alopecia: a controlled study. Br J Dermatol. 1991;125(3):248–52.Google Scholar
  37. 37.
    Nangia J, Wang T, Osborne C, et al. Effect of a scalp cooling device on alopecia in women undergoing chemotherapy for breast cancer: the SCALP randomized clinical trial. JAMA. 2017;317(6):596–605.Google Scholar
  38. 38.
    Choi EK, Kim I-R, Chang O, et al. Impact of chemotherapy-induced alopecia distress on body image, psychosocial well-being, and depression in breast cancer patients. Psychooncology. 2014;23(10):1103–10.Google Scholar
  39. 39.
    Browall M, Gaston-Johansson F, Danielson E. Postmenopausal women with breast cancer: their experiences of the chemotherapy treatment period. Cancer Nurs. 2006;29(1):34–42.Google Scholar
  40. 40.
    Carelle N, Piotto E, Bellanger A, Germanaud J, Thuillier A, Khayat D. Changing patient perceptions of the side effects of cancer chemotherapy. Cancer. 2002;95(1):155–63.Google Scholar
  41. 41.
    McGarvey EL, Baum LD, Pinkerton RC, Rogers LM. Psychological sequelae and alopecia among women with cancer. Cancer Pract. 2001;9(6):283–9.Google Scholar
  42. 42.
    Kim GM, Kim S, Park HS, et al. Chemotherapy-induced irreversible alopecia in early breast cancer patients. Breast Cancer Res Treat. 2017;163(3):527–33.Google Scholar
  43. 43.
    Fonia A, Cota C, Setterfield JF, Goldberg LJ, Fenton DA, Stefanato CM. Permanent alopecia in patients with breast cancer after taxane chemotherapy and adjuvant hormonal therapy: Clinicopathologic findings in a cohort of 10 patients. J Am Acad Dermatol. 2017;76(5):948–57.Google Scholar
  44. 44.
    Wehner MR, Nead KT, Lipoff JB. Association between gender and drug cost for over-the-counter minoxidil. JAMA Dermatol. 2017;153(8):825–6.Google Scholar
  45. 45.
    Alopecia Market Analysis By Treatment (Oral, Topical, Injectable), By Gender (Men, Women) And Segment Forecasts To 2024. PR Newswire. 2016. Available at: Accessed 5 Sep 2018.
  46. 46.
    Chen JX, Justicz N, Lee LN. Platelet-rich plasma for the treatment of androgenic alopecia: a systematic review. Facial Plast Surg. 2018. (epub 28 Jun 2018).
  47. 47.
    Mols F, van den Hurk CJ, Vingerhoets AJJM, Breed WPM. Scalp cooling to prevent chemotherapy-induced hair loss: practical and clinical considerations. Support Care Cancer. 2009;17(2):181–9.Google Scholar
  48. 48.
    Rugo HS, Klein P, Melin SA, et al. Association between use of a scalp cooling device and alopecia after chemotherapy for breast cancer. JAMA. 2017;317(6):606–14.Google Scholar
  49. 49.
    Hershman DL. Scalp cooling to prevent chemotherapy-induced alopecia: the time has come. JAMA. 2017;317(6):587–8.Google Scholar
  50. 50.
    Schumacher JR, Taylor LJ, Tucholka JL, et al. Socioeconomic factors associated with post-mastectomy immediate reconstruction in a contemporary cohort of breast cancer survivors. Ann Surg Oncol. 2017;24(10):3017–23.Google Scholar
  51. 51.
    Karimkhani C, Dellavalle RP, Coffeng LE, et al. Global skin disease morbidity and mortality: an update from the global burden of disease study 2013. JAMA Dermatol. 2017;153(5):406–12.Google Scholar
  52. 52.
    Trost LB, Bergfeld WF, Calogeras E. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. J Am Acad Dermatol. 2006;54(5):824–44.Google Scholar
  53. 53.
    Ganzetti G, Campanati A, Offidani A. Alopecia areata: a possible extraintestinal manifestation of Crohn’s disease. J Crohns Colitis. 2012;6(9):962–3.Google Scholar
  54. 54.
    Quinn M, Shinkai K, Pasch L, Kuzmich L, Cedars M, Huddleston H. Prevalence of androgenic alopecia in patients with polycystic ovary syndrome and characterization of associated clinical and biochemical features. Fertil Steril. 2014;101(4):1129–34.Google Scholar
  55. 55.
    Futterweit W, Dunaif A, Yeh HC, Kingsley P. The prevalence of hyperandrogenism in 109 consecutive female patients with diffuse alopecia. J Am Acad Dermatol. 1988;19(5 Pt 1):831–6.Google Scholar
  56. 56.
    Schmidt JB, Lindmaier A, Trenz A, Schurz B, Spona J. Hormone studies in females with androgenic hairloss. Gynecol Obstet Invest. 1991;31(4):235–9.Google Scholar
  57. 57.
    Ranasinghe GC, Piliang MP, Bergfeld WF. Prevalence of hormonal and endocrine dysfunction in patients with lichen planopilaris (LPP): a retrospective data analysis of 168 patients. J Am Acad Dermatol. 2017;76(2):314–20.Google Scholar
  58. 58.
    Atanaskova Mesinkovska N, Brankov N, Piliang M, Kyei A, Bergfeld WF. Association of lichen planopilaris with thyroid disease: a retrospective case-control study. J Am Acad Dermatol. 2014;70(5):889–92.Google Scholar
  59. 59.
    Katoulis AC, Diamanti K, Sgouros D, et al. Frontal fibrosing alopecia and vitiligo: coexistence or true association? Skin Appendage Disord. 2017;2(3–4):152–5.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Dustin H. Marks
    • 1
  • Lauren R. Penzi
    • 1
  • Erin Ibler
    • 2
  • Athena Manatis-Lornell
    • 1
  • Dina Hagigeorges
    • 1
  • Mariko Yasuda
    • 1
    • 3
  • Lynn A. Drake
    • 1
    • 3
  • Maryanne M. Senna
    • 1
    • 3
    Email author
  1. 1.Department of DermatologyMassachusetts General HospitalBostonUSA
  2. 2.Medical College of WisconsinMilwaukeeUSA
  3. 3.Harvard Medical SchoolBostonUSA

Personalised recommendations