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HRQoL of Patients with Alopecia Areata in Australia


The largest patient study across the continent found a direct link between the extent of hair loss and the negative impact on quality of life.

Doctor examining patient scalp | Image Credit: © salomonus_ - stock.adobe.com

Image Credit: © salomonus_ - stock.adobe.com

To better understand the experiences of adults and adolescents with alopecia areata (AA), researchers in Australia surveyed 337 patients on their health-related quality of life (HRQoL). The items on the questionnaire focused on symptom severity, impact on psychosocial wellbeing and work/classroom productivity.1

Although other patient-reported AA-specific instruments assess symptom severity, emotional burden and impact on daily activities, this study aimed to understand the impact of AA on daily lives of patients living in Australia.


Patients over 12 years old were recruited through the Australia Alopecia Areata Foundation to participate in this study and were asked to complete an online patient questionnaire. After pre-testing the questionnaire for feedback, researchers used the survey to collect data on patient demographics and treatment characteristics.

Researchers used validated patient-reported outcome (PRO) instruments in this survey such as the Scalp Hair Assessment PRO™ (SHA PRO™), the AA Patient Priority Outcomes (AAPPO), the AA Symptom Impact Scale (AASIS) (only for adult patients), the Hospital Anxiety and Depression Scale (HADS), and Work Productivity and Activity Impairment Questionnaire plus Classroom Impairment Questions SHP, Version 2 (WPAI+CIQ:SHP, v2.0).

Analyzing the Data

In total, researchers included 337 patients with AA in the study, including both adolescents (n = 49) and adults (n = 288). Participants were separated using the SHA PRO™ scale, which consisted of a 5-point response scale for varying degrees of hair loss, ranging from 0 (no hair loss) to 4 (95% to 100% hair loss). Based on these responses, patients were characterized into the less extensive hair loss group (0% to 49%) and the more extensive hair loss group (50% or more hair loss).

Both adolescents and adults reported receiving a variety of treatment options, with topicals being the most frequently prescribed option for 79.6% of adolescents and 67% of adults. Fifty percent of adult patients and 4.1% of adolescent patients reported using injection treatments, while 21.2% of adult patients did not pursue any treatment at all. Researchers found satisfaction with these treatments appeared to be more favorable among adolescents with more extensive hair loss, with 38.1% rating their treatment as ‘very useful’ or ‘extremely useful,’ compared to 10.5% of adults in the same category.

Of those in the less extensive hair loss group (n = 137), investigators found 92.8%reported ‘no’, ‘little’ or ‘moderate’ hair loss on the scalp. Among the more extensive hair loss group (n = 151), 88.1% reported ‘a great deal’ of or ‘complete’ hair loss on the scalp. All adolescents in the more extensive hair loss category (n = 21) reported ‘a great deal’ or ‘complete’ hair loss on the scalp.

Psychosocial Results

For the emotional symptoms' domain, researchers observed the mean scores were slightly higher for the adults in the more extensive hair loss group when compared to the less extensive hair loss group (2.5 ± 1.03 vs. 2.2 ± 1.07, p = 0.010) as well as the adolescents (2.2 ± 1.15 vs. 2.1 ± 1.08, p = 0.660). Activity limitations domain scores were reported to be higher in the more extensive hair loss group for both adolescents (1.2 ± 0.99 vs. 0.6 ± 0.73, p = 0.015) and adults (1.4 ± 1.15 vs. 1.0 ± 1.08, p = 0.001).

Researchers found the AASIS global score was significantly higher in the more extensive hair loss group (4.7 ± 1.86) compared to the less extensive hair loss group (3.1 ± 2.01). The interference with daily functioning AASIS subscale scores (work, enjoyment of life, interaction with others, daily activities, sexual relationships and overall quality of life) were reported to be consistently greater in the group with extensive hair loss.

Most of the adolescent (73.5%) and adult (69.4%) patients showed anxiety score levels outside the normal range (0 to 7), as determined by the HADS instrument. Researchers found an increase in the depression scale in the more extensive hair loss group when compared to the less extensive hair loss group.

The investigators found through the WPAI+CIQ:SHP V2 that 70.5% (n = 203) of adults reported some degree of activity impairment in daily activities other than work. They found among the adults, about 18.4% (n = 53) reported loss of work time due to AA (absenteeism), and 37.8% (n = 109) reported reduced productivity at work due to AA (presenteeism), leading to an overall work impairment of 39.2% (n = 113). The classroom questionnaire showed that 57.1% (n = 28) of adolescents reported activity impairment due to AA, 22.4% (n = 11) reported absenteeism, and 40.8% (n = 20) reported presenteeism, meaning an overall classroom impairment of 44.9% (n = 22).


According to the researchers, this is the largest Australian study assessing the HRQoL impacts of AA among adult and adolescent patients. Unlike a previous study that reported an inverse relationship,2 these researchers found a direct link between the extent of hair loss and the negative impact on quality of life. They also observed high anxiety and depression levels in patients with AA when compared to other dermatological conditions,3 as well as high functional impact. 

This study suggests that further emphasis is needed for integrating psychiatric medication and psychological support tailored to disease severity and patient age. In multicultural settings such as Australia, the researchers suggested that further research should explore how cultural and ethnic backgrounds influence patient experiences and outcomes.


  1. Sinclair R, Eisman S, Lee CMY, et al. Health-related quality of life of adult and adolescent patients living with alopecia areata in Australia. Australas J Dermatol. 2024; 00: 1–11. doi.org/10.1111/ajd.14311
  2. Wyrwich KW, Winnette R, Bender R, et al. Validation of the alopecia areata patient priority outcomes (AAPPO) questionnaire in adults and adolescents with alopecia areata. Dermatol Ther (Heidelb). 2022;12(1):149-166. doi:10.1007/s13555-021-00648-z
  3. Silverberg JI, Gelfand JM, Margolis DJ, et al. Symptoms and diagnosis of anxiety and depression in atopic dermatitis in U.S. adults. Br J Dermatol. 2019;181(3):554-565. doi:10.1111/bjd.17683
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