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June 2007
362
The Psychologist Vol 20 No 6
The psychological
impact of alopecia
H
AIR loss is usually thought of as
something men start worrying
about as they get older. But there
are various forms of hair loss, often
extensive and sudden, which can impact on
anyone – male or female – at any time.
There are three main forms,
distinguished largely by the extent of the
loss: alopecia areata, referring to the
partial loss of hair from the head, usually
patchy rather than general thinning;
alopecia totalis, which is the loss of all
head hair; and alopecia universalis, the
loss of all head and body hair. We will
refer to these three as ‘alopecia’ in this
article, and while some of the issues may
also relate to male pattern baldness
(alopecia androgenetica), we are not
specifically concerned with this.
Psychologists have largely neglected
alopecia. There has been very little
research carried out specifically by
psychologists; dermatologists and other
medical practitioners have conducted most
of it. Our aim is to describe the disorder,
outline the psychological research that has
been carried out, and provide some
questions that researchers and practitioners
might wish to address.
The extent of the problem
Alopecia is a chronic inflammatory disease
that affects the hair follicles, and it can
affect men, women or children at any age.
The aetiology and subsequent development
of alopecia is not fully understood, but it is
an autoimmune disorder that arises as a
combination of genetic and environmental
influences (Madani & Shapiro, 2000). The
hair follicles in the anagen stage of
development (growth phase) become the
target for immune cell attack. Why they are
attacked is – again – not fully understood,
but it appears to be a complex relationship
between individual characteristics (e.g.
immune system problems, personality,
coping styles) and the environment (e.g. a
stressful situation).
There is an estimated lifetime risk of
alopecia of 1.7 per cent (Kalish & Gilhar,
2003), though the actual figure is unknown
because many people with alopecia do not
present to the medical community. If the
figure is accurate, that would indicate that
around one million people suffer from
alopecia in the UK at some point in their
life. There is controversy over the rate at
which alopecia is expressed as alopecia
totalis or alopecia universalis. The extent of
the more severe forms of alopecia is
disputed, as there have been no relevant
epidemiological studies; figures from 7 per
cent to 30 per cent have been suggested.
Alopecia is neither life-threatening nor
painful, though there can be irritation of the
skin, weakness of the fingernails, and
physical problems resulting from the loss
of eyelashes and eyebrows. Eyelashes and
brows are surprisingly effective against the
rain, and eyelashes help turn the eyelid
outwards. Without eyelashes the lids turn in
and irritate the cornea, similar to constantly
having grit in the eye.
There is a relationship between the
extent of hair loss and the chances of it
growing back again. The more hair is lost,
the lower the likelihood of regrowth. If the
hair does grow back, there may be repeated
episodes of hair loss. The hair which grows
back may be different in terms of colour
and texture.
Treating alopecia
There is a range of medical treatments for
alopecia, but unfortunately there is no good
evidence that they have more than limited
long-term effectiveness. Treatment is
generally ineffective for the more serious
types of alopecia (totalis and universalis),
while the evidence relating to alopecia areata
is less clear. In many cases the problem
resolves itself, and any treatment can take
three to six months to be effective. Topical
application of corticosteroids is a common
treatment for alopecia, though if they are
taken for prolonged periods of time there
are potentially serious side effects.
Diphenylcyclopropenone (DPCP) is also
used, with varying results – while there is
initially some success, there is a high relapse
rate (Aghaei, 2005). Minoxidil is also used;
again it has limited effectiveness for alopecia
areata, though it is the only treatment
recommended for use by women with hair
loss (Messenger & Rundegren, 2004).
Dobbins et al. (2003), currently
conducting a Cochrane systematic review
of treatments, have found no good clinical
evidence for the effectiveness of any of the
treatments for alopecia. While some studies
show that there is regrowth, spontaneous
regrowth does occur without treatment,
particularly with patchy hair loss (alopecia
areata), and the studies that have been
carried out do not account for this with
NIGEL HUNT and SUE MCHALE
on the limited research and the need
for more.
CASE STUDY
I used to be very proud of my hair. It was almost black, and went
down to my waist. Everyone told me how nice it looked. I didn’t
think about it at the time, but it somehow made me the person I
was.After my accident my hair fell out very quickly – it was gone
within a few weeks.When I looked in the mirror the person I saw
looking back was not me. It was someone else. It is very difficult
to describe when I mean by that, but simply because I do not
have any hair I am now a different person; and I behave differently
with people. Inside I still remember who I was, but in everything I
do, I think I am someone else.
Helen, quoted in Hunt & McHale (2004)
suitable controls. Furthermore, the
treatments can be length and painful,
and cease to be effective when stopped.
Clearly, while alopecia can be
psychosocially damaging, there may also
be psychological consequences resulting
from the treatment itself. If it is prolonged
and of limited effectiveness, this may
impact on the person’s psychological well-
being. Also, knowing that medical treatments
have limited effectiveness will impact on
the way a psychologist deals with alopecia
because it is often a matter of helping the
person learn to live with alopecia rather than
seek a means of enabling the hair to regrow.
Psychology and alopecia
Alopecia can have serious psychosocial
consequences, causing intense emotional
suffering, and personal, social and work-
related problems. Surveys have shown that
around 40 per cent of women with alopecia
have had marital problems, and around 63
per cent claimed to have career-related
problems (Hunt & McHale, 2004).
Alopecia also leads to depression,
anxiety and social phobia in a number of
sufferers. This relationship between
alopecia and psychosocial consequences
can be complicated, in that alopecia can
result from a stressful experience, and then
itself lead to further distress. Limited
research has been carried out in the area.
There is evidence that stressful life
events have an important role in triggering
some episodes of alopecia (Garcia-
Hernandez et al., 1999). Women who
experience high stress are 11 times more
likely to experience hair loss than those
who do not report high stress (York et al.,
1998). Compared with the general
population, increased prevalence rates of
psychiatric disorders are associated with
alopecia (Koo et al., 1994) suggesting that
people with alopecia may be at higher risk
for development of a major depressive
episode, anxiety disorder, social phobia or
paranoid disorder. Egele and Tauschke
(1987) identified a group of alopecia
patients with an ongoing feeling of loss,
suggesting that for some individuals the
process of coping with alopecia may be
equated with the grieving process
following bereavement.
Furthermore, alopecia is a disfiguring
disorder and therefore there are also issues
relating to self and identity. The loss of
hair, particularly the eyelashes and brows
which help to define a person’s face, means
that a person looks very different. Hair loss
may be seen as a failure to conform to the
norms of physical appearance within
society, a situation which has the potential
to set people apart in their own estimation
and in the estimation of others.
Overall, there has been little systematic
research into alopecia’s psychological
consequences
(Hunt & McHale, 2005a).
Our research
We have used a variety of methods,
questionnaires and interviews, to examine
the relationship between alopecia and
psychological factors (Hunt & McHale,
2005b). We have also reviewed the
literature relating to psychological
consequences of alopecia. What follows is
a brief synopsis of our findings so far.
We collected questionnaires and e-mail
interviews with individuals with alopecia,
ranging in age from 12 to 93 years. There
is no claim here that the sample is
representative of people with alopecia. As
is often the case, those with no problems
and those with the most extreme problems
are probably less likely to volunteer to take
part. In fact, the majority of our sample
were women. While we suspect that
alopecia is not more common in women,
there are a number of reasons why they
may be more likely to volunteer. Women
are more likely to want to talk about their
alopecia because the disorder can be more
difficult for them. Put simply, in our culture
a bald man is socially acceptable, a bald
woman is not.
Theme Subcategory Examples
Personal Physical effects
Causes
Psychological distress
Eyes dry and sore
Times of stress
I fell over and was knocked unconscious
Distressing condition
I seriously considered suicide
Difficult to come to terms with
Don’t have to visit the hairdresser
Identity Coping I deliberately set about changing how I viewed my life
Profound effect on my life
Social Social
Work
Relationships
Sex differences
Children and adolescents
Social support
I am more reclusive
I do think people make comments and I feel humiliated
Off work with stress… couldn’t perform my job to the best
of my ability
I felt sensitive to student comment
[Family] cannot comprehend the significance of the loss
Never seen a bald woman out shopping
Losing one’s hair affects men as much as women
Not much fun being a bald teenager
Embarrassing at that age
I was teased a lot
Great support from husband
Extremely difficult to adjust to her baldness
A bald child is handy for getting rid of unwanted visitors
Medical Treatment
Doctors’ attitudes
Travelled the country to find a cure
I only wish there was a miracle cure
Scalp always sore
Large water blisters, headaches
Consultants not interested in your psychological well-being
No help, support or advice… hospital very dismissive and
unhelpful
It is dismissed by doctors as being trivial… ‘it is only your
pride that is hurt’ said one doctor
TABLE 1: Summary of themes and subcategories
June 2007
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www.thepsychologist.org.uk
Alopecia
June 2007
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The Psychologist Vol 20 No 6
Alopecia
The analysis of the qualitative data
proved most interesting, generating a
number of themes (Hunt & McHale,
2005b). The examples in Table 1 are
illustrative of the kinds of quotations we
obtained. Many of the participants
desperately wanted to find out why they
had alopecia, and searched everywhere for
a cure. Others had issues regarding their
relationships, with some spouses being
very supportive, and in some cases the
alopecia was the catalyst to end a
relationship.
Some people could not go outside or go
to work for fear of being mocked. Women
in particular described having problems,
perhaps because of the importance of hair
to a woman’s notion of self and identity.
Children and adolescents had problems, not
just because they might be bullied at
school, but because they are the ones going
through the stages of establishing identity.
If one’s physical appearance changes
abruptly at this point, then this can have
catastrophic consequences.
These issues surrounding relationships
demonstrate the importance of identity and
selfhood, and how one’s identity is not just
personal, but bound up in the physical and
social worlds. These findings are similar to
those obtained for other types of
fundamental appearance change or physical
disfigurement, which often have profound
psychosocial effects (e.g. Rumsey &
Harcourt, 2005). Visible skin disorders
having social anxiety and social avoidance
implications simply because they are
visible, irrespective of any physical
problems associated with the disorder.
Further research needed
We are currently undertaking further
research relating to the psychosocial
consequences of alopecia. There is a lot to
be done. One important psychological issue
involves establishing the role of physical
appearance in defining identity. Previous
research has examined identity construction
generally, but people with alopecia are a
population for whom physical appearance
is heightened. Their experiences,
particularly when eyebrows and lashes are
affected, may be compared with others
who experience facial disfigurement. It is
likely that there is a differential impact on
men, women and children.
The role of psychological trauma as
both a precursor and a consequence of
alopecia should be examined. There is a
need to examine the role of coping and
social support, the latter being seriously
affected by the change in appearance of the
individual with alopecia. The role of
personality and individual differences
should be examined, as it is possible that
particular types of people are more prone
to alopecia.
It is also important to establish links
between psychological and physiological
mechanisms. The evidence points to the
importance of the interaction between
individual characteristics and the
environment. For instance, some theories
of stress propose that self-efficacy is a
powerful factor in mediating stress.
Bandura et al. (1982) suggested that self-
efficacy may moderate immuno-supression,
and this may be relevant to the course of
alopecia.
A strong theoretical understanding of
the psychological impact of alopecia is
required. This will involve carrying out
research drawing together our understanding
of the immune system, the stress response,
and psychological responses. A
psychoneuroimmunological understanding
of alopecia should be developed, as there is
a strong interaction between physiological
and psychological responses.
Finally, it is critical that psychologists
are able to provide appropriate treatment
for people who are severely psychologically
affected by their hair loss. Appropriate
treatment strategies and regimes should be
established and disseminated among
therapists and others responsible for the
care of people with alopecia.
Hair loss has profound social
implications. Within the general population
people ascribe great importance to physical
appearance. Social relationships and social
support severely impact upon coping with
changes in appearance, which may lead to
identity change. From the limited evidence
that is available we can see that alopecia
can have profound effects on an
individual’s life. There is a strong need for
further research leading towards a fuller
psychological understanding of the
implications of alopecia.
■ Dr Nigel Hunt is at the Institute of
Work, Health & Organisations, the
University of Nottingham. E-mail:
nigel.hunt@nottingham.ac.uk.
■ Dr Sue McHale is at Sheffield Hallam
University. E-mail: s.l.mchale@shu.ac.uk.
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efficacy. Journal of Personality and
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M.J. & Sinclair, R. (2003).
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References
WEBLINKS
Alopecia UK: www.alopeciaonline.org.uk
Information and links: www.keratin.com/index.shtml
Regrowth of hair after alopecia totalis
DR P. M ARAZZI/SCIENCE PHOTO LIBRARY
