Özge A
şkın*, Zehra Koyuncu and Server Serdaroğlu
Association of alopecia with self-esteem in
children and adolescents
https://doi.org/10.1515/ijamh-2020-0100
Received May 4, 2020; accepted June 18, 2020; published online August 24, 2020
Abstract
Objectives: Hair is important for individuals due to its cosmetic functions and its anatomical and physiological features. Hair loss in children significantly affects their social and psychological well-being and may lead to sig-nificant psychological distress in those not benefiting from medical and/or traditional therapies. Accordingly, the aim of the present study was to evaluate the self-esteem in children and adolescents with alopecia areata.
Methods: This comparative study included children and adolescents with the diagnosis of alopecia and age- and sex-matched healthy controls. Self-esteem was evaluated by the Rosenberg Self-Esteem Scale (RSES).
Results: The study included 64 patients with alopecia (M/F, 32/32; mean age, 12.2± 3.0 years) and 60 healthy controls (M/F, 30/30; mean age, 12.0± 3.0 years). Age (p=0.64) and sex (p=1.0) distributions were similar be-tween the groups. Of the patients, 35 had alopecia areata, 21 had alopecia universalis, and eight had alopecia totalis. The RSES score of patients was significantly higher than that of the controls (median [interquartile range], 1 [0–2] and 1 [0–1], respectively; p=0.008). The distribution of the participants according to the level of self-esteem (low, moderate, and high) based on the RSES scores revealed that, the proportion of patients with low and moderate self-esteem were significantly higher as compared with controls (p=0.001). The diagnostic
subtype and sex did not affect the distribution of self-esteem scores in both groups.
Conclusions: Hair loss is a significant factor affecting esteem of children and adolescents. Deteriorations in self-esteem may progress to psychological comorbidities if not approached, diagnosed, and treated timely and efficiently.
Keywords: adolescents; alopecia areata; children; hair loss; Rosenberg self-esteem scale; self-esteem.
Introduction
Alopecia is a chronic dermatological disorder that affects hair follicles and results in hair loss particularly on the scalp but may also affect any part of the body with hair [1]. Alopecia may be a psychologically devastating con-dition for people of all ages and both sexes who suffer from the disease [2]. Alopecia may be seen in children due to several reasons including congenital and acquired etiologies, which may occur as an isolatedfinding or as a component of a systemic condition. Most common forms of hair loss in children include alopecia areata, andro-genic alopecia, hair-loss associated with disturbance to the hair cycle (anagen effluvium, loose anagen syn-drome, telogen effluvium), traumatic alopecia (trichotil-lomania, traction alopecia), hair shaft disorders, and several other special disorders associated with hypo-trichosis (such as congenital atrichia and hypohypo-trichosis, Marie-Unna hereditary hypotrichosis, ectodermal dysplasia) [3].
Hair is important for individuals due to its cosmetic functions as well as its anatomical and physiological features. Hair loss or worsening in the appearance of hair may result in decreased self-esteem and a negative body image. It is well-known that hair loss in children signifi-cantly affects their social and psychological well-being and children who do not benefit from medical and/or traditional therapies may encounter significant psycho-logical distress due to factors such as stigmatization, mockery, bullying [4]. Based on this background, the present study aimed to evaluate the self-esteem levels of children and adolescents with alopecia in comparison to their healthy peers without alopecia and also according to the type of alopecia.
*Corresponding author: Özge Aşkın, MD, Deri ve Zuhrevi Hastaliklar Anabilim Dali, Istanbul Universitesi Cerrahpasa Tip Fakultesi, Cerrahpasa Mahallesi Kocamustafapasa Caddesi No: 34/E Fatih, Istanbul, Turkey, Phone:+905303707017,
E-mail: ozgee_karakus@hotmail.com. https://orcid.org/0000-0003-1413-9436 (Ö. Aşkın)
Zehra Koyuncu, Department of Child and Adolescent Mental Health Diseases, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
Server Serdaroğlu, Department of Dermatology and Venereology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
Materials and methods
The present prospective comparative study was conducted in the Dermatology Clinic of Istanbul University Cerrahpasa Medical Faculty between December 2019 and March 2020 and included 64 children and adolescents (age range, 7–17 years) who were newly diagnosed with alopecia areata, alopecia totalis or alopecia universalis or previously diagnosed and followed-up with these diagnoses. Patients who had a dermatologic disease other than alopecia areata, alopecia totalis or alopecia universalis, those who had psychiatric disorders, and those having a critical disease that could hinder the study were excluded. An age- and sex-matched control group including 60 healthy children and adolescents (age range, 7–17 years) was also formed. The study was approved by the Clinical Research Ethics Committee of Istanbul University Cerrahpasa Medical Faculty (Approval number: 83045809-604.01.02; approval date: December 03, 2019) and conducted in accordance with the Helsinki Declaration of 1975, as revised in 1983. Informed consents were obtained from the patients and controls and their legal guardians.
Data regarding demographics included age and sex and the clinical characteristics included diagnosis. The self-esteem levels of the patients and controls were assessed using the Rosenberg self-esteem scale (RSES).
The RSES
TheRSES was originally developed by Rosenberg to evaluate the self-esteem of adolescents through a 10-item scale that measures global self-worth by measuring both positive and negative feelings about the self [5]. The items are responded on a four-point Likert-type scale ranging from strongly agree to strongly disagree. A total score of 0–1 points indicate high level of self-esteem, a total score of 2–4 points indicate moderate level of self-esteem, and a total score of 5–6 points indicate a low level of self-esteem. The Turkish validity and reliability analyses of the RSES were conducted by Cuhadaroğlu [6], who re-ported the validity and reliability coefficients as 0.71 and 0.75, respectively.
Statistical analyses
Data analyses were performed using the IBM SPSS Statistics for Win-dows version 21.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were expressed as mean, standard deviation, or median (interquartile range [IQR]) for numerical variables and as frequency and percentages for categorical variables. For the comparisons of numerical variables between independent groups, the Kruskal-Wallis test and the Mann-Whitney U test were used for two- and multiple- group comparisons, respectively. The Chi-square test was used to compare categorical variables between the study groups. A p-value <0.05 was considered statistically significant [6].
Results
The present study included 64 patients with a mean age of 12.2± 3.0 years and 60 healthy controls with a mean age of
12.0± 3.0 years. The patient group included 32 (50%) girls and 32 (50%) boys and the control group included 30 (50%) girls and 30 (50%) boys. The groups did not differ in terms of age (p=0.64) and sex (p=1.0) distributions.
Of the patients, 35 (28.2%) had alopecia areata, 21 (16.9%) had alopecia universalis, and eight had alopecia totalis (6.5%). The results of the RSES assessments are summarized in Table 1. Accordingly, the median (IQR) RSES scores in the patient and control groups were 1 (0–2) and 1 (0–1), respectively. The median score of the patients was significantly higher than that of the controls (p=0.008). When the distribution of participants according to the level of self-esteem (low, moderate, and high) based on the RSES scores was evaluated, it was observed that as compared with the proportion of controls, the proportion of patients with low and moderate self-esteem were signifi-cantly higher and the proportion of patients with high level of self-esteem were significantly lower (p=0.001).
The findings of the RSES assessments according to the diagnoses are presented in Table 2. Accordingly, the diagnostic sub-groups did not significantly differ in terms of the median RSES scores (p=0.16) and the distribution of the participants according to the level of self-esteem (low, moderate, and high) based on the RSES scores (p=0.25). Thefindings of the RSES assessments according to the sex in the patient and control groups are presented in Table 3. Accordingly, the median RSES scores (p=0.23) and the distribution of the participants according to the level of self-esteem (low, moderate, and high) based on the RSES scores (p=0.14) did not differ according to sex in the patient and control groups.
Table: Results of the Rosenberg self-esteem scale assessments in the patient and control groups.
Patients n= Controls n= p-Value RSES score, median (IQR) (–) (–) . RSES score, n (%) (.) (.) (.) (.) (.) (.) (.) (.) (.) (.) (.) (.) (.) – Level of self-esteem, n (%)
Low (RSES score of–) (.) (.) . Moderate (RSES score of
–) (.) (.) High (RSES score of–) (.) (.) RSES, Rosenberg Self-Esteem Scale; IQR, interquartile range.
Discussion
Regardless of being partial or complete or reversible or permanent, all kinds of hair loss or alopecia has sub-stantial burden on the psychological well-being of in-dividuals and may result in severe anxiety and/or depression [1]. Moreover, self-esteem may deteriorate prior to or simultaneously with the development of psychological or psychiatric disorders. The present study evaluated the self-esteem level of children and adolescents with alopecia in comparison to their healthy peers. The analyses demonstrated that the self-esteem of patients was significantly lower than that of their
healthy counterparts; however, the degree of hair loss determined by the clinical diagnosis had no effect on the level of self-esteem in this patient group. These results implied the importance of the effect of alopecia on body image perceived by individuals regardless of the severity of hair loss.
Self-esteem was originally defined by Rosenberg as the global positive or negative self-evaluation of individuals [5]. Subsequent studies have reported that self-esteem cannot be conceptualized under a single heading as an overall self-evaluation and that it is rather focused on specific domains [7]. Most researchers agree on that the most common domains of self-esteem are academic
Table: Results of the Rosenberg self-esteem scale assessments in the diagnostic sub-groups.
Diagnostic sub-groups Alopecia areata (n=) Alopecia universalis (n=) Alopecia totalis (n=) p-Value RSES score, median (IQR) (–) (–) . (–) . RSES score, n (%) (.) (.) (.) (.) (.) (.) (.) (.) () (.) (.) – (.) (.) – (.) – – – (.) – Level of self-esteem, n (%)
Low (RSES score of–) (.) (.) – . Moderate (RSES score of–) (.) (.) ()
High (RSES score of–) (.) (.) () RSES, Rosenberg Self-Esteem Scale; IQR, interquartile range.
Table: Results of the Rosenberg self-esteem scale assessments according to gender in the patient and control groups.
Patients Controls Boys n= Girls n= p-Value Boys n= Girls n= p-Value RSES score, median (IQR) . (–.) (–) . (–) (–) . RSES score, n (%) (.) (.) (.) (.) (.) (.) (.) () () (.) (.) (.) (.) (.) (.) () (.) (.) (.) () () (.) () (.) () (.) () () Level of self-esteem, n (%)
Low (RSES score of–) () (.) . () (.) . Moderate (RSES score of–) () (.) (.) (.)
High (RSES score of–) () (.) (.) () RSES, Rosenberg Self-Esteem Scale; IQR, interquartile range.
competence, physical appearance, approval from others, relationship status, and family support [8, 9]. Among these most common domains of self-evaluation, physical appearance-based contingency is likely the one that is most negatively associated with self-esteem [10]. The re-sults of the present study were in accordance with these evidences in the literature and demonstrated that similar traits were also present in Turkish children and adoles-cents with hair loss.
In the present study, the hypothesis if severity of alopecia might affect the degree of self-esteem was also evaluated. Previous studies have reported that the extent of alopecia is one of the predictors of psycho-logical distress and that individuals with severe alopecia are more prone to experience these psychological comorbidities [1]. Nevertheless, this was not supported by our analyses. The patients with alopecia areata, al-opecia universalis and alal-opecia totalis were found to have similar levels of self-esteem. However, thisfinding should be interpreted cautiously since the amount or area of hair loss was not quantitatively analyzed in the present study.
One more finding that was found different from the evidence in the literature was the effect of sex on psycho-logical burden of hair loss. A previous study evaluating the psychiatric symptoms in children with alopecia areata re-ported that girls were more affected than boys regarding psychological distress due to hair loss [11]. Nevertheless, the results of the present study revealed that there was no effect of sex on the severity of deterioration in self-esteem. This was also the case in the control group, which sug-gested that sex was not effective on self-esteem among our participants.
In conclusion, alopecia should not be considered solely a clinical condition that needs topical and/or sys-temic treatment. Patients should also be evaluated regarding psychological burden of this debilitating disor-der. Deteriorations in self-esteem may be associated with further psychological comorbidities and therefore should be assessed adequately for each patient.
Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: The authors ensure that they have no conflicts of interests.
Informed consent: This was obtained from the patients and controls and their legal guardians.
Ethical approval: The study was approved by the Clinical Research Ethics Committee of Istanbul University Cerrahpasa Medical Faculty (Approval number: 83045809-604.01.02; approval date: December 03, 2019) and conducted in accordance with the Helsinki Declaration of 1975, as revised in 1983.
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