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Pattern of Alopecia and the Effect of Alopecia on the Quality of Life of Patients

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Pattern of Alopecia and the Effect of Alopecia on the Quality of Life of Patients PATTERN OF ALOPECIA AND THE EFFECT OF ALOPECIA ON THE QUALITY OF LIFE OF PATIENTS BY DR. EKPUDU, VIOLET IDONNI A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL FUFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF FELLOWSHIP OF THE COLLEGE IN INTERNAL MEDICINE (IN THE SUBSPECIALTY OF DERMATOLOGY). MAY 2008 ii TABLE OF CONTENTS Page Title Page --------------------------------------------------- i Declaration ----------------------------------------------- ii Supervisor’s Certification ------------------------------- iii Head of Department’s Signature ----------------------- v Table of contents ------------------------------------ ------ vi List of Figures -------------------------------------------- vii List of Tables ---------------------------------------------- viii List of Abbreviations ------------------------------------ ix Dedication ------------------------------------------------ x Acknowledgement --------------------------------------- xi Summary ------------------------------------------------- xii Chapter 1. Introduction -------------------------------- 1 Chapter 2. Literature Review -------------------------- 4 Chapter 3. Aim and Objectives ------------------------ 49 Chapter 4. Materials and Methods -------------------- 50 Chapter 5. Results ------------------------------------- 62 Chapter 6. Discussion --------------------------------- 113 Chapter 7. Conclusion and Recommendations ----- 131 References ---------------------------------------------- 135 Appendix I. Questionnaire ----------------------------- 152 Appendix II. Ethical approval ------------------------- 161 vi LIST OF FIGURES 1. Fig I - Sex Distribution of Patients and Controls 2. Fig II - Age Distribution of Patients and Controls. 3. Fig III - Age and Sex Distribution of Patients. 4. Fig IV - Clinical Severity of Alopecia. 5. Fig V - Symptoms associated with Hair loss. 6. Fig VI - Places Treatment were sought by Patients. 7. Fig VII - Alopecia areata. 8. Fig VIII - Central centrifugal cicatricial alopecia. 9. Fig IX - Chronic cutaneous lupus erythematosus. 10. Fig X - Dissecting folliculitis. 11. Fig XI - Acne keloidalis nuchae. 12. Fig XII - Anagen effluvium. 13. Fig XIII - Dada hair in a young child. 14. Fig XIV - Folliculitis decalvans with tufted folliculitis. 15. Fig XV - Scleroderma. 16. Fig XVI - Lichen planopilaris. 17. Fig XVII - Male pattern baldness I. 18. Fig XVIII - Male pattern baldness II. 19. Fig XIX - Traction alopecia. 20. Fig XX - Histology of lichen planopilaris. 21. Fig XXI - Histology of CCLE. 22. Fig XXII - Histology of Acne keloidalis nuchae. 23. Fig XXIII - Histology of Pseudopelade. 24. Fig XXIV - Anagen hair. 25. Fig XXV - Telogen hair. 26. Fig XXVI - Employment status of patients and controls 27. Fig XXVII - Marital Status of Patients and controls. vii LIST OF TABLES 1. Table 1 - Top ten groups of skin disorders observed at study site. 2. Table II - Age of onset, sex and clinical severity of alopecia. 3. Table III - Skin diseases co-existing with alopecia. 4. Table IV - Clinical diagnoses of alopecia versus gender. 5. Table V - Literacy levels of patients and controls. 6. Table VI - Diagnoses, sex, mean age distributions and mean and sum of total DLQI scores of patients. 7. Table VII- Distribution of subscale scores of DLQI for patients. 8. Table VIII- DLQI scores for clinical and socio-demographic characteristics of patients. viii LIST OF ABBREVIATIONS VDRL - Venereal Disease Research Laboratory LUTH - Lagos University Teaching Hospital DLQI - Dermatology Life Quality Index DOP - Dermatology Outpatient Clinic. QOL - Quality of Life. ARV - Antiretroviral. DLE - Discoid Lupus Erythematosus. CCLE - Chronic Cutaneous Lupus Erythematosus. KFSD - Keratosis follicularis spinulosa decalvans. CCCA - Central Centrifugal Cicatricial Alopecia. t - Student’s t-test value. Χ2 - Χ2 value. F - Analysis of variance value. ix DEDICATION This work is dedicated to God Almighty, my Hope and my Strength. The One whose own I am and always will be. Amen. x ACKNOWLEDGEMENTS I wish to express my gratitude to my supervisor, Professor Y.M Olumide, who has been both a teacher and a role model. I also wish to thank Dr.J.D Adeyemi, my supervisor also, for his support, time and attention given to this project. I am also deeply indebted to Professor M.A Danesi and Dr. J.N.A Ajuluchukwu for their encouragement and support. To my teachers at the University of Benin Teaching Hospital- Professor E. Okpere, Professor L. Ojogwu and Dr. A. Onunu who stimulated my interest in Internal Medicine and Dermatology respectively, I am most grateful. I also wish to thank Professor C. Ukoli, Professor B. Okeahialam, my teachers and colleagues at the Jos University Teaching Hospital for being there for me. I also appreciate Drs. Ahamefule and Ayanlowo and Residents doctors in the Dermatology unit, Department of Medicine, LUTH, for their support. To Drs A.Uloko and N.Essen, my ‘big brothers’ in residency, you are very much appreciated. Professor A.Y Finlay is gratefully acknowledged for permitting the use of the Dermatology Life Quality Index and its translation. To my family and loved ones, who have encouraged and supported me in the place of prayer, I am deeply indebted. xi SUMMARY Background Skin disease is a significant problem in developing countries but its effect on quality of life has rarely been investigated. Multiethnic developing countries provide valuable opportunities to assess the influences of socio- demographic factors like social class, age and gender on the impact of skin diseases on quality of life. Lagos, Nigeria provides an ideal setting for such a study. The present study is aimed at determining the pattern of alopecia and the effect of alopecia on the quality of life of patients. This would increase awareness about possible underlying psychopathologic disorders in dermatological patients with a view to facilitating early recognition, treatment and optimizing patient management. The study population consisted of 100 consecutive adult patients who presented with alopecia to the dermatology outpatient clinic of the Lagos University Teaching Hospital. An age and sex matched control group consisting of 100 persons with no dermatologic or chronic medical disorders were also recruited from patient relatives, colleagues, friends and medical students. Structured pretested questionnaires incorporating the Dermatology Life Quality Index, modified to meet the language and cultural needs of the population were administered to both the cases and controls, followed by a dermatological examination and laboratory investigations where relevant. xii Results One hundred patients were studied who were aged between 16-61 years. The mean age was 33.65 + 10.82 years. There were 60 (60%) and 40 (40%) females. The controls also consisted of 100 patients who were age and sex matched for the patients. Most of the patients seen (68%) were aged between 21 and 40 years. Generally, all patients presented with alopecia of the scalp with just a few having involvement of other body sites (ninety seven patients had only their scalp affected, two (2%) had both scalp and eye brow alopecia and only 1 patient had involvement of all body sites). The most frequent symptoms associated with hair loss were pruritus and pain, though 30% of patients reported no symptoms at all. The most frequent causes of alopecia were keloid folliculitis (acne keloidalis nuchae and acne folliculitis nuchae) (28%), followed by alopecia areata (15%), CCLE (14%), folliculitis decalvans (9%), lichen planopilaris (6%) and dissecting folliculitis (5%).Mostly male patients presented with keloid folliculitis. Twenty one (21%) patients were observed to have sought the services of a dermatologist only after having been elsewhere for treatment. The mean score of the DLQI was 7.3 + 7.16. The total DLQI scores were significantly higher for patients (median 4, range, 0-30), than for controls (median 0, range 0-1). (P< 0.0001).The Highest DLQI scores were obtained for keloid folliculitis, alopecia areata, Chronic Cutaneous Lupus Erythematosus and lichen planopilaris. xiii There was no significant increase of DLQI scores with increasing severity of alopecia. Majority of patients (54%) had a moderate to extremely large impairment of their quality of life. Female patients had more impairment in their quality of life than the male patients. Patients had their greatest impairment in the symptoms and feelings subscale of the DLQI. Females had the highest scores here and they were also more affected in the daily activities domain. Conclusion A wholistic approach has become increasingly relevant in the management of patients with alopecia as this condition can have a severe psychological impact on an individual’s well being. This study has shown that Alopecia negatively affects the quality of life of affected patients and those with the most cosmetic disfigurements have the greatest impairment in their life quality. CHAPTER ONE INTRODUCTION Hairs are a human characteristic that convey aspects of self image, identity and health among other attributes. Alopecia which can be described as the visible result of hair loss cuts across all ages, socio economic class and gender. It has a varied presentation and its causes are myriad. It may be classified as non-scarring and scarring, diffuse or patchy. Unlike other dermatological conditions, which may be limited to areas covered by clothing, alopecia is quite apparent. Due to great emphasis placed on physical appearance by most cultures, patients
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