|Year : 2019 | Volume
| Issue : 1 | Page : 31-36
Quality of life and willingness-to-pay in patients with androgenetic alopecia
Thamer F Mubki1, Salman A. Bin Dayel2, Abdullah H AlHargan3, Khaled M AlGhamdi4, Abdullah I AlKhalifah3
1 Department of Dermatology, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU) Riyadh, Saudi Arabia
2 Department of Dermatology, College of Medicine, Prince Sattam Bin Abdulaziz University Al-Kharj, Saudi Arabia
3 Department of Dermatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
4 Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||10-Jul-2018|
|Date of Acceptance||12-Sep-2018|
|Date of Web Publication||28-Jan-2019|
Thamer F Mubki
Al Imam Mohammad Ibn Saud Islamic University (IMSIU), PO Box 5701, Othman Ibn Affan Street, Riyadh, 11321
Source of Support: None, Conflict of Interest: None
Objective The objective of the study was to assess the quality of life (QoL) in patients with androgenetic alopecia (AGA). A secondary aim was to determine the correlation between dermatology life quality index and willingness-to-pay (WTP) among subjects of different disease duration, severity, and socioeconomic factors.
Patients and methods A self-administered multiple-choice questionnaire distributed to subjects diagnosed with AGA attending the dermatology clinic at three specialized hospitals in Riyadh from June 2016 to March 2017.
Results Of the 233 subjects, 207 (88%) completed the questionnaires. The dermatology life quality index scores ranged from 0 to 29, with a mean score of 7.8±5.8 indicating a moderate effect on QoL. In 28.5% of subjects, QoL was affected very large to extremely large by AGA. Women showed a significantly higher WTP than men (P<0.001).
Conclusion The present study suggests a moderate effect of AGA on the QoL. AGA impact women more than in men and women show more WTP than mem. More studies should pay more attention on the psychological status of patients with AGA.
Keywords: alopecia, androgenetic alopecia, hair, quality of life
|How to cite this article:|
Mubki TF, Dayel SA, AlHargan AH, AlGhamdi KM, AlKhalifah AI. Quality of life and willingness-to-pay in patients with androgenetic alopecia. Egypt J Dermatol Venerol 2019;39:31-6
|How to cite this URL:|
Mubki TF, Dayel SA, AlHargan AH, AlGhamdi KM, AlKhalifah AI. Quality of life and willingness-to-pay in patients with androgenetic alopecia. Egypt J Dermatol Venerol [serial online] 2019 [cited 2019 May 23];39:31-6. Available from: http://www.ejdv.eg.net/text.asp?2019/39/1/31/250818
| Introduction|| |
Androgenetic alopecia (AGA) is considered the most common cause of hair loss in men and women. It has been well documented to have a negative impact on self-confidence and self-esteem ,. Patients with AGA are commonly affected by psychiatric disorders ,. AGA is present in 50% of men in their 50s, while 70% of men and 38% of women at older ages are affected . Although this disorder is highly prevalent, the current treatments have limited efficacy .
The dermatology life quality index (DLQI) is a dermatology-specific quality of life (QoL) measurement that has been used in many skin diseases. The effect of AGA on QoL was previously assessed in a few populations ,,,; however, there is paucity of data in this regard from the Middle Eastern populations. Willingness-to-pay (WTP) represents a tool to evaluate the burden of disease focusing on the amount of money patients are willing to pay for a hypothetical cure of their disease . In dermatology, a few studies have evaluated WTP in patients with skin diseases. WTP has been used for patients with psoriasis vulgaris , atopic dermatitis , port-wine stains , basal cell carcinoma , melanocytic naevi , rosacea , vitiligo , onychomycosis , melasma , and acne vulgaris . To our best knowledge, the use of WTP in patients with AGA has not been reported.
The purpose of this study is to assess QoL of AGA in the population of Saudi Arab, and to determine the relationship of DLQI scores to demographic data and clinical variables. A secondary aim was to determine the correlation between DLQI and WTP among subjects of different disease durations, severity, and socioeconomic factors.
| Patients and methods|| |
A self-administered multiple-choice questionnaire was distributed to all patients older than 18 years diagnosed with AGA attending the dermatology clinic at three specialized hospitals in Riyadh from June 2016 to March 2017. All patients were generally healthy. Patients with scalp disorders such as scalp psoriasis, scalp infections, and seborrheic dermatitis were excluded. Consent was obtained from each patient. All patients were informed verbally about the study and were asked to participate voluntarily in this survey by filling the questionnaire according to their feelings and opinions. The study was approved by our institution’s ethics committee.
Demographic and clinical data were collected on each patient. The extent of AGA was assessed by a board-certified dermatologist using Hamilton–Norwood and Ludwig’s grading systems for man and woman, respectively.
The DLQI questionnaire consists of 10 questions, each referring to the previous 7 days. This questionnaire covers different aspects of life such as symptoms and feelings, personal relationships, daily activities, leisure, work and school, and treatment. Each item scored 0–3. A sum of score’s results yields a total DLQI of 0–30; the higher the score the greater the impairment of the patient’s QoL .
The Arabic version of the DLQI was used here. ‘Banding’ of DLQI scores allows this measure to be clinically useful . Grade 1 (0–1) means no effect at all on patient’s life, similarly, grade 2 (2–5) means small, grade 3 (6–10) means moderate, grade 4 (11–20) means very large, and grade 5 (21–30) means extremely large effect on patient’s life.
WTP was addressed by asking one question about the amount of money they would be willing to pay as a single payment to achieve a sustainable cure of AGA. Predefined categories: 200–1000 USD, 1001–5000 USD, 5001–10 000 USD. In theory, the more the patients are willing to pay, the more they are impaired in their QoL by the disease.
Data were analyzed using SPSS, version 20.0 (IBM Inc., Chicago, Illinois, USA). The relationships between DLQI scores and clinical and demographic variables were analyzed using ordinal multiple logistic regression. Average interitem correlation, item total correlation, and Cronbach’s alpha were used to assess reliability. A P value less than 0.05 is considered statistically significant.
| Results|| |
Of the 233 patients who had received questionnaires, 207 patients completed the questionnaires (response rate was 88.8%) and were included in the analysis.
Two hundred and seven patients (96 men and 111 women) with an average age of 30.6±9.1 years were enrolled. The average disease duration was 6±4.8 years. [Table 1] demonstrates the different demographic and clinical characteristics.
|Table 1 Demographic and clinical characteristics of patients with androgenetic alopecia (N=207)|
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Dermatology life quality index scores
The mean DLQI score was 7.8±5.8 (range, 0–29). In 28.5% of cases, patients’ QoL was affected very large to extremely large by AGA ([Table 2]).
|Table 2 Dermatology life quality index scores of 207 patients with androgenetic alopecia|
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The individual mean scores ranged from 0.21 to 1.48. Questions 2 (embarrassment) and 4 (clothing) had the most impact on AGA patients. The lowest was for question 9 (sexual life) and question 6 (sport activity) ([Table 3]).
|Table 3 Mean dermatology life quality index item scores for 207 androgenetic alopecia patients|
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QoL was not affected by the patient’s age, disease duration, marital status, and educational level. However, sex was associated with a significantly higher DLQI score (P<0.001). QoL was impaired in women more than men ([Table 4]).
|Table 4 Average dermatology life quality index scores in androgenetic alopecia patients with various demographical and clinical presentations|
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WTP was determined to express the burden of the disease further. Majority of subjects (52.7%) had a monthly household income of 5376 USD or less and hence are eligible for the governmental aid (citizen account) at the time of data acquisition. Of all patients, 46.8% were willing to make a single payment up to 1000 USD for a cure, 33.3% would pay up to 5000 USD, and 19.8% up to 10 000 USD ([Table 1]).
Female patients showed a significantly higher WTP than men (P<0.001). Age and duration of AGA do not significantly correlate with more WTP ([Table 5]). Surprisingly, WTP was significantly higher in patients with mild AGA than those with severe AGA (P=0.004) ([Table 6]).
|Table 6 Correlating severity of androgenetic alopecia with willingness-to-pay|
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| Internal consistency and concurrent validity|| |
The value of Kaiser–Meyer–Olkin measure (0.845) and Bartlett’s test of sphericity=45 (P<0.001) support for factor analysis. The factor solution of the DLQI items was used to obtain factors 1 and 2 as demonstrated in [Table 7]. Both factors accounted for 61.3% of the DLQI score variance. Factor 1 (items 2, 3, 4, 5, 6, 7, 8, and 10) refers to the emotional and social effects of AGA. Psychological effects were represented by the second factor (items 1 and 9). Both Cronbach’s alpha (scale reliability coefficient) and the standardized item alpha were 0.821 and 0.820, respectively. The latter indicates a high degree of internal reliability as both were higher than the threshold of 0.7. The average interitem correlation was 0.313 (>0.2), suggesting good reliability. The item total correlation’s average was 0.505 (range, 0.289–0.661).
| Discussion|| |
AGA is one of the most common hair loss disorders that can significantly affect a patient’s QoL and it is associated with various psychological consequence ,,,. The mean DLQI score in our study was 7.8±5.8, indicating a moderate impact on QoL. This is comparable to that found in previous studies in other countries ,,, and it is clearly lower than the result reported in patients with other chronic dermatological diseases, for example atopic dermatitis (12.5), pruritus (10.5), pemphigus vulgaris (10.0), epidermolysis bullosa (12.1), and burn (17.7) ,,,,.
We observed that the DLQI score and WTP for women were significantly higher than that for men indicating a worse QoL in women with AGA as compared with men. This can be attributed to the fact that women are more conscious about their cosmetic appearance than men. Moreover, women with AGA commonly experience increased self-consciousness, emotional stress, and feel unattractive. The latter may lead to social withdrawal ,,.
In our population, QoL was not affected by the duration of the disease. This contradicts previous findings in the QoL study in Korean  and Chinese populations . A possible explanation for that is patients may gradually adapt to their chronic disease, such as AGA, and as time passes, their QoL gradually improves. In addition, QoL was also not affected by the patient’s age. Other studies reported a worse QoL in younger age patients . Younger patients are probably more likely to have a negative impact of their appearance on their social life as they are looking for work and partners. However, cultural differences may present, as our population usually wear special costumes that cover men’s head (Qutra) or women’s head (Hijab).WTP was significantly higher in patients with mild AGA than those with severe AGA. Patients with mild AGA are probably more interested in preventing the disease from being worse.
Cronbach’s alpha is a commonly used measure of internal consistency of questionnaires. A value of 0.70 is considered the minimum to call a questionnaire internally consistent . The internal reliability of the DLQI for other diseases have been frequently assessed with Cronbach’s alpha scores that ranged between 0.77 and 0.95 ,. Among patients with AGA of our study, Cronbach’s alpha was 0.820, indicating high internal reliability.
The limitation of our study was the small sample size as compared with the total population of AGA patients in Saudi Arabia. The information regarding illness perception, psychological distress, and QoL was being self-reported and thus might have recall bias. Moreover, a selection bias may possibly have affected the results, as all questionnaires were collected from patients with hair problems visiting dermatology clinics.
In summary, the present study suggests a moderate effect of AGA on the QoL of affected patients. AGA has more impact on women than in men and they show more WTP than men. More studies are needed to explore the psychological status of patients with AGA. In diseases such as AGA with limited treatment options, it is important to recognize the psychological issues of patients and offer both medical treatment as well as psychological support.
The authors thank Professor Andrew Finlay for his permission to use the DLQI. The authors also thank Dr Hala AlOtaibi, Dr Sahar Baksh, Dr Abdulrahman Aljamal, and Dr Maha Almarek for her help with the collection of the questionnaires.
Financial support and sponsorship
Conflicts of interest
There are o conflicts of interest.
| References|| |
Williamson D, Gonzalez M, Finlay AY. The effect of hair loss on quality of life. J Eur Acad Dermatol Venereol 2001; 15:137–139.
Cash TF. The psychosocial consequences of androgenetic alopecia: a review of the research literature. Br J Dermatol 1999; 141:398–405.
Hadshiew IM, Foitzik K, Arck PC, Paus R. Burden of hair loss: stress and the underestimated psychological impact of telogen effluvium and androgenetic alopecia. J Investig Dermatol 2004; 123:455–457.
Hunt N, McHale S. The psychological impact of alopecia. BMJ 2005; 331:951–953.
Mubki T, Shamsaldeen O, McElwee KJ, Shapiro J. An update on diagnosis and treatment of female patter hair loss. Expert Rev Dermatol 2013; 8:427–436.
Adil A, Godwin M. The effectiveness of treatments for androgenetic alopecia: a systematic review and meta-analysis. J Am Acad Dermatol 2017; 77:136–141.
Yu NL, Tan H, Song ZQ, Yang XC. Illness perception in patients with androgenetic alopecia and alopecia areata in China. J Psychosom Res 2016; 86:1–6.
Cartwright T, Endean N, Porter A. Illness perceptions, coping and quality of life in patients with alopecia. Br J Dermatol 2009; 160:1034–1039.
Yamazaki M, Miyakura T, Uchiyama M, Hobo A, Irisawa R, Tsuboi R. Oral finasteride improved the quality of life of androgenetic alopecia patients. J Dermatol 2011; 38:773–777.
Han SH, Byun JW, Lee WS, Kang H, Kye YC, Kim KH et al.
Quality of life assessment in male patients with androgenetic alopecia: result of a prospective, multicenter study. Ann Dermatol 2012; 24:311–318.
O’Brien B, Gafni A. When do the ‘dollars’ make sense? Toward a conceptual framework for contingent valuation studies in health care. Med Decis Making 1996; 16:288–299.
Schiffner R, Schiffner-Rohe J, Gerstenhauer M, Hofstädter F, Landthaler M, Stolz W. Willingness to pay and time trade-off: sensitive to changes of quality of life in psoriasis patients? Br J Dermatol 2003; 148:1153–1160.
Lundberg L, Johannesson M, Silverdahl M, Hermansson C, Lindberg M. Quality of life, health-state utilities and willingness to pay in patients with psoriasis and atopic eczema. Br J Dermatol 1999; 141:1067–1075.
Schiffner R, Brunnberg S, Hohenleutner U, Stolz W, Landthaler M. Willingness to pay and time trade-off: useful utility indicators for the assessment of quality of life and patient satisfaction in patients with port wine stains. Br J Dermatol 2002; 146:440–447.
Weston A, Fitzgerald P. Discrete choice experiment to derive willingness to pay for methyl aminolevulinate photodynamic therapy versus simple excision surgery in basal cell carcinoma. Pharmacoeconomics 2004; 22:1195–1208.
Schiffner R, Wilde O, Schiffner-Rohe J, Stolz W. Difference between real and perceived power of dermoscopical methods for detection of malignant melanoma. Eur J Dermatol 2003; 13:288–293.
Beikert FC, Langenbruch AK, Radtke MA, Augustin M. Willingness to pay and quality of life in patients with rosacea. J Eur Acad Dermatol Venereol 2013; 27:734–738.
Radtke MA, Schäfer I, Gajur A, Langenbruch A, Augustin M. Willingness-to-pay and quality of life in patients with vitiligo. Br J Dermatol 2009; 161:134–139.
Cham PM, Chen SC, Grill JP, Jonk YC, Warshaw EM. Reliability of self-reported willingness-to-pay and annual income in patients treated for toenail onychomycosis. Br J Dermatol 2007; 156:922–928.
Leeyaphan C, Wanitphakdeedecha R, Manuskiatti W, Kulthanan K. Measuring melasma patients’ quality of life using willingness to pay and time trade-off methods in thai population. BMC Dermatol 2011; 11:16.
Motley RJ, Finlay AY. How much disability is caused by acne? Clin Exp Dermatol 1989; 14:194–198.
Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) − a simple practical measure for routine clinical use. Clin Exp Dermatol 1994; 19:210–216.
Hongbo Y, Thomas CL, Harrison MA, Salek MS, Finlay AY. Translating the science of quality of life into practice: What do dermatology life quality index scores mean? J Invest Dermatol 2005; 125:659–664.
Holm JG, Agner T, Clausen ML, Thomsen SF. Quality of life and disease severity in patients with atopic dermatitis. J Eur Acad Dermatol Venereol 2016; 30:1760–1767.
Warlich B, Fritz F, Osada N, Bruland P, Stumpf A, Schneider G et al.
Health-related quality of life in chronic pruritus: an analysis related to disease etiology, clinical skin conditions and itch intensity. Dermatology 2015; 231:253–259.
Mayrshofer F, Hertl M, Sinkgraven R, Sticherling M, Pfeiffer C, Zillikens D et al.
Significant decrease in quality of life in patients with pemphigus vulgaris. Results from the German Bullous Skin Disease (BSD) Study Group. J Dtsch Dermatol Ges 2005; 3:431–435.
Horn HM, Tidman MJ. Quality of life in epidermolysis bullosa. Clin Exp Dermatol 2002; 27:707–710.
Mazharinia N, Aghaei S, Shayan Z. Dermatology Life Quality Index (DLQI) scores in burn victims after revival. J Burn Care Res 2007; 28:312–317.
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; 29:568–575.
Van der Donk J, Passchier J, Knegt-Junk C, van der Wegen-Keijser MH, Nieboer C, Stolz E, Verhage F. Psychological characteristics of women with androgenetic alopecia: a controlled study. Br J Dermatol 1991; 125:248–252.
Van Der Donk J, Hunfeld JA, Passchier J, Knegt-Junk KJ, Nieboer C. Quality of life and maladjustment associated with hair loss in women with alopecia androgenetica. Soc Sci Med 1994; 38:159–163.
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; 11:151–155.
Streiner DL, Norman GR, Cairney J. (eds). Health measurement scales: a practical guide to their development and use. 5th ed. Oxford: Oxford University Press 2014.
Aghaei S, Sodaifi M, Jafari P, Mazharinia N, Finlay AY. DLQI scores in vitiligo: reliability and validity of the Persian version. BMC Dermatol 2004; 4:4–8.
Jalel A, Soumaya GS, Hamdaoui MH. Dermatology life quality index scores in vitiligo: reliability and validity of the Tunisian version. Indian J Dermatol 2009; 54:330–333.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]