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SHORT COMMUNICATION
Large-scale Retrospective Cohort Study of Psychological Stress in Patients with Alopecia Areata
According to the Frequency of Intralesional Steroid Injection
Shinwon HWANG 1# , Jaeyong SHIN 2# , Tae-Gyun KIM 1 , Do-Young KIM 1 and Sang Ho OH 1 *
1
Department of Dermatology, Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, 50 Yonsei-
ro, Seodaemun-gu, Seoul 03722, and 2 Institute of Health Services Research, Department of Preventive Medicine, Graduate School of Public
Health, Yonsei University, Seoul, Korea. E-mail: [email protected]
#
These authors contributed equally to this study.
Accepted Nov 1, 2018; E-published Nov 5, 2018
Alopecia areata (AA) is a non-scarring alopecia resulting
from an immune response against hair follicles. It occurs
equally in both sexes and can affect every age group. AA
is a chronic disease that can negatively affect a patient’s
mental health due to its relapsing nature and effect on
appearance. Previous cross-sectional, case-control stu-
dies have demonstrated a relationship between AA and
psychological stress (1–5). Among multiple therapeutic
approaches, intralesional injection (ILI) of corticoste-
roids is most widely used for treating alopecic patches of
AA, but this invasive procedure usually reflects disease
severity and chronicity and is accompanied by painful
discomfort.
There is currently a lack of evidence from a large-scale
population-based cohort study to directly examine the
presence of psychological stress in patients with AA ac-
cording to the invasive therapeutic modalities used. In
this study, psychiatric appointments and the burden of AA
were analysed in patients with AA using Korea National
Health Insurance Cohort Data (NHICD) from 2002 to
2013. In addition, the study evaluated the association
between psychiatric appointments and other factors, such
as type of AA and treatment modalities. in patients with AA than in the non-AA group. Patients
with AA had higher rate of psychiatric visits compared
with controls (2,862.5 vs. 853.7 cases/100,000 person-
years). The demographic findings of enrolled participants
were investigated based on psychiatric visits (Table SII 1 ).
The multivariate analyses of all patients were analysed
with basic demographic data, including age, sex, income,
type of disease and treatment modality. The tendency for
visits to psychiatrists was significantly higher in patients
with AA compared with the control group (HR 1.64, 95%
CI 1.45–1.86) (Table SIII 1 ). Moreover, compared with
non-AA controls, the adjusted HRs for psychiatric visits
were significantly increased according to the number of
ILI treatments (Table I, ILI=1 vs. ILI=2 vs. ILI≥3; HR
1.54, 95% CI 1.09–2.03 vs. HR=2.09, 95% CI 1.31–2.02
vs. HR 1.57, 95% CI 1.22–2.03, respectively). Patients
with alopecia totalis or universalis showed an increased
adjusted HR for psychiatric clinic visits compared with
patients with localized AA; however, this was not sta-
tistically significant (HR 1.41, 95% CI 0.90–2.20). The
psychiatric visit risk for patients who used oral steroids
did not differ from that of control groups (HR 1.08, 95%
CI 0.76–1.53).
MATERIAL AND METHODS DISCUSSION
From a cohort of subjects younger than 20 years, participants who
had been newly diagnosed with AA during the study period were
included as the AA group, and those who had never been diagno-
sed with AA during the same period were included as the control
group. Since the study aimed to explore only those patients with
new onset of AA, subjects with a history of AA and psychiatric
appointments were excluded. The adjusted hazard ratios (HR) and
95% confidence intervals (95% CI) for visits to a psychiatrist were
estimated by applying a Cox proportional-hazard regression (see
Appendix S1 1 for details). Hair is an important part of our appearance, and hair
loss can drastically affect self-esteem and social re-
lationships. A positive correlation between AA and
psychiatric appointments has been confirmed through
Minnesota Multiphasic Personality Inventory, surveys
and questionnaires (6–8). However, most of these studies
RESULTS Alopecia areata
Localized
Totalis or universalis
Oral steroids
No
Yes
Intralesional steroid injection
No alopecia areata
0
1
2
3 or more
This study included 370,019 subjects, including 4,707
patients with AA (1.3%) and 23,943 patients who had
visited the psychiatric clinic at least once during the
follow-up period (Table SI 1 ). The ratio of patients visiting
a psychiatric clinic was approximately 1.6 times higher
https://www.medicaljournals.se/acta/content/abstract/10.2340/00015555-3079
1
doi: 10.2340/00015555-3079
Acta Derm Venereol 2019; 99: 236–237
Table I. Adjusted hazard ratios (HR) for outpatient visits to
psychiatrists by type of disease and treatment modality
HR 95% CI
p-value
1.00
1.41 0.90–2.20 0.130
1.00
1.08 0.76–1.53 0.686
1.00
1.663
1.540
2.089
1.573 1.372–2.016
1.131–2.098
1.464–2.979
1.221–2.028
< 0.0001
0.0062
< 0.0001
0.0005
CI: confidence interval.
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Journal Compilation © 2019 Acta Dermato-Venereologica.