Visibility, Not Lesion Burden, Drives Distress in Alopecia Areata

Alopecia areata (AA) is associated with a substantial psychosocial burden, driven primarily by appearance-related anxiety rather than generalized anxiety or depression, according to findings from a comparative cross-sectional study published in the Journal of Health Psychology.¹ The results indicate that lesion visibility and patient-perceived severity are more strongly associated with quality of life (QOL) impairment than traditional objective measures.

AA is a chronic, immune-mediated dermatologic condition characterized by non-scarring hair loss, affecting approximately 1% to 2% of the global population. Its unpredictable course and visible manifestations are increasingly recognized as drivers of psychosocial distress.²

Measuring the Specificity of Appearance Anxiety

Investigators evaluated social appearance anxiety in 129 adults with AA and 142 age- and sex-matched healthy controls aged 18 to 65 years. All participants completed the Social Appearance Anxiety Scale (SAAS) and the Hospital Anxiety and Depression Scale (HADS). In addition, patients with AA also completed the Dermatology Life Quality Index (DLQI) and a visual analog scale (VAS) assessing perceived disease severity.

Patients with AA exhibited significantly higher SAAS scores (mean 65.32) than healthy controls (21.45; P < .001). In contrast, no statistically significant differences were observed between groups for generalized anxiety or depression. Mean HAD anxiety scores were 7.21 in the AA group and 7.35 among controls (P = .612), while mean HAD depression scores were 6.54 and 6.62, respectively (P = .594).

Researchers identified a moderate positive correlation between SAAS scores and VAS ratings of perceived disease severity (r = .304, P < .05) within the AA cohort. “This underscores the importance of distinguishing subjective illness experience from objective clinical indicators,” the authors noted, as this relationship highlights how subjective illness perception drives distress more than objective clinical parameters.

In contrast, correlations between SAAS and general anxiety or depression, as measured by HADS, were non-significant (P = .231 and P = .186, respectively), reinforcing the specificity of appearance-related concerns in this population.

The Critical Role of Lesion Visibility

The researchers found that lesion location significantly influenced appearance-related anxiety, with differences in SAAS scores varying widely across lesion sites (P < .01). Patients with facial involvement reported the highest levels of social appearance anxiety, particularly those with eyelash and eyebrow involvement. Mean SAAS scores were 71.3 for eyelashes and 70.1 for eyebrows, significantly higher than those observed in patients with truncal or limb involvement, where mean scores were 59.1 and 60.2, respectively. Other visible facial areas were also associated with elevated anxiety, including the frontal scalp (68.5), the vertex scalp (66.4), and the beard region (64.7).

Researchers found that in AA, there was a substantial QOL impairment, which was more closely associated with perceived disease severity and lesion visibility than with lesion count or total involved area. The mean DLQI score was 12.3, with nearly two-thirds of patients (62.8%) scoring 10 or higher, indicating a moderate to very large impact on QOL, while 10.9% scored 20 or higher, consistent with extremely large impairment.

Implications for Patient-Centered Care

The findings indicate that the burden of AA is not adequately captured by objective disease severity metrics alone and “suggest that social appearance concerns in AA represent a discrete psychological domain, one that warrants independent clinical attention,” the authors report. The authors further noted that AA poses unique psychological challenges due to its often sudden onset, patchy progression, and uncertain prognosis, which may compound distress by introducing an ongoing threat to identity and self-image.

“From a clinical implementation standpoint, these results carry actionable implications,” the authors wrote, emphasizing the need for a more patient-centered, psychosocially informed approach to care, including routine assessment of appearance-related anxiety, particularly in patients with facial involvement, even when generalized anxiety or depression is absent.

References

1. Kurhan F, Yavuz GÖ. The hidden burden of visibility: social appearance anxiety in patients with alopecia areata - a comparative cross-sectional study. J Health Psychol. Published online November 30, 2025. doi:10.1177/13591053251383649

2. Mesinkovska N, Craiglow B, Ball SG, et al. The invisible impact of a visible disease: psychosocial impact of alopecia areata. Dermatol Ther. 2023;13(7):1503-1515. doi:10.1007/s13555-023-00941-z