|Year : 2016 | Volume
| Issue : 1 | Page : 24-28
Quality of life and psychological impact of premature canities: A study from North India
Deepashree Daulatabad, Chander Grover, Archana Singal
Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, New Delhi, India
|Date of Web Publication||17-Jun-2016|
Dr. Chander Grover
Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, New Delhi - 110 095
Source of Support: None, Conflict of Interest: None
Background: Premature canities is largely an unexplored zone. Its onset in adolescence may have a significant effect on the developing psyche of an individual sufferer, especially in Indian patients with skin of color. Thus far, the impact of premature canities on quality of life (QoL) has not been documented. Aim: To objectively evaluate the impact of premature canities on QoL. Methods: The impact on QoL was calculated with the help of a modified and validated questionnaire on 52 patients with onset of canities before the age of 20 years. Results: The mean modified Dermatology Life Quality Index score recorded was 16.42 ± 5.93. Almost 85% patients were found to have a very large to extremely large effect on the QoL. Embarrassment, need for treatment and guilt were reported most frequently. The less severely affected domains were those pertaining to interpersonal relationship and work or studies. The limitation of the study was small sample size and lack of control group. Conclusion: Patients of premature canities were found to have an adverse impact on their QoL, attributable to the disease, seen most prominently to affect their psychology or emotional well-being and the felt need of medical care. Considering the age group affected, it could have a long-term detrimental effect on their psychological wellbeing.
Keywords: India, premature canities, premature graying of hair, quality of life
|How to cite this article:|
Daulatabad D, Grover C, Singal A. Quality of life and psychological impact of premature canities: A study from North India. Pigment Int 2016;3:24-8
| Introduction|| |
Although the precise biologic role of hair in humans is not defined, it plays a profound role in social interaction. Disorders of hair are known to be associated with marked impairment in the quality of life (QoL). The World Health Organization (WHO) defines QoL in a broader perspective as “an individual's perception of their position in life in the context of the culture and value systems in which they live; and in relation to their goals, expectations, standards, and concerns.” Further, it states that QoL is a broad ranging concept, influenced in a complex way, by the person's physical health, psychological state, level of independence, social relationships, personal beliefs, and their relationship to salient features of their environment. Alteration in any aspect of life is bound to create discomfort. Various objective indices have been evolved to assess the impact of skin diseases on a patient's life; Dermatology Life Quality Index (DLQI) is one such simple 10-item validated questionnaire that is often used in dermatological literature.
Premature graying (premature canities) is a common and significant hair disorder, defined as the onset of graying before the age of 20 years (in Caucasians) or 30 years (in Africans)., A precise definition with respect to age of onset of premature canities for Indian population is lacking in English literature. Premature canities assumes a very unique place among Indians as even a few gray strands are easily noticeable among the racially pigmented dark hair. With increasing incidence of premature canities and its onset at a relatively early age, more and more patients are seeking medical attention for this psychologically disturbing hair disorder. To the best of our knowledge, there are no studies in published English literature, documenting its impact on QoL in sufferers. Thus, the present study was undertaken to evaluate the impairment of QoL in patients with premature canities in Indian patients. For the purpose of the study, premature canities was defined as the onset of graying of hair prior to 20 years of age irrespective of the gender. Based on the DLQI, a modified questionnaire for use in Indian population was designed. It was prevalidated with 20 patients before initiation of this study for which the final version was used.
| Methods|| |
The study included patients presenting with premature graying of hair with onset before 20 years of age who presented to the outpatient Department of Dermatology, from November 2011 to December 2012. Patients with known systemic disorders such as liver or renal impairment were excluded on the basis of history and baseline biochemical and hematologic tests, and so were patients with a history of smoking. Moreover, subjects with conditions known to cause premature graying such as progeria, Rothmund–Thomson syndrome, Werner's syndrome, and so on were also excluded. Consecutive patients fulfilling the above criteria were included in the study. As the onset of premature canities has not been defined in our population, we selected a cut-off age of 20 years; the rationale being that the study population was North Indian (largely derived from the Anglo-Indian races) and could use the same cut-off of 20 years as used by Caucasian race.
The study was approved by the Institutional Ethical Committee. The QoL assessment was done with the help of a modified and prevalidated questionnaire based on the DLQI proposed by Finley and Kahn. Required permission for modification was obtained from the competent authority. The questionnaire consisted of 10 questions; each with 4 response options graded from 0 to 3 (0 being no effect; 1 – minimal effect; 2 – moderate effect; and 3 – severe effect). Thus, a maximum score of “3” and minimum of “0” was accorded to each question; thereby permitting a maximum and minimum score of “30” and “0”, respectively, for the modified DLQI score. Based on the grading used in DLQI, the final modified DLQI score was categorized into five grades, i.e., 0–4 [Table 1], first and second columns]. Higher scores on the scale used by us implied a greater impact on the patient's QoL. The questionnaire was self-administered. For younger children, who were unable to answer certain questions, parents' responses were included.
|Table 1: Grading of impact on quality of life based on modified Dermatology Life Quality Index Score of the patients|
Click here to view
The questionnaire was designed to evaluate the following aspects of QoL: Patient's perception/physical reactions, psychological aspects, interpersonal relations, efficiency, and participation at home/work/school, and the need for medical care. Three questions used to evaluate the perception/physical reactions included items like how often the gray hair was noticed by others; did they try to conceal the gray; and whether they perceived the disease to be contagious. Another three questions evaluated the psychological impact by evaluating the sense of guilt or hesitation because of gray hair; the frequency of mood fluctuations or loneliness because of their condition; and the perception that graying is due to inadequate self-care (in terms of diet, nourishment, or oil application). Two questions focused on the impact of graying on patient's social and professional activities in the form of whether gray hair hampers their participation in social events or their ability to concentrate in work. Interpersonal relationships were assessed by asking for any arguments or brawls with friends or relatives due to gray hair. Finally, the felt need for therapeutic intervention (medications, supplements, or medicinal oils) was also inquired about. The final scores on the modified DLQI were calculated and statistically analyzed. Statistical software SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc., was used for this purpose and a P < 0.05 was considered as significant.
| Results|| |
A total of 52 patients were enrolled; of these, 27 were girls (51.92%) and 25 were boys (48.08%). More than 90% of these (n = 47) were 11–20 years old while 50% belonged to the 11–15 years age group. The mean recorded modified DLQI score was 16.42 ± 5.93 (range 5–30) (all the questions were answered by the patients themselves, except one question by a very young patient, for which the parent's response was considered). A total of 34 (65.4%) patients were found to have a very large effect on their QoL while 10 (19.23%) had an extremely large effect [Table 1] and [Figure 1].
|Figure 1: Overall impact of premature canities on the quality of life of the study subjects. Most of the patients were found to be markedly affected (very large or extremely large effect)|
Click here to view
[Figure 2] represents the broad spheres of QoL assessed along with the further subdivisions made to help in assessment. With regards to evaluation of perception/physical reactions [Figure 2]a, 48 (92.3%) subjects felt that their gray hair was noticeable and commented upon by their relatives and friends. As many as 37 (71.1%) subjects accepted to having tried to hide their gray at one time or the other. A total of 27 (51.9%) subjects did not consider the disorder contagious and were not afraid of sharing combs. It was seen that 46 (88.5%) subjects suffered from significant guilt and hesitation due to their gray hair. Mood swings attributed to graying were reported by 29 (55.8%) subjects, whereas 20 (38.5%) subjects did not notice any such effects of graying. Up to 33 (63.5%) subjects attributed their graying of hair to a lack of adequate self-care in terms of taking a healthy nutritious diet or due to inadequate oiling of scalp, the latter being an old revered traditional practice in India [Figure 2]b.
|Figure 2: The impact of premature canities on various spheres of the quality of life is demonstrated in these serial graphs. (a) Represents the impact on patient's perception/physical reaction to premature graying. (b) Represents the psychological impact of premature graying. (c) Represents the impact of premature graying on social life and the felt need for medical care. X-axis represents the item wise analysis of the parameter being evaluated and the questions being asked, with different colored bars representing scores accorded by the respondents (ranging from 0 to 3), Y-axis represents the number of subjects giving the score|
Click here to view
Regarding the impact on social and professional domains, it was found that 27 (51.9%) subjects denied any hesitation in participating in social events or any impairment of concentration. Interpersonal relationships were also not markedly affected with 26 (50%) subjects noticing no effect and 7 (13.5%) subjects noticing only a mild effect. The felt need of treatment was very high with 40 (76.9%) recording a strong need for an active intervention; and only 2 (3.8%) subjects denying that any therapeutic intervention is required [Figure 2]c.
| Discussion|| |
Premature canities is a common but incompletely understood disorder in terms of etiopathogenesis, clinical profile as well as management. It assumes importance in Indian population, which has dark brown to black hair making even a few strands of gray hair stand out prominently. As the disease affects the young age group and is a cosmetic concern, it is speculated to have a tremendous impact on the QoL of the patients. Our study threw some light on this aspect in Indian patients.
The mean modified DLQI score of patients with premature canities was found to be very high, viz., 16.4 ± 5.9; with 43 (82.7%) of the patients reporting an extremely large effect (10/52 [19.23%]) to very large effect (33/52 [63.46%]) on the QoL. A significantly high impact on QoL has been recorded in patients suffering from hair disorders such as alopecia areata and androgenetic alopecia. A study from Kuwait documented a significantly high mean DLQI of 13.54 in patients with alopecia areata.
A comprehensive review of the use of DLQI in dermatology (1994–2007) shows that the psychological impact of many of the so-called benign skin conditions such as alopecia, acne, contact dermatitis is far greater than that of cutaneous lupus erythematosus. A study from Thailand also showed the mean DLQI score in patients with systemic sclerosis to be 6.3 ± 5.97, far lower than the mean DLQI for other skin disorders such as vitiligo (8.8), fungal infections (6.5), and urticaria (14.1) evaluated in the same population. Many a times, there is a discrepancy between patient's perception of the disease and the physician's interpretation. Thus dermatological disorders though seemingly benign have often been found to be associated with a high impairment of the QoL, e.g., discoid lupus erythematosus (DLE), a relatively benign condition as compared to systemic lupus erythematosus (SLE), has been found to be associated with a higher DLQI scores (12.42 ± 6.24 in DLE vs. 6.5 ± 6.02 in SLE).
On further analysis of individual questions in the present study, it was observed that the highest impact of graying was on psychology and a felt need of medical care. Mood fluctuations and a sense of guilt in terms of not taking adequate care of their hair were recorded to be very strongly present among these patients. Many of the patients came up with statements such as “hamari hi galti hai, hamne apne balon ka dhyan nahi rakha, isliye baal safed ho gaye hai” (it's my own mistake, I have not taken adequate care of my hair, that's why they have turned gray). The ability to concentrate at work and participate at different events are relatively well preserved, probably because graying of hair presents just as a cosmetic disfigurement and does not drag one's attention unless someone points out, quite unlike an itchy skin condition like atopic dermatitis would. Hence, although many patients (46 [88.5%]) complained of embarrassment due to their gray hair and had to tolerate frequent comments from peers and seniors alike; only a few of these ended up having trouble in relationships with close friends or family members, as reported by 19 (36.6%) of the patients. The patients feared being called as “aged” due to graying of hair, by their friends. As most of the patients were adolescents and conscious of their image, about 37 (71.1%) subjects tried to hide the condition by change in hair style or use of natural coloring agents such as henna. More than a third of the patients (20 [38.5%]) thought the condition was contagious and transmitted by sharing of combs. It was interesting to know that even the patient's parents had such notions thereby consciously avoiding sharing of combs, which is otherwise a common practice. Such practices increase the anxiety and guilt in the young patients. They are at a vulnerable age and already going through a lot of physical and mental changes and personality development. The resultant guilt and mood fluctuations can have a long-term detrimental effect.
This impact on QoL was higher than that for many other disorders, as discussed previously.
Such a high incidence of impact on QoL for this seemingly mundane disorder in this, especially vulnerable age group, strongly points toward a need to recognize and give due importance to premature canities in an attempt to correct it or at least improve the condition. The present study is the first attempt of its kind to assess and document the impact of premature canities on QoL in Indian patients. As the modified DLQI is an easy and rapid means of evaluation of the impact on QoL, it can be used in regular outpatient department also. Moreover, the study documents the varying degree of impact on different spheres of lives in a patient suffering from premature canities.
The study is a first and humble attempt of its kind and does suffer from some major limiting factors. The study was a preliminary study involving a limited sample size restricted to Indian patients. Moreover, inclusion of a control group could have added more value to the results. Further factors that can affect the QoL such as socioeconomic strata and education level of parents and subjects can also be taken into consideration for a more wholesome assessment.
| Conclusion|| |
Thus, premature canities, often considered as a mundane disorder of little significance, seems to have a huge impact on the QoL of the sufferers. The worst affected is the psyche of the patient, such as mood fluctuations and a sense of guilt. The felt need for medical care was also high with sufferers actively seeking treatment for premature canities. Despite a high impact on QoL, the ability to concentrate on work and participate in social activities seems not to be perturbed. The study assumes significance as most of the patients are adolescents who are vulnerable to comments and criticism.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) – A simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6.
Trüeb RM. Pharmacologic interventions in aging hair. Clin Interv Aging 2006;1:121-9.
Odom RB, James WD, Berger TG. Diseases of the skin appendages. In: James WD, Berger TG, Odom RB, editors. Andrew's Diseases of the Skin Clinical Dermatology. 9th
ed. Philadelphia: WS Saunders; 2000. p. 955.
Al-Mutairi N, Eldin ON. Clinical profile and impact on quality of life: Seven years experience with patients of alopecia areata. Indian J Dermatol Venereol Leprol 2011;77:489-93.
Basra MK, Fenech R, Gatt RM, Salek MS, Finlay AY. The dermatology life quality index 1994-2007: A comprehensive review of validation data and clinical results. Br J Dermatol 2008;159:997-1035.
Chularojanamontri L, Sethabutra P, Kulthanan K, Manapajon A. Dermatology life quality index in Thai patients with systemic sclerosis: A cross-sectional study. Indian J Dermatol Venereol Leprol 2011;77:683-7.
Kulthana K, Jiamton S, Wanitphakdeedecha R, Chantharujikaphong S. The validity and reliability of Dermatology Life Quality Index (DLQI) in Thais. Thai J Dermatol 2004;20:113-23.
Martins PR, Skare T, Ferrari TA, Silva AP, Alessio BF. Comparative analysis of the quality of life of patients with discoid lupus erythematosus and systemic lupus erythematosus with skin injuries. An Bras Dermatol 2012;87:326-8.
[Figure 1], [Figure 2]