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Trichodynia refers to pain, discomfort, and/or paresthesia of the scalp. Trichodynia may be associated with anxiety.
To assess serum vitamin B12, folate, thyroid stimulating hormone (TSH), ferritin, and zinc levels, and to investigate anxiety in telogen alopecia patients with trichodynia.
The study included 31 telogen alopecia patients who complained of trichodynia and 30 telogen alopecia patients without trichodynia. Their serum vitamin B12, folate, TSH, ferritin, and zinc levels were assessed and their anxiety levels were scored using the Beck Anxiety Inventory (BAI) and the State-Trait Anxiety Inventory (STAI).
No significant difference was found in the serum levels of vitamin B12, folate, TSH, ferritin, and zinc in the patient and control groups. The anxiety scores in both groups were similar.
Our data provide no evidence for the association of serum vitamin B12, folate, TSH, ferritin, and zinc levels or anxiety scores with trichodynia.
Telogen alopecia is a common complaint and cause of significant emotional distress, particularly in women. The best way to alleviate the anxiety is to treat hair loss effectively. It is critical to address the symptoms systematically. In addition to its psychological impact, hair loss may be a manifestation of a more general medical problem. Trichodynia (cutaneous dysesthesia syndrome) is the term given to the burning or stinging of the scalp related to diffuse alopecia. The etiology of trichodynia is still unknown and it may have a multi-etiological spectrum as vitamin and mineral deficiencies and psychiatric disorders.[2,3,4,5] Increased rates of psychiatric problems have been reported in patients with trichodynia; however, it is not known whether trichodynia is an equivalent of the depression seen in vulvodynia or is a specific pain disorder in the classification of somatoform disorders.[6,7]
Ferritin and thyroid stimulating hormone (TSH) levels in trichodynia patients have not yet been researched. The aim of this study is to measure the levels of serum vitamin B12, folate, TSH, ferritin, and zinc to evaluate the levels of anxiety in telogen alopecia patients with trichodynia.
Data collection for the study was accomplished during the 11 months from January to November 2011.
Patients with telogen alopecia of at least 6 months duration and who had not received any treatment were invited to participate in the study. Thirty-one consecutive telogen alopecia patients with trichodynia were enrolled in the study. Thirty telogen alopecia patients without trichodynia were included as a control group [Figure 1]. Telogen alopecia was diagnosed on the basis of patient history and a physical examination. Hair loss was evaluated using the pull test and a daily count. Biopsies were performed on suspected cases. A trichogram was also performed. The study participants were 16 years of age or older, literate, had telogen alopecia symptoms, but had no psychiatric, neurological, metabolic, or any other systemic illnesses.
In addition, and on the basis of self-reporting, patients with a current issue or a previous diagnosis involving psychoactive substance abuse were excluded. Patients with androgenic alopecia and other subtypes of hair loss were also excluded.
The subjects were asked about the presence of stinging, burning, or pain. Serum vitamin B12, folate, TSH, ferritin, and zinc levels of both groups were measured. Serum vitamin B12 and folate levels were measured by immunoanalysis assay using chemoluminescence (Immulite; Diagnostic Products, Los Angeles, CA, USA), and serum ferritin, TSH, and zinc concentrations were determined using hybrid generation atomic absorption spectrometry (AA-6701-HV6 atomic absorption spectrometer; Shimadzu, Tokyo/Japan).
The Beck Anxiety Inventory (BAI) and the State (STAI-S) and Trait (STAI-T) Anxiety Inventories were administered to all patients in a quiet environment. Instructions on how to complete the tests were given. Patients answered STAI-S questions according to their mood at the moment and to indicate how they state themselves generally when they fill in STAI-T. During this time, attention was paid not to use the words anxiety and depression.
Written informed consent was obtained from all the patients before enrollment. This study was approved by the ethics committee of the Faculty of Medicine at Kahramanmaras Sutcu Imam University.
The BAI is a self-report scale with 21 items. Possible scores range between 0 and 63. Increasing scores indicate increasing intensity of anxiety symptoms. The BAI was developed by Beck and was adapted for Turkish use by Ulusoy.[9,10] Patients with a BAI score between 0 and 17 were evaluated as having mild anxiety, those with a BAI score between 18 and 24 were evaluated as having moderate anxiety, and those with a BAI score higher than 24 were evaluated as having severe anxiety.
The STAI is a validated and widely used instrument to measure patients’ anxiety. The STAI-state (STAI-S) form consists of 20 statements, the answers to which are used to determine a patient's current anxiety level. The STAI-trait (STAI-T) form consists of a different set of 20 statements, the answers to which are used to determine a patient's underlying (ongoing/personality) anxiety level. Each statement in the STAI-S is rated on a 4-point scale for the subject's agreement with that statement (not at all, somewhat, moderately so, and very much so). This form was used at all time points of the study for both groups. Statements in the STAI-T are also rated on a 4-point scale (almost never, sometimes, often, and almost always). This form was used twice for each participant, once on entering the study and once on exiting the study. The overall (total) score for STAI ranged from a minimum of 20 to a maximum of 80.
Data were computerized using the Statistical Package for the Social Sciences (SPSS v. 15.0; SPSS Inc., Chicago, IL, USA). Independent sample t-tests, Chi-square tests, and Spearman correlations were used in the statistical analysis. Values are presented as mean ± standard deviation (SD) and as percentages. P < 0.05 (two-tailed) were considered statistically significant.
The mean age of the participants was 27.32 ± 9.39 years for the patient group and 26.06 ± 8.74 years for the control group. All participants were females. The socio-demographic variables for the study group are presented in Table 1. There was no significant difference between the patient and control groups in terms of their serum vitamin B12, folate, TSH, ferritin, and zinc levels (P > 0.05) [Table 2]. There was also no significant difference in the BAI or the STAI form STAI-S and STAI-T between the patient and controls groups (P > 0.05) [Table 3]. Of the telogen alopecia patients, 35 (57.4%) had BAI scores between 0 and 7, 15 (24.6%) had BAI scores between 18 and 24, and 11 (18%) had BAI scores of more than 25. It was observed that 16 (51.6%) patients with trichodynia had mild anxiety, 7 (22.6%) patients with trichodynia had moderate anxiety, and 8 (25.8%) patients with trichodynia had severe anxiety. For the control group, it was determined that 19 (63.3%) patients had mild anxiety, 8 (26.7%) patients had moderate anxiety, and 3 (10%) patients had severe anxiety. There was no statistically significant difference (P > 0.05) when comparing the anxiety scores of the patient and control groups. Although severe anxiety was higher than the control group in trichodynia, was not statistically significant. (P > 0.05). There was no correlation between serum vitamin B12, folate, TSH, ferritin, and zinc levels and anxiety scores for participants in the patient and control groups.
In this study, we found that trichodynia was not associated with abnormal serum levels of vitamin B12, folate, TSH, ferritin, and zinc. Trichodynia was also not associated with anxiety. This result was inconsistent with the results of other studies that found trichodynia associated with anxiety.[13,14,15] Our experiment included homogeneous groups of females and studied telogen alopecia (excluding other types of hair loss, such as androgenic alopecia). A control group with telogen alopecia but without trichodynia was also included (thus, the etiology of telogen alopecia was ruled out). Only trichodynia was studied. Therefore, the results of our study should be considered reliable.
Complaints such as pain, burning, stinging, and pruritus of the scalp in patients with diffuse alopecia were described by Sulzberger et al. in 1960, and these have also been mentioned in the earlier dermatology literature.[15,16] The cause of trichodynia is not yet fully understood,[2,3,5,15,17,18] although there is much speculation and some preliminary research. Changes in the production and activity of substance P in the skin or increased inflammatory cell activity may play a role.[5,18] Another explanation may be an underlying psychiatric disorder in the affected person.[2,3,4,5,6] Psychological sensitivity in patients with diffuse hair loss may be a cause of painful burning sensations.[2,3,5] It can be speculated that there is a close relationship between somatoform and depressive disorders and trichodynia.[19,20,21] Kivanc et al. found that trichodynia was associated with depression in their telogen alopecia group and with obsessive personality disorder in their androgenic alopecia group. Rebora et al. found trichodynia in 76 of 222 female patients complaining of hair loss (34.2%) and speculated that trichodynia and hair loss may be associated with peribulbar inflammation. Trüeb suggested a connection between trichodynia and psychopathologic findings (such as anxiety) in alopecia patients, particularly in females. Baldary et al. suggested trichodynia is almost exclusive to patients with active telogen effluvium and that it may be a marker of activity of an inflammatory peripilar process, as it probably is in telogen alopecia. Durusoy et al. suggested depressive and somatoform disorders may play an important role in the etiology of trichodynia, in contrast to another study in which anxiety was not elevated in trichodynia patients. The cause of this contradiction might be that unlike our study, the previous studies had taken the healthy subjects as control group.
Various types of nutritional deficiencies have been reported as etiological factors in a number of cutaneous dysesthesia syndromes. For example, glossodynia (“burning tongue” syndrome) is characterized by a burning sensation with clinically normal oral mucosa. Hormonal changes associated with menopause, psychogenic factors (including anxiety, depression, stressful life events, and personality disorders), and nutritional factors have also been suggested to cause glossodynia. There is increasing evidence that a neuropathic process underlies glossodynia symptoms. However, it should be noted that nutritional factors affect hair directly and dietary supplements containing B complex vitamins can influence hair growth. One study reported that the levels of serum zinc, folate, and vitamin B12 were found to be within normal ranges in patients with diffuse hair loss.[23,24] The levels of vitamin B12, folate, TSH, ferritin, and zinc in our study were normal according to our hospital reference ranges. Serum vitamin B12, ferritin, folate, and zinc levels were studied in only one trichodynia study previously. Similar to Durusoy et al., we found the serum levels of vitamin B12, ferritin, folate, TSH, and zinc were no different in the trichodynia and control patients. Also, similar to our study, Durusoy et al. reported that biochemical analysis did not reveal any association between serum zinc, folate, and vitamin B12 levels and trichodynia.
When interpreting our results, it is important to note some limitations of our study. First, our sample size was relatively small and may not be representative of all trichodynia patients. Second, telogen alopecia patients were not compared with healthy controls. Thus, we could not comment about the serum levels of vitamin B12, folate, TSH, ferritin, zinc, and the psychological status of telogen alopecia patients.
Our results indicate trichodynia is not associated with anxiety, serum vitamin B12, folate, TSH, ferritin, or zinc levels. More comprehensive, case-control studies are needed to determine the other factors associated with trichodynia.
Source of Support: Nil
Conflict of Interest: None declared.