Hair transplantation, body dysmorphic disorder, and patients' attitude: A survey‐based study from south India

Dear Editor Male pattern hair loss (MPHL) is a common type of non-scarring alopecia which has been recognized to have significant psychological effects on affected patients. Hair transplantation is one of the most rapidly evolving procedures in aesthetic surgery. However, the availability of hair transplantation facility and the cost of the procedure remain as main barriers of this treatment in developing countries. Body dysmorphic disorder (BDD) is characterized by an exaggerated and excessive preoccupation and perceived abnormality of normal and physiological appearance. Harth and Blume-Peytavi reported higher incidence of hair loss complaints inpatients with BDD. Another study from Brazil reported around 30% of patients with BDD had complaints with hair loss. Studies have also reported that around 6% to 15% patients consulting cosmetic surgery have co-morbid BDD. It is well known that co-morbid BDD is a risk factor for negative outcomes following surgery.Retrospective reports suggest that persons with BDD rarely experience improvement in their symptoms with treatment leading some to suggest that BDD is a contraindication to treatment. In this study, we explored the attitude and willingness to receive hair transplantation among patients with MPHL and explored its association with body dysmorphic disorder to understand how body dysmorphic disorder is mediating the decision making for cosmetology consultation and hair transplantation. Anonline survey was conducted among 50 adult males (>18 years) with MPHL using Dysmorphic Concern questionnaire (DCQ) to assess BDD irrespective of type of MPHL or treatment status other than transplantation. Only the persons with good English literacy were included. An informed consent was obtained from each patient. Patients were also asked about their willingness for hair transplantation procedure using a customized questionnaire. Data was analyzed using SPSS version 21. Descriptive statistics like mean, SD and percentage were used. For inferential statistics, Chi-square/Fisher Exact test were employed and a P value of <. 05 was taken as statistically significant. Ethical approval for this study was obtained from the Institutional Ethics Committee of Iqraa International Hospital and Research Institute. Mean age of responders was 30.24 ± 8.7 years (Table 1). Number of married vs unmarried participants was equal. Vast majority of responders were either graduates or postgraduates (48% each). Common types of MPHL were Hamilton type I (32%), II (24%), and IV (22%). Only four patients had prior consultations to dermatologists or plastic surgeon. Median of the total score of BDD questionnaire was 3 (Interquartile range: 2,7). No significance was noted with marital status, affordability of hair transplantation with respect to total score. Those who had past consultations had very high total score (8 vs 3) and the difference was significant (P = .0221; Two-sample Wilcoxon rank-sum [Mann-Whitney] test; Table 2). Same was seen in group who was ready to accept transplantation if given cheap option (5 vs 2, P = .0141; Two-sample Wilcoxon rank-sum [Mann-Whitney] test). Total score was higher among group who agreed that transplantation does improve quality of life (median 6 vs 3) and the difference was significant (P = .0148; Two-sample Wilcoxon rank-sum [Mann-Whitney] test). The major limitation of our study is a small size community study, among those who have not taken any decision on hair transplantation before. We used DCQ, a practical, seven-item questionnaire, which can be used in cosmetic practices to screen for BDD. Our study revealed that those with higher BDD score may opt for the procedure if there is a price reduction for the procedure. In today's business model of hair transplantation clinics, where various incentives and discounts are offered, our findings are crucial. Ignorance of such contexts may lead to inappropriate patient selection and subsequent increased risk of medico-legal complications. Our findings also point towards improvement in psychosocial situation among those who opt for hair transplant treatment.