Stress-Related Hair Loss Among the General Population in Al Majma'ah, Saudi Arabia: A Cross-Sectional Study

Background Hair loss is a prevalent concern affecting individuals worldwide, often attributed to various factors including genetics, hormonal changes, and stress. This study aims to investigate the prevalence of stress-related hair loss among the general population in Al Majma'ah, Saudi Arabia, and hair loss association with sociodemographic characteristics and risk factors. Methods A cross-sectional study was conducted involving 1080 participants. Data were collected through a structured questionnaire that encompassed sociodemographic factors, stress levels, psychosocial factors, and habits related to hair care and lifestyle. The data were analyzed using descriptive statistics, chi-square tests, and logistic regression analysis. Results The study revealed that 770 (71.3%) of participants reported experiencing hair loss, with females showing a higher prevalence compared to males 622 vs. 148 (78.2% vs. 51.9%). A significant relationship between age and hair loss was observed (Chi-x2 = 8.264, p-value = 0.016), with individuals aged 31 to 40 years experiencing hair loss more frequently 108 (80.6%). Stress was found to be a significant contributing factor to hair loss (χ^2 = 37.533, p < 0.001), with 674 (73.8%) of participants reporting stress. Moreover, stress levels exhibited a dose-response relationship with the severity of hair loss. Psychosocial factors, including personal relationship problems and financial difficulties, also demonstrated significant associations with hair loss (p-value = 0.005, 0.003, respectively). Conclusion The study underscores the considerable prevalence of stress-related hair loss among the general population in Al Majma'ah, Saudi Arabia. Stress, along with various sociodemographic and psychosocial factors, emerged as significant contributors to hair loss. These findings emphasize the need for holistic approaches that address both physiological and psychological aspects to mitigate the burden of hair loss in the community. Further research is warranted to explore the underlying mechanisms and develop targeted interventions for individuals at risk of stress-induced hair loss.


Introduction
Normally, people have between 100,000 and 150,000 hairs on their heads.Hair has a programmed life cycle: a growth phase (anagen), a resting phase (catagen), and a shedding phase (telogen).The number of strands lost in a day varies but on average is 50-100.These strands lost usually don't cause noticeable hair loss because new hair is growing simultaneously.If this growth-loss cycle is disrupted, then hair loss (alopecia or baldness) is seen [1].
Hair loss is a common complaint in clinical practice.It can be classified as scaring and non-scaring.The causes of hair loss can fall into focal or diffuse alopecia.Focal hair loss may be caused by non-scaring and scaring alopecia.Non-scarring focal alopecia is usually caused by tinea capitis, alopecia areata, traction alopecia, or trichotillomania (where a person compulsively pulls out or breaks their hair).Scarring focal alopecia is rare and has several causes, usually discoid lupus erythematosus.The diffuse alopecia includes male and female hair patterns, diffuse alopecia areata, alopecia totalis or universals, and telogen effluvium.Telogen effluvium can be triggered by physiologic stress, such as surgical trauma, high fever, and chronic systemic illness.Emotional stress, medical conditions such as hypothyroidism or hyperthyroidism, and dietary deficiency can also cause diffuse telogen effluvium which can be reversible once the condition has been treated.In addition, multiple drugs can cause telogen effluvia like oral contraceptive pills, androgens, retinoids, beta-blockers, angiotensin-converting enzyme inhibitors, anti-convulsants, anti-depressants, and anti-coagulants [2][3][4][5][6].
In humans, hair loss is often reported clinically during periods of excessive stress, and especially when hair loss does not indicate underlying organic disease it can be disturbing for hair loss patients and their doctors [7,8].It was therefore hypothesized that analogous to the animal models, in humans, stress activates neuroendocrine-immune circuits, which terminate hair growth in the absence of other clinically noticeable health disturbances [6,7].Soon a person goes through a stressful event, hairs can go into the resting phase.Hair loss often becomes noticeable two-to-six months after the trauma.
As stress has long been considered as one of the main causal factors involved in hair loss, information about stress and hair loss interaction should be well known.With respect to the connections between psychoemotional stress and hair loss, levels of interactions can be distinguished as acute or chronic stress as a primary inducer of telogen effluvium, acute or chronic stress as an aggravating factor in a hair loss disorder whose primary pathogenesis is of endocrine, toxic, metabolic, or immunological nature (e.g.AGA, alopecia areata) and stress as a secondary problem in response to prior hair loss.The latter might also contribute to the perpetuation or aggravation of hair loss and induce a self-perpetuating vicious circle [7].
Although there is a large body of research relating to stress and inflammation in animals and humans, which extensively examines cytokines and other pro-inflammatory effects of stress, only a small number of human studies have addressed the association between stress, immune response, and tissue regeneration in healthy, non-wounded humans, under prolonged, real life-stress exposure and as a result, no scientific evidence for stress-induced hair loss in humans is available to date [9][10][11].
Also, limited specific pharmacological intervention is currently available to manage stress-induced hair loss in men.An effective therapeutic intervention in this respect would have to prolong the anagen phase of the hair cycle, thus preventing the premature onset of catagen, which forms the basis of stress-induced telogen effluvium [12].
Limited research has been undertaken on the prevalence of hair loss and its relationship to stress in Al Majma'ah, KSA.This cross-sectional study will attempt to assess the prevalence of hair loss among the general population and to determine the relationship between stress and hair loss.
This study aims to determine the prevalence, causes of hair loss, and the relationship between stress and hair loss among the general population in Al Majma'ah, Saudi Arabia.

Study design
A descriptive cross-sectional community-based study was adopted to investigate the prevalence and factors associated with stress-related hair loss among the general population in Al Majma'ah, Saudi Arabia.

Participants
A randomized sample technique was recruited from the general population of Al Majma'ah.Inclusion criteria included being 18 years of age or older and willing to participate in the study.A sample size of 1080 participants was taken.

Data collection
Data were collected through an electronic pre-structured questionnaire, developed after expert consultation and extensive literature review.The questionnaire was designed in English language and translated to Arabic by an expert translator, and the data were collected in both Arabic and English language depending on what language the participant preferred.The questionnaire underwent validation by a panel of three experts to ensure its content validity and applicability.The reliability of the tool was assessed through a pilot study involving 15 participants, resulting in a reliability coefficient (α-Cronbach's) of 0.71 for the satisfaction and perception section.

Questionnaire structure
The self-administered online questionnaire comprised two main sections.Section 1 gathered sociodemographic information, including age, sex, marital status, occupation, nationality, BMI group, and monthly income.Section 2 explored factors related to hair loss and stress, including questions about hair

Data analysis
Descriptive statistics, including frequencies and percentages, were employed to summarize the sociodemographic characteristics of the participants.The chi-square test was utilized to examine associations between sociodemographic factors and hair loss.Logistic regression analysis was employed to determine the relationship between stress and hair loss, adjusting for potential confounding variables.

Ethical considerations
The research proposal obtained approval from the Regional Research and Ethics Committee in Al Majma'ah.Permission was sought from the Joint Program of Family Medicine in Al Majma'ah, as well as the directors of the primary healthcare centers involved in the study.
In terms of nationality, the overwhelming majority of participants were Saudi, accounting for 1029 (95.3%) of the total, while non-Saudi participants constituted 51 (4.7%).Marital status distribution showed that the majority of participants were single 810 (75%), followed by married individuals 242 (22.4%), and a smaller proportion of divorced/widowed participants 28 (2.6%).
Participants' daily study hours revealed that a substantial number reported not studying 372 (34.4%), while the highest proportion reported studying for 6 to 8 hours per day 357 (33.1%).When it came to daily working hours, a significant proportion were not working 554 (51.3%), while 243 (22.5%) reported working 6 to 8 hours per day.
Leisure activities and physical activity patterns were also explored.The majority of participants reported engaging in leisure activities for less than six hours per day 853 (79%), and physical activity for less than six hours per day 880 (81.5%).
When it came to dietary habits, 710 (65.7%) of participants reported not following a diet containing fruit, vegetables, and proteins, while 370 (34.3%) indicated that they did follow such a diet.
Participants' consumption of coffee and tea was also assessed.The majority reported consuming one cup per day (356 participants (33%)), followed by two cups by 316 participants (29.3%) and three cups by 167 participants (15.5%).A smaller percentage reported consuming no coffee or tea 20 (1.9%), while 221 (20.5%) consumed more than three cups per day.
Smoking habits were analyzed, with the majority of participants indicating that they did not smoke954 (88.3%), while 126 (11.7%) reported being smokers.Additionally, family history of hair loss was explored, revealing that 483 (44.7%) of participants reported having a family history of hair loss, while 597 (55.3%) did not have such a history.
Table 1 presents the relationship between hair loss and various sociodemographic characteristics among the study participants.The analysis revealed several noteworthy patterns.Firstly, a statistically significant association was observed between sex and hair loss (χ^2 = 70.957,p < 0.001).Females exhibited a higher prevalence of hair loss 622 (78.2%) compared to males 148 (51.9%).Age also demonstrated a significant correlation with hair loss (χ^2 = 8.264, p = 0.016).Participants aged 31 to 40 years had the highest proportion of hair loss vs no hair loss, while the proportion decreased among those aged 41 to 68 and 18 to 30 (80.6% vs 76.1% vs 69.3%).Regarding marital status, a significant relationship was found (χ^2 = 13.476,p = 0.001), with divorced or widowed individuals showing a higher prevalence of hair loss 26 (92.9%).Interestingly, participants who reported not studying exhibited a higher prevalence of hair loss (285, 76.6%) compared to those still studying (485, 68.5%), demonstrating a statistically significant association (χ^2 = 11.053,p = 0.001).
Furthermore, participants who reported not working had a slightly higher prevalence of hair loss (391, 72.0%) compared to those who were working (379, 70.6%), although this association was not statistically significant (χ^2 = 0.132, p = 0.887).Notably, the presence of a family history of hair loss exhibited a strong correlation with hair loss (χ^2 = 41.466,p < 0.001), with individuals having a family history of hair loss showing a higher prevalence 392 (81.2%) compared to those without such a history378 (63.3%).The frequency of using heat to straighten hair per week was explored.Participants using heat "more than three times" 96 (8.5%) and "one time" 222 (20.6%) reported varying levels of hair loss, while those who did not use heat accounted for 526 (48.7%) of the sample.

As seen in
Combing habits were investigated, with "every day" combing reported by 543 (50.3%) of participants.The relationship between combing frequency and hair loss was notable, as participants who combed "more than three times" 151 (14%) and "three times" 131 (12.1%) also reported experiencing hair loss.
The frequency of shampooing per week was examined, with participants reporting varying levels of hair loss based on shampooing habits.Those who shampooed "every day" 219 (20.3%) and "more than three times" 249 (23.1%) showed different patterns of hair loss.
The impact of regular coloring on hair loss was assessed, with participants who reported "No" regular coloring accounting for 845 (78.2%) of the sample, and those reporting "Yes" comprising 235 (21.8%).
The relationship between self-reported hair loss and other factors such as the presence of a pathological condition associated with hair loss, stress levels, personal relationships, work or studying issues, and financial problems was analyzed.Interestingly, participants who reported suffering from hair loss during the stress period (558 (51.7%)) were almost equal to those who did not (522 (48.3%)).The participants' stress levels were further examined, revealing that varying levels of stress were associated with different proportions of hair loss.Those reporting "Moderate" stress (464 (43%)) and "Severe" stress (237 (21.9%)) showed different patterns of hair loss.
Moreover, the presence of depression signs was assessed, demonstrating a connection between depression and hair loss, as participants reporting "Yes" to depression signs accounted for 523(48.4%) of the sample, and 398(76.1%) of them suffered from hair loss.
hair health [11,13].However, the association between stress levels and the severity of hair loss necessitates further exploration to better understand the underlying mechanisms [11].
This study's findings hold implications for both clinical practice and public health initiatives.The comprehensive understanding of the interplay between stress, sociodemographic factors, and hair loss can guide healthcare professionals in developing personalized interventions.Public health campaigns targeting stress management and psychosocial well-being could potentially mitigate the burden of hair loss in the community.
Future research endeavors should delve deeper into the underlying physiological mechanisms linking stress with hair loss.Additionally, longitudinal studies could provide insights into the temporal dynamics of stressinduced hair loss and identify potential intervention windows.Exploring the impact of cultural norms and lifestyle factors specific to the Saudi Arabian context on hair health could further enrich our understanding.
Limitations of the current study is represented by the descriptive cross-sectional design that limits its evidence strength.Furthermore, as a questionnaire-based study, it is subjected to a recall bias in which participants are largely dependent on pure memory to answer the questions.Finally, as the study was conducted through an online survey only, the findings represented the study sample only and cannot be generalized.

Conclusions
In conclusion, this study significantly contributes to the growing body of knowledge on stress-related hair loss by shedding light on the prevalence, associated risk factors, and their interactions among the general population in Al Majma'ah, Saudi Arabia.The findings highlight the clear interplay between stress, sociodemographic characteristics, and hair loss.By advancing our comprehension of these relationships, this research paves the way for more targeted interventions to address hair loss and enhance overall wellbeing.

Table 2 ,
the hair type was examined in relation to hair loss, revealing that participants with different hair types reported experiencing hair loss at varying frequencies.Those with "Heavy curled" hair type comprised a smaller proportion (56, 5.2%) of the sample, while "Curled" (478, 44.3%) and "Straight" (546, 50.6%) hair types were more prevalent.