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Brigham Eyebrow Tool for Alopecia: A Reliable Assessment of Eyebrow Alopecia Areata

  • Author Footnotes
    7 These authors contributed equally to this work.
    Elizabeth Tkachenko
    Footnotes
    7 These authors contributed equally to this work.
    Affiliations
    Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    University of Massachusetts Medical School, Worcester, Massachusetts, USA
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  • Author Footnotes
    7 These authors contributed equally to this work.
    Kathie P. Huang
    Footnotes
    7 These authors contributed equally to this work.
    Affiliations
    Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Department of Dermatology, Harvard Medical School, Boston, Massachusetts, USA
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  • Justin M. Ko
    Affiliations
    Department of Dermatology, Stanford School of Medicine, Stanford, California, USA
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  • Kristina J. Liu
    Affiliations
    Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Department of Dermatology, Harvard Medical School, Boston, Massachusetts, USA
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  • Deborah A. Scott
    Affiliations
    Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Department of Dermatology, Harvard Medical School, Boston, Massachusetts, USA
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  • Maryanne M. Senna
    Affiliations
    Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA

    Department of Dermatology, Harvard Medical School, Boston, Massachusetts, USA
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  • Sara J. Li
    Affiliations
    Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Department of Dermatology, Harvard Medical School, Boston, Massachusetts, USA
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  • Cara J. Joyce
    Affiliations
    Health Sciences Division, Loyola University, Chicago, Illinois, USA
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  • Arash Mostaghimi
    Correspondence
    Correspondence: Arash Mostaghimi, Department of Dermatology, Brigham and Women’s Hospital, 75 Francis Street, PBB-B 421, Boston, Massachusetts 02115, USA.
    Affiliations
    Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Department of Dermatology, Harvard Medical School, Boston, Massachusetts, USA
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  • Author Footnotes
    7 These authors contributed equally to this work.
      There are no tools to evaluate eyebrow involvement in patients with alopecia areata. We developed and assessed the reliability of the Brigham Eyebrow Tool for Alopecia (BETA) as a quantitative evaluation of eyebrow alopecia areata. BETA uses facial landmarks of eyebrow anatomy and is calculated using surface area and density. A total of 50 eyebrow images with varying levels of hair loss were distributed to six board-certified dermatologists at three academic medical centers with standardized instructions and examples. Interrater and intrarater reliability were calculated using intraclass correlation coefficients (ICCs). BETA demonstrated high interrater (ICC = 0.88, confidence interval = 0.83–0.92 right eyebrow scores and ICC = 0.90, confidence interval = 0.85–0.94 left eyebrow scores) and intrarater (ICC = 0.90, confidence interval = 0.85–0.93 right eyebrow scores and ICC = 0.91, confidence interval = 0.87–0.94 left eyebrow scores) reliability. When measured in the same patient with varying degrees of hair loss over time, BETA demonstrated sensitivity to change. BETA is a simple and reliable objective assessment of eyebrow alopecia areata. BETA is easy-to-use and quick to calculate, making it feasible for a variety of clinical and research settings. Although developed for alopecia areata, we hope that BETA will be investigated in other etiologies of eyebrow alopecia to serve as a universal tool for monitoring disease progression, improvement, and response to treatment.

      Abbreviations:

      AA (alopecia areata), BETA (Brigham Eyebrow Tool for Alopecia)

      Introduction

      Alopecia areata (AA) is an autoinflammatory disease of hair loss that can have a profound negative impact on QOL, self-esteem, and mental health (
      • Hunt N.
      • McHale S.
      The psychological impact of alopecia.
      ,
      • Liu L.Y.
      • King B.A.
      • Craiglow B.G.
      Health-related quality of life (HRQoL) among patients with alopecia areata (AA): a systematic review.
      ). AA can affect hair on the scalp, face, or elsewhere on the body, with eyebrows and/or eyelashes involved in 76% of patients (
      • Liu L.Y.
      • King B.A.
      Response to tofacitinib therapy of eyebrows and eyelashes in alopecia areata.
      ). Eyebrow involvement can be particularly distressing, as the eyebrow is a defining facial feature important not only for aesthetics but also for communication, emotional expression, and identity (
      • Harries M.J.
      • Sun J.
      • Paus R.
      • King Jr., L.E.
      Management of alopecia areata.
      ,
      • Hunt N.
      • McHale S.
      The psychological impact of alopecia.
      ,
      • Jabbour S.
      • Nasr M.
      • Kechichian E.
      • Aderian S.S.
      • Nseir I.
      • Levan P.
      • et al.
      The evolution of eyebrow morphology: the Westmore model revisited.
      ,
      • Yalçınkaya E.
      • Cingi C.
      • Söken H.
      • Ulusoy S.
      • Muluk N.B.
      Aesthetic analysis of the ideal eyebrow shape and position.
      ). There is no validated instrument to evaluate the degree of eyebrow hair loss in patients with AA. The Severity of Alopecia Tool is a validated assessment for scalp hair loss severity that uses surface area and density, allowing for consistent endpoints for patient evaluation and research (
      • Olsen E.A.
      • Hordinsky M.K.
      • Price V.H.
      • Roberts J.L.
      • Shapiro J.
      • Canfield D.
      • et al.
      Alopecia areata investigational assessment guidelines--part II. National Alopecia Areata Foundation.
      ,
      • Olsen E.
      • Hordinsky M.
      • McDonald-Hull S.
      • Price V.
      • Roberts J.
      • Shapiro J.
      • et al.
      Alopecia areata investigational assessment guidelines. National Alopecia Areata Foundation.
      ). A similar tool is needed for eyebrow alopecia to monitor disease progression, improvement, and response to treatment. We developed the Brigham Eyebrow Tool for Alopecia (BETA) and validated its use for the assessment of eyebrow alopecia in patients with AA.

      Results

      Interrater reliability (absolute agreement) had an intraclass correlation coefficient of 0.88 (confidence interval = 0.83–0.92) for right eyebrow scores and 0.90 (0.85–0.94) for left eyebrow scores. Intrarater reliability (consistency) had an intraclass correlation coefficient of 0.90 (0.85–0.93) for right eyebrow scores and 0.91 (0.87–0.94) for left eyebrow scores.
      When measured in the same patient with varying degrees of hair loss over time, BETA appropriately increased with increased eyebrow hair growth (Figure 1). This pattern highlights the utility of BETA for tracking alopecia over time.
      Figure thumbnail gr1
      Figure 1Average BETA scores over time in the same patient with varying degrees of eyebrow hair loss at monthly intervals during treatment (a–d). Right refers to the patient’s right. Copyright 2019, 2020 Brigham and Women’s Hospital (Boston, MA). All rights reserved. BETA, Brigham Eyebrow Tool for Alopecia.

      Discussion

      Our data suggest that BETA is a reliable and effective tool that provides a standardized, quantitative method to evaluate eyebrow AA. BETA is straightforward, easy-to-use, and quick to calculate, making it feasible for clinical practice and trials. BETA demonstrated high interrater and intrarater reliability across multiple raters.
      These findings must be considered in the context of the study design. The BETA was validated in photographs, not in live patients. However, given the ease of establishing landmarks from photographs for eyebrow hair loss, the performance in face-to-face patient encounters will likely be very similar. In addition, because there is no existing tool to evaluate eyebrow alopecia, there is no “gold standard” for comparison to our reviewer scoring. The face validity, high reliability of BETA scores between reviewers, and responsiveness to change suggest the reproducibility and accuracy of results using this tool.
      Although clinical severity of hair loss is not always predictive of disease impact and QOL in patients with alopecia (
      • Reid E.E.
      • Haley A.C.
      • Borovicka J.H.
      • Rademaker A.
      • West D.P.
      • Colavincenzo M.
      • et al.
      Clinical severity does not reliably predict quality of life in women with alopecia areata, telogen effluvium, or androgenic alopecia.
      ), an objective tool to assess AA of the eyebrow is needed to evaluate patients and for research. In combination with forthcoming patient-reported outcomes, we hope this tool will provide a comprehensive assessment of this critical aspect of AA. Future efforts will focus on the continued validation of this tool across other types of alopecia.

      Materials and Methods

      Tool development and design

      BETA was developed by alopecia experts at Brigham and Women’s Hospital using existing criteria of landmarks and ratios for eyebrow anatomy, adapted from the original Westmore guidelines (

      Westmore MG. Facial cosmetics in conjunction with surgery. Paper presented at the Aesthetic Plastic Surgical Society Meeting. 4–8 May 1975; Vancouver, BC.

      ,
      • Yalçınkaya E.
      • Cingi C.
      • Söken H.
      • Ulusoy S.
      • Muluk N.B.
      Aesthetic analysis of the ideal eyebrow shape and position.
      ). In BETA, the medial eyebrow margin (a) is defined by the vertical line from the mid-nare, and the lateral eyebrow margin (d) is defined by the line from the alar-facial groove through the lateral canthus (Figure 2). The mid-pupillary (b) line is drawn vertically through the pupil, and the eyebrow arch (c) is angled from the top of the philtrum through the pupil. These landmarks aid in establishing the maximum (100%) potential eyebrow surface area.
      Figure thumbnail gr2
      Figure 2BETA: (a) instructions and (b–e) sample calculations. Copyright 2019, 2020 Brigham and Women’s Hospital (Boston, MA). All rights reserved. BETA, Brigham Eyebrow Tool for Alopecia.
      BETA was modeled similarly to the Severity of Alopecia Tool, which is calculated using scalp surface area and density of terminal hairs. In BETA, hair density is defined as degree of eyebrow hair present on a scale of 0–3 (0 = absent, 3 = very dense), and surface area is defined as the extent of eyebrow area covered (0–100%), accounting for missing or skipped lesions (Figure 2). Each eyebrow score is obtained by multiplying density by surface area (range 0–3). The BETA score is the sum of the right and left eyebrow scores (range 0–6).

      Validation

      This study was approved by the Partners Institutional Review Board. A set of 50 eyebrow images of patients with varying degrees of eyebrow AA hair loss and gain throughout their treatments were distributed to six board-certified reviewers from three academic medical centers. Each reviewer independently assessed the photographs after reviewing standardized instructions and examples (Figure 2). A total of 25 of the images represented unique patients, whereas the other 25 represented seven patients at different time points with varying levels of eyebrow alopecia. The photographs were presented in random order and included a range of hair loss from the complete absence of eyebrow hair to full density and surface area of eyebrow hair.

      Statistical analysis

      Internal reliability of BETA was computed using intraclass correlation coefficients (Table 1), in which absolute agreement represents interrater reliability, and consistency represents intrarater reliability.
      Table 1ICCs for Cases Across Six Raters


      Measures
      ICC (95% CI)
      Absolute AgreementConsistency
      Right
       Density0.80 (0.73–0.87)0.81 (0.74–0.88)
       Surface area0.55 (0.43–0.67)0.57 (0.45–0.69)
       BETA0.88 (0.83–0.92)0.90 (0.85–0.93)
      Left
       Density0.83 (0.76–0.89)0.85 (0.79–0.90)
       Surface area0.58 (0.46–0.70)0.59 (0.48–0.71)
       BETA0.90 (0.85–0.94)0.91 (0.87–0.94)
      Abbreviations: BETA, Brigham Eyebrow Tool for Alopecia; CI, confidence interval; ICC, intraclass correlation coefficient.

      Data availability statement

      Datasets available upon demand.

      Conflict of Interest

      JMK has received consulting fees from Eli Lilly, Concert Pharmaceuticals, and Arena Pharmaceuticals. KPH and AM have received royalty payments from Pfizer for licensing of the Alopecia Areata Assessment tool and have participated in clinical trials related to alopecia from Incyte, Eli Lilly, Concert, and Aclaris. KPH and AM have received consulting fees from Pfizer. AM has received consulting fees from Hims and 3Derm and has equity in Lucid and Hims.

      Acknowledgments

      This article is published as part of a supplement sponsored by the National Alopecia Areata Foundation .
      Funding for the Summit and publication of this supplement was provided by the National Alopecia Areata Foundation . This Summit was supported (in part) by the National Institute of Arthritis and Musculoskeletal and Skin Diseases under award number R13AR074890. The opinions or views expressed in this professional supplement are those of the authors and do not necessarily reflect the official views, opinions, or recommendations of the National Institutes of Health or the National Alopecia Areata Foundation.

      Author Contributions

      Formal Analysis: CJJ; Investigation: ET, KPH, AM; Project Administration: ET, KPH, AM; Resources: JMK, KJL, DAS, MMS, SJL, AM; Supervision: ET, KPH, AM; Writing - Original Draft Preparation: ET, AM; Writing - Review and Editing: ET, KPH, AM

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