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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 28-33

A comparative study of psychosocial morbidity in stable versus unstable vitiligo


1 Dermatology Department, SKNMCGH, India
2 Department of Psychiatry, SKN Medical College, India
3 Preventive and Social Medicine Department, SKNMCGH, Pune, Maharashtra, India

Date of Web Publication29-May-2018

Correspondence Address:
Swapna S Khatu
OPD 6, Bldg. No. 1, Smt. Kashibai Navale Medical College, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/Pigmentinternational.Pigmentinternational_

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  Abstract 


Context: Vitiligo is a cosmetically disfiguring condition especially in dark-skinned individuals, thereby adversely affecting their quality of life (QOL). Studies have reported higher psychiatric morbidity in patients with vitiligo, but a comparative study between patients with stable and unstable vitiligo has not been reported.
Aims: To compare the psychiatric morbidity, perceived stress, and QOL in patients suffering from stable versus unstable vitiligo.
Settings and Design: This was a clinical observational, cross-sectional liaison study conducted over a period of 2 years and included 100 consecutive patients with vitiligo, who came for treatment to the dermatology clinic of a tertiary care hospital.
Materials and Methods: A dermatologist clinically assessed the patients and calculated their vitiligo area severity index score and dermatology life quality index. A psychiatrist evaluated the patients on the basis of the perceived stress scale (PSS), hospital anxiety and depression scale (HADS), and clinically established diagnosis using International Classification of Diseases (ICD-10).
Statistical Analysis: The aforementioned variables between the two groups were compared using chi-square test and independent t test.
Results: High psychiatric morbidity (65%) was reported in patients with vitiligo, with adjustment disorder being the most common morbidity. The most common reported stress was grief or emotionally significant loss. Psychiatric morbidity, scores on HADS, and PSS were significantly higher in patients with unstable vitiligo in comparison to patients with stable vitiligo. The quality of life (QOL) was mildly affected among the patients in both the groups.
Conclusions: There is higher psychiatric morbidity in patients with unstable vitiligo along with a worse QOL in comparison to those with stable vitiligo. Patients with vitiligo should be assessed for stability as well as psychiatric morbidity, because it will have significant management implications.

Keywords: Perceived stress in vitiligo, psychiatric morbidity in vitiligo, unstable vitiligo


How to cite this article:
Khatu SS, Deshpande SS, Gokhale NR, Khismtarao D, Chavan DC. A comparative study of psychosocial morbidity in stable versus unstable vitiligo. Pigment Int 2018;5:28-33

How to cite this URL:
Khatu SS, Deshpande SS, Gokhale NR, Khismtarao D, Chavan DC. A comparative study of psychosocial morbidity in stable versus unstable vitiligo. Pigment Int [serial online] 2018 [cited 2018 Oct 22];5:28-33. Available from: http://www.pigmentinternational.com/text.asp?2018/5/1/28/233459




  Introduction Top


Vitiligo is the most important cause for acquired depigmentation, with an average worldwide prevalence of 0.5–2%. In India, prevalence rates are up to 4–8.8%.[1],[2] Vitiligo is disfiguring in all races, but more profound among those with darker skin due to strong color contrast.

The presence of lesions on the exposed parts of the body (such as the face, neck, hands, and feet) is associated with a poor quality of life (QOL) and more stress, which is independent of the extent of disease. The involvement of the genitalia is also associated with a negative effect on the QOL, more so among girls.[1],[3]

Although vitiligo is completely asymptomatic, it causes various degrees of psychosocial impairment and an altered QOL.[1],[2],[4] Psychiatric morbidity in patients with vitiligo is high (16–34%), and mainly comprises adjustment disorders, depression, and dysthymic disorder.[2],[5],[6]

The role of stressful life events in the onset and exacerbation of vitiligo has been suggested by Silverberg and Silverberg[7] In addition, disease-related stress resulting from social stigma and impaired self-image may further exacerbate the disease and adversely affect the course of the disease.[8]

The concept of stability in vitiligo is crucial for deciding its management. Savant (1992). had mentioned it as 2 years, after which the chances of successful repigmentation after surgery are significantly high.[9],[10] This was the operational definition of stable vitiligo used in this study.

It was our clinical observation, patients suffering from unstable vitiligo were emotionally more disturbed. Hence, we planned a systematic study to compare these patients with patients having stable vitiligo and ascertain the nature of their emotional disturbances.

On literature search, there was no comparative study on psychological morbidity in stable versus unstable vitiligo. Therefore, this study set out to compare the perceived stress, anxiety, and depression in patients suffering from stable versus unstable vitiligo, who were attending a dermatology clinic.


  Materials and methods Top


Aim

To compare the perceived stress, anxiety, and depression in patients suffering from stable versus unstable vitiligo, who were attending our dermatology clinic.

Setting

This was a comparative clinical observational cross-sectional study conducted at a tertiary care hospital attached to a medical college. It was a liaison study, and assessment was done by both the dermatologist and psychiatrist. Permission was obtained from the institutional ethics committee (IEC) of the parent institute, and the study was conducted over a period of 2 years starting from January 2014. Data were collected after obtaining an informed written consent. During this period, 109 consecutive patients in the age group of 18–65 years and suffering from vitiligo attended our Outpatient Department of Dermatology. Both new cases as well as follow-up cases were enrolled in this study. Among these, nine patients were not willing for participation due to time constraint and unwillingness. They could not be included in the study. All the remaining 100 patients were interviewed for the study. Considering 4% prevalence of vitiligo and 99% confidence interval, using Epi Info software, the sample size was derived at 102.

Patients lacking insight or having concurrent clinically significant intellectual/cognitive impairment were excluded from this study. However, we did not come across any such patient in our study.

Methods

A dermatologist collected the demographic details (age, sex, gender, the age of onset, marital status, the family history of vitiligo, and information regarding the activity of disease). A history of stressful events experienced by the patients was also recorded. The development of new lesions and an increase in the size of the preexisting lesions in the last 2 years was considered as an unstable variant, whereas the development of no new lesions in the last 2 years was labelled as a stable variant of vitiligo.[8],[9] The localization of the disease was examined and classified depending on the visibility of lesion (vitiligo over the exposed area—the face, neck, and hands—and over the unexposed area, involving the covered parts of the body).

Tools

The severity of disease was calculated using the vitiligo area severity index (VASI).[11] We used a well-validated scale called the dermatology life quality index (DLQI) for the measurement of QOL, which was designed by Finaly and Khan.[12]

A psychiatrist clinically interviewed the patients and diagnosed psychiatric morbidity as per ICD-10 DCR (diagnostic criteria for research).[13] Perceived stress was calculated by perceived stress scale-4 (PSS4) consisting of a total of four questions about the patients perception of stress in the last 1 month with a five-point scale (0 = never, 1 = almost never, 2 = sometimes, 3 = fairly often, and 4 = very often).[14] The hospital anxiety and depression scale (HADS) was also administered.[15] This 12-item scale has been extensively used to assess symptoms of anxiety (six questions) and depression (six questions) in a clinical population in a reliable and valid way (Annexure).

Statistical test

All the outcome variables related to vitiligo, psychological parameters, and stress were compared between the patient groups in which the patients had stable and unstable vitiligo. The statistical tests used for comparison were chi-square test and independent t test.


  Results Top


A total of 100 patients suffering from vitiligo were studied. Out of these 100 patients, 65 were suffering from unstable vitiligo while 35 were having stable vitiligo. Their sociodemographic details are given in [Table 1]. Out of the 100 patients suffering from vitiligo, 48 were males and 52 were females. Most of the cases (61%) were in the age group of 21–40 years, and out of these, 37 patients (60.65%) were suffering from unstable vitiligo. Significantly more number of married patients had unstable vitiligo (P = 0.02). The family history of Vitiligo was comparable across the two groups.
Table 1: Sociodemographic variables

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The clinical characteristics of patients are described in [Table 2]. More number of patients with unstable vitiligo had lesions over the exposed parts of their body as compared to patients with stable vitiligo. This difference is statistically significant (P = 0.014). The mean duration of disease was less (62.55 months) in patients with unstable vitiligo as compared to stable patients (91.34 month). Mean VASI score was significantly lower (3.54) in patients of stable vitiligo as compared to the unstable cases (7.29).
Table 2: Clinical characteristics of vitiligo

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Psychological variables in vitiligo are described in [Table 3].
Table 3: Psychosocial variables

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Mean DLQI ranged from 0 to 24. Mean score was 5.78, mean DLQI was 6.52 in patients with unstable vitiligo cases, and 4.17 in patients with stable vitiligo. This difference was statistically significant (P = 0.02). Moreover, 31.4% of the patients with stable vitiligo had HADS score more than 11, which means they qualified as a psychiatric case. This was clinically significant, because it depicts anxiety–depression, necessitating treatment. Conversely, in patients with unstable vitiligo, this percentage was much higher (64.6%). Though the mean score of PSS was comparable in both groups, significantly more number of patients with unstable vitiligo had high perceived stress (41.5% in unstable versus 25.7% in stable vitiligo).

Psychiatric morbidity was higher in unstable vitiligo than in stable vitiligo. Adjustment disorder was the most common diagnosis followed by depressive disorder in both the groups. Surprisingly, none of the patients in either of the groups had any anxiety disorder [Table 4]. However, patients with unstable vitiligo were often emotionally disturbed. The cause of this was reported to be vitiligo itself according to six patients with unstable vitiligo. None of the patients with stable vitiligo reported stress due to vitiligo. An unpredictable course of vitiligo in terms of the fear of expansion of the preexisting lesions and the involvement of the exposed body parts was stressful for patients with unstable vitiligo. Significantly more number of patients with unstable vitiligo (58.5%) reported underlying stressful event as compared to patients with stable vitiligo (34.3%) (χ2 = 5.26, P = 0.022). Many of them had personal emotional stresses, which are summarized in [Table 5] and [Table 6]. The most common stressor was emotional loss (grief) in both the groups.
Table 4: Psychiatric morbidity (as per ICD-10) in stable and unstable vitiligo

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Table 5: Stressful event after which vitiligo started/exacerbated

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Table 6: Details of the stressful events

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The impact of psychiatric treatment on the course of vitiligo needs to be studied.


  Discussion Top


Importance of diagnosis of stable versus unstable vitiligo

In an Indian setting, the fear of vitiligo is significant especially among young, unmarried patients. Vitiligo per say need not affect the functioning of the patients, but stigma leading to anxiety and the avoidance of social situations significantly affects their QOL.

This leads to a desperate search for treatment to “cure” vitiligo. Although skin grafting is a promising treatment, it can be undertaken only if the vitiligo patches are stable over a period of time. Ongoing stress or depression is known to worsen vitiligo, making it unstable.

Psychiatric morbidity in vitiligo

High psychiatric morbidity in vitiligo (16–34%) has been reported in literature.[5],[6],[16]

This study had 65% of the patients with unstable vitiligo approaching a dermatologist as against only 35% with stable vitiligo. [Table 1] shows that the population between the two groups was comparable in terms of age and sex. Significantly higher numbers of patients with unstable vitiligo were married than in the stable vitiligo group, though there was no difference across the age groups.

Family history of Vitiligo in the two groups was comparable and less (6 and 8%). Literature mentions that 7.7–50% of the patients reported to have a family history of the disease.[1]

[Table 2] reveals that 77.2% of the patients had lesions on the exposed parts of the body in the case of stable vitiligo as against 93.9% in the case of unstable vitiligo. This difference was statistically significant. During the interview, many reported that they tried to hide their patches by covering them with suitable clothing, and this reduced their stigma.

Though the stigma of vitiligo appears to be a main factor responsible for disturbing the mental health of these patients, we discovered other psychiatric morbidities in a much higher proportion.

[Table 3] shows that a very high number of patients with unstable vitiligo had morbid scores on the HADS than among those with stable vitiligo. Perceived stress was comparable across the two groups. Mean DLQI was 5.78 (DLQI was 6.52 in patients with unstable vitiligo and 4.17 in patients with stable vitiligo), which indicates moderate effect on the QOL. DLQI reported by Ongenae et al.[17] was 4.95 in Belgium, whereas Parsad et al. in India and Kostopoulou in France reported a higher mean DLQI of 10.67 and 7.17, respectively.[4],[18] However, they have not compared it across stable and unstable vitiligo.

[Table 4] describes the psychiatric morbidity across the groups. In this study, 67% of the patients had some psychiatric illness. This percentage was much higher as compared to other studies.[4],[5],[16]

Differences in method and study setting could be responsible for this. During the clinical interview of these patients, they initially denied any anxiety or depressive features, but changed their statement after developing a rapport with their interviewers. At the end of the interview, most of them were also willing to start intervention for their mental health problems. The use of a screening questionnaire may not be, thus, adequate to identify psychiatric morbidity in these patients. In our study, HADS revealed morbidity (score >11) in 53% of the cases.

Anxiety and depression were significantly higher in patients with unstable vitiligo than in those with stable vitiligo (P = 0.005), as per HADS. Overall psychiatric morbidity was also significantly higher in patients with unstable vitiligo (P = 0.049).

Stress and vitiligo

The most common psychiatric disorder was adjustment disorder [Table 4] followed by depressive disorder. This finding was similar to that by Ongenae et al.[19] We had asked the patients if they could recall any significant event temporally associated with onset or exacerbation of vitiligo. Their answers were manually grouped into different groups. The most common stress reported by 23 patients was either due to the loss of emotional support due to separation from family or death or a serious illness in a close family member. However, vitiligo was reported as the underlying stressor by only six patients with unstable vitiligo [[Table 5] and [Table 6]]. This has been reported by a recently published research by Silverberg and Silverberg[7] Their study emphasized on the etiological role of stress in vitiligo as against stress secondary to having vitiligo. This study infers the same. Earlier studies had also reported the association of stressful events preceding the onset of vitiligo.[20],[21] Neurobiological factors associated with the emotions of sadness and grief reaction need to be explored in future research. This will enlighten us on the neurohormonal mechanisms associated with the onset and exacerbation of vitiligo.

Limitation

There is a limitation in the results being generalized, because this was a hospital-based study. Other limitations of the study are relatively small sample size and cross-sectional data collection. The follow-up of patients after psychiatric intervention was beyond the scope of our study.


  Conclusion Top


Psychosocial morbidity is high in vitiligo cases, especially significantly more in patients with unstable vitiligo than in those with stable vitiligo. The assessment of every patient with vitiligo by a dermatologist must include this parameter regarding disease activity. It is important not only to choose the modality of treatment, namely, psoralene and utraviolet A therapy (PUVA), steroids, skin grafting, etc., but also to identify psychosocial morbidities in the person. These may have a causative role, and, importantly, their management will lead to a better QOL for the patient. The treatment of stress-induced emotional disorders in patients with unstable vitiligo may make the lesions stable, thereby enhancing the feasibility of surgical management. The authors are planning further research to scientifically confirm this possibility, which will make a significant difference in deciding strategies for the management of vitiligo.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
  References Top

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2.
Parsad D, Dogra S, Kanwar AJ. Quality of life in patients with vitiligo. Health Qual Life Outcomes 2003;1:58.  Back to cited text no. 2
    
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Ongenae K, Dierckxsens L, Brochez L, van Geel N, Naeyaert JM. Quality of life and stigmatization profile in a cohort of vitiligo patients and effect of the use of camouflage. Dermatology 2005;210:279-85.  Back to cited text no. 3
    
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Silverberg JI, Silverberg NB. Vitiligo disease triggers: Psychological stressors preceding the onset of disease. Cutis 2015;95:255-62.  Back to cited text no. 7
    
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Hautmann G, Panconesi E. Vitiligo: A psychologically influenced or influencing disease. Clin Dermatol 1997;15:879-90.  Back to cited text no. 8
    
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Savant SS. Autologous miniatures punch grafting in vitiligo. Ind J Dermatol Venereol Leprol 1992;58:310-4.  Back to cited text no. 9
    
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Sahani K, Parsad D. Stability in vitiligo: Is there a perfect way to predict it? J Cutan Aesthetic Surg 2013;6:75-82.  Back to cited text no. 10
    
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Bhor U, Pande S. Scoring systems in dermatology. Indian J Dermatol Venerol Leprol 2006;72:315-21.  Back to cited text no. 11
    
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Finaly AY, Khan GK. Dermatology life quality index—A simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6.  Back to cited text no. 12
    
13.
WHO. The ICD10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization 1993.  Back to cited text no. 13
    
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Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.  Back to cited text no. 14
    
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Zigmond AS, Snaith XX. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70.  Back to cited text no. 15
    
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Kent G, Abadie M. Psychologic effects of vitiligo: A critical incident analysis. J Am Acad Dermatol 1996;35:895-8.  Back to cited text no. 16
    
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Ongenae K, Van Geel N, De Schepper S, Naeyaert JM. Effect of vitiligo on self reported health-related quality of life. Br J Dermatol 2005;152:1165-72.  Back to cited text no. 17
    
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Kostopoulou P, Jouary T, Quintard B, Ezzedine K, Marques S, Boutchnei S et al. Objective vs. subjective factors in psychological impact of vitiligo: The experience from a French referral centre. Br J Dermatol 2009;161:128-33.  Back to cited text no. 18
    
19.
Ongenae K, Beelaert L, Van Geel N, Naeyaert JM. Psychosocial effects of vitiligo. J Eur Acad Dermatol Venereol 2006;20:1-8.  Back to cited text no. 19
    
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Picardi A, Pasquini P, Cattaruzza MS, Gaetano P, Melchi CF, Baliva G et al. Stressful life events, social support, attachment security and alexithymia in vitiligo. A case control study. Psychother Psychosom 2003;72:150-8.  Back to cited text no. 20
    
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Papadopoulos L, Bor L, Legg C, Hawk JL. Impact of life events on the onset of vitiligo in adults: A preliminary evidence for a psychological dimension in aetiology. Clin Exp Dermatol 1998;23:243-8.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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