|Year : 2014 | Volume
| Issue : 2 | Page : 81-89
Impact of vitiligo in afflicted patients
Shilpa Garg1, Rashmi Sarkar2
1 Department of Dermatology, Army College of Medical Sciences, Base Hospital, Delhi Cantonment, India
2 Department of Dermatology, Maulana Azad Medical College, New Delhi, India
|Date of Web Publication||15-Dec-2014|
22/11 Geeta Mandir Marg, New Rajinder Nagar, New Delhi - 110 060
Source of Support: None, Conflict of Interest: None
Diseases affecting the skin are visible to others; therefore, patients with skin diseases not only cope with the effect of the disease, but also with the reaction of people to their disease. Skin color plays an important role in an individual's perception of health, desirability, worth and wealth. Vitiligo presents as milky-white patches in the skin and/or mucosae which can result in psychosocial distress and social stigmatization. Vitiligo has a profound impact on the quality of life (QoL) of the patient. Vitiligo affects emotional, physical, social, psychological and occupational aspects of the QoL of an individual. An empathetic and supportive doctor-patient interaction, information regarding vitiligo, prompt treatment, good social support, psychotherapeutic interventions or psychotropic therapy can help the patient to live with their disease, and to manage the associated psychosocial and psychiatric comorbidity.
Keywords: Anxiety, Depression, Emotions, Psychological stress, Quality of life, Vitiligo
|How to cite this article:|
Garg S, Sarkar R. Impact of vitiligo in afflicted patients. Pigment Int 2014;1:81-9
| Introduction|| |
Quality of life (QoL) is defined by the World Health Organization, as an individual's perception of their position in life, in context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.  QoL is measured in three domains: Physical functioning (functional difficulties, symptoms), psychological state (emotional and cognitive functions) and social interaction (public relations, daily activities and work). Both subjective (self-assessment of physical and mental condition, social situation, interpersonal relation) and objective (medical or psychological diagnosis, laboratory tests and socioeconomic status) factors affect the QoL of the patient. It is important to measure the QoL, in order to evaluate the nonclinical aspects of the disease, holistic understanding of the disease, recognize the psychological and functional limitations, choosing a treatment and improving the doctor-patient relationship. 
Disorders of pigmentation can influence the social interactions of an individual, as the patient has to cope not only with the effects of the disease, but also to the response of people. Vitiligo affects about 1-4% of the world population, and presents as milky-white patches over the skin and/or mucosa which can result in psychosocial distress and social stigmatization. Although the disease is disfiguring in all the races, it is particularly more so in darker skinned individuals, due to the strong contrast. Though considered as a harmless cosmetic dermatological disorder in the Western-European countries, vitiligo is considered as a major medical problem in India, as it can lead to social exclusion. Vitiligo was often confused with leprosy, which leads to greater stigmatization of those affected and was referred as "Sweta Kustha,", which means "White leprosy." Vitiligo patients in India face social problems, as the disease is associated with social beliefs like people who have vitiligo are considered to have done "Guru Droh" in their previous life. Furthermore in India, vitiligo spoils the chances of a young women who are getting married, and may result in divorce in those who is affected by the disease after marriage.  Vitiligo along with leprosy and malaria were ranked as one of the three major medical problems in India by Pt Jawaharlal Nehru, former Prime Minister of India.
Quality of life measures help in evaluating the extent of disability due to skin diseases in a standardized and quantitative manner. Vitiligo affects physical, social, psychological and occupational aspects of the QoL of an individual.  Various dermatology specific questionnaires have been used to measure the QoL in vitiligo patients, and recently a vitiligo-specific scale containing 25 items was developed by Senol et al.  [Table 1].
Literature search was performed using PubMed database feeding in the following key words: QoL in vitiligo, psychosocial impact of vitiligo and vitiligo.
| Emotional Impact of Vitiligo|| |
Numerous studies have reported the psychosocial impact of vitiligo in patients, which is the most important factor that affects the QoL in patients with vitiligo. The psychological factor is derived from various symptoms of depression, anger, anxiety, self-consciousness, and embarrassment that are felt by the patients of vitiligo.  These patients are often glared at and avoided due to disgust and fear of infection. The significant discrepancy between the dermatologist's and the patient's assessment of the vitiligo severity gives a clue about the psychosocial factors, which contribute to the morbidity associated with vitiligo. 
In a study conducted by Linthorst Homan et al.  QoL was assessed in 245 multiracial adult patients (≥18 years) with generalized vitiligo. These vitiligo patients had a low mental Health Related Quality of Life (HRQL), which was comparable to the patients with other major skin diseases like eczema, , hand eczema  and psoriasis. ,,, Emotional problems in vitiligo patients were of comparable severity to patients having acne, , psoriasis, , eczema  and chronic hand dermatitis.  Another study reported that the mean Dermatology Life Quality Index (DLQI) score in women with vitiligo was 6.45, which was comparable with patients having psoriasis.  However, in another study with 25 patients,  was found that the patients with vitiligo felt less impaired as compared to those with psoriasis in terms of choice of clothes, job discrimination, social relations and embarrassment. In a study by Radtke et al.  it was found that the mean DLQI and EuroQol (EQ-5D) in vitiligo patients were 7.0 and 83.6 respectively, as compared to 8.6 and 75.3 in psoriasis patients. The QoL was severely reduced in 24.6% patients with vitiligo and 34.1% patients with psoriasis. For achieving complete remission, 32.9% of the vitiligo patients were willing to pay greater than 5000 Euro. Willingness to pay (WTP) in patients with vitiligo was significantly correlated with the DLQI scores, duration of the disease and with the affected body surface area. The significantly reduced QoL and high values of WTP in patients with vitiligo indicate the negative influence of vitiligo on the patient's life.
Vitiligo was associated with feeling of embarrassment, and interfered with patient's choice of clothing.  In various other studies, impairment of QoL was predicted by the extent of disease and self-assessed disease severity. ,, In the study by Houman et al.  on patients with generalized vitiligo with Fitzpatrick skin type IV-VI, having vitiligo on chest and undergoing treatment in the past had a negative impact on HRQL. In contrast to this study, in which vitiligo patients with darker skin type had a negative impact on HRQL, a study by Porter and Beuf.  reported no significant association between the race and the overall self-esteem and degree of disturbance caused by vitiligo. In patients with African descent, QoL was moderately impaired in patients with vitiligo with mean DLQI score being 7.2. This could be due to the sharp contrast of vitiligo patches with the dark skin.  In Indian patients  with greater than 10% body surface area involvement, the mean DLQI was found to be 10.67, which was even higher than that found in patients with African descent.
Patients with involvement of head/face/neck were particularly bothered by the disease.  Schmid-Ott et al.  found that the stigmatization experienced by the patients with vitiligo was not related to the location of vitiligo lesions. In contrast to this finding, Linthorst Homan et al.  reported that the location of vitiligo on chest was significantly associated with the emotion and functioning scales, and the sum score of the Skindex-29 and vitiligo involving the face and the hands had no negative impact on the HRQL. In contrast to the study by Schmid-Ott et al.  who found itching to be only rarely associated with vitiligo lesions, Linthorst Homan et al. reported pruritus in 20% of vitiligo patients. Another study observed that the face and other uncovered areas were particularly bothersome for the patients. 
The majority of the studies on HRQL in vitiligo have used the DLQI. In these studies ,,,,, a negative impact was found on the psychosocial functioning of the patient. The DLQI score in various studies has ranged from 4.94 to 15. ,, In a study  of 614 vitiligo patients, 35% patients had scored above threshold on the General Health Questionnaire (GHQ) indicating psychological distress. 59% patients had experienced a relevant incidence of vitiligo affecting their lives in the past 3 weeks which was related to their lower self-esteem, increased levels of perceived stigma and disability, and younger age; and was unrelated to the disease involvement. Higher scores in GHQ were reported by patients who were using camouflage, avoided activities and relevant incidence of emotional or negative reactions by others (like embarrassment, anger, frustration). These results suggest that those patients who feel that they are not able to cope with their own, as well as others' reactions, are more prone to distress and disability by vitiligo or vice versa. The mean score of DLQI was 4.82, which were related to the perceived stigma, GHQ, race and self-esteem. This suggests that interventions made to target these variables may have a potential benefit on the level of disability.  A study  reported that 75% patients with vitiligo found their disfigurement to be moderately or severely intolerable. An Indian study  of 150 vitiligo patients found an inverse correlation between the DLQI scores and response to treatment suggesting the role of an additional psychological approach.
Sampogna et al.  found that the problems of QoL, which were 'often' or 'all the time' experienced by the vitiligo patients were: Worry of worsening of the disease (60%), anger (37%), embarrassment (34%), depression (31%), affected social life (28%) and shame (28%). Vitiligo patients who were at greater risk for impairment in QoL were: women, patients above 40 years of age, and patients with vitiligo patches located on the feet, legs and arms. Patients with a family history of vitiligo were found to be significantly less worried by their disease as compared to patients with no family history of vitiligo. Rumpf et al.  used Skindex-29 to validate the self-administered version of the Pictorial Representation of Illness Measure in 333 vitiligo patients. This pictorial representation of illness was found to correlate significantly, with disease activity, perceived impairment of outward appearance, mental health and Skindex subscales of emotions and functioning. The validity of this measure is supported by the correlation with the psychological variables. A non-validated Tunisian translation of the Skindex-29 was used in 60 dermatological patients, and showed that the QoL was worst in patients with psoriasis (n = 20), followed by vitiligo (n = 20), and lastly in onychomycosis (n = 20). Low HRQL was seen in the emotional and functioning scales in 20 vitiligo patients in another study. 
In studies by Porter et al. ,, it was found that two-thirds of the patients were embarrassed by vitiligo and over 50% patients felt ill at ease, anxious, concerned and worried about vitiligo. One-third of the patients reported interference in their sex life due to vitiligo. Although friends and family members were perceived as supportive by 80% of the patients, patients were uncomfortable meeting strangers, as they felt that strangers were less understanding. Many patients felt stigmatized by their disease, as they often felt stared at, felt discriminated against and were subjected to rude remarks. Patients with vitiligo experienced psychological problems such as depression, shame and anxiety, which lead to social isolation and low self-esteem. Patients younger than 40 years and those who belonged to the working class felt more embarrassed, self-conscious and discriminated.
In a study  of 158 patients with vitiligo, sexual relationship was negatively impacted in < 23% patient mostly due to embarrassment. It was seen predominantly in those with low self-esteem, to whom appearance was more important, those who were single and in men. Hence, overall development of self-esteem was thought to be helpful. Women felt more embarrassed, and were more self-conscious of their disease as compared to men, and it impaired their social life, sexual activity, personal relationships and choice of clothing.  The mean DLQI score in children with vitiligo was 11.68, which was higher than 7.74 in children with atopic dermatitis and 0.62 in controls. The low QoL in children with vitiligo was critical in the psychosocial development. 
| Impact on Occupation|| |
Vitiligo patients often have to take leave from their jobs due to their hospital appointments for treatment like psoralen-ultraviolet-A (PUVA) therapy; and hence, suffer financial losses. These patients also face restricted career choices as the lesions that are present on the exposed body sites adversely affect their chances in the job interviews. Not only the patient, but also the parents of children with vitiligo have to take leave from work in order to accompany the child to the hospital. 
| Psychiatric Morbidity|| |
Vitiligo patients from India suffer more social problems, as compared to other countries.  The prevalence of psychiatric co-morbidities in vitiligo patients from India was found to be 16-34% using the GHQ, whereas the prevalence of psychiatric co-morbidities in patients with psoriasis was 24-53%. ,, In an Indian study by Sharma et al.  30 patients each of psoriasis and vitiligo were evaluated and compared for the psychiatric morbidity. The prevalence of psychiatric morbidity which was assessed using the GHQ-H was 53.3% in patients with psoriasis and 16.7% in patients with vitiligo, the difference being statistically significant (P = 0.0028). Prevalence of depression was 23.3% in psoriasis, and 10% in patients with vitiligo; with prevalence of anxiety being 3.3% in each group. Disturbance in sleep was the most common complaint in both the groups and was present in 56.6% patients with psoriasis and 20% in patients with vitiligo, the difference being statistically significant (P = 0.0034). Suicidal ideation and suicidal attempt was present in 23.3% and 3.3% respectively, in psoriasis patients; and in 13.3% and 6.7% respectively, in vitiligo patients, the difference being statistically insignificant. There was no statistically significant difference between interpersonal conflicts and somatic complaints between the 2 groups of patients. In both the groups there was no correlation between the extent of the skin disfigurement with the psychiatric morbidity suggesting that the extent of skin involvement was not important as a single factor. In another Indian study by Mattoo et al.  psychiatric morbidity was assessed in 113 patients with vitiligo and 103 patients with psoriasis using the GHQ. Psychiatric morbidity was present in 33.63% patients with vitiligo and 24.7% patients with psoriasis. The International Classification of Diseases-10 psychiatric disorders in the GHQ positive patients were: Adjustment disorders (56% vs. 62%), depressive episodes (22% vs. 29%) and dysthymia (9% vs. 4%) in patients with vitiligo and psoriasis respectively. In contrast to this study the most common standardized psychiatric disorders reported in other studies were neurotic depression (50%) and anxiety neurosis (20%) in patients with vitiligo, , and depressive disorders (50-97%) and anxiety disorders (15-50%) in patients with psoriasis. ,, Depression, anxiety and total psychopathology levels as assessed by the comprehensive psychopathological rating scale were found to be similar in the vitiligo and psoriasis GHQ positive subgroups in the study done by Mattoo et al.  There was significant correlation between the psychopathology, dysfunction and behavior change; and all of these were more prominent in patients with vitiligo as compared to patients with psoriasis.  Picardi et al.  found that the female patients who had vitiligo on the visible body parts had increased psychiatric morbidity. Sampogna et al.  used the Skindex-29 in 32 vitiligo patients and found the psychiatric morbidity to be strongly associated with poorer HRQL in the emotions and functioning scales. In another study by Sampogna et al.  vitiligo patients were found to have a higher prevalence of anxiety or depression (39%) and alexithymia (24%) than the general population. There was a significant and very strong association between the QoL impairment and psychological problems.
Mood disturbances such as irritability and depression were commonly seen especially in teenagers. Children with vitiligo would avoid or restrict their sports activities and lose vital days at school. Vitiligo beginning in the childhood caused significantly greater psychological trauma and may have a lasting impact on the self-esteem.  The manner in which the children deal with their disease depends on the attitude of their sibling, parents, friends, teachers, baby sitters etc. 
The prevalence of psychiatric co-morbidities in patients with vitiligo in UK  was 35%, and in Italy it was 25%.  The Indian studies ,, showed that 56-75% of GHQ-positive patients had adjustment disorders. The prevalence of various psychiatric diagnosis and symptoms in patients with vitiligo were: Dysthymia (7-9%), depression (10%), depressive episode (18-22%), sleep disturbance (20%), suicidal thoughts (10%), anxiety (3.3%) and suicidal attempts (3.3%). Though the psychiatric co-morbidity correlated significantly, with psychological dysfunction and change in the social behavior seen in vitiligo patients, it did not correlate well with the extent or severity of the disease. , Severe depression can lead to suicide attempts.  The psychiatric morbidity caused by skin disorders can be predicted better by the impact of the disease on the QOL of the patients than by a physician's evaluation of the clinical severity of the disease. , Due to the high prevalence of psychiatric morbidity in various studies ,,,, it is suggested that psychiatric evaluation should be done for chronic and stigmatizing disease like vitiligo. Patients with psychological distress, and those with formal psychiatric disorders may need referral, and can be identified using a self-rating questionnaire like GHQ-12.  It is important to screen and identify such patients as the appropriate treatment of their psychiatric disorder can reduce the psychological distress, improve their QoL, enhance the adherence to treatment and increase the patient satisfaction. ,
| Psychological Influence and Vitiligo|| |
There is no certain evidence of the role of stress in vitiligo. Papadopoulos et al.  conducted a retrospective study on 73 vitiligo patients and found that the patients with vitiligo had encountered significantly, higher number of stressful situations in life as compared to matched patients who had skin disease, which was not thought to be associated with stress, suggesting the role of psychological distress in the onset of vitiligo. However, stress events were not found to have a role in vitiligo in another study on 31 vitiligo patients.  In this study, it was found that certain personality characteristics such as alexithymia, poor social support and insecure attachment increased the susceptibility of vitiligo patients. This was probably related to a deficiency in the regulation of emotions or decreased ability to cope up with stress. 
Stress is thought to affect the immune system, increases the levels of neuroendocrine hormones, and alters the levels of neuropeptides and neurotransmitters. , Descending autonomic nerves have been found to stimulate the release of neuropeptides in the skin. , Skin biopsies from patients with nonsegmental vitiligo have found higher reactivity of neuropeptide and neuronal markers. , In patients with widespread and localized vitiligo, correlation has been found between the activity of vitiligo and the aberrations in the circulating neuropeptides, which also modulate the activity of the natural killer cells. , A significant increase in the circulating levels of norepinephrine in patients with primarily nonsegmental vitiligo as compared to controls suggest a probable link between the exacerbation of vitiligo and catecholamine-based stress.  These observations suggest an immunological hypothesis in the pathogenesis of vitiligo and propose a hypothetical psycho-neuro-endocrine-immunological pathogenesis in vitiligo. 
The potential of therapeutic implications regarding the effect of stressful events in vitiligo and the disease related stress in vitiligo are not very well established. However, there are few studies that suggest the advantage of psychosocial interventions and counseling in the treatment of vitiligo. Papadopoulos et al.  found that counseling may have a positive effect on the course of vitiligo. Parsad et al.  found that the response to treatment was less favorable in patients with higher DLQI scores. This suggests that recognizing and dealing with the psychological problem can be helpful in improving the treatment outcome in these patients.
| Coping Strategies Adopted by the Patient|| |
In order to cope with their chronic illness, patients usually develop strategies for regaining equilibrium.  Porter et al. , identified that around 20% of the patients adopted the strategy of 'active mastery' wherein the patients, who are self-conscious about their disease learnt to accept vitiligo with less embarrassment by learning about it. Around 40% of the patients had "passive acceptance" of their disease. These patients were not overly embarrassed by their disease, ignored it and made no special efforts to hide the vitiligo lesions. The rest 40% of the patients had "poor adjustment" with their disease. They made extra efforts to hide their skin lesions, were chronically embarrassed, withdrew from social interactions, and were depressed about their illness. The ability to cope with the disease is related to the level of self-esteem as people with positive self-image can cope better with their physical disabilities.  Patients who accepted their disease had a stronger self-esteem as compared to patients with "poor adjustment" whose self-esteem was less as compared to the normal controls.  Although the overall lower self-esteem of patients with psoriasis and vitiligo (n = 25) were comparable as compared to those without skin disease (n = 66), patients who had vitiligo were better adjusted with their disease as compared to those with psoriasis. This could be due to greater physical discomfort as well as more negative social response in patients with psoriasis.  In an interview with seven women with vitiligo, 2 strategies were identified. Behavioral strategies were focused on the problems and involved avoidance of situations and concealment of the vitiligo lesions. These though helpful in the short term, caused restriction in activities. The cognitive strategies were focused on the emotions. It dealt with modifying the patients feeling of being different and their interpretation of others' behavior. With this, a strategy of acceptance of difference was attained over a period, which was facilitated by social support; however, it was difficult to maintain this strategy.  In an attempt to hide their vitiligo lesions, many patients wore adapted clothing and applied large quantities of cosmetics. ,,
The negative response to vitiligo by other people was shown to cause greater embarrassment for the patient with vitiligo and probably lead to lesser adjustment to the disease.  Poor adjustment among patients with vitiligo is related to discrimination by others, and is directly affected by the perceived stigmatization. ,, African American patients with vitiligo were more adjusted to their disease, which shows the critical role of patient's perception of a reassuring and a caring physician in adjusting with this disfiguring disease.  Age, race, gender, severity and visibility had no direct significant effect but had an indirect effect on the adjustment to vitiligo due to their effects on stigmatization and perceived discrimination. ,
| Effectiveness of Therapeutic Interventions on QoL in Vitiligo Patients|| |
Quality of life measures are a tool to assess the effectiveness of the treatment and along with the cost effectiveness of the treatment will be used for allocation of the health care resources in the management of chronic diseases. In a study, evaluating the safety and efficacy of narrow-band ultraviolet B (NB-UVB) in children with generalized vitiligo, it was found that a significant improvement in the QoL, paralleled the degree of repigmentation obtained.  Studies have shown the beneficial effect of the cosmetic camouflage on the DLQI in patients with disfiguring skin diseases including vitiligo. , Camouflage was shown to improve the "feeling of embarrassment and self-consciousness" and "choice of clothing" in vitiligo patients.  Studies have been done to assess the impact of lifestyle-altering interventions on QoL in vitiligo patients by assessing the effectiveness of psychological therapy using Cognitive Group Therapy  and camouflage.  Studies have also been done to assess the effect of disease-altering interventions on the QoL of vitiligo patients.  These included interventions like occlusive treatment in enhancing the efficacy of topical tacrolimus 0.1%,  transplantation of the noncultured epidermal cellular graft,  use of twice weekly NB-UVB along with 250 mg oral polypodium leucotomus versus NB-UVB and placebo,  308 nm excimer laser and topical hydrocortisone 17-butyrate cream versus 308 nm excimer laser,  PUVA and 8-methoxypsoralen tablets versus NB-UVB with placebo tablets,  NB-UVB versus initial NB-UVB and calcipotriol versus placebo treated areas  and 150 mg oral levamisole tablets versus placebo tablets on 2 consecutive days of the week.  All these studies using either lifestyle-altering or disease-altering interventions showed, that all type of interventions in vitiligo patients resulted in improvement in their QoL measured using dermatology specific QoL instruments regardless of their effect on repigmentation. These findings should instil confidence in the dermatologist to recommend treatment with the above mentioned therapies for their vitiligo patients, as it can improve their QoL even if complete repigmentation were not achieved.
| Approach to the Patient with Vitiligo|| |
There is a need for information and reassurance in patients with vitiligo, as these patients experience anxiety due to the spreading depigmenting lesions, and are worried as they appear different from others. Patients have reported shortcomings in their interaction with the physician. ,, The studies showed that 45% of the vitiligo patients felt that their queries regarding vitiligo were not adequately answered by a doctor.  Around 50% of the patients were inadequately informed regarding the cause, course and treatment of vitiligo. , The patients also perceived that their physicians were unconcerned and insensitive. The patients who felt embarrassed by their disease, received only limited emotional support from their treating physician, and wished that they were assured of their interest by the physician. This suggests the significance of supportive physician-patient interaction.  Caring and reassuring interaction with the physician helps the patient to adjust to vitiligo. A good social support can help the patient in developing strategies to accept their difference by self-talk, reducing distress, and encouraging exposure to feared situations. According to the dermatologist in Netherlands 'giving information and reassurance concerning the nature of the disease' was considered as the most important aim in the treatment of vitiligo patients.  Providing supportive measures and counseling the patients regarding various causes, and the natural course of vitiligo are considered to be essential components of a good treatment. Counseling can improve the body image, QoL and self-esteem of the patient and can influence their ability to cope and live with vitiligo and its consequences. The beneficial effect of counseling was sustained at 5 months of follow-up.  Apart from information and supportive interaction with the treating physician, the psychosocial and psychiatric comorbidity in vitiligo patients can be treated with psychotropic agents and psychotherapeutic interventions. , Studies have reported the beneficial effect of interventions that target the perceived stigma or self-esteem on the level of disability caused by vitiligo. ,
The importance of treatment in vitiligo is underestimated. In a survey, around 80% of the respondents had never used any form of treatment for vitiligo, suggesting inadequate information.  Many patients were told that there was no treatment for their disease.  In a study, 60% of the patients had never taken any treatment for their vitiligo, and around 72% patients were not currently on any treatment at the time of survey. , Majority of the dermatologist in Netherlands considered vitiligo, as a benign cosmetic problem, and did not offer any treatment to the patients, most probably due to the low effectiveness of the treatment.  Similarly, the Belgian dermatologists were also reluctant in treating vitiligo due to the poor treatment outcome.  Studies have reported that around 60% of the patients who received treatment for vitiligo found that the treatment to be partially effective, and worthwhile. , The new emerging therapies and evidence based guidelines should help the physicians to change their outlook towards this disease and improve the treatment of their patients. Even the incomplete results achieved by the treatment can help in reducing the psychological burden of the disease.  Patients should be treated as soon as possible, irrespective of the localization and size of the lesion. , Physician's encouragement plays an important role in motivating the patient for treating their disease. Good interpersonal skills of the physician determine the patient's satisfaction with care and compliance with treatment.
| Measures to Improve the QoL in Vitiligo Patients|| |
Presence of psychosocial stress and psychiatric comorbidity related to vitiligo can have implications in the management of this disease. It is important for the dermatologist to recognize and understand the psychosocial and the psychiatric comorbidities, and consequences of vitiligo, so that they can deal with them. Therefore, it is essential for the doctor to have an empathetic approach; and a good doctor-patient relationship is the first step in improving the QoL in vitiligo patients. Physician's good interpersonal skills with vitiligo patients can increase a patient's satisfaction and his compliance to treatment. 
Management of vitiligo should include evaluation of the psychological (psychiatric comorbidity and psychological aspects of daily life) and social (effects on occupational and social functioning) factors along with the dermatological factors. , In a busy set up, at least psychosocial evaluation should be done, as this is a good predictor of the psychiatric comorbidity. This can be done using a standardized questionnaire or by asking the patient "How is your vitiligo affecting your daily life?" While evaluating the psychosocial aspect, it is important to make a note of the patient's life situation such as attitude of intimates, social support network, and work. It is also important to consider the localization of the vitiligo lesions as even a "mild" disease in the "emotionally charged" body sites such as face, head and neck areas may be particularly, debilitating to the patients. , A multidisciplinary approach can be adapted, for treating patients with vitiligo. Psychologist can treat symptoms of anxiety and depression through cognitive-behavior therapy, stress management program, dermatological education and other structured educational programes. Prevention of secondary psychiatric diseases such as anxiety and depression, which are caused by the chronic nature of the diseases, should be considered.
Vitiligo must be treated with the available options for treatment, and patients should not be dismissed due to incomplete success with treatment. Patients should be informed regarding the various available options of treatment. This can reduce the psychosocial burden of the disease, improve the compliance to treatment and increase the patient's satisfaction.
It is also essential to evaluate the effect of treatment and other interventions on the psychosocial disability in patients with vitiligo.
Online groups and support communities for vitiligo can improve the QoL by providing support, educational resources and advice.
| Conclusion|| |
Vitiligo has a profound impact on the QoL of the patient. An empathetic and supportive doctor-patient interaction, information regarding vitiligo, prompt treatment, good social support, psychotherapeutic interventions or psychotropic therapy can help the patient to live with their disease and to manage the associated psychosocial and psychiatric comorbidity. More trials are needed to measure the QoL and effectiveness of psychological therapy in patients with vitiligo.
| References|| |
WHOQOL Group. Measuring Quality of Life: The Development of the World Health Organization Quality of Life Instrument (WHOQOL). Geneva: WHO; 1993.
Teovska Mitrevska N, Eleftheriadou V, Guarneri F. Quality of life in vitiligo patients. Dermatol Ther 2012;25 Suppl 1:S28-31.
Parsad D, Dogra S, Kanwar AJ. Quality of life in patients with vitiligo. Health Qual Life Outcomes 2003;1:58.
Senol A, Yücelten AD, Ay P. Development of a quality of life scale for vitiligo. Dermatology 2013;226:185-90.
Gupta MA, Gupta AK. Psychiatric and psychological co-morbidity in patients with dermatologic disorders: Epidemiology and management. Am J Clin Dermatol 2003;4:833-42.
Linthorst Homan MW, Spuls PI, de Korte J, Bos JD, Sprangers MA, van der Veen JP. The burden of vitiligo: Patient characteristics associated with quality of life. J Am Acad Dermatol 2009;61:411-20.
Holm EA, Wulf HC, Stegmann H, Jemec GB. Life quality assessment among patients with atopic eczema. Br J Dermatol 2006;154:719-25.
Lundberg L, Johannesson M, Silverdahl M, Hermansson C, Lindberg M. Health-related quality of life in patients with psoriasis and atopic dermatitis measured with SF-36, DLQI and a subjective measure of disease activity. Acta Derm Venereol 2000;80:430-4.
Wallenhammar LM, Nyfjäll M, Lindberg M, Meding B. Health-related quality of life and hand eczema - a comparison of two instruments, including factor analysis. J Invest Dermatol 2004;122:1381-9.
Shikiar R, Willian MK, Okun MM, Thompson CS, Revicki DA. The validity and responsiveness of three quality of life measures in the assessment of psoriasis patients: Results of a phase II study. Health Qual Life Outcomes 2006;4:71.
Wahl A, Hanestad BR, Wiklund I, Moum T. Coping and quality of life in patients with psoriasis. Qual Life Res 1999;8:427-33.
Wahl A, Moum T, Hanestad BR, Wiklund I. The relationship between demographic and clinical variables, and quality of life aspects in patients with psoriasis. Qual Life Res 1999;8:319-26.
Lasek RJ, Chren MM. Acne vulgaris and the quality of life of adult dermatology patients. Arch Dermatol 1998;134:454-8.
Jones-Caballero M, Chren MM, Soler B, Pedrosa E, Peñas PF. Quality of life in mild to moderate acne: Relationship to clinical severity and factors influencing change with treatment. J Eur Acad Dermatol Venereol 2007;21:219-26.
Chren MM, Lasek RJ, Flocke SA, Zyzanski SJ. Improved discriminative and evaluative capability of a refined version of Skindex, a quality-of-life instrument for patients with skin diseases. Arch Dermatol 1997;133:1433-40.
Sampogna F, Picardi A, Chren MM, Melchi CF, Pasquini P, Masini C, et al.
Association between poorer quality of life and psychiatric morbidity in patients with different dermatological conditions. Psychosom Med 2004;66:620-4.
Fowler JF, Ghosh A, Sung J, Emani S, Chang J, Den E, et al.
Impact of chronic hand dermatitis on quality of life, work productivity, activity impairment, and medical costs. J Am Acad Dermatol 2006;54:448-57.
Ongenae K, Beelaert L, van Geel N, Naeyaert JM. Psychosocial effects of vitiligo. J Eur Acad Dermatol Venereol 2006;20:1-8.
Porter JR, Beuf AH, Lerner A, Nordlund J. Psychosocial effect of vitiligo: A comparison of vitiligo patients with "normal" control subjects, with psoriasis patients, and with patients with other pigmentary disorders. J Am Acad Dermatol 1986;15:220-4.
Radtke MA, Schäfer I, Gajur A, Langenbruch A, Augustin M. Willingness-to-pay and quality of life in patients with vitiligo. Br J Dermatol 2009;161:134-9.
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.
Kent G, al-Abadie M. Factors affecting responses on Dermatology Life Quality Index items among vitiligo sufferers. Clin Exp Dermatol 1996;21:330-3.
Parsad D, Pandhi R, Dogra S, Kanwar AJ, Kumar B. Dermatology Life Quality Index score in vitiligo and its impact on the treatment outcome. Br J Dermatol 2003;148:373-4.
Porter JR, Beuf AH. Racial variation in reaction to physical stigma: A study of degree of disturbance by vitiligo among black and white patients. J Health Soc Behav 1991;32:192-204.
Kiprono S, Chaula B, Makwaya C, Naafs B, Masenga J. Quality of life of patients with vitiligo attending the Regional Dermatology Training Center in Northern Tanzania. Int J Dermatol 2013;52:191-4.
Jayaprakasam A, Darvay A, Osborne G, McGibbon D. Comparison of assessments of severity and quality of life in cutaneous disease. Clin Exp Dermatol 2002;27:306-8.
Schmid-Ott G, Künsebeck HW, Jecht E, Shimshoni R, Lazaroff I, Schallmayer S, et al.
Stigmatization experience, coping and sense of coherence in vitiligo patients. J Eur Acad Dermatol Venereol 2007;21:456-61.
Zghal A, Zeglaoui F, Kallel L, Karmous R, Ben Ammar H, Labbane R, et al.
Quality of life in dermatology: Tunisian version of the Skindex-29. Tunis Med 2003;81:34-7.
Aghaei S, Sodaifi M, Jafari P, Mazharinia N, Finlay AY. DLQI scores in vitiligo: Reliability and validity of the Persian version. BMC Dermatol 2004;4:8.
Belhadjali H, Amri M, Mecheri A, Doarika A, Khorchani H, Youssef M, et al.
Vitiligo and quality of life: A case-control study. Ann Dermatol Venereol 2007;134:233-6.
Mechri A, Amri M, Douarika AA, Ali Hichem BH, Zouari B, Zili J. Psychiatric morbidity and quality of life in vitiligo: A case controlled study. Tunis Med 2006;84:632-5.
Papadopoulos L, Bor R, Legg C. Coping with the disfiguring effects of vitiligo: A preliminary investigation into the effects of cognitive-behavioural therapy. Br J Med Psychol 1999;72(Pt 3):385-96.
Kent G, Al'Abadie M. Psychologic effects of vitiligo: A critical incident analysis. J Am Acad Dermatol 1996;35:895-8.
Salzer BA, Schallreuter KU. Investigation of the personality structure in patients with vitiligo and a possible association with impaired catecholamine metabolism. Dermatology 1995;190:109-15.
Sampogna F, Raskovic D, Guerra L, Pedicelli C, Tabolli S, Leoni L, et al.
Identification of categories at risk for high quality of life impairment in patients with vitiligo. Br J Dermatol 2008;159:351-9.
Rumpf HJ, Löntz W, Uesseler S. A self-administered version of a brief measure of suffering: First aspects of validity. Psychother Psychosom 2004;73:53-6.
Porter J, Beuf A, Nordlund JJ, Lerner AB. Personal responses of patients to vitiligo: The importance of the patient-physician interaction. Arch Dermatol 1978;114:1384-5.
Porter J, Beuf AH, Nordlund JJ, Lerner AB. Psychological reaction to chronic skin disorders: A study of patients with vitiligo. Gen Hosp Psychiatry 1979;1:73-7.
Porter J, Beuf AH, Lerner A, Nordlund J. Response to cosmetic disfigurement: Patients with vitiligo. Cutis 1987;39:493-4.
Porter JR, Beuf AH, Lerner AB, Nordlund JJ. The effect of vitiligo on sexual relationships. J Am Acad Dermatol 1990;22:221-2.
Al Robaee AA. Assessment of quality of life in Saudi patients with vitiligo in a medical school in Qassim province, Saudi Arabia. Saudi Med J 2007;28:1414-7.
Dertlioglu SB, Cicek D, Balci DD, Halisdemir N. Dermatology life quality index scores in children with vitiligo: Comparison with atopic dermatitis and healthy control subjects. Int J Dermatol 2013;52:96-101.
Sharma N, Koranne RV, Singh RK. Psychiatric morbidity in psoriasis and vitiligo: A comparative study. J Dermatol 2001;28:419-23.
Mattoo SK, Handa S, Kaur I, Gupta N, Malhotra R. Psychiatric morbidity in vitiligo: Prevalence and correlates in India. J Eur Acad Dermatol Venereol 2002;16:573-8.
Mattoo SK, Handa S, Kaur I, Gupta N, Malhotra R. Psychiatric morbidity in vitiligo and psoriasis: A comparative study from India. J Dermatol 2001;28:424-32.
Attah Johnson FY, Mostaghimi H. Co-morbidity between dermatologic diseases and psychiatric disorders in Papua New Guinea. Int J Dermatol 1995;34:244-8.
Weiss MG, Doongaji DR, Siddhartha S, Wypij D, Pathare S, Bhatawdekar M, et al.
The Explanatory Model Interview Catalogue (EMIC). Contribution to cross-cultural research methods from a study of leprosy and mental health. Br J Psychiatry 1992;160:819-30.
Bharath S, Shamasundar C, Raghuram R, Subbakrishna DK. Psychiatric morbidity in leprosy and psoriasis - a comparative study. Indian J Lepr 1997;69:341-6.
Deshpande N, desai N, Mundra VK. Psychiatric aspects of psoriasis. Arch Indian Psychiatry 1998;4:61-4.
Picardi A, Abeni D, Renzi C, Braga M, Puddu P, Pasquini P. Increased psychiatric morbidity in female outpatients with skin lesions on visible parts of the body. Acta Derm Venereol 2001;81:410-4.
Hill-Beuf A, Porter JD. Children coping with impaired appearance: Social and psychologic influences. Gen Hosp Psychiatry 1984;6:294-301.
Picardi A, Abeni D, Melchi CF, Puddu P, Pasquini P. Psychiatric morbidity in dermatological outpatients: An issue to be recognized. Br J Dermatol 2000;143:983-91.
Cotterill JA, Cunliffe WJ. Suicide in dermatological patients. Br J Dermatol 1997;137:246-50.
Renzi C, Picardi A, Abeni D, Agostini E, Baliva G, Pasquini P, et al.
Association of dissatisfaction with care and psychiatric morbidity with poor treatment compliance. Arch Dermatol 2002;138:337-42.
Papadopoulos L, Bor R, Legg C, Hawk JL. Impact of life events on the onset of vitiligo in adults: Preliminary evidence for a psychological dimension in aetiology. Clin Exp Dermatol 1998;23:243-8.
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.
Farber EM, Rein G, Lanigan SW. Stress and psoriasis. Psychoneuroimmunologic mechanisms. Int J Dermatol 1991;30:8-12.
O'Leary A. Stress, emotion, and human immune function. Psychol Bull 1990;108:363-82.
Al'Abadie MS, Kent GG, Gawkrodger DJ. The relationship between stress and the onset and exacerbation of psoriasis and other skin conditions. Br J Dermatol 1994;130:199-203.
Hautmann G, Panconesi E. Vitiligo: A psychologically influenced and influencing disease. Clin Dermatol 1997;15:879-90.
Al'Abadie MS, Senior HJ, Bleehen SS, Gawkrodger DJ. Neuropeptide and neuronal marker studies in vitiligo. Br J Dermatol 1994;131:160-5.
Katsambas AD, Schulpis KH, Antoniou CH, Rigopoulos D, Papakostandinou ED, Stratigos J. Beta endorphin serum levels in patients with vitiligo. J Eur Acad Dermatol Venereol 1994;3:22-26.
Mozzanica N, Villa ML, Foppa S, Vignati G, Cattaneo A, Diotti R, et al.
Plasma alpha-melanocyte-stimulating hormone, beta-endorphin, met-enkephalin, and natural killer cell activity in vitiligo. J Am Acad Dermatol 1992;26:693-700.
Thompson AR, Kent G, Smith JA. Living with vitiligo: Dealing with difference. Br J Health Psychol 2002;7:213-25.
Porter J. The psychological effects of vitiligo: Response to impaired appearance. In: Hann SK, Nordlund JJ, editors. Vitiligo: A Monograph on the Basic and Clinical Science. Oxford: Blackwell Science; 2000. p. 97-100.
Porter JR, Beuf AH. The effect of a racially consonant medical context on adjustment of African-American patients to physical disability. Med Anthropol 1994;16:1-16.
Njoo MD, Bos JD, Westerhof W. Treatment of generalized vitiligo in children with narrow-band (TL-01) UVB radiation therapy. J Am Acad Dermatol 2000;42:245-53.
Boehncke WH, Ochsendorf F, Paeslack I, Kaufmann R, Zollner TM. Decorative cosmetics improve the quality of life in patients with disfiguring skin diseases. Eur J Dermatol 2002;12:577-80.
Holme SA, Beattie PE, Fleming CJ. Cosmetic camouflage advice improves quality of life. Br J Dermatol 2002;147:946-9.
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.
Chan MF, Chua TL. The effectiveness of therapeutic interventions on quality of life for vitiligo patients: A systematic review. Int J Nurs Pract 2012;18:396-405.
Hartmann A, Bröcker EB, Hamm H. Occlusive treatment enhances efficacy of tacrolimus 0.1% ointment in adult patients with vitiligo: Results of a placebo-controlled 12-month prospective study. Acta Derm Venereol 2008;88:474-9.
van Geel N, Ongenae K, Vander Haeghen Y, Vervaet C, Naeyaert JM. Subjective and objective evaluation of noncultured epidermal cellular grafting for repigmenting vitiligo. Dermatology 2006;213:23-9.
Middelkamp-Hup MA, Bos JD, Rius-Diaz F, Gonzalez S, Westerhof W. Treatment of vitiligo vulgaris with narrow-band UVB and oral Polypodium leucotomos extract: A randomized double-blind placebo-controlled study. J Eur Acad Dermatol Venereol 2007;21:942-50.
Sassi F, Cazzaniga S, Tessari G, Chatenoud L, Reseghetti A, Marchesi L, et al.
Randomized controlled trial comparing the effectiveness of 308-nm excimer laser alone or in combination with topical hydrocortisone 17-butyrate cream in the treatment of vitiligo of the face and neck. Br J Dermatol 2008;159:1186-91.
Yones SS, Palmer RA, Garibaldinos TM, Hawk JL. Randomized double-blind trial of treatment of vitiligo: Efficacy of psoralen-UV-A therapy vs Narrowband-UV-B therapy. Arch Dermatol 2007;143:578-84.
Hartmann A, Lurz C, Hamm H, Bröcker EB, Hofmann UB. Narrow-band UVB311 nm vs. broad-band UVB therapy in combination with topical calcipotriol vs. placebo in vitiligo. Int J Dermatol 2005;44:736-42.
Agarwal S, Ramam M, Sharma VK, Khandpur S, Pal H, Pandey RM. A randomized placebo-controlled double-blind study of levamisole in the treatment of limited and slowly spreading vitiligo. Br J Dermatol 2005;153:163-6.
Njoo MD, Bossuyt PM, Westerhof W. Management of vitiligo. Results of a questionnaire among dermatologists in The Netherlands. Int J Dermatol 1999;38:866-72.
Agarwal G. Vitiligo: An under-estimated problem. Fam Pract 1998;15 Suppl 1:S19-23.
Grimes PE, Kenney JA Jr. Should vitiligo be treated? Cutis 1983;32:343-4, 346.
Ongenae K, Van Geel N, De Schepper S, Vander Haeghen Y, Naeyaert JM. Management of vitiligo patients and attitude of dermatologists towards vitiligo. Eur J Dermatol 2004;14:177-81.