|Year : 2015 | Volume
| Issue : 1 | Page : 28-33
Quality-of-life and psychosocial impact of vitiligo in Indian patients
Sacchidanand Sarvajnamurthy Aradhya1, Kavya Manjunath2, Kasturi3, Savitha Somaiah1
1 Department of Dermatology, BMCRI, Bengaluru, Karnataka, India
2 Department of Dermatology, Mandya Institute of Medical Sciences, Mandya, Bengaluru, Karnataka, India
3 Department of Psychiatry, BMCRI, Bengaluru, Karnataka, India
|Date of Web Publication||26-Jun-2015|
Department of Dermatology, OPD No. 13, Skin Opd, Mandya Institute of Medical Sciences, Mandya, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Vitiligo is a chronic pigmentary disorder affecting about 0.5-1% of the population. Although the disease is not life-threatening, it considerably influences the patient's quality-of-life (QoL) and psychological well-being. Aims: The aim was to assess the impact of clinical and sociodemographic variables that affect the generic and dermatological health-related QoL in vitiligo patients. Methods: The prospective cross-sectional study was conducted from February 2012 to February 2013 in the dermatology outpatient department of Bangalore Medical College and Research Institute. A total of 300 vitiligo patients and 300 healthy controls, who were matched on sociodemographic data, completed two questionnaires (general health questionnaire 28 items [GHQ-28] and Dermatologic Life Quality Index). Patients with higher scores in GHQ were further assessed for psychiatric illness by using mini international neuropsychiatric interview 5 questionnaire. SPSS statistical package was used for the analysis of the data. Results: The prevalence of psychiatric morbidity was 21.7% (65 patients). Female patients with vitiligo, patches on exposed parts of the body, longer duration of disease and past treatment history had an adverse impact on QoL. Conclusion: Our study concludes that QoL impairment and psychiatric morbidity is high in vitiligo patients. Hence, along with the medical intervention, it is important to assess the psychological and sociocultural aspects of the disease for better management of these patients.
Keywords: General health questionnaire-28, mini international neuropsychiatric interview 5, psychiatric morbidity, vitiligo
|How to cite this article:|
Aradhya SS, Manjunath K, Kasturi, Somaiah S. Quality-of-life and psychosocial impact of vitiligo in Indian patients. Pigment Int 2015;2:28-33
| Introduction|| |
The skin is the most visible organ of our body which determines to a great extent our appearance and plays a major role in social and sexual communication. In our society, appearance is very important, and it greatly influences the way we are perceived by others.  Vitiligo is no exception to these observations. With an incidence of about 1% of the total population, it is probably one of the most common causes of disfigurement due to skin diseases.  However, as it does not cause any direct physical impairment vitiligo is often considered as a mere cosmetic problem rather than a major skin disease. As skin color plays a major role in an individual's perception of health, wealth, and worth, pigmentary disfigurements like vitiligo cause severe psychosocial distress and social stigmatization. ,, It may also lead to social exclusion in certain societies. Therefore, vitiligo is considered to be one of the major medical problems in India. ,
Most of the studies worldwide have used only dermatology- specific health-related quality-of-life (HRQL) questionnaires and reported vitiligo had an adverse impact on HRQL, particularly on psychosocial functioning. ,,,, Only a few studies in vitiligo have used a combination of a generic and a dermatology specific HRQL questionnaire. , By using this combination, a wide range of domains and aspects of quality-of-life (QoL) can be assessed.
Our aim of the study was (i) to assess the prevalence of psychiatric morbidity among vitiligo patients (ii) to determine the generic HRQL and Dermatologic Life Quality Index (DLQI) in sociodemographically and clinically distinct subgroups of vitiligo patients and (iii) to know the associations between HRQL and sociodemographic and patient clinical characteristics.
| Methods|| |
The study was conducted from February 2012 to February 2013 in the dermatology outpatient department of our institute.
The sample comprised of two groups: (1) Patient group (n = 300), included all vitiligo patients attending the dermatology outpatient department of our institute. Exclusion criteria were age under 14 years, patients who had obvious intellectual impairment and difficulty or inability to communicate in English/Kannada. (2) Healthy control group (n = 300), included subjects recruited from the attendants/relatives of the patients attending the dermatology outpatient (excluding dermatology diseases such as psoriasis, vitiligo, and leprosy) of the institute. They were group matched with the patient group for sex, age, and education, and were to be free from any major physical or psychiatric illness. Institutional review board approval was obtained for this study and written informed consent was obtained from all the participating patients and controls.
Sociodemographic and clinical data
0A booklet specially designed for this study was used to record the relevant demographic data (age, gender, level of study, residential locations, marital status) and clinical information (disease duration, family history of vitiligo, treatment history, affected body sites (exposed/covered), percentage of body area affected and disease activity.
Psychological test inventories
- General Health Questionnaire-28 items (GHQ-28): is a self-report measure of psychological distress. It is a 28 items scaled measure for the mental health domains of severe depression, anxiety, social dysfunction, and somatic symptoms. We used the Kannada version of the questionnaire. This was used as a screening instrument and any person scoring ≥6 was considered to have psychiatric morbidity based on bimodal scoring system 
- Mini international neuropsychiatric interview (MINI) - English version 5 was used in our study as a brief structured interview for the major axis I psychiatric disorders in Diagnostic and Statistical Manual of Mental Disorders-IV and International Classification of Diseases-10. It is divided into modules consisting of 14 diagnostic categories like major depressive episode, suicidal tendency, manic episode, etc., At the beginning of each diagnostic module, screening questions corresponding to the main criteria of the disorder are presented. The questions are rated as either yes or no. At the end of each module, diagnostic boxes permit the clinician to indicate whether the criteria are met or not
- Dermatology Life Quality Index questionnaire by Finlay and Khan  was used to determine the QoL impairment in vitiligo patients. The DLQI consists of 10 questions, each with four possible answers scored from 0 to 3, giving a maximum score of 30. The greater the score, the more the patient's QoL is affected. Persons who scored ≥10 were considered as DLQI positive cases. The kannada version of this instrument was used in this study.
The consenting participants were given the relevant questionnaires: Sociodemographic data, GHQ-28 and DLQI. The clinical data of vitiligo patients were noted by the consultant dermatologist. Any person with GHQ score ≥ 6 was subjected to the detailed interview by a psychiatrist as per MINI mental scoring system to determine the psychiatric morbidity.
Statistical analysis was performed using SPSS 14.0 (SPSS Inc., Chicago, IL, USA).
| Results|| |
Three hundred vitiligo patients and 300 healthy control group who fulfilled the criteria to participate in the study were enrolled, and no subject refused to participate in the study. The vitiligo patients and healthy control groups were comparable on all variables of sociodemographic data as cited in [Table 1].
[Table 2] summarizes the sociodemographic and clinical data of the study population which consisted of 142 men and 158 women with a mean age of 35.26 ± 14.75 (14-80). Most of the patients were married (65.3%), and hailing from urban locality (64.3%). The mean duration of the disease was 4.9 years. The vitiligo lesions were present on the exposed parts in 58.7% patients with mean body surface area (BSA) involvement of 16.47%. Ninety-nine patients were attending for the first time and had no previous history of treatment. The percentage of patients with unstable vitiligo was 73%.
Generic health-related quality-of-life
The results of the univariate analysis are presented in [Table 3]. The GHQ-28 assessment of the vitiligo group led to the generation of two subgroups: GHQ Negative (i.e. GHQ score ≤5 i.e., those without psychiatric morbidity, n = 235) and GHQ positive (i.e. GHQ score ≥6, i.e., those suffering from psychiatric morbidity, n = 65). The prevalence rate of GHQ positive psychiatric morbidity was 21.7%. It was observed that younger age group, vitiligo in unmarried female sex, longer duration of disease (>5 years) and patients who had past treatment history were all associated with psychiatric illness. Other variables like lesions on exposed parts, percentage of BSA involvement and disease activity had no significant outcome on GHQ scoring.
|Table 3: Univariate association of GHQ and sociodemographic and clinical variables |
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Further assessment of 65 GHQ positive cases with MINI mental scoring, the diagnostic break up was as follows: Major depressive illness was observed in 33, suicidal risk - 40, social phobia - 20 and anxiety disorder - 21. Many patients had more than one diagnosis of psychiatric illness.
Dermatology-specific health-related quality-of-life
The overall mean ± standard deviation DLQI score was 6.71 ± 6.86 (range 0-28). According to distribution, no or minimal (DLQI 0-1), mild (2-5), moderate (6-10), severe (11-20) and very severe (21-30) impairment of QoL was found in 90 (30%), 85 (28%), 46 (15.3%), 65 (21.7%) and 14 (4.7%) patients, respectively. Similar variables as observed in GHQ positive cases such as younger age, unmarried status, and longer duration of disease and past treatment history were associated with QoL impairment as shown in [Table 4]. But there was no significant difference in men's and women's QoL. In addition patients having lesions on the exposed parts and on the face had higher DLQI scores.
|Table 4: Univariate association of DLQI and sociodemographic and clinical variables |
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Multivariate regression analysis
To identify independent predictors of vitiligo severity, we performed multiple regression analysis taking GHQ and DLQI as outcome variables and demographic and clinical variables as independent variables [Table 5]. Female sex, longer disease duration (>5 years) and past treatment history had statistically significant association with higher GHQ and DLQI scores.
| Discussion|| |
The results of our study clearly show that vitiligo severely affects QoL of most patients, as described both by a generic test, the GHQ 28 and a dermatology-specific DLQI test which quantifies the burden of vitiligo on the QoL in Indian patients.
The prevalence of psychiatric morbidity in our study evaluated by GHQ 28 was 21.7% which was slightly lower when compared to other studies done in India  and worldwide , with prevalence rate ranging from 25% to 35%.
Mean DLQI score was 6.71 in our study which indicates a moderate effect on the patient's life. Significant differences between men and women were not found. Ongenae et al.  in Belgium and Kostopoulou et al.  in France also reported similar effect 6.9 and 7.17, respectively. In contrast, Parsad et al.,  in India, found a higher mean DLQI score (10.67) but no significant gender differences.
Our results showed that demographic factors such as age, gender, marital status, and clinical variables such as duration of disease and past treatment history had a significant influence on GHQ and DLQI outcome.
Patients of younger age group had higher QoL, which was also observed in the study conducted by Wang et al.  which could be due to the fact that as age advances there will be a better adaptation to the disease, tolerance to social stigmatization and development of coping mechanisms.
In our study, psychiatric morbidity was more commonly observed in women who had vitiligo lesions on exposed parts of the body especially on face which was in accordance with earlier studies ,, implying that women are more cosmetically concerned and self-conscious about their appearance when compared to men. As a result of which they reported earlier to hospitals.
It was also noticed that unmarried patients especially women had higher DLQI scores. Effect of vitiligo on marital status was studied by Wang et al. in China and he concluded that vitiligo patients experienced shame when meeting a stranger or beginning an emotional relationship with a new partner.
An interesting observation in our study was that patients with a family history of vitiligo were significantly more concerned about their disease than patients who had negative family history. This was in contrast to the observation made by Sampogna et al.  which may be due to the fact that these patients would have closely observed the mental trauma and the associated social stigma in the society as experienced by their vitiligo affected family members. And hence would be more apprehensive about the disease prognosis.
Furthermore, we observed that patients who had vitiligo for > 5 years and who had treatment in the past reported worse GHQ and DLQI scores. Explanations for this were that patients with shorter disease duration and not on treatment were more optimistic about the possibility of improvement compared with the earlier group who were dissatisfied patients with a low degree of acceptance of their disease.
As our hospital is tertiary care center for dermatological disorders, we see a selected population of patients with vitiligo with a relatively high burden of the disease and that our study population may not reflect the impact of the disease in the larger community of people with vitiligo who do not seek care.
However, our study was the second, only to study conducted by Mattoo et al.  and first of its kind in South India to include both generic and dermatology-specific QoL in a large group of vitiligo patients. It quantifies the burden of vitiligo on the QoL and indicates specific areas of patient's lives most affected by the disease. Age, sex, marital status, distribution pattern of vitiligo, and disease severity had a significant impact on QoL of vitiligo patients. These results emphasize the need for a complete assessment of vitiligo patients including psychological assessment to improve the QoL and help them to lead a near normal life in our society.
| Acknowledgment|| |
We thank Mr. K. P. Suresh for his statistical analysis of data. Financial support for this research work was received from IADVL-Loreal Grant.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]