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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 63-65

Psychological management of vitiligo during the COVID-19 pandemic


1 Department of Dermatology, Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
3 Central Michigan University College of Medicine, Department of Psychiatry, Saginaw, Michigan, USA

Date of Submission15-Oct-2020
Date of Decision05-Nov-2020
Date of Acceptance20-Nov-2020
Date of Web Publication03-Dec-2020

Correspondence Address:
Dr. Anupam Das
Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, Building − “PRERANA”, 19, Phoolbagan, Kolkata 700086
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/Pigmentinternational.Pigmentinternational_

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  Abstract 


COVID-19 pandemic has changed our outlook toward the diagnosis and treatment of dermatological conditions. Accessibility to health care facilities has been jeopardized due to lockdowns, fear of contracting COVID infection, maintaining social distance, and financial concerns. Vitiligo, one of the notorious chronic dermatoses, had a negative impact on the quality of life of patients, even during pre-COVID era. Now, with the arrival of the pandemic, patients are unable to seek consultation for the disease. Stress being one of the key players in the pathogenesis of the disease, is leading to exacerbation of the condition. In this review, we have attempted to highlight the role of psychological management of vitiligo, amidst the ongoing pandemic


How to cite this article:
Fatima F, Das A, Jafferany M. Psychological management of vitiligo during the COVID-19 pandemic. Pigment Int 2020;7:63-5

How to cite this URL:
Fatima F, Das A, Jafferany M. Psychological management of vitiligo during the COVID-19 pandemic. Pigment Int [serial online] 2020 [cited 2021 Mar 2];7:63-5. Available from: https://www.pigmentinternational.com/text.asp?2020/7/2/63/302075




  Introduction Top


Disease in any organ inevitably has an impact on an individual’s sense of personal integrity. The skin is unique, being the largest and the most visible among all other organs. The appearance of the skin plays an important role in an individual’s self-worth, desirability, and perception of health. So, patients having skin diseases not only suffer from the disease itself but from the reaction of people to their disease.

There are many specialties of medicine that cross over into dermatology. As dermatologists, we often co-manage psoriatic arthritis or lupus erythematosus with internal medicine and oral lesions with dentistry/otolaryngology. In contrast, patients with overlapping dermatological and psychological morbidities are more challenging to manage. About one third of dermatology patients need concurrent psychological management.[1]

These patients usually refuse a psychiatry referral. It is crucial to identify any psychological morbidity in these patients and to establish a close bond before any referral, otherwise it can worsen the patient’s sense of social isolation.

Herein, comes the importance of a field that is gaining prominence all over the world–-psychodermatology. Psychodermatological disorders can be classified into the following:
  1. Psycho-physiological disorders
  2. Primary psychiatric disorders
  3. Secondary psychiatric disorders
  4. Cutaneous sensory disorders


Vitiligo falls under the category of secondary psychiatric disorders. Secondary psychiatric disorders develop in response to a primary trigger by a dermatological disorder.

Vitiligo is essentially a benign condition but it has a devastating impact on the quality of life and psychosocial well-being of the patient. It is caused by autoimmune destruction of melanocytes resulting in milky white patches over the skin and/or mucosa. The starkly visible change in appearance gives rise to social ostracism and discriminatory attitudes. This leads to significant lifestyle changes like decrease in social activities, change of clothing choices, and poor interpersonal relations.

World Health Organization defines quality of life as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.” It can be measured by various quality of life indexes such as Dermatology Life Quality Index (DLQI), Vitiligo impact scale-22, Vitiligo Quality of Life index, Skindex-29, and General health questionnaire.[2],[3],[4],[5]

DLQI is a commonly used self-administered questionnaire that was the first dermatology specific tool to measure the impact of skin disease on the quality of life of the patient. This assessment is important especially in cases of incurable, chronic diseases like vitiligo. This is because it measures the patient’s perception of their illness and the extent of quality of life affected as well as assesses the factors that affect the quality of life (such as the demographic profile, extent of disease, and treatment outcomes).[6],[7] Several studies have demonstrated poorer quality of life and psychosocial functioning in vitiligo.[8],[9],[10] Presently, COVID-19 pandemic has led to an increased psychological burden among the masses, and patients of vitiligo who were already under stress, have been facing a multitude of psychiatric issues that need to be addressed in a skillful manner.

The pandemic caused by the SARS-COV2 virus is having a profound effect on the mental health of the general population. The pandemic fear, financial losses, and public health measures restricting personal freedom are acting as triggers for psychiatric illnesses.[11] The risk is even higher with people with pre-existing psychological morbidities. Poor access to regular follow ups, missed medications, flare up of the disease, and uncertain prognoses are all adding to the woes of vitiligo patients. It has already been established in various previous studies that psychological stressors contribute to the onset and progression of vitiligo, although the exact pathogenesis is unkown.[12],[13] However, it is thought that chronic stressors give rise to a pro-inflammatory state, resulting in dysregulated immune responses that may lead to autoimmunity.[14] In a web-based study, it was found that vitiligo on sensitive sites was associated with more psychological impact. Interventions directed at increasing acceptance, confidence and self‐esteem, as well as managing embarrassment, were important. These issues could be managed through interventions such as cognitive behavioral therapy, mindfulness and acceptance, and commitment therapy.9


  Role of telemedicine Top


In order to continue health services and maintain social distancing, telemedicine has come up as a viable option.[15] Dermatology is particularly suitable for this method of healthcare delivery due to the diagnoses being visually oriented. A recent study on the impact of management of vitiligo during the pandemic came to the conclusion that teledermatology is a useful tool for cases with no clinical ambiguity and for follow up of already established cases (study conducted by Das A, ahead of publication). However, teledermatology services may not be suitable for doubtful diagnoses, while prescribing immunosuppressive drugs and for procedures (phototherapy or surgery).


  Role of psychological management Top


Irrespective of the kind of consultation provided, effective management of vitiligo should include consideration of the psychological morbidities of daily life and psychiatric illnesses of the patient as a part of the total treatment plan. This is even more significant during the current pandemic. Results of a survey among Dutch dermatologists revealed that ‘giving information and reassurance concerning the nature of the disease’ was the most important part of the approach to managing a case of vitiligo.[10] Patient education and counseling about the nature of vitiligo, prognosis, the treatment options, and dispelling various myths about the disease should be essential components of a good treatment plan. Apart from this, discussion about the current pandemic and its implications on the disease and treatment options should be given importance. In addition to this, assessment of patient’s own perception of their disease is important. Consultations should include standardized questionnaires assessing the quality of life of the patient.[16] This improves the compliance to treatment and reduces the psychological burden of the patient. This also gives us a clue about a possible psychological morbidity. It is important to develop good interpersonal skills to establish a supportive bond with the patient. Referral to a psychiatrist for psychotherapeutic interventions and psychotropic drugs should be discussed.[13],[17],[18] Because of the considerable impact of vitiligo beyond its physical symptoms, dermatologists should consider the utility of adjuvant therapies to adequately address impairments in self-esteem, body image, and quality of life in patients with vitiligo.[14] Since the pandemic is here to stay, and the long-term effects of the pandemic cannot be ignored; cognitive behavioral therapy, antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), talk therapy, and support groups can all play a role in the psychological improvement in patients with vitiligo.[15] An emphatic doctor–patient relationship and a multidisciplinary approach should be adapted for the comprehensive management of vitiligo.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors report no conflicts of interest.



 
  References Top

1.
Gupta MA, Gupta AK. Psychodermatology: an. J Am Acad Dermatol 1996;34:1030-46.  Back to cited text no. 1
    
2.
Patvekar MA, Deo KS, Verma S, Kothari P, Gupta A. Quality of life in vitiligo: relationship to clinical severity and demographic data. Pigment Int 2017;4:104-8.  Back to cited text no. 2
  [Full text]  
3.
Sampogna F, Tabolli S, Abeni D. Impact of different skin conditions on quality of life. G Ital Dermatol Venereol 2013;148:255-61.  Back to cited text no. 3
    
4.
Hamidizadeh N, Ranjbar S, Ghanizadeh A, Parvizi MM, Jafari P, Handjani F. Evaluating prevalence of depression, anxiety and hopelessness in patients with vitiligo on an Iranian population. Health Qual Life Outcomes 2020;18:20.  Back to cited text no. 4
    
5.
Hedayat K, Karbakhsh M, Ghiasi M, Goodarzi A, Fakour Y, Akbari Z et al. Quality of life in patients with vitiligo: a cross-sectional study based on Vitiligo Quality of Life index (VitiQoL). Health Qual Life Outcomes 2016;14:86.  Back to cited text no. 5
    
6.
Kent G, Al-Abadie M. Factors affecting responses on Dermatology Life Quality Index items among vitiligo sufferers. Clin Exp Dermatol 1996;21:330-3.  Back to cited text no. 6
    
7.
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. 7
    
8.
Parsad D, Dogra S, Kanwar A. Quality of life in patients with vitiligo. Health Qual Life Outcomes 2003;1:58.  Back to cited text no. 8
    
9.
Karelson M, Silm H, Kingo K. Quality of life and emotional state in vitiligo in an estonian sample: comparison with psoriasis and healthy controls. Acta Derm Venereol 2013;93:446-50.  Back to cited text no. 9
    
10.
Ramakrishna P, Rajni T. Psychiatric morbidity and quality of life in vitiligo patients. Indian J Psychol Med 2014;36:302-3.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Pfefferbaum B, North CS. Mental Health and the Covid-19 Pandemic. N Engl J Med. 2020;383:510-2.  Back to cited text no. 11
    
12.
Manolache L, Benea V. Stress in patients with alopecia areata and vitiligo. J Eur Acad Dermatol Venereol. 2007;21:921-8.  Back to cited text no. 12
    
13.
Henning SW, Jaishankar D, Barse LW et al. The relationship between stress and vitiligo: evaluating perceived stress and electronic medical record data. PLoS One 2020;15:e0227909.  Back to cited text no. 13
    
14.
Dhabhar FS. Effects of stress on immune function: The good, the bad, and the beautiful. Immunol Res. 2014;58:193-210.  Back to cited text no. 14
    
15.
Jakhar D, Sharma A, Kaur I, Sharma R, Das A, Madke B et al. Indian dermatologists wield technology to combat COVID-19!. Indian Dermatol Online J 2020;11:991-4.  Back to cited text no. 15
  [Full text]  
16.
Garg S, Sarkar R. Impact of vitiligo in afflicted patients. Pigment Int 2014;1:81-9.  Back to cited text no. 16
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17.
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.  Back to cited text no. 17
    
18.
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.  Back to cited text no. 18
    




 

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