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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 25  |  Issue : 2  |  Page : 114-118

Quality of life and psychiatric comorbidity in vitiligo: A hospital-based cross-sectional study from a tertiary care center in South India


1 Department of Dermatology, Government Medical College, Kannur, Kerala, India
2 Department of Psychiatry, Government Medical College, Kannur, Kerala, India

Date of Submission10-Oct-2020
Date of Acceptance03-Aug-2021
Date of Web Publication29-Mar-2022

Correspondence Address:
Dr. Pretty Mathew
Department of Dermatology, Government Medical College, Kannur - 670 503, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_113_20

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  Abstract 


Background: Vitiligo is a common, acquired, idiopathic, depigmenting disorder with a profound effect on the patient's quality of life (QoL). Purpose: The objective of the study was to measure the QoL of patients with vitiligo using the dermatology life quality index (DLQI) and to assess psychiatric comorbidity in vitiligo patients using the General Health Questionnaire-28 (GHQ-28). Methods: Sixty patients above 16 years of age with vitiligo were enrolled. Age, sex, occupation, marital status, duration of disease, extent of involvement, visibility of lesions, details of treatment, duration of treatment, and response to treatment were collected. Independent t-test and ANOVA were used to test for significance of continuous variables and Chi-square test for categorical variables. Correlation between DLQI and GHQ-28 was assessed using Spearman's rho correlation coefficient. Results: Females scored higher than males on overall GHQ-28 scores and in individual domains of anxiety/insomnia, social dysfunction, and severe depression. Unmarried participants had higher scores compared to married subjects in all dimensions of DLQI and GHQ-28, indicating worse QoL and mental health. Conclusion: More than half of vitiligo patients had psychiatric comorbidity. There was a strong correlation between DLQI and GHQ-28 score, indicating strong association of QoL impairment with psychological problems. Proper counseling of patients of vitiligo along with specific treatment may be prudent.

Keywords: Psychiatric co-morbidity, quality of life, vitiligo


How to cite this article:
Benny D, Makkuni A, Thyvalappil A, Mathew P, Sridharan R, Druhin A V. Quality of life and psychiatric comorbidity in vitiligo: A hospital-based cross-sectional study from a tertiary care center in South India. J Dermatol Dermatol Surg 2021;25:114-8

How to cite this URL:
Benny D, Makkuni A, Thyvalappil A, Mathew P, Sridharan R, Druhin A V. Quality of life and psychiatric comorbidity in vitiligo: A hospital-based cross-sectional study from a tertiary care center in South India. J Dermatol Dermatol Surg [serial online] 2021 [cited 2022 Jul 2];25:114-8. Available from: https://www.jddsjournal.org/text.asp?2021/25/2/114/341194




  Introduction Top


Vitiligo is a common, acquired, idiopathic, and depigmenting disorder, has a prevalence of 0.5%–2% worldwide, and has a profound effect on patients' quality of life (QoL). The mean age of onset is about 20 years.[1] Autoimmune, genetic, and environmental factors are involved in the etiopathogenesis of vitiligo.[2] Social acceptance of vitiligo patients is largely dependent on perceptions of the disease in the population.[3] The chronic nature of disease, long-term treatment, lack of uniform effective therapy, and unpredictable course of the disease can be demoralizing.[4] We conducted this study to measure the burden of vitiligo on the QoL of patients, to identify variables that might predict poorer QoL, and to assess psychiatric comorbidty in vitiligo patients.


  Methods Top


This cross-sectional study was conducted in the Department of Dermatology of a South Indian Tertiary Care Center over a period of 1 year. Patients above 16 years of age with vitiligo were enrolled. Patients not willing to participate in the study, patients with other associated chronic severe dermatological conditions and systemic illnesses, and patients with preexisting psychiatric illness were excluded. Written informed consent was obtained from study participants. Approval of the Institution Ethical and Research Committee was obtained.

Age, sex, occupation, marital status, duration of disease, extent of involvement, visibility of lesions, details of treatment, duration of treatment, and response to treatment were collected. We used two questionnaires, namely, the dermatology life quality index (DLQI) and General Health Questionnaire-28 (GHQ-28) to assess QOL and psychiatric comorbidity. Prior permission to use the questionnaires was obtained. Both the questionnaires were translated to regional language (Malayalam) and validated by back-translation to English by two unbiased individuals separately. Patients with GHQ-28 score more than or equal to 4 were sent for psychiatric counselling.

Data were entered into Microsoft Office Excel and analysis was carried out using the Statistical Package for Social Sciences version 13.0 (SPSS Inc., Chicago, USA). Continuous variables were described using means with standard deviations and categorical variables with numbers and percentages. Independent t-test and ANOVA were used to test for significance in continuous variables and Chi-square test for categorical variables. MannWhitney U-test was employed to test for differences in scores between two groups, while KruskalWallis test was employed to test for differences in scores between >2 groups. P < 0.05 was considered as statistically significant. Correlation between DLQI and GHQ-28 was assessed using Spearman's rho correlation coefficient.


  Results Top


Sixty patients with age ranging from 17 to 75 years filled out the questionnaire completely. Mean age of the study population was 44 years. There were 28 males (47%) and 32 (53%) females, giving a male:female ratio of 0.8:1. Mean total duration of the disease was 4 years. Patients were divided in to four groups according to age as <20, 20–39, 40–59, and 60–80 [Table 1]. QoL was affected worst in <20-year age group with highest mean DLQI value. Dimensions of daily activities, leisure, and treatment in DLQI scale were high in <20-year age group with P = 0.00, P = 0.04, and P = 0.04 respectively.
Table 1: Statistical mean differences in dermatology life quality index and General Health Questionnaire-28 scores by age

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The mean DLQI score for males was 6.5 as compared with 7.8 in females (P = 0.35). Females also scored higher in the dimensions of “symptoms and feelings,” “daily activities,” “leisure,” and “work and school.” The mean GHQ-28 score was higher in femles as compared to males (P = 0.02). The following three dimensions of the GHQ-28 scale, namely, anxiety/insomnia, social dysfunction, and severe depression were also high in females with P = 0.04, P = 0.02, and P = 0.01, respectively [Table 2]. Occupation of study subjects had no significant impact on DLQI and GHQ-28.
Table 2: Mean dermatology life quality index and General Health Questionnaire-28 scores by gender

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Patients who were separated from their partners had higher DLQI scores compared to married and unmarried patients (P = 0.01). There were also statistically significant differences in individual dimensions of the scale, namely, “daily activities,” “leisure,” and “work and school” (P = 0.00, P = 0.00, and P = 0.04, respectively). GHQ-28 scores did not vary significantly with marital status.

Although the mean DLQI score was higher in patients with >20% body surface area (BSA) affected, the difference between groups was not statistically significant. However, the group with more than 20% BSA involvement scored statistically significant higher values for the dimensions of “symptoms and feelings” (P = 0.03) and “daily activites” (P = 0.04) of DLQI [Table 3].
Table 3: Statistical mean differences in dermatology life quality index and General Health Questionnaire-28 scores by percentage of body surface area

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DLQI and GHQ-28 scores were lower in subjects with the involvement of only nonexposed areas, and statistically significant difference between groups was there in the dimension of leisure (P = 0.04). Duration of vitiligo did not affect DLQI and GHQ-28 scores significantly, even though scores were higher in total DLQI and in the dimensions of “symptoms and feelings,” “daily activities,” “leisure,” and “work and school” in >5-year duration group.

DLQI scores in patients receiving treatment were higher (P = 0.05) and “daily activities” component of DLQI was particularly high (P = 0.04). Duration of treatment had no statistically significant impact on DLQI and GHQ-28. There was higher DLQI and GHQ-28 scores in study subjects who had no response to treatment, with statistically significant impact in the dimension of “work and school” (P = 0.05).

[Table 2] enumerates mean DLQI and GHQ-28 scores of the total sixty patients in our study, as well as mean scores obtained in each dimension of questionnaires. Vitiligo had a “small effect” on QoL in 38.33%. We evaluated the number of patients who obtained GHQ-28 score more than or equal to 4 to assess psychiatric comorbidity in the study population. Thirty-two patients (53%) had psychiatric comorbidity in our study. We assessed the correlation between DLQI and GHQ-28 scores obtained by the study subjects, using Spearman's rho correlation coefficient and obtained a coeffiecient of 0.54 (P = 0.00).


  Discussion Top


Mean DLQI was impaired maximum in the age group of <20 years, where subjects were significantly affected in their daily activities, social or leisure activities, sports, and the disease influenced their choice of clothes. Patients in 20–40-year age group reported maximum impairment in personal relationships and noticed difficulty in treatments, the latter being statistically significant. Several studies, including ours, did not show any statistical correlation between age of patients at the time of observation and DLQI mean score.[5],[6],[7],[8] Mean GHQ-28 and individual scales of “social dysfunction” and “severe depression” were highest in 20–40-year age group in our study. This was comparable with other studies in the literature.

In DLQI scale, females were more affected than males with respect to being embarrassed or self-conscious of their disease, impairment of daily activities, and leisure activities. However, men had more impairment in personal relationships. Our results were consistent with the study by Al Robaee who reported that women are more embarrassed and self-conscious about their disease than men.[9]

QoL was impaired significantly in patients who were separated fromthere partners. This variable also affected the daily activities and leisure of subjects, who also reported significant impairment at job/study. GHQ-28 scores did not vary significantly with marital status. Since we had only one subject who was seperated, our study population cannot be considered ideal to assess this variable. Thus, for comparison, if only married and unmarried groups are taken into account, unmarried subjects scored more than married subjects in all dimensions of DLQI and GHQ-28 as well as in total scores, indicating poor QoL and mental health. Similar results were noted in the studies by Ramakrishna and Rajni.[10]

Impairment in DLQI was noted in >20% BSA group. This was consistent with the study by Ingordo et al.[8] The same group showed impairment of daily activities and were embarrassed about their disease. GHQ-28 scores did not vary between the groups. Vitiligo patients with generalized involvement having increased DLQI scores were reported by Al Robaee, as well as by Dertlioğlu et al.[9],[11]

Highest GHQ-28 score was seen in 10%–20% BSA involvement group. Similar findings were noted by Karia et al. and Khattri et al.[12],[13] We observed impairment in social life, leisure, and sports activities, in those having involvement of exposed areas. However, majority (95%) of our cases had exposed lesions and only 5% of them had exclusively nonexposed lesions, the study's sample population was not a suitable one to assess this variable. In our study, GHQ-28 scores were higher in those having visible lesions which is consistent with previous literature.[13],[14]

Duration of vitiligo did not affect DLQI and GHQ-28 scores in our study. However, there were higher scores in total DLQI and in the dimensions of “symptoms and feelings,” “daily activities,” “leisure,” and “work and school” in >5-year duration group. Mean DLQI score was high in patients receiving treatment. The daily activities of patients were also impaired. The paradoxical increase in impairment of QoL with attempted treatment could be due to increased expectations.[15] According to Garg and Sarkar, all types of interventions, either lifestyle-altering or disease-altering interventions in vitiligo patients, resulted in improvement in their QoL measured using dermatology-specific QoL instruments regardless of their effect on repigmentation.[16] After treatment with NBUVB, mean DLQI of all vitiligo patients was significantly reduced in a study by Chahar et al.[17]

Dertlioğlu et al. in his study of DLQI scores in children with vitiligo found no correlation between disease duration and DLQI scores.[11] Patients who had no response to treatment had higher DLQI and GHQ-28 scores in our study. Pahwa et al. reported that patients with greater impairment of QoL responded less favourably to treatment.[18] Total DLQI was not influenced by previous treatment in the study by Karelson et al. and Ingordo et al.[8],[19]

In our study, vitiligo had no effect on QoL in 10% of the subjects, small effect in 38.33%, moderate effect in 25%, very large effect in 25%, and extremely large effect in a minority (1.67%). In a study by Krüger and Schallreuter, QoL in patients with vitiligo was affected in 36.5%, while Ingordo et al. noted the same in 29.3%.[8],[20] In another study by Kota et al. using DLQI, 26% of patients were found to have moderate, 23.3% had very large, and 1.3% had extremely large effect on QoL. Analysis of the individual items of the DLQI found that symptoms and feeling item was worst affected, followed by daily activity and leisure.[21] A moderate effect on QoL of vitiligo patients was seen in another study.[22] In cases of vitiligo in children, QoL in the family members was affected in all respondents in another study. There was significantly more impairment, if vitiliginous child was female.[23]

GHQ-28 score was found to be ≥4 in 53% of subjects, thereby indicating psychiatric comorbidity, which was comparable with various studies in the literature. They were sent for psychiatric counseling. We found strong correlation between DLQI and GHQ-28 score. This was consistent with the results of Karia et al. who demonstrated that people with probable depression or anxiety always reported a worse QoL compared with patients without them, thereby indicating strong association of QoL impairment with psychological problems.[12]

Limitations

Our study was limited by its small sample size, cross-sectional nature, and also patients were not followed up to see the effects of treating psychiatric comorbidities. Furthermore, we were not able to compare our results with a control group of healthy subjects. Questionnaire like Vitiligo Impact Scale-22 has vitiligo-specific questions and better QoL measurement properties compared to DLQI. Another limitation was that, in Indian society, vitiligo is already associated with enormous stigma and hence, some degree of impaired QoL among the patients was expected.


  Conclusion Top


In our study, females had higher scores in GHQ-28 and also higher scores in individual domains of anxiety/insomnia, social dysfunction, and severe depression. Visibility of lesions had a negative impact on overall QoL. More than half of vitiligo patients had psychiatric comorbidity. There was a strong correlation between DLQI and GHQ-28 score, indicating strong association of QoL impairment with psychological problems. We recommend a multidisciplinary approach in the management of vitiligo as it is crucial to focus not only on medical treatment but also on the psychological aspects of this stigmatizing disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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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.  Back to cited text no. 9
    
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Khattri S, Bist JS, Arun A, Mehta AK. Clinical correlates of vitiligo with depression and anxiety: A comparative study in patients and their caregivers. Int J Adv Res 2015;3:200-5.  Back to cited text no. 13
    
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