Effect of Topical Steroid-Dependent Facial Dermatitis on Quality of Life: A Hospital-Based Cross-Sectional Study Using DLQI.

BACKGROUND: The rampant, disturbing, and dismal unrestricted use of topical corticosteroids on face results in steroid-induced dermatitis termed topical steroid-dependent face (TSDF). It is an embarrassing and irritating condition for a patient. There is paucity of data from India regarding the effect of TSDF on the quality of life (QoL) of such patients. AIMS: The aim of this study was to study the effect of TSDF on the QoL of patients with the help of a validated, easy-to-use, and reproducible dermatology life quality index (DLQI).
METHODS: A cross-sectional study was done among the outpatients seeking treatment for TSDF at a tertiary care hospital of a medical college. Patients were administered Hindi questionnaire version of DLQI. Controls were apparently healthy age- and sex-matched individuals.
RESULTS: DLQI scores revealed that TSDF had some effect on QoL in 98.11% of study patients. Study group had a mean DLQI score of 11.49. Statistically significant higher DLQI scores were recorded among females, patients aged <20 years and those who had no formal education/illiterate.
CONCLUSIONS: TSDF affects QoL in majority of patients and it has a very large effect on the QoL in more than one-third of the patients. Copyright:

Introduction

Topical corticosteroids (TCs) are the mainstay of dermato-therapeutics.[1] Though they were introduced in 1952, earliest reports of TC dependence or addiction started appearing shortly thereafter within next two decades by 1970s.[23] Due to wide availability of these TCs, there is rampant, dismal, and disturbing misuse of topical steroid on face in India which results in severe cutaneous damage characterized by erythema, monomorphic acne, steroid atrophy, steroid rosacea, telangiectasia, perioral dermatitis, striae, and severe addiction to the TC.[45] The occurrence of this unexpected dermatoses might not be merely a medical problem but also a social problem as the patient becomes psychologically and physically dependent on the drug. Attempts to withdraw the drug result in rebound or flare of symptoms causing immense distress to the patient so that the patient resumes the usage of TC and refuses any further withdrawal of the drug.[5] Patients often voice discomfort, embarrassment, and concern for facial dermatitis as it impacts their self-esteem.[6] Self-image molds one's personality.[7] It affects mental health and our attitude toward the environment.[8] Self-image is also predictive of overall satisfaction and, therefore, has a major effect on quality of life (QoL).[7]

From India, TC misuse on face was first reported in 2006.[9] Subsequently, topical steroid-dependent face (TSDF) was defined as the semipermanent or permanent damage to the skin of the face precipitated by the irrational, indiscriminate, unsupervised, or prolonged use of TC resulting in a plethora of cutaneous signs and symptoms and psychological dependence on the drug.[5]

Though facial steroid dermatitis has an effect on the QoL of these patients, there is a paucity of literature regarding the same worldwide and none from the Indian subcontinent. As perceptions regarding skin diseases may vary, their impact among patients may also vary from one country to another; the aim of this work was to study the effect of TSDF on the QoL of patients with the help of a validated dermatology life quality index (DLQI) questionnaire and ascertain its relationship with various variables in study population.

Materials and Methods

This cross-sectional, study was performed among outpatients seeking treatment for clinical diagnosis of TSDF at the department of dermatology of a tertiary level teaching hospital in central UP from January 2017 to June 2017. About 225 patients with suspected clinical diagnosis of TSDF were screened for inclusion in this study as per the study design [Figure 1]. Inclusion criteria were any patient aged >16 years presenting in the outpatient department with a clear history of any corticosteroid application on face for at least 1 month continuously before presentation. Diagnosis of TSDF was made as per standard definition accepted in the literature and with the consensus of two Consultant Dermatologists from the Department of Dermatology (MKR and PG).[5]

Figure 1

Enrollment of the study group

Exclusion criteria were patients having pregnancy, polycystic ovarian disease, Cushing's syndrome, chronic alcoholism, depression, history of systemic administration of immunomodulators or immunosuppressants including but not limited to cyclosporine/azathioprine/cyclophosphamide, and/or corticosteroids in last 3 months. Besides, patients having any disability, chronic medical or cutaneous disease, photodermatoses, rosacea, atopic dermatitis, seborrheic dermatitis, contact dermatitis, or any other steroid responsive facial dermatitis prior to the use of TCs were also excluded from this study.

Controls were apparently healthy age- and sex-matched individuals having no disease/psychological impairment, which may have a bearing on their QoL.

No formal sample size calculation could be performed due to the lack of availability of any reliable data regarding prevalence or incidence of this relatively new disorder among general population in Indian subjects. However, a total of 106 subjects (53 patients and 53 age- and sex-matched healthy controls) were enrolled in this study during the study period of 6 months to provide a lead toward the QoL of TSDF patients.

The study was approved by the registered institutional ethical committee before starting the study.

Data collection

Data were collected by two questionnaires. The first questionnaire included demographic data, clinical features, and clinical severity score of the disease in study and control population. Clinical severity score was calculated as described elsewhere.[10] The second questionnaire was a Hindi translated and validated version of DLQI available free online for noncommercial academic usage with permission.[11]

The severity was assessed based on various clinical signs and symptoms, namely, erythema, papules, edema, dryness, telangiectasia, burning sensation, sensation of tightness, and itching. Each sign and symptom was graded by the principal investigator on a scale of 0–3 representing absence (0), mild (1), moderate (2), and severe (3). Scores of these signs and symptoms were added to arrive at a cumulative score for each patient, which ranged from 0 to 24. Clinical severity of TSDF was graded as mild, moderate, or severe depending on cumulative scores calculated as follows: mild (0–8), moderate (9–16), and severe (17–24).

DLQI is self-administered, easy, and user-friendly; first, dermatology-specific QoL instrument/questionnaire designed by Finlay and Khan in 1992 with an average completion time of 126 s.[12] It was the first dermatology-specific QoL tool to measure the overall impact of skin diseases on QoL.[13] The total DLQI ranges between 0 (no impairment) and 30 (maximum impairment). DLQI questionnaire consists of 10 questions, subdivided into 6 domains, that relate to different aspects of a person's health-related QoL as follows: symptoms and feelings (questions 1, 2), daily activities (3, 4), leisure (5, 6), work/school (7), personal relationships (8, 9), and treatment (10). Higher scores mean greater impairment of the patient's QoL and vice versa.[12] Total DLQI score between 0 and 1 indicates no effect on patient's QoL, 2–5 represent small effect, 6–10 moderate effect, 11–20 very large effect, 21–30 indicate extremely large effect on patients' QoL. A validated Hindi version of DLQI questionnaire was used to assess the QOL.[11]

The aim of the study was explained to the participants. Patients were called individually to fill the questionnaire after obtaining written consent from them. Principal investigator (RM) was present during filling and all the queries raised by the participants were resolved. Patients were given full right to withdraw from study at any juncture without assigning a reason.

Data analysis

Data were analyzed by using SPSS software (version 20). Student's t-test and analysis of variance were applied for comparison of means. Scores were correlated with continuous variables using Pearson's correlation analysis. P value less than 0.05 was considered statistically significant. DLQI and domain scores were correlated with various variables, such as age, sex, marital status, education level, employment status, potency of steroids, and duration of disease.

Results

As per the study design, final analysis was done on 53 patients and 53 healthy controls. The study group consisted of 38 (71.7%) females and 15 (28.3%) males aged 16–45 years (mean 29.00 ± 8.69 SD). The control group was age- and sex-matched consisting of 37 (69.8%) females and 16 (30.19%) males, aged 17–47 years (mean 30.56 ± 6.98 SD). Table 1 gives the comparison of DLQI scores in study and control groups.

Table 1

DLQI scores in study group and healthy controls

DLQI domains (minimum-maximum scores)	DLQI scores				P (t-test)
	TSDF (study group)		Controls
	Mean	Standard deviation	Mean	Standard deviation
Symptoms and feelings (0-6)	3.84	1.71	0.46	0.78	0.0001
Daily activity (0-6)	2.20	2.01	0.16	0.47	0.0001
Leisure (0-6)	1.54	1.71	0.03	0.18	0.0001
Work and school (0-3)	0.77	0.97	0.00	0.00	-
Personal relationships (0-6)	1.49	1.71	0.00	0.00	-
Treatment (0-3)	1.13	1.54	0.00	0.00	-
Total (0-30)	11.49	6.84	0.66	1.12	0.0001

DLQI score interpretation revealed that TSDF had at least some effect on QoL in 52 (98.11%) study patients. Among them 10 (18.86%) patients had small effect, 16 (30.19%) had moderate effect, 19 (35.85%) had very large effect, and 7 (13.20%) had extremely large effect on QoL. Table 2 illustrates the DLQI scores with various parameters and sociodemographic variables for the study group.

Table 2

DLQI scores and various variables among the study group

Parameter		Number (%)	Mean±std. dev.	P
Gender	Female	38 (71.7)	12.28±0.7270	0.0001*
	Male	15 (28.3)	9±1.44
Age	<20	24 (45.3)	12.21±0.722	0.0001**
	20-40	27 (50.9)	12.01±1.10
	>40	2 (3.7)	6.5±1.89
Occupation	Employed	13 (24.52)	12.17±7.12	0.7105*
	Unemployed	40 (75.47)	11.29±6.84
Area of residence	Urban	11 (20.75)	12.26±0.7547	0.0005*
	Rural	42 (79.24)	8.67±1.001
Education	No formal education	33 (62.26)	12.3±1.20	0.0001**
	Primary school	12 (22.64)	11.6±2.43
	Secondary school and above	8 (15.09)	8.88±1.92
Marital status	Married	19 (35.84)	12.21±1.02	0.0891*
	Single	34 (64.15)	12.26±0.7415
Potency of topical steroid (American classification)	Lower-mid strength	30 (56.60)	8.50±6.34	0.0694**
	Mid strength	13 (24.52)	11.91±6.36
	Superpotent	10 (18.86)	13.75±7.94
Treatment	Regular use of steroids	20 (37.73)	10.2±6.449	0.2627*
	Irregular use of steroids	33 (62.26)	12.45±7.21
Duration of disease	<6 months	24 (45.28)	12.5±4.22	0.1553**
	6 months-1 year	9 (16.98)	11.8±3.03
	>1 year	20 (37.73)	9.7±5.87
Clinical severity score for TSDF	Mild	11 (20.75)	9.76±3.65	0.4452**
	Moderate	29 (54.71)	12.12±7.08
	Severe	13 (24.53)	12.68±4.56

*t-Test, **ANOVA

There was statistically no significant relationship of DLQI scores with clinical severity scores (r = 0.054, P = 0.677) or duration of disease (r = −0.162, P = 0.361).

Domain-wise analysis of DLQI score in different subgroup of study population revealed that for domain of leisure, patients using superpotent topical steroid in TSDF had maximal effect on QoL compared to the patients using mid-strength or lower-mid strength steroids (P = 0.0025). There was no statistically significant difference among domains for various other study parameters.

Discussion

The QoL for patients with skin disease in developing countries has continued to be a major problem because related issues have not been adequately addressed.[14] QoL measures in patients with skin lesions can supplement measures of clinical severity for comprehensively assessing the disease and treatment outcomes, and they are an important area for future research.[15]

DLQI is one of the most extensively used dermatology-specific QoL tool to measure the effect of more than 40 different skin conditions. With its availability in 90 languages in >80 countries, its use has been described in over 1000 publications including many multinational studies.[12] The DLQI questionnaire is designed for use in patients aged more than 16.[16]

The present study reports the dermatology-specific QoL in the patients of TSDF. In the last couple of years, a lot of literature has appeared worldwide and India, particularly regarding clinical presentations and magnitude of TSDF.[5917181920] To the best of our knowledge, extensive literature search failed to reveal any literature studying effect of TSDF on QoL in Indian patients. Moreover, there is paucity of data worldwide on this topic as well.[610]

The present study shows that TSDF has a very large effect on study patients. The mean DLQI score of >11 represents a very large effect on the QoL in these patients. Our results are comparable to earlier study of Liu et al. who also reported a very large effect on QoL among Chinese patients having facial steroid dermatitis with a mean DLQI of 13.76.[10]

The findings of the present study are in concordance to the results published in past for other chronic skin diseases such as psoriasis and vitiligo but not for acne and melasma from India.[21222324]

Domain-wise analysis of the present study is also comparable to the earlier report of Liu et al. (3.84/3.52, 2.20/3.18, 1.54/2.88, 0.77/1.5, 1.49/1.46, 1.13/1.22 for the domains of symptom and feelings, daily activities, leisure, work and school, personal relationships, treatment, respectively).[10] The highest score (3.84) was obtained in the domain of symptoms and feelings which represents how much embarrassment was caused to a patient by the lesions of TSDF. Subsequently, TSDF causes a feeling of worthlessness and unattractiveness in these patients. Furthermore, patient starts avoiding social gathering and thereby hampers his/her QoL. The lowest score (1.13) was seen in the domain of treatment. This may be explained by the fact that all our study patients were fresh and yet to start treatment. Few of them had taken some home or nonmedical remedies with partial or no relief. Hence, the effect of treatment domain may not be reflected properly in such patients.

Patients of TSDF experience “rebound phenomenon” within 5–7 days of stopping steroid applications. This rebound phenomenon is unbearable and results in a flare of the dermatitis on the face.[10] It may be accompanied by marked erythema or severe burning sensation, and hence, patients of TSDF discontinue TC very reluctantly. This may be a possible explanation for increased DLQI scores observed in the present study due to irregular usage of TC when compared to regular use of TC. However, these results failed to reach a statistically significant level. This may be due to smaller sample size in the present study.

In the present study, 98.11% of patients reported some effects on their QoL. This is again comparable to the findings of Liu et al. who reported at least some effect on the QoL in 100% of their study population.[10] Although 84% (42/50) of patients in the same past study had moderate-to-extremely large effect, present study revealed similar effect in 79.24% (42/53) patients.

DLQI scores revealed that QoL in TSDF patients of the present study varied significantly with respect to female gender, younger age group, urban population, and uneducated patients in the present study.

Past studies have reported significantly greater QoL impairment in females compared to males in a wide array of skin diseases.[15252627] Cited reasons for the same range from women being more emotional, sensitive, and conscious of their appearance in public to the higher concern regarding appearance and hence the potential detrimental impact on their marital prospects.[1527] Further, this QoL impairment in female may cause more depression, anxiety, and community isolation.[27]

In the absence of specific past findings of DLQI in patients of TSDF, QoL in different skin diseases is being compared for age. In many previous studies, while no significant association was found, few studies reported significantly higher QoL impairment in younger patients like the present study.[1528] Younger patients are more susceptible to the psychological effects of skin lesions. The late adolescents and young adults have a higher degree of QoL impairment compared to adults because they are more conscious about their self-esteem and self-appearance. Furthermore, the skin lesions may put an effect on their mental health and social obligations.[25]

Abolfotouh et al. have found better QoL in dermatological patients of rural origin due to better family and social support and this phenomenon was observed in the present study as well.[15] Lack of social support is an important predictor of poor physical and psychosocial functioning.[29]

Education may affect one's life indirectly. In the present study, there was significant difference in the QoL of patients when compared to their educational levels. The impairment was maximum in patients who were not formally educated and least in patients who were educated to secondary school and above. It is quite possible that formal education empowers one with rationale thinking about disease and hence decreases the effect of TSDF on the QoL of such patients. In this context, these findings are similar to past studies from India done for other cutaneous diseases.[2225]

The main limitations of the present study are a small sample size, single-center study, and noncalculation of a formal sample size in the absence of any data regarding the prevalence of TSDF in Indian population. However, these may not negate the findings here that TSDF has a large effect on the QoL of a patient.

This study highlights the fact that clinical severity of TSDF is not proportional to its impact on the QoL. Hence, it is imperative to manage every patient as a whole, considering both the clinical as well as emotional aspect irrespective of the clinical severity at the time of presentation. Treating dermatologist should pay due regards to the assessment and treatment of TSDF after considering the QoL experiences of these patients. QoL has emerged as one of the most important end points in clinical research lately and it is now included as an essential outcome to be evaluated in systematic reviews and meta-analyses.[730]

Conclusions

TSDF affects QoL in almost all the patients. It has a very large effect on QoL of more than one-third of patients having TSDF. Female patients, young age (<20 years), nonformal education, and illiteracy are the main variables in this study having a significant detrimental effect on QoL in patients having TSDF. Any future clinical trial or study gauging efficacy of treatment for TSDF should include comparison of QoL as a key indicator for estimation.

Authors' contributions

MKR performed data analysis and editing of the primary draft. RM was the principal investigator and collected the data followed by preparation of primary draft. PG conceptualized the study and revised the manuscript for preparing final draft. NM designed the study along with critical appraisal for preparing the manuscript. MT helped in data collection and prepared the primary draft by performing relevant literature search along with statistical analysis. All the authors approved the final version. PG will act as guarantor and corresponding author for this article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.