Psychosocial and Financial Impact of Disease among Patients of Dermatophytosis, a Questionnaire-Based Observational Study.

INTRODUCTION: In the present epidemic of chronic, recalcitrant, and widespread dermatophytosis, impact of disease on quality of life (QoL) can be severe. Similarly, financial impact due to treatment cost and loss of wages needs consideration too. AIMS AND
OBJECTIVES: Our primary aim was to evaluate the impact of dermatophytosis on QoL and the financial burden on individual and family.
MATERIALS AND METHODS: Adult patients having dermatophytosis were included in the study. Standard Dermatology Life Quality Index (DLQI) questionnaire was used to evaluate the psychosocial impact, and financial burden was evaluated by nine binary questions.
RESULTS: A total of completed 299 DLQI surveys and 275 financial burden surveys were taken for final analysis. Mean DLQI was 12.25 (SD = 5.56, n = 299). Significant association between total body surface area (BSA) and DLQI score was observed (r s = 0.251, P < 0.001, n = 299). Presence of tinea corporis was found to be significantly affecting the choice of clothing (P = 0.018, χ2 = 5.127, CI 95%). More numbers of male respondents reported loss of work or study hours due to their illness (P = 0.015, χ2 = 5.196, CI 95%), which was significantly associated with the BSA involved (P < 0.05, t = 5.529, CI 95%). Some difficulties in sexual activity were reported by 35.6% patients, which has significant association with tinea cruris (P = 0.001, χ2 = 10.810, CI 95%). Median household income was 10,000 INR and interquartile range (IQR) being 8,000-19,000. Mean financial burden calculated at 3.458 (SD = 1.696, n = 275), whereas mean financial worry reported by patient stood at 3.661 (SD = 1.216, n = 275). Financial burden showed significant correlation with "previous treatment approximate cost," financial worry, and DLQI (P < 0.05, CI 95%). Financial worry (P = 0.016, r s = 0.145, CI 95%) and financial burden (P = 0.002, r s - = 0.145, CI 95%) both showed positive correlation with duration of disease.
CONCLUSION: In present scenario of Dermatophytosis in India, the disease and its treatment causing impact on QOL as well as on personal financial burden and worry need consideration. Copyright:

Introduction

Indian dermatologists are witnessing an onslaught of chronic and recurrent dermatophytosis in the last 4–5 years. Data for community level prevalence of this condition is not available, but various hospital-based studies present disease burden in the range of 36.6%–78.4%.[12345] Considering that these data are from highly specialized skin care facilities, these numbers represent just the tip of the iceberg; and as it is common community practice to seek advice from general practitioners, quacks, and even pharmaceutical stores for dermatophytosis, this study was undertaken to analyze disease impact on quality of life (QoL) of patient and finance of the family. A striking feature of this epidemic is its chronicity and recurrence of dermatophytosis.[6] Any chronic dermatological condition produces profound psychological and social impact on patient.[789] Extensive dermatophytosis involving large body surface area (BSA) is another striking feature of present epidemic. Tinea corporis stand-alone or in combination with tinea cruris is overtaking as the leading presentation of dermatophytosis.[10] Presence of visible lesions of dermatophytosis on body can severely impact social interaction and the self-image of patient. Majority of patients being in sexually active age group, impact of disease on sexual life can also be profound.

Similarly, financial impact of chronic dermatological conditions on individual and family is a matter of great concern in a developing country like India where the average per capita income is 1,24,865 INR per annum (USD 1790 conversion rate 69.78).[11] Lack of response to cheaper antifungals has made most dermatologists shift to Itraconazole as first line of treatment which is reflected in increase in sale of this molecule from 361.4 to 815.9 crores between March 2017 and 2019 in India.[12] Combined with that, most dermatologists prefer to continue treatment for 6–8 weeks or beyond to prevent relapse, increasing overall cost of treatment to many fold of what it used to be 5 years ago. When multiple family members are involved with disease, which is another observed phenomenon in present epidemic, overall impact of cost of therapy for family can be bothersome.

Aims and objectives

We conducted this study with the primary aim of evaluating impact of dermatophytosis on QoL and financial burden on individual and family.

Materials and Methods

After the Institutional ethics committee approved the study, all consecutive adult patients of both sexes (age ≥18 years) diagnosed with dermatophytosis with more than 3-month duration, presenting for the first time to our institute were offered to participate in the survey for QoL. After signing an informed consent, demographic details of the patient such as age, sex, total family members, monthly family income, educational status, and occupation were captured by investigator. Disease-specific details such as duration of disease, total BSA involvement, anatomical site, and details of previous treatment were evaluated by investigator. Patients were asked to fill a standard Dermatology Life Quality Index (DLQI) questionnaire in language of their choice.

The financial burden survey was offered to adult patients with dermatophytosis for minimum 3-month duration. In case the patient was financially dependent, earning member of family who was paying for treatment was offered the survey in local language. Financial impact due to treatment of dermatophytosis was evaluated using a composite financial burden score in which nine binary questions were asked [Table 1]. This score was adapted from original work by Veenstra et al., who used it to measure financial burden due to colorectal cancer.[13] Veenstra et al. used seven binary questions. We added question number 8 and 9 pertaining to evaluation of the impact of financial burden on treatment compliance and self-medication. Financial burden was calculated as sum of selected responses. Financial worry was self-reported by patient on a scale of 1–5 with 1 being “no worry” and 5 being “very much worried.”

Table 1

Questionnaire to assess financial burden and worry

Survey item to assess financial burden and worry

Burden

We would like to learn about how your dermatophytosis treatment has affected your finance. Please check ALL of the response below that apply.

1. I had to use savings

2. I had to borrow money or take out loan.

3. I could not make payments on other bills.

4. I cut down on spending for food and/or clothes.

5. I cut down on spending for health care for other family members.

6. I cut down on recreational activities.

7. I cut down on expenses in general.

8. I had to delay/interrupt treatment because of financial problem

9. Cost was the barrier I chose to self-medicate/consulted general practitioner.

Worry

How much do you worry about financial problems that have resulted from your dermatophytosis (ring worm infection) and its treatment?

1 (Not at all) 2 3 4 5 (Very much)

Patients having other concomitant skin disorders or on medication for other medical or surgical illness, pregnant and lactating females, illiterate patients, subjects with history of major surgical or medical illness in preceding 3 months, and patients with disease duration of <3 months were excluded from the study.

All captured data were entered into MS Excel and analyzed using IBM SPSS statistics for Windows, version 20.0, IBM Corp., Armonk, NY. For statistical significance, Spearman's rho correlation coefficient, Pearson's Chi-square, and unpaired t-test were applied.

Results

In total, 545 patients were screened for inclusion and exclusion criteria during the study period out of which 320 subjects meeting the study criteria were offered to take DLQI survey. Similarly, out of total 320 subjects, 280 financially independent (bearing treatment cost himself or herself) or accompanied by earning member of family were offered financial impact survey. Incomplete or overwritten forms were excluded from final analysis. Final analysis was undertaken for completed forms by 299 DLQI respondents and 275 respondents of financial impact survey.

Males marginally outnumbered females in this study (male = 151, female = 148). Maximum respondents were in age group between 18 and 30 years (n = 117, 39.13%). Tinea corporis with tinea cruris was leading clinical presentation in study group (n = 196, 65.55%) followed by tinea corporis as stand-alone presentation (n = 48, 16.05%). Tinea cruris alone was the presentation in 24 (8.03%) patients. Tinea faciei stand-alone or in combination with other anatomical presentations was noted in 30 (10.03%) patients.

Analysis of impact on QoL

Mean DLQI among study respondents was 12.25 (SD, 5.56, n = 299). Table 2 shows impact on QoL among study participants.[14] No significant difference was observed in DLQI scores between males and females. Significant association between total BSA and DLQI score was observed among study participants [Figure 1]. There was no significant association found between DLQI and duration of the disease (P = 0.171).

Table 2

DLQI score and impact among study participant[14]

DLQI	Impact	Number of patients (n=299)	Percentage
0-1	No impact	3	1.0
2-5	Small impact	25	8.4
6-10	Moderate impact	88	29.4
11-20	Very large impact	154	51.5
21-30	Extremely large impact	29	9.7
Total		299	100.0

Figure 1

Association between DLQI score and BSA

Table 3 shows analysis of individual components of DLQI questionnaire among study participants. Presence of tinea corporis was found to significantly affect choice of clothing among respondents (P = 0.018, χ2 = 5.127, CI 95%). Impact on social and leisure activities was observed in 67.2% patients, which was significantly higher in patients below 50 years of age (P = 0.040, χ2 = 4.490, CI 95%) and showed significant correlation with increasing BSA (P = 0.009, t = 2.637, CI 95%). More numbers of male respondents reported loss of work or study hours due to their illness (P = 0.015, χ2 = 5.196, CI 95%) compared with females, which was significantly associated with BSA involvement (P < 0.05, t = 5.529, CI 95%). Some difficulties in sexual activity were reported by 35.6% patients, which has significant association with presence of tinea cruris (P = 0.001, χ2 = 10.810, CI 95%). Around 70% of patients said that treatment of dermatophytosis is affecting their household activities by taking up their time.

Table 3

Response to individual questions in DLQI questionnaire among study participants

Quality of life component	Some effect (%)	Very large effect (%)
Itching	100	53.80
Embarrassment	95.70	22.10
Daily routine	83.90	11.70
Choice of clothing	55.90	8.70
Social and leisure activity	62.20	4.70
Sports activity	27.10	6
Loss of work or study	70.56	61.90
Socialization	60.10	6.10
Sexual life	35.60	6.10
Time spent for treatment	71.90	7.40

Analysis of financial burden due to disease

Median household income of respondents was 10,000 INR; inter quartile range (IQR) being 8,000–19,000. Median “previous treatment approximate cost” (amount spent for treatment of dermatophytosis before taking this survey) was 2,500 INR (IQR 1,000 to 7,590), lowest being 20 to highest 1,75,000 INR. Mean financial burden was calculated at 3.458(SD = 1.696, n = 275) whereas mean financial worry reported by patient stood at 3.661(SD = 1.216, n = 275). Financial burden showed significant correlation with “previous treatment approximate cost” (P < 0.05, r = 0.311, CI 95%), financial worry (P < 0.05, rs = 0.379, CI 95%), and DLQI (P < 0.05, rs = 0.275, CI 95%). Similarly, financial worry showed significant correlation with “previous treatment approximate cost” (P < 0.05, rs = −0.211, CI 95%), DLQI (P < 0.05, rs = 0.340, CI 95%). With increasing duration of disease, previous treatment cost, investigator calculated financial burden, and patient reported financial worry showed significant increase [Figures 2-4]. Financial worry also showed positive correlation with increasing age (P = 0.001, rs = 0.203 CI 95%).

Figure 2

Association between duration of disease and financial burden

Figure 4

Association between duration of disease with previous treatment cost

Associating between duration of disease and financial worry score

Discussion

Many skin diseases like psoriasis, eczema, and vitiligo though not associated with mortality are associated with considerable morbidity. Similarly, cutaneous dermatophytosis due to intense pruritus is associated with considerable morbidity and social embarrassment. Chronic, recurrent, widespread, and treatment resistant dermatophytosis are posing phenomenal public health problem for patients and dermatologists alike. Mean DLQI in our study was 12.25 which has “very large” impact on QoL. Another study from India reported mean DLQI at 13.41.[15] Maximum respondents in our study were from socially and economically most active and productive age group between 18 and 40 years. Itching and discomfort due to dermatophytosis was the top most disrupter of QoL followed by embarrassment due to disease. Effect on “choice of clothing” was found in >50% respondents and was significantly associated with presence of tinea corporis which may be a visible lesion. This correlates with the rising incidence of tinea corporis as leading presentation of dermatophytosis. Severe itching, visible lesions of dermatophytosis, and resultant embarrassment can be a big deterrent for attending work place or study place due to dermatophytosis which reflects in our study also where >70% respondents reported loss of work and study and significant association was found in presence of tinea corporis. Presence of itchy and unsightly skin lesions particularly around genitals combining with fear of transmitting infection to partner can severely hamper sexual activity of individual. In our study, 35.6% respondents reported some effect on sexual activity, among whom only 6.1% reported a “very large” effect. Presence of tinea cruris had significant association with effect on sexual activity. If we evaluate above findings in light of large numbers of reproductively active respondents in our study, it could be an indication of lack of awareness of dermatophytosis being an infectious disease. Before present epidemic, tinea cruris used to be leading presentation of dermatophytosis; in most recent studies, tinea corporis has overtaken tinea cruris as leading presentation. This aspect has the potential to profoundly affect all indicators of QoL. Visible lesions on skin (in comparison to tinea cruris) in addition to severe itching can lead to embarrassment and restriction of social and recreational activities. Our study too finds significant association between BSA and DLQI. Previous studies with other dermatological diseases such as vitiligo and psoriasis have also found association between socially visible lesions and QoL.[16]

According to World Bank data, average per capita income of an Indian citizen is ~10,400 INR/month.[11] In our study, median income of participants was 10,000 INR. According to data by government of India, poverty line threshold is set at 99,960 INR/year for urban population.[17] In present epidemic of dermatophytosis in India, chronic, relapsing nature of disease, involvement of multiple family members, use of higher anti-fungal medicine, and loss of wages due to frequent visits to dermatologist can all have profound effect on personal finances of such lower income patients. This reflected in our study also where 80.36% patients reported that they had to utilize their savings for treatment.

In our study, though 38.2% patients agreed that cost was a factor, they choose to self-medicate or consult a nonspecialized physician, significant correlation of previous treatment cost and financial burden is an indicator that cost behind ineffective treatment by self-medication and general physicians eventually add to financial burden of patient. Our study also shows significant correlation of DLQI with financial burden and financial worry, which is indicative of the detrimental effect financial aspect of disease produces on QoL. Compliance with anti-fungal treatment is fundamental to effective cure of dermatophytosis but in our study 64.27% patients said that they had to delay or interrupt treatment because of financial reasons.

Conclusion

Many times, improper counseling or noncompliance to treatment by patient due to early cure is considered to be the reason behind poor compliance. Our study shows that the financial aspect behind this also needs careful consideration by the treating dermatologist. Our study shows significant correlation between duration of disease and financial burden as well as worry. Overall, our study highlights a very large detrimental effect of dermatophytosis on QoL among patients of dermatophytosis, particularly in young, economically active group. Chronic dermatophytosis with increasing cost of therapy too is producing severe financial strain for lower socioeconomic class of patients.

Our study is a single-center study with majority of patients belonging to a particular socioeconomic strata; larger multicenter studies in future can throw more light on this aspect of dermatophytosis.

Limitation

Financial burden survey was not validated.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.