Assessment of quality of life in vitiligo patients attending a tertiary care hospital - A cross sectional study.

BACKGROUND: Vitiligo is a common form of localized depigmentation of skin which draws unusual attention to the patient especially when it is in visible areas of the body. The appearance of visible skin lesions and its chronic progression may cause a significant burden on patients' health-related quality of life and psychiatric morbidity may arise as a complication. AIMS: An endeavor has been made to find out how the disease influences the quality of life of affected persons.
METHODOLOGY: This was a hospital based cross sectional study. Clinically diagnosed eighty vitiligo patients were selected from dermatology outpatient department with purposive sampling method and compared them with those of healthy control group. In selected cases Dermatology Life Quality Index (DLQI) questionnaire was used for the assessment of quality of life. Also International classification of mental and behavioral disorders research criteria along with 17-item Hamilton Rating scale of Depression were applied to diagnose the presence of depression. Data were collected and "Chi Square Test" or "Fisher Exact t Test" was used. All analysis were done using SPSS version 20.0.
RESULTS: In this study 92.5% of the patients had elevated DLQI scores. We found higher DLQI mean score in vitiligo patients ( 9.68+5.24) compared to (1.36+ 1.37) of control and depression was significantly associated with the impairment of quality of life.
CONCLUSION: Vitiligo patients have significant impairment in their quality of life and more in those who develops depression. Copyright:

Vitiligo is a common form of localized depigmentation of the skin. It is an acquired condition resulting from the progressive loss of melanocytes. It is characterized by milky-white sharply demarcated macules. It is stated that vitiligo affects 0.5%–2% of the world's population.[12] Vitiligo can begin at any age but in the majority of cases becomes apparent between the age of 20 and 30 years.[3]

Depigmenting dermatosis of which vitiligo is one draws unusual attention to the patient, especially when in visible areas of the body. Its onset is often correlated with certain personality characteristics, stress, illness, and personal crisis.[4] Disfiguring nature often leads to social and sexual embarrassment, which in turn perceived as discrimination or rejection.[5] The bewildered person already psychologically disturbed by his skin changes finds himself an object of unnecessary public focus because of this disfigurement. The loss of skin pigment, therefore, poses a severe cosmetic and social problem to those affected.[1] Skin coloration is part of the body image of a person and any pathological change in it can decrease their self-esteem and isolate them from society.[6] Thus vitiligo, as a result of its visibility and chronicity, may cause a significant burden on patients' health-related quality of life.

Previously, multiple observational studies have suggested an epidemiological link between vitiligo and psychiatric morbidity such as depression.[78] It can affect one's happiness and can substantially diminish their quality of life. In earlier studies, the prevalence of depression in vitiligo was 20%.[9]

The appearance of skin lesions and the chronic progression of the disease may frequently affect the quality of social and work life of patients, thus, psychiatric morbidity may arise as a complication which further impairs their quality of life.[78]

In India and particularly Northeast India a limited number of studies were done regarding this subject. Hence, an endeavor had been made to assess the quality of life of the affected person with vitiligo attending a tertiary care hospital. In addition, an attempt was made to see the effect of depression on their quality of life.

METHODS

This was a hospital-based cross-sectional study. With institutional ethical committee approval, the sample was drawn with purposive sampling method from the outpatient department (OPD) of Dermatology of a tertiary care hospital, in the Northeastern part of India from June 2019 to December 2019.

After informed consent, eighty vitiligo patients of age group 18–60 years of both sexes were included in the study. Only patients affected in their exposed parts of the body were selected for the study. Patients with a present or history of any major physical or dermatological illness other than vitiligo were excluded from the study. Patients with present psychiatric disorder other than depression and history of any psychiatric disorder were excluded from the study. Patients with bipolar depression were excluded from the study. Pregnant and lactating women were excluded as depression is commonly seen in pregnancy and the postpartum period, patients on systemic steroid and substance dependence were excluded from the study. Control group comprised eighty attendants of patients attending dermatology OPD without any dermatological illness with the same inclusion and exclusion criteria. They were demographically matched with the study group. Controls were subjected to the same tools.

Operational procedure

Clinically diagnosed cases of vitiligo were selected from the Dermatology OPD with purposive sampling method as per inclusion and exclusion criteria. After obtaining informed consent pretested and validated dermatology life quality index (DLQI)[10] questionnaire was applied for the assessment of the quality of life and documented. On those patients after mental status examination international classification of mental and behavioral disorders (International Classification of Diseases [ICD–10]) research criteria along with 17-item Hamilton rating scale for depression (HAM-D)[11] were applied to diagnose the presence of depression and grading them as mild, moderated, severe, and profound.

Description of tools

Especially designed performa was used to record the sociodemographic data, present, family, medical and drug history, also physical examination as designed by the researchers

DLQI: DLQI[10] is a reliable questionnaire for assessing the quality of life of an affected person with the dermatological illness. There are ten questions such as symptoms, embarrassment, shopping and home care, clothes, social and leisure, sport, work or study, close relationships, sex, and treatment. Each question refers to the impact of the skin disease on the patient's life over the previous week. Each question is scored from 0 to 3, giving a possible score range from 0 (meaning no effect of skin disease on quality of life) to 30 (very large effect on the quality of life). In our study, as many patients were illiterate and primary educated, hence they might face difficulties in responding to the questions in the English language. Therefore, the Bengali version of the DLQI questionnaire which was translated from English and back-translated to see the validity was used

Depression was diagnosed and assessed by the International classification of mental and behavioral disorders (ICD–10) tenth revision research criteria

HAM-D[11] with 17 items each item was scored as 2–5 point assessed the severity of depression. A score of >7 was taken as significant depression.

Statistical analysis

All analysis was performed using Microsoft Excel software and Statistical Package for Social Sciences (SPSS for Windows, Version 20.0. Chicago, Illinois, USA, SPSS Inc.). P < 0.05 was taken as statistically significant in all aspects. Descriptive statistics were applied with the calculation of mean and standard deviation. On the parametric test “Chi-square test” or “Fisher's exact t-test” was administered to compare between the groups.

RESULTS

A total of eighty patients were enrolled. Among them, 36.25% and 40% had moderate and very large effect on the quality of life [Table 1]. On comparing the mean DLQI score between vitiligo cases and healthy controls, we found higher DLQI score in vitiligo patients (9.68 ± 5.24) compared to control group (1.36 ± 1.37) P < 0.0001. Among the total sample, we found 19 cases (23.75%) and 5 control (6.25%) were depressed. Among them, 68.42% had mild depression, whereas 31.57% had moderate depression. In the control group, all five patients had mild depression [Table 2]. Similarly, the mean HAM-D score of the study patients was (8.20 ± 3.99) which was significantly higher than in the control group (3.26 ± 1.91) P < 0.0001.

Table 1

Distribution of dermatology life quality index score and quality of life affected according to study and control group

DLQI score	QoL affected	Study group (n=80), n (%)	Control group (n=80), n (%)
0-1	No effect	6 (7.5)	53 (66.25)
2-5	Small effect	13 (16.25)	27 (33.75)
6-10	Moderate effect	29 (36.25)	Nil
11-20	Very large effect	32 (40)	Nil
21-30	Extremely large effect	Nil	Nil

DLQI - Dermatology life quality index; QoL - Quality of life

Table 2

Presence and severity of depression in cases and controls

Severity of depression (HAM-D score)	Study group having depressive disorder (n=19), n (%)	Control group having depressive disorder (n=5), n (%)
Mild (8-13)	13 (68.42)	5 (100)
Moderate (14-18)	6 (31.57)	Nil
Severe (19-22)	Nil	Nil
Profound (>23)	Nil	Nil

HAM-D - Hamilton rating scale of depression

Again 22.5% and 31.25% of females had moderate and very large effect on the quality of life as compared to 13.75% and 8.75% of males, respectively. The mean DLQI score between female and male patients in the study group which was (10.73 ± 4.51) and (8.40 ± 5.91), respectively (P < 0.003) [Table 3]. In our study quality of life was very largely effected in 78.94% and 27.86% of vitiligo patients with and without depression respectively P < 0.005 [Table 4].

Table 3

Comparison of quality of life affected according to gender in the study group

Gender	QoL affected				χ 2	P
	No Effect, n (%)	Small effect, n (%)	Moderate effect, n (%)	Very large effect, n (%)
Male	5 (6.25)	11.25	11 (13.75)	7 (8.75)	31.82	0.003
Female	1 (1.25)	4 (5)	18 (22.5)	25 (31.25)

QoL - Quality of life

Table 4

Quality of life in study patients with or without depression as measured by dermatology life quality index

QoL affected	Depression		χ 2	P
	Present (n=19), n (%)	Absent (n=61), n (%)
No effect (n=6)	Nil	6 (9.83)	22.87	0.001
Small effect (n=13)	1 (5.26)	12 (19.67)
Moderate effect (n=29)	3 (15.78)	26 (42.62)
Very large effect (n=32)	15 (78.94)	17 (27.86)

QoL - Quality of life

DISCUSSION

Of all the participants in the study and control group, the majority of them were in the age group of 18–27 years (38.8%). The mean age in the study group was 33.3 years and in the control group, it was 36 years.[12] This may be because vitiligo is more common in the second to fourth decades of life.[13] Regarding gender, we found that there was a higher incidence of vitiligo cases in females (60%).[1214] In our study group, Hindus and Muslims were in equal numbers. It was in approximate conformity with the religious composition of the catchment area. Considering the locality, we found that most of the patients in the study and control group were from rural backgrounds, i.e., 73.75%, and 68.75%, respectively. We found that the highest percentage of our patients was married, i.e., 71.25%. In our study, we have found that most of the patients were from middle socioeconomic status, i.e., 67.5%. This reflects the general makeup of the Indian population which consists middle-class group and also in Government hospitals mostly people from lower and middle socioeconomic strata use to come. In the study, 15% are illiterate, 66.25% have studied up to high school level. Thus, 81.25% of the patients were under matriculate. Regarding occupation highest percentage of patients in the study were unemployed (55%). It was followed by daily wage earner and unskilled worker (20%) and service holder (18.75%), respectively, in the study group [Table 5].

Table 5

Sociodemographic variables of patients with vitiligo

Variable	n (%)
Age (years)
18-27	31 (38.8)
28-37	19 (23.7)
38-47	19 (23.7)
48-60	11 (13.8)
Sex
Male	32 (40)
Female	48 (60)
Socioeconomic status
Lower	17 (21.3)
Middle	54 (67.5)
High	9 (11.25)
Educational status
Illiterate	12 (15)
Up to high school	53 (66.25)
Higher secondary	12 (15)
Graduate	3 (3.75)
Locality
Rural	59 (73.75)
Urban	21 (26.25)
Marital status
Married	57 (71.25)
Single	23 (28.75)
Occupation
Unemployed	44 (55)
Daily wage earner and unskilled worker	16 (2o)
Businessman	5 (6.25)
Service holder	15 (18.75)
Type of family
Nuclear	57 (71.25)
Joint	23 (28.75)
Religion
Hindu	40 (50)
Muslim	40 (50)

We assessed the quality of life of eighty vitiligo patients and eighty healthy controls. In this study, 92.5% of the patient had elevated DLQI scores. Only 33.75% of the healthy control had a small effect on the quality of life compared to 16.25%, 36.25%, and 40% of the study group patients who had small, moderate, and very large effects on the quality of life, respectively [Table 1]. On comparing the mean DLQI score between vitiligo cases and healthy controls, we found higher DLQI scores in vitiligo patients (9.68 ± 5.24) compared to that of control (1.36 ± 1.37).[141516] Difference in quality of life may be related to social acceptability and how the society or family members react to the disease. Furthermore, quality of life affected more in the case of females than males. Females (22.5%) have moderate effect on the quality of life compared to 13.75% of males. While 31.25% of females had very large effect on their quality of life, whereas only 8.75% of males had very large effect (P = 0.03).[141516] The reason for more impairment in the case of females maybe because they are more cosmetically conscious and females share more social burden as they still have to face more discrimination in society compared to males.[6]

We used ICD-10 research criteria and HAM-D to diagnose depression and to measure the severity of depression. We have found a total of 19 patients were having depression in the study population. After applying HAM-D on these 19 patients, we found that 13 cases, i e., (68.42%) were having mild depression while six patients, i.e., (31.57%) had moderate depression [Table 2]. In the control group, only five patients were found having depression and all were having mild depression. Thus, we found the severity of depression was more in vitiligo patients than healthy controls. In cases of vitiligo patients mean depression score (HAM-D) in our study patients (8.20 ± 3.99) was significantly higher than in the control group (3.26 ± 1.91).[13] The higher rate of depression in vitiligo was similar to previous studies.[1417] The reason for a higher rate of depressive disorder in vitiligo patients could be feeling of inferiority regarding their appearance, fear of social rejection, embarrassment for self and family, and low self-esteem.

In our study, regarding the association between depression and the quality of life, we have found 78.94% of the study patients with depression were having very large effect on their quality of life compared to only 27.86% of the patients without depression [Table 1] and the association was statistically significant.[1718] Thus, the vitiligo patients who were suffering from depression had negative impact on their quality of life which leads to significant impairment of the same.

The limitations of the study were small sample size and the patients were evaluated once only. Larger sample size and further evaluation would have been helpful to assess the quality of life in the course of illness. In addition, the study did not include measurement of the area involved in the body as only patients with vitiligo in their exposed body parts were included in the study.

CONCLUSION

Thus, vitiligo patients have significant impairment in their quality of life which is more in females and in those who develop depression.

Thus, the patient should be assessed with more holistic approach. We should account both physical and psychological aspects of these patients. There should be good collaboration between dermatologists and psychiatrists in treating vitiligo patients to improve their quality of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.