Evaluating of Life Quality in Iranian Patients With Vitiligo Using Generic and Special Questionnaires

authors:

avatar Reza Ghaderi 1 , * , avatar Alireza Saadatjoo 2

Department of Dermatology, Birjand University of Medical Sciences, Birjand, IR Iran
Department of Nursing, Birjand University of Medical Sciences, Birjand, IR Iran

how to cite: Ghaderi R, Saadatjoo A. Evaluating of Life Quality in Iranian Patients With Vitiligo Using Generic and Special Questionnaires. Shiraz E-Med J. 2014;15(3):e22359. https://doi.org/10.17795/semj22359.

Abstract

Background:

Vitiligo is a common acquired pigmentary skin disease that can adversely affect the patients’ quality of life (QOL).

Objectives:

The aim of this study was to evaluate the QOL in patients with vitiligo.

Patients and Methods:

This study included 70 patients with vitiligo. All the patients filled out two questionnaires: Short Form 36 (SF-36) and Dermatology Life Quality Index (DLQI). Data were compiled and analyzed by SPSS 17.

Results:

The mean score of patients with vitiligo on DLQI scale was 8.40 ± 5.76 (rang, 0-23). Although males scores on SF-36 scale was higher than females, the difference was not statistically significant (ANOVA, P = 0.68). With regard to age, The mean total score of SF-36 indicated insignificant differences among age groups (ANOVA, P = 0.456). There was a significant reverse correlation between the scores of different dimensions of QOL obtained from the study questionnaires.

Conclusions:

The study findings showed that vitiligo has a significant effect on the patients’ QOL. It seems that psychotherapy should be considered in the treatment of vitiligo.

1. Background

"Quality of life" (QOL) is a general term, which includes a feeling of joy and satisfaction with life. Yet, insufficient attention has been drawn toward the QOL, self-confidences, and self-esteem in patients with skin diseases. Since skin diseases affect mental and general health as well as function and social adaptation of the patients, they can decrease patients’ self-confidence and definitely disrupt their psychological health and quality of life (1). Skin appearing can show a human's self-image or cutaneous body image and any pathologic alterations may lead into disruption of emotional feelings (2). Even with chronic itching, life of a person will be considerably disturbed (3). In addition to evaluating the treatment effectiveness, recording QOL can improve our knowledge regarding emotional stress related with dermatologic disorders (4). According to the studies in the Netherlands (5), the United States (6), Germany (7), Denmark (8), and many other countries (9-23), skin diseases have a great effect on the patients’ QOL. Vitiligo is a chronic, acquired pigmentary disease of the skin, which is characterized by well-circumscribed white macules or patches. Although vitiligo is not fatal, it may significantly affect the patients’ mental health(15). The present study can signify the psychological aspects to its readers and as a result, the necessity of psychological consultation and intervention in patients with vitiligo. Moreover, measuring the incapacities of patients with the aim of taking better care of them can be helpful for leading healthcare services towards the real needs of these patients.

2. Objectives

Regarding the abovementioned facts and according to the regulations of World Health Organization (WHO) stating that one of the duties of healthcare officials is to promote the level of QOL, the present study was conducted to determine the QOL in patients with vitiligo.

3. Patients and Methods

Patients with the confirmed diagnosis of vitiligo were included in this study. Our sampling method was consecutive sampling. Inclusion criteria were diagnosis of vitiligo by a dermatologist and being older than 16 years. Exclusion criteria included diagnosis of skin diseases other than vitiligo, chronic disease such as diabetes mellitus, hypertension, heart disease, stroke, asthma, chronic obstructive pulmonary disease, musculoskeletal illnesses such as rheumatism, arthritis, and back pain, and cancer, any conditions that might have an effect on QOL, and apparent disability. The study was conducted in the Dermatology Clinic of Vali-e-Asr Hospital of Birjand City, Iran, from May 2009 to May 2010. Those who were referred to the clinic and met the eligibility criteria were recruited and the aims of the survey were explained to them. The responders signed a written informed consent. The Institutional Ethical Committee approved the study protocol.

The Farsi version of two questionnaires, namely, Short Form 36 (SF-36) and Dermatology Life Quality index (DLQI), were given to all participants. DLQI, which is a special questionnaire regarding the effect of skin diseases, was designed by Finlay and Khan in 1992 and since then, it has been vastly used in different communities (2, 7, 9-11, 13-17, 20, 21, 23). Furthermore, reliability and validity of the Farsi version of the DLQI questionnaire had been proved through a study in a group of Iranian patients with vitiligo by Aghaei et al. (9) The questionnaire contains ten multiple-choice questions; the points for each question ranges between zero and three. Total score of every individual's QOL would be the sum of the scores of all the questions, i.e., between zero and 30; the higher an individual's score is, the worse his QOL would be. The questionnaire was classified into six headings: symptoms and feelings (questions 1 and 2), daily activities (questions 3 and 4), leisure (questions 5 and 6), personal relationships (questions 8 and 9), work and school (question 7), and treatment (question 10)" (10). SF-36 questionnaire is a generic one that has been used in different communities (12, 24-30). Reliability and validity of the Farsi version of SF-36 had been proved through a study by Montazeri et al. on a random sample of 4163 healthy individuals aged ≥ 15 years (24) and by Jafari et al. on a group of Iranian patients with thalassemia major (25). It comprise 36 items that assess eight dimensions of QOL: physical functioning (PF); role physical (RP), which refers to role restrictions due to physical problems; bodily pain (BP); general health (GH); vitality (VT); social functioning (SF); role emotional (RE), which refers to role restrictions due to emotional problems; and mental health (MH) (12). The obtained scores in each of the dimensions are separately summed up and range from zero to 100; the higher total score is, the better QOL would be. Data were compiled and analyzed by SPSS (version 17, SPSS Inc., Chicago, IL, USA). Data analysis was performed through descriptive Statistics, t test, ANOVA, and Pearson's correlation coefficient test. The conclusions were drawn based on 5% significance level.

4. Results

A total of 70 patients with the diagnosis of vitiligo were included in this study. Overall, 20 patients (28.6%) were male and 50 (71.4%) were female. The age of patients ranged from 16 to 47 years (Table 1).

Table 1.

Mean Age of Patients With Vitiligo Regarding Sex

SexNumber of PatientsMean ± SDStd. Error of MeansP value
Male2028.15 ± 11.82.640.55
Female5026.66 ± 8.341.18

The occupation of participants was homemaker in 23 patients (32.9%), clerk in 18 (25.7%), university or high-school student in 13 (18.55%), and farmer in 6 (8.6%); ten patients (14.25%) were unemployed. There was no significant difference in the mean total score of SF-36 between males and females (ANOVA, P = 0.679) (Table 2).

Table 2.

Comparison of Mean score of Short Form 36 and Dermatology Life Quality Index in Different Dimensions With Respect to Sex a,b,c

DimensionSexP value
TotalMaleFemale
Physical Functioning69.00 ± 21.7368.75 ± 24.1169.10 ± 20.970.95
Role Physical56.43 ± 38.9455.00 ± 39.4057.00 ± 39.140.85
Role Emotional 50.95 ± 37.9556.67 ± 37.6248.67 ± 38.220.43
Vitality51.14 ± 21.4455.50 ± 20.8949.40 ± 21.610.29
Mental Health49.60 ± 22.4251.20 ± 22.8748.96 ± 22.430.71
Social Functioning72.14 ± 24.6570.63 ± 22.3172.75 ± 25.720.75
Bodily Pain74.57 ± 21.6074.38 ± 20.0174.65 ± 22.390.96
General Health54.16 ± 19.2357.06 ± 18.4953.00 ± 19.590.43
Total478.00 ± 141.54489.18 ± 126.89473.53 ± 147.980.68
DLQI8.40 ± 5.808.40 ± 5.638.40 ± 5.921.000

There was no significant difference among age groups in the mean total score of SF-36 (ANOVA, P = 0.46) (Table 3).

Table 3.

Mean Scores of Short Form 36 and Dermatology Life Quality Index in Different Dimensions With Respect to Age a,b

DimensionAge GroupP value c
≤ 20 y21-30 y> 30 y
Physical Functioning67.89 ± 22.1373.18 ± 19.0762.50 ± 25.160.24
Role Physical51.32 ± 37.7156.82 ± 39.6661.11 ± 40.420.75
Role Emotional 56.14 ± 38.5748.48 ± 39.1750.00 ± 36.600.78
Vitality48.42 ± 22.7356.06 ± 17.8445.00 ± 24.970.17
Mental Health45.26 ± 26.6453.09 ± 19.6347.78 ± 22.690.45
Social Functioning67.11 ± 29.2375.38 ± 20.1371.53 ± 27.390.51
Bodily Pain75.00 ± 19.4978.94 ± 16.8966.11 ± 29.010.13
General Health48.68 ± 17.7058.64 ± 20.2851.73 ± 17.800.17
Total459.82 ± 148.90500.59 ± 131.37455.76 ± 153.210.47
DLQI9.84 ± 7.127.88 ± 5.337.83 ± 5.140.45

The mean score of the DLQI in patients with vitiligo was 8.40 ± 5.76 (range, 0-23). There was no significant difference in the mean score of DLQI between males and females (P = 1.000) (Table 2). Moreover, the difference between age groups with regard to the mean score of DLQI was insignificant (ANOVA, P = 0.453) (Table 3). Pearson's correlation coefficient test revealed that there was a significant reverse correlation between all the Dimensions of QOL in SF-36 and the obtained scores from DLQI (Table 4).

Table 4.

Pearson Correlation Between the Scores of Different Domains of Quality of Life Obtained From Short Form 36 and Dermatology Life Quality Indexa

Quality of Life DimensionsDLQIQuality of Life Dimensions
PFRPREVTMTSFBPGH
PF
Pearson Co-0.199
P Value0.099
RP
Pearson Co-0.3270.327
P Value0.0060.006
RE
Pearson Co-0.3240.1480.552
P Value0.0060.2230.000
VT
Pearson Co-0.3490.3810.3430.269
P Value0.0030.0010.0040.024
MT
Pearson Co-0.3650.2010.3200.2730.764
P Value0.0020.0940.0070.0220.000
SF
Pearson Co-0.2960.2180.4770.3520.5340.474
P Value0.0130.0700.0000.0030.0000.000
BP
Pearson Co-0.3600.3250.4160.4150.3920.2710.495
P Value0.0020.0060.0000.0000.0010.0230.000
GH
Pearson Co-0.3470.1460.3710.3650.5360.5460.3240.353
P Value0.0030.2290.0020.0020.0000.0000.0060.003
Total
Pearson Co-0.4720.4800.7730.7000.7230.6640.7090.6650.636
P Value0.0000.0000.0000.0000.0000.0000.0000.0000.000

5. Discussion

In another study on 532 outpatient patients with dermatologic problems (include Vitiligo) by Farsi version of SF-36 questionnaire, mean score of the patients in every domain were significantly lower than the mean of Iranian healthy individuals (12), which were in agreement with our results. Furthermore, their results showed no correlation between the scores in domains of SF-36 questionnaire and severity, extent, and history of hospital admission for skin disorders; however, there was a strong correlation with location of lesion (12). Regarding the age, the mean score of QOL varied in different age groups, but the difference was insignificant, which was in agreement with the finding by Dolatshahi et al. (2). On the other hand, in another study in Germany, the age group between 20 and 30 years demonstrated a lower QOL (7). The difference between the results of the present study and other study might be due to cultural or socioeconomic differences.

The mean DLQI score in the patients of this study (mean, 8.40) was higher in comparison with that in the studies by Dolatshahi et al (mean, 8.16) in Iran (2), Aghaei et al. (mean, 7.05) in Iran (Shiraz) (9), Finlay and Khan (mean, 7.2) in England (13), Radtke et al. (mean, 7.0) in Germany (7), Kent et al. (mean, 4.82) in UK (14), and Ongenae et al. (mean, 4.95) in Belgium (15). However, it was lower than that in the studies by Parsad et al. (mean, 10.67) in India (16) and Al Robaee (mean, 14.72) in Saudi Arabia (17). The observed difference between the findings of different studies might be due to the contrast between vitiligo lesions and darker skins as some studies showed that there was statistically significant association between DLQI scores and skin phototypes (2). Generally, there was no clear-cut correlation between QOL score and sex in most of the previous studies (15-18), which was in agreement with our result. In contrast, Radtke et al. found a correlation between QOL score and sex (mean of 7.5 in women and 5.5 in men) (7). Kim do et al. also suggested that patients with vitiligo were extremely affected in the functional and emotional dimensions of QOL, with some sex differences (worse in females) (19) and Borimnejad et al. reported that in Iran, Muslim women with vitiligo have more deterioration in QOL than Muslim men do (20). Belhadjali et al. also showed that QOL was considerably deteriorated in patients with vitiligo and to a more extent in women (21). These results disagree with ours. The difference seen between the results of the present study and other studies might be due to cultural or socioeconomic differences.

After determining QOL score through DLQI and SF-36 questionnaires in skin patients, it was found that there was a significant reverse correlation between the scores of all dimensions of QOL obtained from SF-36 with those of DLQI. In other words, the higher the QOL score in any of the dimensions of SF-36 was, the lower DLQI score would be and vice versa. Recent results indicated that the treatment strategies to reduce the number and size of vitiligo lesions and their disfiguring results were certainly useful and enhanced their QOL (2, 31). Tjioe et al. evaluated QOL after long-term narrowband ultraviolet B for the treatment of vitiligo. The patients, with prolonged stable vitiligo who were managed at their clinic, were instructed to complete a purposed QOL questionnaire. Most patients showed an improvement in an emotional level, but an extension in disguising (22). Tanioka et al. assessed the emotional feelings on patients with vitiligo through disguising lessons. Disguise enhanced the scores of DLQI when compared with those without disguise and disguise lessons enhanced a subcategory of "symptoms and feelings". These data confirmed the idea that disguise for patients with vitiligo not only masks the depigmented lesions but also enhances their QOL (23). Recently, Lilly et al. created and validated a new vitiligo-specific QOL tool (VitiQoL) (32). The VitiQoL components demonstrated high internal consistency (Cronbach’s alpha, 0.935). Convergent validity was demonstrated by significant correlations between VitiQoL and outside dermatology indices assessing comparable concepts (Skindex-16, r = 0.82; and DLQI, r = 0.83)" (32). However, this new vitiligo-specific QOL instrument should be evaluated in further studies due to limitations of their study.

Regarding the findings of the present study and other surveys, psychiatric consult or psychotherapy should be included in the treatment of vitiligo. In addition, to promote patients' satisfaction and QOL, the following points are recommended:

1) Establishing supportive groups for patients in the specialized dermatology departments and hospitals

2) Establishing consultation and psychotherapy centers for patients with vitiligo

3) Dermatologists should consider the effect of vitiligo on health-related QOL and educate patients on possible treatments.

The study findings showed that vitiligo has a significant effect on the patients’ QOL. There was not a significant sex-related difference in QOL. We recommend considering psychiatric consult or psychotherapy in the treatment of patients with vitiligo.

Acknowledgements

References

  • 1.

    Potocka A, Turczyn-Jablonska K, Merecz D. Psychological correlates of quality of life in dermatology patients: the role of mental health and self-acceptance. Acta Dermatovenerol Alp Pannonica Adriat. 2009;18(2):53-8-62. [PubMed ID: 19588058].

  • 2.

    Dolatshahi M, Ghazi P, Feizy V, Hemami MR. Life quality assessment among patients with vitiligo: comparison of married and single patients in Iran. Indian J Dermatol Venereol Leprol. 2008;74(6):700. [PubMed ID: 19177700].

  • 3.

    Misery L, Finlay AY, Martin N, Boussetta S, Nguyen C, Myon E, et al. Atopic dermatitis: impact on the quality of life of patients and their partners. Dermatology. 2007;215(2):123-9. [PubMed ID: 17684374]. https://doi.org/10.1159/000104263.

  • 4.

    Wahl AK, Mork C, Lillehol BM, Myrdal AM, Helland S, Hanestad BR, et al. Changes in quality of life in persons with eczema and psoriasis after treatment in departments of dermatology. Acta Derm Venereol. 2006;86(3):198-201. [PubMed ID: 16710574]. https://doi.org/10.2340/00015555-0062.

  • 5.

    Linthorst Homan MW, Spuls PI, de Korte J, Bos JD, Sprangers MA, van der Veen JP. The burden of vitiligo: patient characteristics associated with quality of life. J Am Acad Dermatol. 2009;61(3):411-20. [PubMed ID: 19577331]. https://doi.org/10.1016/j.jaad.2009.03.022.

  • 6.

    Taylor A, Pawaskar M, Taylor SL, Balkrishnan R, Feldman SR. Prevalence of pigmentary disorders and their impact on quality of life: a prospective cohort study. J Cosmet Dermatol. 2008;7(3):164-8. [PubMed ID: 18789050]. https://doi.org/10.1111/j.1473-2165.2008.00384.x.

  • 7.

    Radtke MA, Schafer I, Gajur A, Langenbruch A, Augustin M. Willingness-to-pay and quality of life in patients with vitiligo. Br J Dermatol. 2009;161(1):134-9. [PubMed ID: 19298268]. https://doi.org/10.1111/j.1365-2133.2009.09091.x.

  • 8.

    Cvetkovski RS, Zachariae R, Jensen H, Olsen J, Johansen JD, Agner T. Quality of life and depression in a population of occupational hand eczema patients. Contact Dermatitis. 2006;54(2):106-11. [PubMed ID: 16487283]. https://doi.org/10.1111/j.0105-1873.2006.00783.x.

  • 9.

    Aghaei S, Sodaifi M, Aslani FS, Mazharinia N. An unusual presentation of anetoderma: a case report. BMC Dermatol. 2004;4:9. [PubMed ID: 15318943]. https://doi.org/10.1186/1471-5945-4-9.

  • 10.

    Basra MK, Fenech R, Gatt RM, Salek MS, Finlay AY. The Dermatology Life Quality Index 1994-2007: a comprehensive review of validation data and clinical results. Br J Dermatol. 2008;159(5):997-1035. [PubMed ID: 18795920]. https://doi.org/10.1111/j.1365-2133.2008.08832.x.

  • 11.

    Ozturkcan S, Ermertcan AT, Eser E, Sahin MT. Cross validation of the Turkish version of dermatology life quality index. Int J Dermatol. 2006;45(11):1300-7. [PubMed ID: 17076710]. https://doi.org/10.1111/j.1365-4632.2006.02881.x.

  • 12.

    Entezari A, Nabaei L, Tousi P. Quality of life in outpatients dermatologic clients. Pajoohandeh J. 2008;13(1):65-9.

  • 13.

    Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)--a simple practical measure for routine clinical use. Clin Exp Dermatol. 1994;19(3):210-6. [PubMed ID: 8033378].

  • 14.

    Kent G, al-Abadie M. Factors affecting responses on Dermatology Life Quality Index items among vitiligo sufferers. Clin Exp Dermatol. 1996;21(5):330-3. [PubMed ID: 9136149].

  • 15.

    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(6):1165-72. [PubMed ID: 15948977]. https://doi.org/10.1111/j.1365-2133.2005.06456.x.

  • 16.

    Parsad D, Pandhi R, Dogra S, Kanwar AJ, Kumar B. Dermatology Life Quality Index score in vitiligo and its impact on the treatment outcome. Br J Dermatol. 2003;148(2):373-4. [PubMed ID: 12588405].

  • 17.

    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(9):1414-7. [PubMed ID: 17768471].

  • 18.

    Kostopoulou P, Jouary T, Quintard B, Ezzedine K, Marques S, Boutchnei S, et al. Objective vs. subjective factors in the psychological impact of vitiligo: the experience from a French referral centre. Br J Dermatol. 2009;161(1):128-33. [PubMed ID: 19298280]. https://doi.org/10.1111/j.1365-2133.2009.09077.x.

  • 19.

    Kim do Y, Lee JW, Whang SH, Park YK, Hann SK, Shin YJ. Quality of life for Korean patients with vitiligo: Skindex-29 and its correlation with clinical profiles. J Dermatol. 2009;36(6):317-22. [PubMed ID: 19500179]. https://doi.org/10.1111/j.1346-8138.2009.00646.x.

  • 20.

    Borimnejad L, Parsa Yekta Z, Nikbakht-Nasrabadi A, Firooz A. Quality of life with vitiligo: comparison of male and female muslim patients in Iran. Gend Med. 2006;3(2):124-30. [PubMed ID: 16860271].

  • 21.

    Belhadjali H, Amri M, Mecheri A, Doarika A, Khorchani H, Youssef M, et al. [Vitiligo and quality of life: a case-control study]. Ann Dermatol Venereol. 2007;134(3 Pt 1):233-6. [PubMed ID: 17389846].

  • 22.

    Tjioe M, Otero ME, van de Kerkhof PC, Gerritsen MJ. Quality of life in vitiligo patients after treatment with long-term narrowband ultraviolet B phototherapy. J Eur Acad Dermatol Venereol. 2005;19(1):56-60. [PubMed ID: 15649192]. https://doi.org/10.1111/j.1468-3083.2004.01124.x.

  • 23.

    Tanioka M, Yamamoto Y, Kato M, Miyachi Y. Camouflage for patients with vitiligo vulgaris improved their quality of life. J Cosmet Dermatol. 2010;9(1):72-5. [PubMed ID: 20367677]. https://doi.org/10.1111/j.1473-2165.2010.00479.x.

  • 24.

    Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The Short Form Health Survey (SF-36): translation and validation study of the Iranian version. Qual Life Res. 2005;14(3):875-82. [PubMed ID: 16022079].

  • 25.

    Jafari H, Lahsaeizadeh S, Jafari P, Karimi M. Quality of life in thalassemia major: reliability and validity of the Persian version of the SF-36 questionnaire. J Postgrad Med. 2008;54(4):273-5. [PubMed ID: 18953145].

  • 26.

    Al Robaee AA. Assessment of general health and quality of life in patients with acne using a validated generic questionnaire. Acta Dermatovenerol Alp Pannonica Adriat. 2009;18(4):157-64. [PubMed ID: 20043053].

  • 27.

    Mallon E, Newton JN, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br J Dermatol. 1999;140(4):672-6. [PubMed ID: 10233319].

  • 28.

    Motamed N, Ayatollahi AR, Zare N, Sadeghi-Hassanabadi A. Validity and reliability of the Persian translation of the SF-36 version 2 questionnaire. East Mediterr Health J. 2005;11(3):349-57. [PubMed ID: 16602453].

  • 29.

    Ware JE, Kosinski M. Interpreting SF-36 summary health measures: a response. Qual Life Res. 2001;10(5):405-13. discussion 415-20. [PubMed ID: 11763203].

  • 30.

    Ludwig MW, Oliveira Mda S, Muller MC, Moraes JF. Quality of life and site of the lesion in dermatological patients. An Bras Dermatol. 2009;84(2):143-50. [PubMed ID: 19503982].

  • 31.

    Chan MF, Chua TL. The effectiveness of therapeutic interventions on quality of life for vitiligo patients: a systematic review. Int J Nurs Pract. 2012;18(4):396-405. [PubMed ID: 22845640]. https://doi.org/10.1111/j.1440-172X.2012.02047.x.

  • 32.

    Lilly E, Lu PD, Borovicka JH, Victorson D, Kwasny MJ, West DP, et al. Development and validation of a vitiligo-specific quality-of-life instrument (VitiQoL). J Am Acad Dermatol. 2013;69(1):e11-8. [PubMed ID: 22365883]. https://doi.org/10.1016/j.jaad.2012.01.038.

pandi subash
2020-04-06 08:02:46
The progress of disease is hard to predict. Sometimes it stops forming without any treatment most cases, pigment loss spreads and eventually involves most of your skin. Rarely, the skin gets its color back.Seek advice from the best dermatologist,if your skin, hair or eyes lose coloring. Vitiligo can not be cured. But treatment may help to stop or slow the discoloring process and return some color to your skin.