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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 4
| Issue : 2 | Page : 104-108 |
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Quality of life in vitiligo: Relationship to clinical severity and demographic data
Milind A Patvekar, Kirti S Deo, Sampurna Verma, Preeti Kothari, Aayush Gupta
Department of Dermatology, Dr. D.Y. Patil Medical College and Hospital, Pimpri, Pune, India
| Date of Web Publication | 1-Dec-2017 |
Correspondence Address:
Aayush Gupta
Sanjeevani Nursing Home, Salar Gunj Gate, Panipat 132103, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2349-5847.219684
Background: Vitiligo, a common, acquired, idiopathic, depigmenting disorder of the skin and/or mucosae has a profound effect on the patient’s quality of life (QoL). However, its relationship with clinical severity remains equivocal.
Aim: To measure the impairment in QoL of patients having vitiligo and correlate it with the severity of the disease.
Materials and Methods: A cross-sectional, questionnaire-based study was conducted on a cohort of 100 consecutive vitiligo patients attending the outpatient department of our tertiary care hospital over a period of 1 year. A physician utilized the vitiligo area severity index to measure the severity of the disease, whereas the patient’s QoL was assessed by using the vitiligo impact scale-22. Demographic data and clinical characteristics were also documented. Spearman’s correlation coefficient, chi-squared, and independent ‘t’ tests were used as appropriate.
Results: Our study revealed a highly significant correlation between the extent of vitiligo and impairment in QoL. Patients with early onset of disease, those having previously taken any kind of treatment, unmarried individuals or those with vitiligo involving the face and/or upper extremities had a significantly greater impact on their QoL.
Conclusion: The severity of vitiligo, among other factors, is significantly correlated with the impairment in the QoL of its sufferers.
Keywords: Quality of life, severity, VASI, VIS-22, vitiligo
How to cite this article:
Patvekar MA, Deo KS, Verma S, Kothari P, Gupta A. Quality of life in vitiligo: Relationship to clinical severity and demographic data. Pigment Int 2017;4:104-8 |
| Introduction | |  |
Vitiligo, a common acquired depigmenting disorder, affects approximately 1% of the population worldwide and is clinically characterized by well-demarcated areas of depigmentation as a result of loss of melanocytes.[1],[2] Although generally considered to be a cosmetic issue, vitiligo is usually psychologically devastating, especially in darker individuals.[3] Patients with vitiligo often suffer from poor body image along with low self-esteem, and experience discomfort, inferiority, and discrimination in social and societal relationships,[4] leading ultimately to an impaired quality of life (QoL).[5]
Though many studies have been successful in quantifying the negative impact of vitiligo on QoL, its direct correlation with disease severity remains equivocal.[6] Hence, we undertook this study to delineate demographic factors contributing to the impairment of QoL in patients suffering from vitiligo and to ascertain their correlation, if any, with its clinical severity.
| Materials and methods | | |
This cross-sectional, questionnaire-based study was conducted after receiving ethical clearance from our Institute and comprised a cohort of 100 patients of vitiligo (of any type) attending the outpatient department of our tertiary care hospital over a period of 1 year. After obtaining their informed consent and demographic details, each patient was asked to fill in, without any time limit, the vitiligo impact scale-22 (VIS-22) questionnaire.[7]
VIS-22, a disease-specific, modified version of VIS questionnaire,[8] validated in the Indian population, consists of 22 easily comprehensible questions: 19, common to all patients and one each for patients who are married, unmarried, working, or studying. Individual responses are scored from 0 to 3; a higher score indicating a worse QoL.[7]
The clinical severity of vitiligo was assessed using the vitiligo area severity index (VASI),[9] which is a standardized, sensitive method to measure the extent and percentage of de- and/or repigmentation. This index divides the patient’s body into five mutually exclusive regions: the hands, upper extremities (includes axillae), trunk, lower extremities (includes buttocks and inguinals), and the feet. The face and neck are assessed separately. For each region, the VASI is determined by measuring in ‘hand units’ (1% per unit), the area of vitiligo, and multiplying this with the extent of depigmentation within each ‘hand unit’ (possible values being 0, 10, 25, 50, 75, 90 or 100%: 10%, only specks of depigmentation; 25%, pigmented area exceeds depigmented one; 50%, pigmented area is equal to the depigmented area; 75%, depigmented area exceeds the pigmented area; 90%, only specks of pigmentation and 100%, complete depigmentation). The total VASI, with a score ranging from 0 to 100, is then calculated using the formula: VASI = Σ (all body sites) (hand units) × (residual depigmentation).
Statistical analysis
Quantitative variables were described using percentages, ranges, means, and standard deviations. The independent sample t-test, Chi-squared test, and Spearman’s correlation analysis were performed using the Statistical Package for the Social Sciences version 22 (SPSS Inc., Chicago, IL, USA for Windows) software as appropriate. A two-tailed probability value of less than 0.05 was considered significant.
| Results | | |
Demographic data
One hundred patients, 45 males and 55 females [Figure 1], with age ranging from 18 to 69 (mean: 34.3± 13.38) years, consisted our study population; students (31%), housewives (29%), and professionals (20%) forming the majority. Of them, 90 were Hindus, eight Muslims, one Christian, and one Sikh. A total of 59 individuals were married; 37, single and 4, divorcees. The majority (30%) first noticed vitiligo between 15–24 years of age; 28%, between 25 and 34 years and 17%, between 35 and 44 years; 30%, presented to our department within 5–10 years of onset of vitiligo, whereas 24% did so after a period of 10 years [Table 1]. A first-degree family history was present in 24 (11 males, 13 females) patients. Nonsegmental vitiligo was the most common (96) type encountered by us (vulgaris, 63%; focal, 17%; acral, 5%; acrofacial, 5%; mucosal, 4%; and universal, 2%). Segmental vitiligo was seen in only four patients [Figure 2]. Lower extremities were the most common body part to be involved (74%), followed by upper extremities (58%), the scalp being involved in only 13% of our patients. The majority of our study population (72%) had already taken some kind of therapy prior to visiting our institute, the most common being alternative (Ayurveda/Homeopathy) medicine by 53 (73.61%) [Table 1].
Vitiligo impact scale-22
The mean VIS-22 in our study was 32.57 ± 18.44, higher in females (34.07 ± 17.19) than males (30.73 ± 19.12), though not significantly so. There was a significant negative correlation (ρ = −0.197, P = 0.049) between the patients’ age and the VIS-22. Gender, occupation, religion, family history, and duration of disease had no correlation with the VIS-22. Single patients had a significantly higher VIS-22 (38.51 ± 19.21) as compared to married ones (29.42 ± 17.16, P = 0.047). Patients with vitiligo involving the face (41.23 ± 18.18 vs 24.89 ± 15.06, P < 0.000) and upper extremities (38.07 ± 16.51 vs 24.98 ± 18.01, P < 0.000) had a significantly higher VIS-22 than those whose disease did not involve these areas. Patients with vitiligo vulgaris had a significantly higher VIS-22 (37.60 ± 17.12) than those with focal vitiligo (22.59 ± 16.12, P = 0.026). Surprisingly, patients having taken any kind of treatment in the past had a significantly higher VIS-22 (37.68 ± 16.53) than those who had taken none (20.68 ± 17.04, P < 0.000); this impairment being significantly more pronounced in patients who had taken psoralen and ultraviolet A (PUVA) therapy (45.19 ± 13.48 vs 28.14 ± 17.95, P < 0.000), topical steroids (41.97 ± 15.09 vs 27.94 ± 18.26, P < 0.000), and/or systemic steroids (41.54 ± 16.92 vs 29.08 ± 17.92, P = 0.002).
Vitiligo area severity index
The overall mean VASI in our study was 13.95 ± 21.42 (range: 1–99), significantly higher in females (18.36 ± 23.92) than in males (8.57 ± 16.63, P = 0.018). Patients with a positive family history had a significantly higher VASI score (24.82 ± 29.14) than those without (10.52 ± 17.2, P = 0.03). There was no association of VASI with the duration of disease, though it had a significant, positive correlation with increasing age (ρ = 0.265, P = 0.008). Patients who had undergone prior treatment had a significantly higher VASI (18.57 ± 23.92) than those who had not taken any treatment (2.54 ± 2.32, P < 0.000). Farmers had a significantly higher VASI at presentation (50 ± 49.00) as compared to students (11.69 ± 18.39, P = 0.045) and those employed in clerical jobs (5.77 ± 6.63, P = 0.041). Divorcees were found to have a significantly higher VASI (39.25 ± 45.35) than patients who were single (12.84 ± 18.60, P = 0.049) as well as married (12.94 ± 20.40, P = 0.045).
Correlation of vitiligo impact scale-22 scores with vitiligo area severity index
There was a significant, positive correlation between VIS-22 and VASI (ρ = 0.422, P < 0.000).
| Discussion | | |
Although vitiligo equally affects people across all races and ethnicities, a greater impact on QoL is generally seen in individuals with darker skin types. This is especially true in India where vitiligo was once considered to be one of the top 3 major medical problems.[10] Our study reiterates the significant impairment of QoL in patients of vitiligo reported in earlier studies. However, in contrast to several earlier studies reporting females to have a worse QoL, our study revealed no such significant difference in the QoL of females vis-a-vis males.[11]
There was a significant negative correlation between age and impaired QoL, that is, the impairment of QoL decreased progressively with age in our study. A previous study, too, demonstrated that negative experiences due to vitiligo in childhood continue to be associated with impairment of QoL in young adults, probably as childhood, particularly adolescence, is characterized by rapid psychological and social development, which when coupled with emotional vulnerability and negative experiences due to disfiguring diseases such as vitiligo may permanently affect their psychological and emotional development.[12]
Single patients had a significantly higher impairment of QoL than married ones in our study, similar to another study conducted in Saudi Arabia, probably because of the inherent stability and security provided by marriage. In India, the inability to find suitors for marriage by sufferers of vitiligo forms one of the major reasons of their significantly higher VIS-22.[13] In contrast, an Iranian study revealed a greater impact on QoL of patients who were married due to a unique law that supports Iranian men to file for divorce without any alimony if, before marriage, the presence of vitiligo was not disclosed by their wives.
Our study reiterated the finding of most previous studies which demonstrated that vitiligo involving the face and hands had the greatest impact on QoL, probably as a result of the highly visible nature of these sites and the inability to cover them with clothes.[11]
Surprisingly, in contrast to earlier studies, patients treated previously for vitiligo had a significantly greater impairment of their QoL than that in those untreated.[11] This suggests that there is a ‘paradoxical’ increase in impairment of QoL due to vitiligo with attempted treatment, probably due to increased expectations. This impairment was significantly more pronounced in patients having previously taken PUVA therapy, topical steroids, and/or systemic steroids as compared to Narrow band ultraviolet B, topical tacrolimus, and Ayurveda, suggesting a higher level of satisfaction with the latter.
Increasing age, female sex, and/or positive family history were associated with significantly increased severity of vitiligo probably due to underlying genetic factors and specific HLA haplotypes.[14] A significantly higher VASI of farmers could be explained by lesser social and societal pressures leading to a delay in their presentation to a hospital. A significantly greater clinical severity of vitiligo in divorcees could probably be explained by stress-induced exacerbation of their disease.
QoL based on VIS-22 demonstrated a significant, positive correlation with the extent of vitiligo as assessed by VASI in our study, findings consistent with multiple prior studies.[15],[16],[17] However, this is in contrast to other dermatological conditions such as acne vulgaris and melasma, where the correlation between disease severity and impaired QoL remains equivocal.[18],[19]
Small sample size, a lack of guaranteed reliability of the self-reported QoL, and inability to get patients investigated for biochemical and/or serological abnormalities formed the limitations of this study.
In conclusion, an increased extent of vitiligo, younger age, and vitiligo involving the face and/or upper extremities is associated with a worse QoL, which may in turn lead to exacerbation of disease, forming a vicious circle. Thus, the impairment of QoL in vitiligo patients should be routinely assessed via objective scoring systems such as the VIS-22, and the findings incorporated into therapeutic decision-making, as patients having a greater impairment of their QoL may benefit from more aggressive intervention, such as phototherapy and systemic therapy including surgery and/or psychological intervention.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1]
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