|Year : 2019 | Volume
| Issue : 1 | Page : 244-249
Effect of Vitiligo Area Scoring Index on the quality of life in patients with vitiligo
Mustafa A Hammam1, Hossam A Yasien1, Asmaa F Algharably2
1 Department of Dermatology, Andrology and STIs, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Dermatology, Andrology and STIs, Shebin El Kom Hospital, Shebin El Kom, Egypt
|Date of Submission||31-May-2017|
|Date of Acceptance||07-Aug-2017|
|Date of Web Publication||17-Apr-2019|
Asmaa F Algharably
Department of Dermatology, Andrology and STIs, Shebin El Kom Hospital, Shibin El Kom City, Menoufia Governate, 32511
Source of Support: None, Conflict of Interest: None
The aim of this study was to find out the relation between the vitiligo severity and quality of life of patients with vitiligo.
Vitiligo is the chronic pigmentary disorder of the skin. It greatly affects psychological well-being, and patients experience poor body image and low self-esteem, which may lead to lower level of life quality.
Patients and methods
Overall, 203 patients with vitiligo were studied. Disease severity was assessed using Vitiligo Area Scoring Index (VASI), and patients were asked to answer the Dermatology Life Quality Index (DLQI) questionnaire. DLQI scores and subscores were calculated, and disease characteristics were evaluated.
Mean age of all patients was 26.21 years. The overall DLQI mean score was 5.80 ± 5.04. The DLQI mean score was 6.68 and 3.16 in women and men, respectively. In 18.2% of patients with vitiligo, no effect was seen on the DLQI, little effect was reported in 35% of patients, moderate effect was seen in 32.5% of patients, and extremely high effect was seen in 3% of them. VASI, duration of diseases, and site of lesion were significantly positively correlated with DLQI score.
VASI, duration of the disease, and site of the lesion were positively correlated with DLQI score. Concentrating on patient's life quality is essential in the management of patients with vitiligo. Moreover, significantly strong gathering-based consultations and treatments are additionally imperative arms for dealing with vitiligo.
Keywords: body image, dermatology, quality of life, vitiligo
|How to cite this article:|
Hammam MA, Yasien HA, Algharably AF. Effect of Vitiligo Area Scoring Index on the quality of life in patients with vitiligo. Menoufia Med J 2019;32:244-9
|How to cite this URL:|
Hammam MA, Yasien HA, Algharably AF. Effect of Vitiligo Area Scoring Index on the quality of life in patients with vitiligo. Menoufia Med J [serial online] 2019 [cited 2019 May 27];32:244-9. Available from: http://www.mmj.eg.net/text.asp?2019/32/1/244/256109
| Introduction|| |
The skin is the biggest and most noticeable organ of the human body. Subsequently, any blemish on the skin noticeably influences the spectator, and along these lines, the individual is influenced significantly .
In the past decades, it has been noticed an expanding enthusiasm for studying the psychological effects of different skin diseases and personal satisfaction in patients experiencing these diseases. A healthy normal skin is basic for a person's physical and mental prosperity. It is an imperative part of their sexual attractiveness, a feeling of prosperity, and a feeling of self-assurance .
Vitiligo is a disorder of pigmentation, with a worldwide prevalence of around 1–2%. It is described by well-demarcated areas of depigmentation, which are regularly symmetrical, owing to the loss of pigment cells. Because of its long term, often unpredictable nature, it can cause critical disability in personal satisfaction .
Vitiligo influences all races, ethnicity, and skin types. On account of severity of differentiation between depigmented and normal skin, darker skin people usually face more stigmatization, discrimination, and perhaps major psychosocial issues .
There might be huge constraints to the patients' quality of life (QoL) when vitiligo affects the obvious parts of the body or the genitals . Specific QoL instruments can be used to give a detailed picture of the burden caused by this condition .
The Dermatology Life Quality Index (DLQI) is considered one of the personal satisfaction surveys particularly intended for skin diseases, and it can be used to measure life quality . This instrument has been used in several studies to evaluate QoL of patients with dermatological disease in general and in case of particular skin sicknesses in essential, optional, and tertiary administrations .
Hamzavi et al.  have presented a quantitative parametric score, named Vitiligo Area Scoring Index (VASI), that is theoretically obtained from the Psoriasis Area and Severity Index score, which is generally used as a part of psoriasis evaluation. The aggregate body VASI is computed using an equation that incorporates scores from all body regions (possible range: 0–100) :
VASI = Σ(all body sites) (hand units) × (depigmentation)
One hand unit, which includes the palm plus the volar surface of all the digits, is roughly 1% of aggregate body surface region and is used as a manual to simulate the standard rate of vitiligo contribution in each body district. The body was classified into five independent and fundamentally unrelated areas: hands, upper extremities (excluding hands), trunk, lower extremities (excluding feet), and feet. The extent of remaining depigmentation is expressed as follows: at 100% of the depigmentation, the depigmented area exceeds the pigmented area; at 50%, the depigmented and pigmented areas are equal; at 25%, the pigmented area exceeds the depigmented area; and at 10%, only specks of depigmentation are present . The aim of this study was to find out the relation between the vitiligo severity and life quality in patients with vitiligo.
| Patients and Methods|| |
This was a cross-sectional investigational study carried out on 203 patients from the Outpatient Clinic of Dermatology in Menoufia University hospital between April 2016 and October 2016. The age of the studied group ranged from 14 to 60 years, and they all were clinically diagnosed as having vitiligo.
Information on patients' demographic data (sex, age, residence, skin type, disease duration, occupation, marital status, and family history), vitiligo type (e.g., acrofacial, focal, segmental, universal, and vitiligo vulgaris), and previous treatments was collected.
A widely validated tool for the measurement of QoL, the DLQI, was used, which was planned by Finlay and Khan according to the terms and conditions for clinical use . This questionnaire is simple, which consists of a 10-item four-point scale (from 'not at all' to 'very much', with score from 0 to 3).
The vitiligo involvement percentage is computed according to units of hand, with an assumption that unit of hand represents ∼1% (% only) of the total body surface area . The pigmentation level is evaluated to the closest of the accompanying rates: 100% represents complete depigmentation, with no pigment present; 90% represents some pigmentation present; 75% represents depigmented area with an increase in pigmented area; 50% where equal percentage of pigmented and depigmented areas present; 25% represents pigmented area exceeds depigmented area; and 10% shows specks of depigmentation present . The VASI for each body district is controlled by the result of the territory of this vitiligo in hand units and the degree of depigmentation within each hand unit measured patch :
VASI = Σ(all body sites) (hand units) × (depigmentation)
DLQI was calculated by summing the score of all questions, with a maximum score of 30 and a minimum of 0: 0–1, no effect at all on patient's life; 2–5, small effect on patient's life; 6–10, moderate effect on patient's life; 11–20, very large effect on patient's life; 21–30, extremely large effect on patient's life.
The study was approved by the Ethical Committee of Menoufia Faculty of Medicine, and an informed consent obtained from all participants before the study was commenced.
Data were fed to the computer and analyzed using SPSS software package version 20.0 (IBM Corp, Armonk, New York, USA). Qualitative data were described using number and percentage. The Kolmogorov–Smirnov test was described using range (minimum and maximum), mean, SD, and median. Significance of the obtained results was judged at the 5% level.
| Results|| |
Population under study (203 cases) comprised 152 (74.9%) females and 51 (25.1%) males, with females: males ratio of 2.9: 1. Their ages ranged from 14 to 60 years, with a mean of 26.21 ± 12.40 years [Table 1].
There were 133 (65.5%) patients with no precipitating factors, 58 (28.6%) patients with history of stress, eight (3.9%) patients with history of sunburn, and four (2%) patients with history of pregnancy. Moreover, there were 76 (37.4%) patients with vitiliginous lesions in covered sites, 57 (28.1%) patients with vitiliginous lesions in exposed sites, and 70 (34.5%) patients with vitiliginous lesions in exposed and covered sites [Table 2].
|Table 2: Distribution of the studied cases according to precipitating factors and lesion site|
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The DLQI scores ranged from 0 to 26, with a mean ± SD of 5.80 ± 5.04 (6.68 in women and 3.16 in men). The difference was highly statistically significant (<0.001). Regarding the distribution of the studied cases according to DLQI score, there were 14 (27.5%) males compared with 23 (15.1%) females whose DLQI scores showed no effect on QoL. In addition, 27 (52.9%) males compared with 44 (28.9%) females had DLQI scores that showed a small effect on patients' lives. Moreover, 10 (19.6%) males compared with 56 (36.8%) females had DLQI score that showed moderate effect on patients' lives. Moreover, 23 (15.1%) females had DLQI scores that showed very large effect on patients' lives, and six (3.9%) females had DLQI scores that showed extremely large effect on patients' lives compared with no males. Regarding the relation between sex and DLQI, there was a significant difference in the first question between males (74.5%) and females (49.3%). Moreover, a significant difference was seen in the second question between males (64.7%) and females (36.8%). Significant difference in third question was seen between males (84.3%) and females (69.1%) [Table 3].
|Table 3: Distribution of the studied cases according to Dermatology Life Quality Index score|
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Insignificance was seen in the sixth question (Over the past week, how much has your skin made it difficult for you to play any sport?), seventh question (Over the past week, has your skin prevented you from working or studying?), ninth question (Over the past week, how much has your skin caused any sexual difficulties?), and 10th question (Over the past week, how much of a problem has the treatment for your skin caused, e.g., by making your home messy or by taking up time?) [Table 4].
|Table 4: Relation between sex and Dermatology Life Quality Index (% from row)|
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There were significantly positive correlation between disease duration and question 7 (school/work) and question 9 (sexuality) in males, and also between disease duration and question 2 (self-consciousness about lesions) and question 5 (social/leisure activities) in females, as well as between disease duration and total DLQI score [Table 5].
|Table 5: Correlation between duration of disease and Dermatology Quality Life Index|
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There were significant differences among grades of DLQI score regarding VASI score. It was higher in moderate and very large effect on patient's life than in no effect, small effect, and extremely large effect on patient's life. There was highly significant positive correlation between VASI score and DLQI score (P < 0.001) [Table 6].
|Table 6: Relation between Dermatology Life Quality Index score with Vitiligo Area Scoring Index score|
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| Discussion|| |
The mean DLQI found in the current study was 5.80, representing moderate limitation of QoL. This was a high DLQI score when compared with mean DLQI scores reported in other studies; example, for Kent and Al-Abadie  it was 4.8, Ongenae et al.  it was4.9, and Wang et al.  it was 4.4, and nearly equal with Tanioka et al.  it was 5.9.
However, Parsad et al.  reported a high DLQI score (10.67) among Indian patients, and higher mean DLQI scores were reported in Saudi Arabia, Al-Robaee  (14.7) and Al-Mubarak et al.  (17.1). This may be explained by difference in color of race. Indians and Arabs in the gulf area have darker skin than those in the European and Mediterranean area.
Among participants who had high DLQI score, females represented three times more than males (male/female ratio = 1: 2.98), which was a common finding with Akrem et al. .
In this study, the total mean DLQI score for male patients was 3.13 as compared with 6.68 in females. This difference was highly statistically significant and denoted that the effect of QOL in female patients with vitiligo was fundamentally influenced than their male counterparts. This result was compatible with Dolatshahi et al.  and Al-Mubarak et al.  who demonstrated a relationship between sex and QOL, so more attention to this group is needed. On the contrary, Parsad et al.  and Kent and Al-Abady  studies showed that the effect of QOL is not different regarding sex.
Our study demonstrated that women (as opposed to men) are specifically more humiliated and self-conscious about the disease, more influenced in their choice of clothing, and more impaired in their daily routine. These items appear to trouble more women than men in a variety of dermatological conditions studied in a primary care setting as stated by Ongenae et al. .
This study showed no statistical significant difference in sexual relationship between male and female. However, Porter et al.  studied the effect of vitiligo on sexual relationships and found that embarrassment during sexual relationships was frequent especially in men with vitiligo.
In our study, 101 (49%) patients are younger than 20 years. This is confirmed by the findings reported by Taïeb and Picardo , whereas Wong and Babee  in a survey of Malaysian patients with vitiligo stated that the mean DLQI was not associated with sex or age of patients with vitiligo.
In this study, 58 (28.6%) of the patients with vitiligo showed stress as precipitating factor, which agrees with Cucchi et al.  indicated that psychological stress increases level of neuroendocrine hormones, which affect the immune system and alter the level of neuropeptides. The increase in the level of neuropeptides may be the initiating event in pathogenesis of vitiligo. This study showed positive correlation between disease duration and total DLQI score.
Parsad et al.  found a statistically significant relationship between DLQI scores and disease duration. Radtke et al.  also found a significantly more prominent constraint in QoL with increasing duration of disease.
Ghajarzadeh et al.  on a linear regression model study showed that disease duration was an indicator element of QoL impairment. Kent and colleagues did not find any significant correlation between the DLQI score and disease duration ,,,.
This study suggested that the 'visible lesions' group scored higher compared with the 'invisible lesions' regarding DLQI score and showed that patients with visible lesions experienced a higher level of stigmatization, and this result was consistent with that of Schmid-Ott et al. .
In this study, the overall scores of cases were 3.9% for females compared with 0.0% males with extremely large effect on patients' life, 15.1% females compared with 0.0% males with very large effect, 36.8% females compared with 19.6% males with moderate effect, 28.9% females compared with 52.9% males with small effect, and 15.1% females compared with 27.5% males without any effect on patients' life.
This study showed positive correlation between VASI score and total DLQI score, and also between VASI and question 2 (self-conscious about lesions) and question 4 (clothing decisions) in female in comparison with correlation between VASI score with question 7 (work and school) in male; this is explained by the fact that females are more concerned with their appearance, self-esteem, and more influenced in their choice of clothing, whereas men focus more to the pursuit of work and form relationships.
In this study, there was significant difference among grades of DLQI score regarding VASI score. It was high in moderate and very large effect on life of patient, then in no effect, small effect, and extremely large effect on life of patients. There was high significant positive correlation between VASI score and OLQI score.
We acknowledge the limitation of our study as not having outer control mass, consisting of healthy individuals, to compare life quality, and it makes it hard to estimate the pure effects of vitiligo on QL. We used DLQI, and it is a specific questionnaire designed to measure the life quality affected by skin disorders. Although it is a valid measurement tool for patients with skin disorders, its applicability in healthy individuals is not confirmed yet. However, designing studies with control group is highly recommended.
| Conclusion|| |
VASI, duration of the disease, and site of the lesion were positively correlated with DLQI score. Concentrating on patient's life quality is essential in the management of patients with vitiligo; significantly strong gathering-based consultations and treatments are additionally imperative arms when dealing with vitiligo.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]