|Year : 2021 | Volume
| Issue : 1 | Page : 281-284
Psychiatric comorbidity and quality of life in patients with dermatological diseases
Nabil R Mohamed1, Afaf Z Rajab1, Amr S Shalaby1, Azza G Farg2, Amira A El-Bakry1
1 Department of Neuropsychiatry, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Dermatology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||13-Apr-2019|
|Date of Decision||08-May-2019|
|Date of Acceptance||20-May-2019|
|Date of Web Publication||27-Mar-2021|
Amira A El-Bakry
Berket El-Sabea, Menoufia
Source of Support: None, Conflict of Interest: None
The aim of the study was to compare the psychiatric comorbidities in patients with vitiligo with control group considering the burden in their life quality.
Several studies reported high rates of depression and anxiety particularly for specific dermatological diseases such as vitiligo, affecting their life quality.
Patients and methods
A total of 30 patients with vitiligo as well as 30 participants as a control group were included. The study was conducted in Neuropsychiatry Department, Menoufia University. Arabic version of the Structured Clinical Interview for psychiatric Disorders 1 based on the Diagnostic and Statistical Manual of Mental Health Disorders, fourth ed., was used for psychiatric diagnosis. Dermatology life quality index was used to assess life quality in patients with vitiligo. Arabic version of the Holmes and Rahe Stress Scale was used to determine stressful life events that might increase risk for illnesses.
A statistically significant difference between the patients with vitiligo and controls was found regarding psychiatric comorbidities (P < 0.001). Only seven (23.3%) patients of vitiligo group were free of psychiatric disorders. Overall, 23 patients of vitiligo group had psychiatric comorbidities versus control group (76.7 vs. 16.7%). Quality of life (QOL) affection was at moderate effect in 16.7%, very large effect in 30%, and extreme large effect in 10%.
Patients with vitiligo disease were associated with high rates of psychiatric comorbidity. A significant disruption was found in QOL. Screening may be helpful for early diagnosis, improving their QOL.
Keywords: anxiety, depression, psychiatric comorbidity, quality of life, vitiligo
|How to cite this article:|
Mohamed NR, Rajab AZ, Shalaby AS, Farg AG, El-Bakry AA. Psychiatric comorbidity and quality of life in patients with dermatological diseases. Menoufia Med J 2021;34:281-4
|How to cite this URL:|
Mohamed NR, Rajab AZ, Shalaby AS, Farg AG, El-Bakry AA. Psychiatric comorbidity and quality of life in patients with dermatological diseases. Menoufia Med J [serial online] 2021 [cited 2021 Oct 23];34:281-4. Available from: http://www.mmj.eg.net/text.asp?2021/34/1/281/311996
| Introduction|| |
Vitiligo is an acquired cutaneous disorder of pigmentation, with an incidence of 0.5–2% worldwide. There are three major hypotheses for the pathogenesis of vitiligo that are not exclusive of each other: biochemical/cytotoxic, neural, and autoimmune. Recent data provide strong evidence supporting an autoimmune pathogenesis of vitiligo. As vitiligo can have a major effect on quality of life (QOL), treatment can be considered and should preferably begin early when then disease is active .
Vitiligo is characterized by hypopigmentation or depigmentation of skin and mucosae. Skin being the outermost covering of the body and being exposed to environment, its appearance greatly influences body image and self-esteem. The sense of being stigmatized or being different from others is a common reaction and may affect an individual's interpersonal and social behavior. The chronic nature and unpredictable course of the disease along with lack of uniform effective therapy can be a cause of stress, anxiety, depression, and frustration. It influences the way we are perceived by others and can affect the social and marital life .
Although many studies have been successful in quantifying the negative effect of vitiligo on QOL, patients with nonsegmental type of vitiligo had more impairment than corresponding subgroups because of irregularly spread depigmented patches on the exposed part of the skin. Hence, improvement of the QOL of the vitiligo-affected persons is a very essential and challenging matter .
The objective of vitiligo treatment is to get better skin appearance, which requires long time, usually 6–18 months. Response to treatment is ~70–75%, and how to choose a treatment modality depends on severity, extent, and location of disease. Vitiligo Area Scoring Index is one of the most valid indexes for evaluation of disease extent and severity and also it can be measured in all situations . The aim of the study was to compare the psychiatric comorbidities in patients with vitiligo with control group consisted of healthy volunteers considering the burden in their life quality.
| Patients and methods|| |
This descriptive cross-sectional study included 60 participants chosen according to inclusion and exclusion criteria. This study was conducted in Neuropsychiatry Department, Menoufia University. Participants were recruited from Outpatient Dermatology Clinic in Menoufia University Hospitals during the period from January 2018 to March 2019 after approval from the Research and Ethics Committee of Faculty of Medicine, Menoufia University. The nature of the study and its objectives were explained to participants, and an informed consent was signed by all participants before being recruited in the study.
Participants of the study were classified into the following groups: group I which included 30 patients diagnosed with vitiligo disease, and group II which was a control group including 30 volunteers free of dermatological diseases.
All participants were subjected to the Arabic version of modified structured clinical interview for Diagnostic and Statistical Manual of Mental Health Disorders, fourth ed., disorders Structured Clinical Interview for psychiatric Disorders 1 scale  which was used for clinical psychiatric diagnosis. Arabic version of the Holmes and Rahe Stress Scale  was used to determine whether stressful life events might increase risk for illnesses and showed that score of more than 300 is at high risk of illness. Score of 150–299 was at moderate risk of illness, and score of less than 150 only had a slight risk of illness.
Group I was subjected to dermatological diagnosis done by a dermatologist. Vitiligo Area Severity Index Scale , for vitiligo severity assessment, is another scoring system offering accurate measures of disease severity indexes and treatment evaluation criteria. Additionally, it has the potential to be a source of any computed application for researchers who work on patients with vitiligo. Arabic version of dermatology life quality index  is the most frequently used instrument in randomized controlled trials in dermatology. It includes 10 questions covering different domains of QOL and shows no effect (0–1), small effect (2–5), moderate effect (6–10), very large effect (11–20), and extremely large effect (21–30).
Data were collected and coded and then entered into a spreadsheet. Data collected were tabulated and analyzed by statistical package for the social sciences (SPSS) version 22.0 on IBM (IBM Corp, IBM SPSS Statistics for Windows [Internet]. Armonk, NY: 2013) compatible computer. Owing to the small sample size, two types of statistics were performed: descriptive statistics, where quantitative data were shown as mean, SD, minimum, and maximum, and qualitative data were expressed as frequency and percent, and analytical statistics, using χ2-test. P was considered significant if it is less than 0.05.
| Results|| |
The study was conducted on 60 participants. In group I, 20 (66.7%) were females and 10 (33.3%) were males, with mean age of 28.80 ± 15.64 years. In group II, 24 (80%) were females and six (20%) were males, with mean age of 32.93 ± 12.02 years, with a statistically nonsignificant difference between the studied groups regarding age and sex distribution. Stressful life events were high in seven (23.3%) patients, moderate in nine (30%) patients, and low in 14 (46.7%) patients in group I. Stressful life events were high in five (16.7%) patients, moderate in 12 (40%) patients, and low in 13 (43.3%) patients in group II [Table 1].
Psychiatric comorbidities found in group I were 15 (50%) patients had depression, three (10%) patients had generalized anxiety disorder, two (6.7%) patients had obsessive compulsive disorder (OCD), two (6.7%) patients had panic disorder, and one (3.3%) patient had phobia. Psychiatric comorbidities found in group II were two (6.7%) patients had depression and three (10%) patients had generalized anxiety disorder. There was a significant difference between the group I and group II, as the P value was less than 0.001 [Table 2].
|Table 2: Psychiatric comorbidities associated with vitiligo and controls|
Click here to view
QOL affection in group I (vitiligo group) showed no effect in one (3.3%) patient, small effect in 12 (40%) patients, moderate effect in five (16.7%) patients, very large effect in nine (30%) patients, and extremely large effect in three (10%) patients [Figure 1].
The correlation was found to be positive between severity of vitiligo disease and QOL affection (r = 0.248) [Figure 2].
|Figure 2: Correlation between severity of vitiligo and effect on quality of life.|
Click here to view
| Discussion|| |
The relationship between skin and brain is based on both being originated from the same ectodermal structure and being under the influence of the same hormones and neurotransmitters. Psychodermatology makes up a common area of interest based on the mutual relationship and interaction between psychiatry and dermatology .
This study measured stress events that trigger vitiligo among studied 60 participants. In group I, there were 20 (66.7%) females and 10 (33.3%) males, with mean age of 28.80 ± 15.64 years. In group II, 24 (80%) were females and six (20%) were males, with mean age of 32.93 ± 12.02 years. The reported stressful life events were high in seven (23.3%) patients, moderate in nine (30%) patients, and low in 14 (46.7%) patients in group I (vitiligo patients).
This is in agreement with a recent study by Vrijman et al.  who studied patients with vitiligo, and there were 64 (36%) male and 113 (64%) female patients. The mean age of the patients at inclusion was 43.7 ± 14.1 years (range: 17–80). They reported that 55% of the patients had emotional stress and stressful events that triggered their vitiligo, as psychological stress was found to increase the level of neuroendocrine hormones with an effect on the immune system. Therefore, one plausible hypothesis is that this increase in neuroendocrine hormones might be the initiating event in the pathogenesis of vitiligo.
Our findings suggested a highly statistically significant difference (P < 0.001) between the studied groups regarding psychiatric morbidity. Psychiatric morbidity was found to be significantly higher in the vitiligo group versus control group (76.7 vs. 16.7%). Vitiligo group showed depression in 50% and anxiety disorders in 26.7% of patients. This goes with Vernwal  who also found that psychiatric morbidity was significantly higher in the vitiligo group (62 vs. 25%). Overall, 37, 18, and 7% of patients with vitiligo had mixed anxiety and depressive disorder, depressive disorder, and generalized anxiety disorder, respectively. Incidence of psychiatric morbidity was higher in patients who had lesions more on the exposed body areas.
The study by Mufaddel and Abdelgani , who studied psychiatric morbidity in vitiligo and other dermatological diseases, reported that 58.3% of patients with vitiligo received psychiatric diagnosis. Significantly higher rates of anxiety disorders were found in vitiligo group of patients compared with the miscellaneous group of patients (P = 0.0439), and the different types of anxiety disorders reported included the following: OCD (13.3%), generalized anxiety disorder (5.7%), panic disorder (4.8%), phobic anxiety disorder (3.8%), and post-traumatic stress disorder (0.95%).
This is in agreement with our findings, which showed only seven (23.3%) patients of vitiligo group were free of psychiatric disorders, and 23 (76.7%) patients of vitiligo group had psychiatric comorbidities, with depression in 50% and anxiety disorders in 26.7%, including generalized anxiety disorder (10%), OCD (6.7%), panic (6.7%), and phobia (3.3%). These psychiatric morbidities occur because vitiligo affects marital status, sex life and intimacy and disrupts the social relationship, creating a vicious stress-vitiligo cycle. Most patients had to spend a lot of time and money for the treatment as long follow-ups were needed owing to chronic nature of illness. Moreover, their daily routine and work were disturbed owing to repeated hospital visits.
The effect of vitiligo on life quality was determined in this study, as it showed a very large effect in 30% and extremely large effect in 10% of patients with vitiligo. This agreed with Sangma et al.  who mentioned that vitiligo-affected patients had elevated total dermatology life quality index scores compared with healthy controls. All those who were depressed experienced more stigma and showed restrictions in job or work opportunities, visiting markets or bazaar, schools, or shops, meeting new people, participating in chatting, or meeting friends or neighbours. Moreover, many claimed that they had less respect in community as compared with others and had difficulty in maintaining long-term relationship with their partners.
Patients with vitiligo in this study had significantly impaired QOL in both sexes. Studies have shown that embarrassed patients experience low self-esteem and poor QOL, which lead to significantly higher depression rates among them. It was also found that there was a positive correlation between severity of vitiligo and the effect on QOL, which agreed with the study of Hedayat et al. . These helpless patients felt desperate and worried about illness and future with a lot of attention and time spent on inspecting their skin. They experienced higher severity of symptoms, with an almost complete loss of control over the course of the disease.
| Conclusion|| |
Vitiligo disease is associated with psychiatric comorbidities mainly depression and anxiety disorders such as generalized anxiety, OCD, panic disorder, phobic disorder, and post-traumatic stress disorder. Comorbidities must be assessed and considered in the treatment of vitiligo disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ghafourian E, Ghafourian S, Sadeghifard N, Mohebi R, Shokoohini Y, Nezamoleslami S, et al
. Vitiligo: symptoms, pathogenesis and treatment. Int J Immunopathol Pharmacol 2014; 27
Sarkar S, Sarkar T, Sarkar A, Das S. Vitiligo and psychiatric morbidity: a profile from a vitiligo clinic of a rural-based tertiary care center of eastern India. Indian J Dermatol 2018; 63
Ahmad D. A community based study on finding the quality of life of the patients with vitiligo. J Appl Pharm Sci [Internet] 2017; 7
Hedayat K, Karbakhsh M, Ghiasi M, Goodarzi A, Fakour Y, Akbari Z, et al
. Quality of life in patients with vitiligo: a cross-sectional study based on Vitiligo Quality of Life index (VitiQoL). Health Qual Life Outcomes 2016; 14
First MB, Gibbon M, Spitzer RL, Williams JB. User's guide for the structured clinical interview for DSM-IV axis I disorders – research version
. New York, NY: Biometrics Research Department, New York State Psychiatric Institute; 1996.
Holms TH, Rahe RH. The social readjustment rating scale. J Psychosom Res 1967; 11
Feily A. Vitiligo Extent Tensity Index (VETI) score: a new definition, assessment and treatment evaluation criteria in vitiligo. Dermatol Pract Concept 2014; 4
Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) – a simple practical measure for routine clinical use. Clin Exp Dermatol 1994; 19
Vrijman C, Hosseinpour D, Bakker JG, Wolkerstorfer A, Bos JD, van der Veen JP, et al
. Provoking factors, including chemicals, in Dutch patients with vitiligo. Br J Dermatol 2013; 168
Vernwal D. A study of anxiety and depression in vitiligo patients: new challenges to treat. Eur Psychiatry 2017; 41
Mufaddel A, Abdelgani AE. Psychiatric comorbidity in patients with psoriasis, vitiligo, acne, eczema and group of patients with miscellaneous dermatological diagnoses. Open J Psychiatry 2014; 4
Sangma LN, Nath J, Bhagabati D. Quality of life and psychological morbidity in vitiligo patients: a study in a teaching hospital from North-East India. Indian J Dermatol 2015; 60
[Figure 1], [Figure 2]
[Table 1], [Table 2]