|Year : 2020 | Volume
| Issue : 2 | Page : 99-105
Assessment of depression and anxiety in relation to quality of life in patients with vitiligo
Ensaf M Abdelmaguid1, Hossam Khalifa2, Manal M Salah3, Doaa S Sayed MD 1
1 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Assiut University, Assiut, Egypt
2 Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt
3 Department of Dermatology and Andrology, Mental Health Hospital, Assiut, Egypt
|Date of Submission||12-Nov-2019|
|Date of Acceptance||19-Apr-2020|
|Date of Web Publication||09-Jun-2020|
Dr. Doaa S Sayed
Associate Professor of Dermatology, Venereology and Andrology, Assiut University
Source of Support: None, Conflict of Interest: None
Background Vitiligo is a common skin disease that has been reported to affect ∼1% of the population worldwide. Many patients with vitiligo feel distressed and stigmatized by their condition.
Objective The aim was to assess the effect of vitiligo on the patients’ quality of life and to ascertain comorbidity of depression and anxiety associated with the disease using Hamilton rating scale for anxiety and depression.
Patients and methods One hundred patients with vitiligo and 50 control participants were subjected to clinical examination with assessment of vitiligo severity by vitiligo area scoring index (VASI) in addition to their assessment by dermatology life quality index (DLQI), Hamilton depression rating scale, and Hamilton anxiety rating scale.
Results In this study, there was a significantly higher DLQI score among the study group compared with controls (P<0.001). Moreover, there was a highly significant difference in the Hamilton depression score (P<0.001) between the study group (24±7) and control group (3.8±1.6). Moreover, the study group scored higher on the Hamilton anxiety scale in comparison with the control groups, and this difference was statistically significant (P<0.001). A significant positive correlation was found between VASI score and both DLQI and Hamilton depression score (r=0.41 and 0.33, respectively). These correlations were statistically significant (P<0.001). Moreover, there was a significant positive correlation between VASI score and Hamilton anxiety score (r=0.20, P=0.022).
Conclusion Vitiligo has a negative effect on patient’s psychological status in terms of anxiety and depression, especially in female patients, patients with increased body surface involvement, and those with lesions on exposed parts of the body.
Keywords: anxiety, depression, vitiligo
|How to cite this article:|
Abdelmaguid EM, Khalifa H, Salah MM, Sayed DS. Assessment of depression and anxiety in relation to quality of life in patients with vitiligo. Egypt J Dermatol Venerol 2020;40:99-105
|How to cite this URL:|
Abdelmaguid EM, Khalifa H, Salah MM, Sayed DS. Assessment of depression and anxiety in relation to quality of life in patients with vitiligo. Egypt J Dermatol Venerol [serial online] 2020 [cited 2020 Nov 29];40:99-105. Available from: http://www.ejdv.eg.net/text.asp?2020/40/2/99/286291
| Introduction|| |
Patients with dermatological diseases experience mental health problems more often than the general population ,.
Some studies on the incidence of mental health problems in patients with dermatological diseases focus on whether the presence of mental health problems is only a comorbidity or if they are mutually related clinical conditions .
The type of dermatological disease, its extent, the severity of subjective problems it causes, and the areas of skin affected by such a disease are related factors that influence the incidence of mental health problems in patients with dermatological diseases .
Vitiligo is a long-term skin condition characterized by loss of color (pigment) in areas of the skin, resulting in uneven white patches with sharply defined margins. The patches often begin on the sun-exposed areas and more noticeable in people with dark skin who feel stigmatized by such skin lesions . Vitiligo is thus an important skin disease having major effect on the patient’s quality of life ,.
Anxiety and depression are described as the most common mental health problems related to dermatological diseases ,. Extensive and visible manifestations on the skin add to the problem .
The Hamilton anxiety rating scale (HAMA) is a psychological questionnaire originally published by Max Hamilton in 1959 and used by clinicians to rate the severity of a patient’s anxiety. Although it was one of the first anxiety rating scales to be published, the HAMA remains widely used by clinicians ,. It was originally published by Max Hamilton in 1959 ,. The HAMA has been considered a valuable scale for many years, but the ever changing definition of anxiety, new technology, and new research have affected the scale’s perceived usefulness ,.
The Hamilton depression rating scale (HDRS), also abbreviated as HAMD, is a multiple-item questionnaire used to provide an indication of depression, and as a guide to evaluate recovery ,.
Max Hamilton originally published the scale in 1960. The questionnaire is designed for adults and is used to rate the severity of their depression by probing mood, feelings of guilt, suicide ideation, insomnia, agitation or retardation, weight loss, and somatic symptoms ,.
HRSD has been criticized for use in clinical practice as it places more emphasis on insomnia than on feeling of hopelessness, self-destructive thoughts, suicidal cognitions, and actions ,.
| Patients and methods|| |
This was a cross-sectional, case–control, hospital-based study, conducted in the Dermatology, Venereology and Andrology Outpatient’s Clinics, Assiut University Hospitals, between April 2015 and April 2016. The study was approved by the ethical committee of Assiut faculty of medicine, Assiut, Egypt.
The study was carried out on 100 patients with vitiligo attending the Outpatient Dermatology Clinic and Phototherapy Unit, Assiut University Hospital, over 1-year duration, and 50 healthy controls.
Inclusion criteria were patients aged 18–60 years old of both sexes, complaining of vitiligo (as an isolated dermatological complaint).
Exclusion criteria were patients with past history of psychiatric abnormality.
Patients were subjected to full history taking (name, age, sex, residence, marital status, and special habits), age of onset, and duration and course of the disease. Family and therapeutic history were also recorded.
Patients were examined to determine the skin type, type of vitiligo, site of involvement, and extent of involvement using vitiligo area scoring index (VASI).
In VAS1, the body is divided into five separate and mutually exclusive regions: hands, upper extremities (excluding hands), trunk, lower extremities (excluding the feet), and feet. The axillary and inguinal regions are included with the upper and lower extremities, respectively, whereas the buttocks are included with the lower extremities. The face and neck areas are not included in the overall evaluation. One hand unit, which encompasses the palm plus the νlar surface of all digits, is ∼1% of the total body surface area and is used as a guide to estimate the baseline percentage of vitiligo involvement of each body region. Depigmentation within each area was estimated to the nearest of one of the following percentages: 0, 10, 25, 50, 75, 90, or 100% ,.
Both patients and controls were assessed using the following:
- Arabic Version of dermatology life quality index (DLQI) (9,10).
- Arabic Version of HAMD (11,12).
- Arabic Version of HAMA ,.
The DLQI is a 10-question questionnaire used to measure the effect of skin disease on the quality of life of an affected person. It is designed for people aged 16 years and above ,.
Responses to questionnaires were recorded and compared with those of the control group and then findings were correlated in relation to patient’s demographics and clinical profile of the disease.
Data entry and data analysis were done using SPSS version 21.0 (IBM Corp., Armonk, New York, USA). Descriptive statistics such as means, SD, medians, and percentages were calculated. Test of significances included the following: χ2-test was used to compare the difference in distribution of frequencies among different groups, and independent t-test analysis was carried out to compare the means of normally distributed data. Correlation was done using Spearman’s correlation test between variables. P values equal or less than 0.05 were considered significant.
| Results|| |
The study included 100 patients with vitiligo and 50 healthy controls. Their ages ranged from 18 to 60 years old, with a mean±SD of 32.8±13 years. There were statistically significant differences among patients with vitiligo compared to controls regarding sex, marital status, residence and occupation (P=0.018, <0.001, 0.001, and <0.001, respectively), where 76% of patients with vitiligo were females, 80% of them were married, the majority of patients were rural residents (70%), and the highest frequency of patients were either students or had no jobs. The majority of the cases (87%) had sudden onset and 81% had a progressive course ([Table 1]).
There were significantly higher DLQI scores and Hamilton depression and anxiety scores among the study groups compared with the controls (P<0.001) ([Table 2]).
|Table 2 Dermatology life quality index and Hamilton depression and anxiety total scores in the study and control groups|
Click here to view
The current study revealed that there was a significantly high positive correlation between DLQI score and both Hamilton depression score and Hamilton anxiety score (r=0.8 and 0.7, respectively) (P<0.001) ([Table 3]).
|Table 3 Correlation between dermatology life quality index and Hamilton depression and Hamilton anxiety scores|
Click here to view
There was a highly significant difference (P<0.001) in the mean DLQI scores between males and females. The same was observed regarding HAMD and HAMA scores ([Figure 1]).
|Figure 1 Mean differences in dermatology life quality index and Hamilton depression and anxiety total scores in the study groups.|
Click here to view
The findings of the current study revealed that there was a significant positive correlation between VASI score and both DLQI and Hamilton depression and anxiety scores ([Table 4]).
|Table 4 Correlation between vitiligo area scoring index and dermatology life quality index, as well as Hamilton depression and Hamilton anxiety scores among cases|
Click here to view
Although the average DLQI and depression score were lower in cases with skin type II compared with those with other skin photo types, this association was statistically nonsignificant (P>0.05) ([Table 5]).
|Table 5 Relationship between skin type, dermatology life quality index, Hamilton depression and Hamilton anxiety scores among cases|
Click here to view
The average DLQI score was higher in cases with progressive disease course; patients with vitiligo vulgaris; patients with face, neck, and trunk lesions; and those with bilateral affection ([Table 6]).
|Table 6 Univariate predictors of dermatology life quality index total scores among cases|
Click here to view
The average Hamilton depression score was higher in cases with progressive disease course; patients with vitiligo vulgaris; and patients with face, neck, and trunk lesions; and those with bilateral affection ([Table 7]).
|Table 7 Univariate predictors of Hamilton depression total scores in vitiligo cases|
Click here to view
The average Hamilton anxiety score was higher in cases with progressive disease course; patients with vitiligo vulgaris; and patients with neck and trunk lesions ([Table 8]).
| Discussion|| |
Vitiligo is a common skin disease that has been reported to affect ∼1% of the population worldwide. It is characterized by the development of white macules and patches owing to the loss of functioning melanocytes in the skin, hair, or both ,.
Such disfigurement lowers individual’s quality of life by unfavorably influencing the overall social life .
This study was carried out to assess depression and anxiety and their relation to quality of life in patients with vitiligo using HAMD, HAMA, and DLQI questionnaires, respectively.
The age of these patients ranged from 18 to 60 years to avoid age-related influence in QOL and psychological evaluation ,,.
In the present study, the mean±SD age of our patients was 32.8±13 years, which is similar to the study done by Soyinka in Western Nigeria, who found that that patients with vitiligo had an age between 25 and 35 years . In another series, 70% of the studied population was below 30 years of age . Therefore, it seems that vitiligo presents in the productive years when the negative psychosocial effect will have a vast effect on the socioeconomic output of the individual.
In our study, as in previous studies, females constituted the majority (76%) of participants. Women had a greater feeling of embarrassment and were more concerned about the disease and about seeking out medical care more often than men ,.
Moreover, females showed more affection of QOL than males with a higher mean DLQI scores (P<0.001). This is in agreement with many other studies which had reported lower QOL in women with vitiligo ,, and disagrees with the results reported by other authors, who stated that there was no statistically significant difference in DLQI between women and men ,,.
We expected this finding, as women are more aware about the beauty of their skin and they are more emotional and sensitive about their appearance and the potential effect of the disease on their marital status.
A positive correlation between DLQI score and marital status was found in the study of Marjan et al. . No significant differences have been found between single and married patients in our study, which was in agreement with the study of Mohammed Kotb et al. . This could be explained by the fact that in our culture young individuals with vitiligo have little chance of getting married whereas married individuals who developed vitiligo after marriage may have marital problems sometimes ending in divorce ,.
Interestingly, we found no effect of skin color on quality of life in our study, which disagrees with the result of Linborst Homan et al. , who reported that participants with darker skin are more anxious about their appearance. This could be owing to presence of other stressful factors or it could be revealed in a larger sample size.
In this study, face and neck involvement has been associated with a significant effect on quality of life, with a significant increase in the mean DLQI score compared with other parts of the body (P<0.05). This was in agreement with other studies which reported that exposed areas have a higher effect on quality of life than nonexposed areas of the body ,,. However, some studies have not observed any correlation ,, and in other studies, the fact that the quality of life improves after the use of camouflage for disfiguring skin conditions suggests the importance of the visibility of such skin lesions ,,,.
Moreover, vitiligo vulgaris significantly affects the patients’ quality of life (higher DLQI scores) compared with other clinical types, as seen in previous studies ,, because generalized vitiligo is easily visible compared with other localized varieties.
Likewise, we observed that high DLQI score is associated with increase body surface involvement (using VASI score) and lesions on exposed parts of the body. All of these can add to the disease-related stress, influencing the patient’s response to therapy adversely. An Indian study reported better response to therapy in patients with low DLQI scores ,.
Accordingly, we assessed our patients for the possibility of psychiatric illness using the HAMD and HAMA scales, which can differentiate between people who are normal and those who need to have further evaluation and assessment. It was found that depression and anxiety were more seen in females compared with males (P<0.001). These differences were significant, as explained in a previous study where females have a higher potential to have anxiety and depression more than males .
In our study, most of the patients had an elevated DLQI score. The mean DLQI was significantly elevated in the patient group compared with controls (P<0.001). This was similar to the study done by Lucybeth et al. .
In agreement with the result of Mechri et al.  and Saleh et al. , we found that the patients who experienced a large effect on their quality of life scale had an abnormal HAM score for both depression and anxiety. The higher the quality of life impairment, the higher will be the chance of developing psychological problems such as depression or anxiety.
High mean HAMD scores in female patients noted in our study resemble what was observed by Zaki and Elbatrawy  but was on the contrary to that of Maleki and colleagues, who did not observe such correlation ,.
| Conclusion|| |
To conclude, vitiligo has a negative effect on patient’s psychological status in terms of anxiety and depression, especially in female patients, those patients with increased body surface involvement, and those with lesions on exposed parts of the body.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Turčeková L. Výskyt psychopatologických čŕt a kvalita života u pacientov s atopickou dermatitídou. Dermatol Pract 2012; 6:71–73.
Rajczyová Z. Quality of life of patients with skin diseases. Dermat Mag 2015; 4:19–20.
Hůlková M, Hosák L, Ettler K, Bukač J. Depresivita a úzkost u vybraných kožních onemocnění-vliv na kvalitu života a léčbu. Psychiatr Pro Praxi 2008; 9:35–37.
Ezzedine K, Sheth V, Rodrigues M, Eleftheriadou V, Harris JE, Hamzavi IH, Pandya AG. Vitiligo is not a cosmetic disease. J Am Acad Dermatol 2015; 73:883–885.
Parsad D, Dogra S, Kanwar AJ. Quality of life in patients with vitiligo. Health Qual Life Outcome 2003; 1:58–63.
Bae J, Lee S, Kim T, Yeom S, Shin J, Lee W et al.
Factors affecting quality of life in patients with vitiligo: a nationwide study. Br J Dermatol 2018; 178:238–244.
Magin P, Pond C, Smith W, Watson A, Goode S. A cross‐sectional study of psychological morbidity in patients with acne, psoriasis and atopic dermatitis in specialist dermatology and general practices. J Eur Acad Dermatol Venereol 2008; 22:1435–1444.
McDowell I. Measuring Health: A Guide to Rating Scales and Questionnaires. New York, New York: Oxford University Press 2006; 7:251–255.
Maier W, Buller R, Philipp M, Heuser I. The Hamilton anxiety scale: reliability, validity and sensitivity to change in anxiety and depressive disorders. J Affect Disord 1988; 14:61–68.
Zimmerman M, Thompson JS, Diehl JM, Balling C, Kiefer R. Is the DSM-5 anxious distress specifier interview a valid measure of anxiety in patients with generalized anxiety disorder: a comparison to the Hamilton anxiety scale. Psychiatry Res 2020; 6:112–119.
Hamilton M. Arating scalefordepression. J Neurol1960; 23:42–56.
Porter E, Chambless DL, McCarthy KS, DeRubeis RJ, Sharpless BA, Barrett MS et al.
Psychometric properties of the reconstructed Hamilton depression and anxiety scales. J Nerv Ment Dis 2017; 205:656–660.
Kobak KA, Reynolds WM, Greist JH. Development and validation of a computer-administered version of the Hamilton rating scale. Psychol Assess 1993; 5:487–491.
Carneiro AM, Cavalcanti A, Carvalho LdF, Moreno RA. Predicting response to treatment and discriminating bipolar and depression symptoms using Hamilton depression rating scale. J Br Psiquiatr 2017; 66:125–130.
Hedlund J, Vieweg B. The Hamilton rating scale for depression: a comprehensive review. J Operation Psychiatr 1979; 10:149–165.
Shariq AS, Brietzke E, Rosenblat JD, Barendra V, Pan Z, McIntyre R. Targeting cytokines in reduction of depressive symptoms: a comprehensive review. Prog Neuropsychopharmacol Biol Psychiatr 2018; 83:86–91.
Firestone R. Firestone Assessment of Self-Destructive Thoughts. San Antonio, TX: Psychological Corporation; 1996. 7 52–59.
Firestone RW. Basic tenets of separation theory. J Hum Psychol 2019; 3:112–119.
Hamzavi I, Jain H, McLean D, Shapiro J, Zeng H, Lui H. Parametric modeling of narrowband UV-B phototherapy for vitiligo using a novel quantitative tool: the Vitiligo area scoring index. Arch Dermatol 2004; 140:677–683.
McKesey J, Pandya AG. A pilot study of 2% tofacitinib cream with narrowband ultraviolet B for the treatment of facial vitiligo. J Am Acad Dermatol 2019; 81:646–648.
Finlay AY, Khan G. Dermatology life quality index (DLQI) − a simple practical measure for routine clinical use. Clin Exp Dermatol 1994; 19:210–216.
Barbieri JS, Shin DB, Syed MN, Takeshita J, Gelfand JM. Evaluation of the frequency of ‘not relevant’ responses on the dermatology life quality index by sociodemographic characteristics of patients with psoriasis. JAMA Dermatol 2020; 3:11–19.
van Geel N, Speeckaert M, Brochez L, Lambert J, Speeckaert R. Clinical profile of generalized vitiligo patients with associated autoimmune/autoinflammatory diseases. J Eur Acad Dermatol Venereol 2014; 28:741–746.
Bilgiç Ö, Bilgiç A, Akiş H, Eskioğlu F, Kiliç E. Depression, anxiety and health‐related quality of life in children and adolescents with vitiligo. Clin Exp Dermatol 2011; 36:360–365.
Son SE, Kirchner JT. Depression in children and adolescents. Am Fam Physician 2000; 62:2297–2308.
Hetrick SE, Cox GR, Witt KG, Bir JJ, Merry SN. Cognitive behavioural therapy (CBT), third‐wave CBT and interpersonal therapy (IPT) based interventions for preventing depression in children and adolescents. Cochrane Database Syst Rev 2016; 3:95–106.
Singh A, Misra N. Loneliness, depression and sociability in old age. Ind Psychiatry J 2009; 18:51–55.
] [Full text]
European Medicines Agency. Reflection paper on the regulatory guidance for the use of health-related quality of life (HRQL) measures in the evaluation of medicinal products. London: European Medicines Agency; 2005. 42–51
Ramam M, Mehta M, Sreenivas V, Sharma VK, Khandpur S. Vitiligo impact scale: An instrument to assess the psychosocial burden of vitiligo. Indian J Dermatol Venereol Leprol 2013; 79:205–210. [Full text]
Berthe S, Faye O, Bagayogo B, Dicko A, Traore P, Coulibaly K, Keita S. Etiologies des hypochromies acquises en milieu dermatologique etiology of acquired hypochromic patches in dermatological area in Mali. Mali Med. 2012; 27:6–9.
Akrem J, Baroudi A, Aichi T, Houch F, Hamdaoui MH. Profile of vitiligo in the south of Tunisia. Int J Dermatol 2008; 47:670–674.
Karelson M, Silm H, KINgO K. Quality of life and emotional state in vitiligo in an Estonian sample: comparison with psoriasis and healthy controls. Acta Derm Venereol 2013; 93:446–450.
Al-Mubarak L, Al-Mohanna H, Al-Issa A, Jabak M, Mulekar SV. Quality of life in Saudi vitiligo patients. J Cutan Aesthet Surg 2011; 4:33–39.
] [Full text]
Özlem BD, Atagün MI, Özgüven HD, Özsan HH. Psychiatric morbidity in patients with vitiligo. Dusunen Adam 2011; 24:306.
Zandi S, Farajzadeh S, Saberi N. Effect of vitiligo on self reported quality of life in Southern part of Iran. J Pak Assoc Dermatol 2016; 21:4–9.
Mishra N, Rastogi MK, Gahalaut P, Agrawal S. Dermatology specific quality of life in vitiligo patients and its relation with various variables: A hospital based cross-sectional study. J Clin Diagn Res 2014; 8:YC01.
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; 74:700–711.
] [Full text]
Mohammed Kotb I, Fathy Y, Mohsen AERMA, Azab RMA, Hashim RM. Impact of vitiligo on patient’s qulity of life. AAMJ 2014; 12:3–6.
Savin J. The hidden face of dermatology. Clin Exp Dermatol 1993; 18:393–395.
Radwan N. Eczema the hidden face of primary immunodeficiency diseases. Egypt J Pediatr Allerg Immunol 2019; 17:3–11.
Homan MWL, Spuls PI, de Korte J, Bos JD, Sprangers MA, van der Veen JW. The burden of vitiligo: patient characteristics associated with quality of life. J Am Acad Dermatol 2009; 61:411–420.
Jalel A, Soumaya GS, Hamdaoui MH. Dermatology life quality index scores in vitiligo: reliability and validity of the Tunisian version. Indian J Dermatol 2009; 54:330–339.
Ongenae K, Van Geel N, De Schepper S, Naeyaert J-M. Effect of vitiligo on self‐reported health‐related quality of life. Br J Dermatol 2005; 152:1165–1172.
Mashayekhi V, Javidi Z, Kiafar B, Manteghi AA, Saadatian V, Esmaeili HA, Hosseinalizadeh S. Quality of life in patients with vitiligo: a descriptive study on 83 patients attending a PUVA therapy unit in Imam Reza Hospital, Mashad. Indian J Dermatol Venereol Leprol 2010; 76:592–599.
] [Full text]
Boehncke W-H, Ochsendorf F, Paeslack I, Kaufmann R, Zollner TM. Decorative cosmetics improve the quality of life in patients with disfiguring skin diseases. Eur J Dermatol 2002; 12:577–580.
Kornhaber R, Visentin D, Thapa DK, West S, McKittrick A, Haik J, Cleary M. Cosmetic camouflage improves quality of life among patients with skin disfigurement: a systematic review. Body Image 2018; 27:98–108.
Holme S, Beattie P, Fleming C. Cosmetic camouflage advice improves quality of life. Br J Dermatol 2002; 147:946–949.
Salsberg JM, Weinstein M, Shear N, Lee M, Pope E. Impact of cosmetic camouflage on the quality of life of children with skin disease and their families. J Cutan Med Surg 2016; 20:211–215.
Robaee A. Assessment of quality of life in Saudi patients with vitiligo in a medical school in Qassim province, Saudi Arabia. Saudi Med J 2007; 28:1414–1416.
Ahmed I, Ahmed S, Nasreen S. Frequency and pattern of psychiatric disorders in patients with vitiligo. J Ayub Med Coll Abbottabad 2007; 19:19–21.
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; 60:142–149.
Mechri A, Amri M, Douarika A, Ali BH, Zouari B, Zili J. Psychiatric morbidity and quality of life in vitiligo: a case controlled study. Tunis Med 2006; 84:632–635.
Saleh HM, Salem SAM, El-Sheshetawy RS, Abd El-Samei AM. Comparative study of psychiatric morbidity and quality of life in psoriasis, vitiligo and alopecia areata. Egypt Dermatol Online J 2008; 4:2–3.
Zaki M, Elbatrawy A. Catecholamine level and its relation to anxiety and depression in patients with vitiligo. J Egypt Women Dermatol Soc 2009; 6:74–79.
Maleki M, Javidi Z, Kiafar B, Saadatian V, Saremi A. Prevalence of depression in vitiligo patients. J Affect Disord 2005; 11:82–89.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]