|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 Jul 6];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|
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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|
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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.|
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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|
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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|
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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|
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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|
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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.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]