Nigerian Postgraduate Medical Journal

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 28  |  Issue : 3  |  Page : 169--174

Quality of life impairment amongst persons living with vitiligo using disease specific vitiligo quality of life index: A Nigerian perspective


Umar Abdullahi1, Tahir Turaki Mohammed1, Bolanle O P. Musa2,  
1 Department of Medicine, Dermatology Unit, Ahmadu Bello University, Zaria, Nigeria
2 Department of Medicine, Immunology Unit, Ahmadu Bello University, Zaria, Nigeria

Correspondence Address:
Dr. Umar Abdullahi
Department of Medicine, Dermatology Unit, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria

Abstract

Background: Vitiligo is an acquired pigmentary disorder of the skin and mucous membranes which manifests as white macules and patches due to selective loss of melanocytes. This condition can affect the patients' psychology, leading to an impairment of quality of life (QOL). Recently, much attention is been given to the emotional and psychological issues in the affected subjects. Aim of the Study: This was to assess the QOL impairment among Nigerian patients with vitiligo using a disease-specific quality of life index questionnaire (VitiQoL). Materials and Methods: Seventy seven adults aged 18 years and above with vitiligo attending the Dermatology Clinic of a tertiary health center were included in this cross-sectional study. The QOL was assessed using the vitiligo quality of life questionnaire (VitiQoL). Disease severity was assessed using Vitiligo Area Severity Index (VASI). Results: The mean age of the study participants was 38.97 ± 13.2 years, comprising of 32 (41.6%) and 45 (58.4%) females. Almost half of the vitiligo patients belong to the lower socioeconomic class, 37 (48.1%). The mean age of first onset of vitiligo was 33.5 ± 14.84 years, with 32 (41.6%) of the participants having age of first onset between 24 and 42 years. The mean VitiQoL score was 30.51 ± 15.74 (range 3–64). There was a significant relationship between VASI score and VitiQoL (P = 0.036, r = 0.517). Other factors such as age, gender, socioeconomic status, disease activity, family history of vitiligo, duration of the disease and educational attainment were significantly associated with VitiQoL score (P < 0.05). Conclusion: QOL is impaired significantly in Nigerian patients with vitiligo. Focusing on patient's QOL is an essential aspect in the management of patients with vitiligo.



How to cite this article:
Abdullahi U, Mohammed TT, P. Musa BO. Quality of life impairment amongst persons living with vitiligo using disease specific vitiligo quality of life index: A Nigerian perspective.Niger Postgrad Med J 2021;28:169-174


How to cite this URL:
Abdullahi U, Mohammed TT, P. Musa BO. Quality of life impairment amongst persons living with vitiligo using disease specific vitiligo quality of life index: A Nigerian perspective. Niger Postgrad Med J [serial online] 2021 [cited 2021 Dec 7 ];28:169-174
Available from: https://www.npmj.org/text.asp?2021/28/3/169/328776


Full Text



 Introduction



Vitiligo is an acquired pigmentary disorder of the skin and mucous membranes which presents as macules and patches as a result selective loss of melanocytes.[1] It is a skin pigmenting disorder of great concern affecting 0.1%–2% of the world's population.[2] More attention is currently being directed on the emotional and psychological aspects of vitiligo. Thus, this depigmenting disorder may be considered as a psychosomatic disorder, involving both physical and psychological wellbeing of the affected individual.[3] Although vitiligo is usually an asymptomatic disease that does not often lead to severe physical illness, it can causes significant psychological disturbance in the affected patients, with most of them suffering from shame, embarrassment, low self-esteem, and social withdrawal.[4] Other psychosocial problems caused by vitiligo that may affect quality of life (QOL) include unpleasant body images, poor social relationships, matrimonial problems and higher social discrimination and stigma.[5],[6],[7],[8],[9],[10],[11] All the above factors can lead to significant impairment in QOL. Vitiligo lesions appear more obvious in individuals with darker skin phenotypes, especially the black Africans because of the remarkable contrast with normal skin. Thus vitiligo patients with dark skin phenotypes usually experiences more overall psychosocial disturbances from the disease.[5] A study done in Nigeria to evaluate QOL in vitiligo subjects using general Dermatology Life Quality Index (DLQI) and the general health questionnaire-12 indicates that vitiligo causes a significant impact on the QOL of affected patients.[12] However, there is a newer validated disease specific instrument for estimating QOL in Vitiligo developed by Lilly et al.[13] Vitiligo Quality of Life (VitiQoL) with questions covering three principal factors including: Stigma, participation limitation, and behavior.

There is no documented evidence of assessment of QOL of persons living with Vitligo in Nigeria using a specific index. Therefore, the objective of this study was to assess the QOL among Nigerians with vitiligo using VitiQoL, and to determine those clinical and sociodemographic factors that affect the QOL in the study participants.

 Materials and Methods



The study was approved by the Health Research and Ethics committee of Ahmadu Bello University Teaching hospital Zaria on July 29, 2019, with a protocol number ABUTHZ/HREC/M05/2019, and an informed consent was obtained from all participants before enrollment in the study.

Seventy seven vitiligo patients aged 18 years and above who attended the Dermatology Clinic of Ahmadu Bello University Teaching Hospital Nigeria, between July 2019 and March 2020 were included in this descriptive cross-sectional hospital based study. The study participants were consecutively enrolled using convenient sampling technique as they present to the clinic and fulfilled the inclusion criteria. Data were collected using a well-structured interviewer administered questionnaire. The diagnosis of vitiligo in this study was made on the basis of clinical findings of depigmented or hypopigmented lesions. In cases of uncertainty, a skin biopsy was done to rule out other hypopigmentary skin lesions. Participants were stratified into 3 social classes using Oyedeji's classification as high class (score 1–2), middle class (score 2.1–3) and lower class (score 3.1–5), using information on their educational status and their job descriptions.[14] Physical examination was carried out in a well-lit and ventilated consulting room by a consultant dermatologist. The subtype of vitiligo was documented and classified based on the review by the Vitiligo Global Issues Consensus Conference (between 2011 and 2012).[15]

The total surface area affected by the vitiligo lesions was estimated using the vitiligo calculator developed and validated by van Geel et al.[16] Vitiligo severity was assessed using Vitiligo Area Severity Index (VASI) developed by Hamzavi et al.[17] Vitiligo was further classified as active vitiligo when there was either expansion of existing lesions or appearance of new lesions in the last 6 months, and stable vitiligo when there was no expansion or appearance of new lesions.

The QOL was assessed using the VitiQoL as the specific index for assessment of QOL in patients with vitiligo. Each of the participants completed the VitiQoL questionnaire, which contains 15 questions. The questionnaire has a seven-point Likert scale (0–6) with a total of 15 questions. Questions number 3, 4, 6, 9, 10, 11 and 14 cover domain of participation limitation, questions number 1, 2, 5, 7 and 15 covers the domain of stigma, while questions number 8, 12 and 13 deals with the domain of behavior.[13] Each question has six possible responses with scores of 0, 1, 2, 3, 4, 5 and 6 depending on the patients response to each question. VitiQoL total score was calculated by summing the score of all questions, with final scores ranging from 0 to 90, in which, patients with higher scores showed poorer QOL.[13]

Data entry and analysis

The study data was entered into and analysed using Statistical Package for Social Sciences IBM 20.0 (SPSS Chicago Inc., IL, and U.S.A.). The socio-demographic variables of the participants were summarized using descriptive statistics. The categorical data were presented using frequencies and proportions. The Student's t-test was used to compare means for numeric variables when normally distributed and Chi-square test was used to test for association between categorical variables. Analysis of variance was used to compare a normally distributed dependent variable like VitiQoL value with an independent variable having three or more options like the socioeconomic class. Kruskal–Wallis and Mann–Whitney U test were used to analyze skewed dependent variables against independent variables. The Pearsons and Spearman correlation were used for comparison of two normally and skewed continuous variables respectively. All values were considered for statistical significance at P < 0.05.

 Results



Clinical and sociodemographic features of the study participants

The mean age of the study participants was 38.97 ± 13.2 years. Almost half of the vitiligo patients belong to the lower socioeconomic class [Table 1].{Table 1}

The mean age of first onset of vitiligo was 33.5 ± 14.84 years, with 32 (41.6%) of the participants having age of first onset between 24 and 42 years. There were 2 (2.6%) patients with vitiliginous lesions in covered sites only, 43 (55.8%) patients with lesions in exposed body parts only, and 32 (41.6%) patients with lesions involving both exposed and covered body parts [Table 2]. Vitiligo was active in 42 (54.5%) of the subjects while 35 (45.5%) have a stable disease.{Table 2}

Vitiligo area severity index

The overall mean VASI for the subjects was 6.57 ± 10.89 (range 0.04–45). There was a positive correlation between VASI score and VitiQoL (r = 0.517, P = 0.036).

Quality of life of the vitiligo patients

The observed mean VitiQoL from this study was 30.51 ± 15.74 (with a range of 3–64). The QOL is significantly more impaired in females than in males (P = 0.037). However, stigma component of VitiQoL was the major contributor to the high mean VitiQoL (P < 0.001), after subscale analysis of the three factors of VitiQoL [Table 3]. Individuals with vitiligo lesions on exposed body parts feels more stigmatized compare to those with lesions on covered body parts (P = 0.039).{Table 3}

There was an observed positive correlation between VitiQoL and VASI (P = 0.036, r = 0.517). Furthermore, individuals from a high socioeconomic class had significantly higher mean VitiQoL than those from other socioeconomic classes (P = 0.042) [Table 4]. Moreover, significantly higher mean VitiQoL was observed in patients with no family history of vitiligo (P = 0.001). Patient that had the disease for 1–4 years had significantly higher mean VitiQoL (P = 0.002). Vitiligo patients that had higher educational attainment were observed to have higher mean VitiQoL compare to those with lower educational attainment (P < 0.001). More so, patients with a progressive disease have significantly higher mean VitiQoL than those with stable disease (P = 0.010). Analyzing the score for the stigma component of VitiQoL, subjects with lesions on exposed body parts were noted to be significantly more stigmatized than those with lesions on covered body parts [Table 4]. However, no significant relationship was observed between VitiQoL and clinical type of vitiligo, marital status, prior treatment of disease, and patient's occupation.{Table 4}

 Discussion



Vitiligo is the commonest acquired pigmentary disorder of the skin and mucous membranes affecting 0.1%–2% of the world's population.[2] This condition can be psychologically devastating and stigmatizing, especially in dark skinned individuals in whom the skin contrast is more prominent. From this study the mean VitiQoL of the study participants is similar to what was reported by Hedayat et al.[4] This was observed to be significantly higher in females than in males, implying a worst QOL in females than in males. This gender preference may be attributed to the fact that females are more conscious of their appearance, self-esteem, and choice of clothing than men, and thus are easily stigmatized. This finding is also consistent with observations made by other researchers.[4],[5],[18],[19] However, other studies had reported no impact of gender on QOL of vitiligo subjects.[12],[20],[21]

The observed positive correlation between disease severity (as measured by VASI) and QOL was in keeping with results of similar studies.[4],[5],[20],[22] This may be attributed to the fact that an increased body surface area affected, including the exposed body parts, reflects an increased disease severity and ultimately a poorer outcome on QOL. This will cause some difficulties in the choice of clothing worn by the patient to cover up the blemishes, thus causing some psychological disturbance. However, a similar study did not observe any significant relationship between severity of vitiligo and QOL impairment.[21]

Vitiligo patients with higher socioeconomic class were observed to have more QOL impairment as compared to those of lower socioeconomic class. This is because individuals from high social class tend to be more conscious of their health and appearance since they have the financial capacity to afford quality healthcare. Similarly, these individuals have the means to also purchase different fashionable clothing, but because of their lesions they may not be able to wear those clothes comfortably, thus becoming frustrated. Radtke et al.[23] in a study to assess the willingness to pay for treatment among vitiligo patients and QOL, reported a positive correlation between QOL impairment in vitiligo and willingness to pay for treatment. However, Mishra et al.[24] did not observed any correlation between QOL and socioeconomic status of vitiligo patients. They concluded that vitiligo similarly affects QOL across different socio-economic classes.

This study observed that patients with vitiligo with no family history of the disease tend to have poor QOL compared to those with a positive family history of vitiligo. Possible explanation for the above finding may be because such individuals with no family history of the disease are not very familiar with the disease since no family member has ever been affected, thus the condition appear novel and strange to them, and a such are more likely to be stigmatized even within the family. It could also possibly be that patients with vitiligo and a prior family history have a social support system of empathy within a group of people with vitiligo. Even though, other studies have shown a positive association between QOL and family history of vitiligo.[20] This may be as a result of a positive family history being associated with significantly increased severity of vitiligo likely due to underlying genetic factors and specific HLA haplotypes.[25]

In this study, it was observed that the more educated a vitiligo patient is, the worst the QOL. This may be attributed to the fact that patients that are more educated may be more conscious of their health, have better access to electronic media to get more information about the disease, and are likely to have used a lot of medications with higher expectations of treatment outcome. A similar finding was reported in South Korea, where a higher level of education was associated with a worse QOL among patients with vitiligo.[26] This is contrary to findings by other studies that revealed no relationship between QOL in vitiligo and level of education.[21],[22],[27] Furthermore, this study showed that younger subjects especially those in age group 28–37 year-old had poorer QOL. This is expected, since cosmetic issues are more of concern to the youth; as they are been faced with numerous challenges such as peer pressure, being unequally considered, lack of respect, occupational struggles, and challenging social or emotional relationships.[4],[12],[26] Duration of vitiligo lesions <1 year and >4 years showed better QOL, which may be due to higher hopes for successful treatment in the early course of the disease or the patient getting used to the disease haven been with it for a while. This is similar to findings by Hedayat et al.[4]

The finding of poorer QOL in those with progressive disease is in keeping with reports from similar studies.[12] Progressive vitiligo is characterized by rapid spread and increased body surface area affected with eventual more embarrassment and social inhibition.[12] This makes the choice of clothes to cover up the lesions more difficult with eventual frustration. Individuals with lesions on exposed body parts are more stigmatized than those with lesions on covered body parts. This is consistent with previous findings by other researchers.[12],[23],[28],[29] Lesions on exposed body parts are more obvious to others, thus people are more likely to comment negatively about it. There are several reports however that did not show any relationship between QOL score and visibility of vitiligo lesions.[11],[19],[30],[31],[32]

Limitations

Study participants were restricted to only those that presented to the Dermatology clinic, which may not be an accurate representative sample of vitiligo patients in the society.

 Conclusion



Vitiligo as the commonest depigmenting skin disorder significantly affects the QOL of the affected patients. Factors such as gender, socioeconomic status, educational status, exposure of lesion, severity of the disease, and duration of the disease are significantly associated with QOL impairment. Thus, QOL in patients with vitiligo should be routinely assessed using a vitiligo-specific tool (VitiQoL), so that the psychological aspect of the disease will be thoroughly and appropriately addressed.

Acknowledgement

This research was financially supported by the Tertiary Education Trust Fund (TETFUND) institution based research grant (IBR), Ahmadu Bello University Zaria, with a Ref. no. DPM/TETFUND/01/12.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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