Guideline for the Diagnosis and Management of Vitiligo

D.J. Gawkrodger; A.D. Ormerod; L. Shaw; I. Mauri-Sole; M.E. Whitton; M.J. Watts; A.V. Anstey; J. Ingham; K. Young

Disclosures

The British Journal of Dermatology. 2008;159(5):1051-1076. 

In This Article

What is the Quality of Life in Patients With Vitiligo Compared With Other Skin Diseases?

Introduction

Vitiligo can be a psychologically devastating disease which has a significant impact on quality of life (QoL) and self-esteem.[4,11] It may cause social isolation and significant depression,[12,13] create difficulties in sexual relationships, and affect perceived suitability for marriage.[14,15]

Some assessment of the impact of vitiligo on the patient's QoL should be made at the initial consultation, along with an assessment of the disease extent. The assessment of 'quality of life' is likely to be done differently by different clinicians and patients, unless standardized. Vitiligo differs from other diseases as it has no physical symptoms to speak of - its main impact is psychological.

QoL indices are important outcome measures in studies of vitiligo because there may be discrepancy between a researcher's definition of successful outcome and the patient's. For example, a study may show a statistical significance using an outcome measure of >50% repigmentation when only 10% of patients with vitiligo consider this a successful result.[16] Hence, there is discrepancy between doctor and patient assessment of disease severity which may reflect the fact that psychological factors are important in overall morbidity.[17]

Methods

Several large studies have recorded a dermatology QoL index score (Dermatology Life Quality Index, DLQI) for vitiligo.[2,14,15,18,19,20,21,22,23,24,25] The scores range widely (3·5-15). This probably reflects the disease severity in the patient group examined, i.e. varying between primary care and tertiary centres. Few studies directly compare QoL scores in vitiligo with other skin diseases. Two studies compared vitiligo and psoriasis using the DLQI.[15,26] Both had patient populations that were not well matched. Two other studies used Skindex and the World Health Organization's GHQ12 scoring system.[27,28]

Evidence Statements

One study comparing QoL in vitiligo and psoriasis showed a higher DLQI for psoriasis than vitiligo (mean 6·26 and 4·95, respectively).[26] The scoring pattern was different, with vitiligo scoring lower on the symptoms and treatment subscales and higher on the social, clothing and leisure subscales. This suggests that QoL scales with a weighting on the effect of symptoms and treatment effects underestimate the effect of vitiligo on QoL. DLQI might not be the most appropriate tool for assessing QoL in vitiligo as it may inevitably give a rather low score (level of evidence 2+).

In a study using Skindex and the GHQ12 score vitiligo scored higher than psoriasis on the social functioning subscale and emotions subscale but much lower on the symptoms subscale (level of evidence 2+).[27] The GHQ questionnaire reveals that QoL is more affected by vitiligo than by psoriasis (level of evidence 3).[28]

Race, colour and culture all influence how vitiligo affects QoL. DLQI is higher in studies looking at more racially pigmented groups. Loss of pigmentation may be seen as a threat to racial identity.[29] There may be cultural perceptions that wrongdoing in a previous life causes vitiligo. This stigma may itself affect QoL. There may be lay confusion with leprosy. Vitiligo causes unique psychosocial problems in some parts of the world (level of evidence 3).[30]

Gender also influences the way vitiligo affects QoL. Women are more severely affected, being more likely to be depressed about their appearance and more likely to internalize stigmatization and attribute an internal cause (level of evidence 3).[20] Women with vitiligo scored as highly on the DLQI as did women with psoriasis, whereas men with vitiligo scored significantly lower than men with psoriasis (level of evidence 2+).[26]

Psychological effects are prominent when visible body areas, e.g. the hands and face, are affected (level of evidence 3).[20] Studies of treatments for vitiligo should employ measures of QoL to assess the end result of any treatment, i.e. patient satisfaction with their response to therapy (consensus view of the GDG).

Evidence to Recommendations

Vitiligo has an impact on a patient's QoL comparable with that of psoriasis. The DLQI may not be the best tool for measuring QoL in vitiligo, because vitiligo has no physical symptoms and is often not treated. Vitiligo has more impact on QoL in women, in those with racially pigmented skin, and in a cultural setting where there is attribution of blame for disfigurement.

Recommendations

  1. Clinicians should make an assessment of the psychological and QoL effects of vitiligo on patients.

    Grade of recommendation C
    Level of evidence 2+

     

  2. In therapeutic trials relating to vitiligo, researchers should make the patient's improvement in QoL the most important outcome measure.

    Grade of recommendation D
    Level of evidence 4

     

Research Recommendation

  1. More research is needed on appropriate QoL assessments for vitiligo and they should always be used as outcome measures.

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