Development of the lichen planus quality of life questionnaire (LPQoL) informed by expert clinician input and patient feedback: a retrospective survey study

Lichen planus (LP) can affect multiple body sites including skin, mucosae, scalp and nails, causing considerable impact on patients' quality of life. Currently, there are no LP patient-reported outcome measures (PROMs) that address all body sites potentially affected by LP. We developed a LP Quality of Life Questionnaire (LPQoL), informed by an expert consortium and patient survey study, to address this gap. The study was approved by our institution's Institutional Review Board. First, a 22-item LPQoL was designed with input from LP experts at our institution. The tool was then optimized by garnering input from patients recently diagnosed with LP, who were asked to complete the LPQoL, as well as the Dermatology Life Quality Index (DLQI) and a feedback form about the LPQoL. Fifty-eight of 150 patients (39% response rate) returned the questionnaire. Mean DLQI score was 4.9 ± 5.6 SD (range 0-25) and mean LPQoL score was 13.6 ± 10.4 SD (range 0-54). LPQoL score was positively correlated with DLQI score (r = 0.79; p < 0.001). Forty-nine out of 56 (88%) and 6/56 (11%) rated the LPQoL as 'very easy' or 'fairly easy' to complete, respectively. Based on participants' feedback, we increased the recall period from one week to one month and added questions on esophageal involvement. With iterative input from LP experts and patients, we developed a LPQoL to address the gap in a multi-site PROM specific to LP. This is a pilot study and there is ongoing validation studies; therefore, this measure should not be used in clinical practice or research until validated.

Quality of life in Hidradenitis Suppurativa (Acne Inversa): A scoping review

Background

Hidradenitis Suppurativa (HS) is a chronic, relapsing, inflammatory skin condition which is physically, psychologically and socially disabling and often affects a patient's quality of life (QOL). There are numerous QOL tools used in dermatology. However, assessment of QOL in patients with HS is difficult due to the inability of generic QOL tools to specifically capture QOL in patients with HS. Numerous HS-specific QOL tools have been developed in recent years. It is important to identify evidence on full psychometric evaluation of these tools.

Objectives

There has been a gradual increase in the use of generic and disease-specific QOL tools in the last few decades. The aim of this scoping review (SR) is to evaluate the most widely used generic QOL tools and HS-specific QOL tools to identify the psychometric evaluation of such tools.

Methods

Design: An SR guided by Joanna Briggs Institute manual and Arskey O'Malley framework guidelines. Data extraction included the studies available on full psychometric evaluation of the most widely used dermatology generic QOL tools in HS and HS-specific QOL tools.

Results

Ten papers were included in the review, eight papers demonstrated HS-specific QOL assessment tools. The psychometric properties of these tools were underpinned by reliability, validity and sensitivity measurement. Six disease-specific tools were identified in this SR. However, they all lack full psychometric evaluation.

Conclusion

This review indicates that an extensive research in the field of QOL tools for HS is much needed. It is crucial to develop user-friendly and validate disease-specific tools to measure the real impact of disease on patients QOL. QOL instruments can evaluate the impact on life of an HS patient, thus helping improve intervention and management of disease. There is a necessity for more research into existing HS-specific QOL tools and they should be widely tested and fully validated.

Cross-cultural adaptation and validation of the Bangla version of the Psoriasis Disability Index

Background

The Psoriasis Disability Index (PDI) is used for the quality-of-life assessment of psoriasis patients. However, a locally adapted Bangla version of the PDI (B-PDI) instrument is currently lacking in Bangladesh. To translate the instrument, adapt, and validate it among psoriatic patients of the country was the objective of the study.

Methods

Translation, adaptation, and back-to-back translation to Bangla were made from the original English PDI. The final Bangla instrument was applied among 83 psoriasis patients twice at 10 days intervals. The psychometric property of the instrument was evaluated. Item-level content-validity index (CVI) was used to check the content validity of the instrument. Convergent validity was tested by comparing the B-PDI with the validated Bangla version of Short Form 36(SF-36) and the Psoriasis Area Disability Index (PASI) score. Necessary testing was used to assess internal consistency and test-retest reliability.

Result

The B-PDI was well-accepted by the patients. It showed good internal consistency (Cronbach's alpha = 0.76) and very high test-retest reliability (Pearson r = 0.92, p < 0.001). The scale demonstrated excellent content validity (Content Valid Index [CVI] = 1). The instrument had satisfactory convergent validity with four components of SF-36. Pearson correlation coefficient for physical, emotional, social, and pain domains of SF-36 was 0.663, 0.644, 0.808, and 0.862, respectively, and for PASI score was 0.812. Factor exploration using Principal Component Analysis revealed four factors reflecting working disabilities, social, and hygienic disabilities, lifestyle difficulties, and leisure-associated disabilities.

Conclusion

This study supports the reliability and validity of the B-PDI instrument for measuring health-related quality-of-life for Bangla-speaking psoriasis patients.

Burden of visible [face and hands] skin diseases: Results from a large international survey

BACKGROUND

While numerous surveys over the last decade have evaluated the burden of skin diseases, none have focused on the specific impact of disease-location on the hands and face.

AIM

The purpose of our study was to evaluate the burden of 8 skin diseases on the multidimensional aspects of subjects' daily lives in respect to their location on visible body areas (face or hands) versus non-visible areas.

METHODS

This was a population-based study in a representative sample of the Canadian, Chinese, Italian, Spanish, German and French populations, aged over 18 years using the proportional quota sampling method. All participants were asked (i) to complete a specific questionnaire including socio-demographic characteristics, (ii) to declare if they had a skin disease. All respondents with a skin disease were asked (iii) to specify the respective disease locations (hands, face, body) and (iv) to complete the DLQI questionnaire. Respondents with 8 selected skin diseases were asked (v) to complete a questionnaire evaluating the impact of the skin disease on their daily life, including their professional activity, social relations, emotional and intimate life, leisure, sports activities and perceived stigma.

RESULTS

A total of 13,138 adult participants responded to the questionnaire, of whom 26.2 % (n = 3,450) had skin diseases, and 23.4 % (n = 3,072) reported having one of the 8 selected skin diseases. Fifty-three percent were women and the mean age was 39.6 ± 15.5 years. The QoL was mostly impaired when the visible localization was solely on the hands as compared with the face (38 % had a DLQI > 10 versus 22 % respectively). More subjects with a visible localization on the hands reported felt-stigma, having difficulty falling asleep and felt that their sex life had been affected.

CONCLUSION

Special attention should be given to patients with skin disease on the hands and face as they are at higher risk of social exclusion and lower quality of life.

Representing the values of program participants: Endogenous evaluative criteria

Evaluative conclusions are grounded in implicit and explicit criteria that describe a successful or high-quality intervention. Most often, evaluative criteria are drawn from program objectives that reflect the values and priorities of program designers and funders. Yet, an exclusive focus on program goals risks overlooking the values of program participants, the extent to which their actual needs and priorities are addressed, and, in certain types of programs, the choices participants make and agency they exercise. This article presents concepts and methods to guide evaluators in drawing some of the criteria used in an evaluation from program participants. The article outlines a typology of evaluative criteria and seven methods for drawing outcomes-focused criteria from program participants. The article concludes with a discussion of implications and future directions for research and practice.

No immediate effect of regulatory reduction of chromium in leather among adult patients with chromium allergy

BACKGROUND

In March 2014, the European Commission issued a new regulation restricting the content of hexavalent chromium (Cr) in leather to no more than 3 mg/kg. We previously performed a questionnaire study in January 2014 to characterize our patients with Cr contact allergy prior to regulatory intervention.

OBJECTIVES

To assess whether clinical characteristics, self-reported sources of Cr exposure, and burden of disease changed in patients with Cr allergy over time.

METHODS

A questionnaire study was performed among 172 adult dermatitis patients with Cr allergy and 587 age- and sex-matched dermatitis patients without Cr allergy. A questionnaire was sent to all dermatitis patients patch tested from 2003 to 2018 in August 2019.

RESULTS

The overall response rate was 61.2% (759/1241). Patients with Cr allergy were still more commonly affected by current foot dermatitis (odds ratio [OR] 3.82, 95% confidence interval [CI] 2.07-7.08) and hand dermatitis (OR 1.98, 95% CI 1.13-3.49) compared with controls diagnosed during 2013 to 2018. The proportion of patients with Cr allergy reporting dermatitis caused by leather exposure did not change during 2003 to 2012 vs 2013 to 2018 (71.0% vs 66.2%, P = .5). Furthermore, estimates on occupational performance and disease severity (eg, current dermatitis), number of anatomical locations with dermatitis, worst-case dermatitis, and effect on work were similar in patients with Cr allergy for 2003 to 2012 vs 2013 to 2018.

CONCLUSION

No immediate sign of improvement was found in patients with Cr allergy concerning severity of disease and dermatitis from leather exposures 5 years after adoption of the regulation against hexavalent Cr in leather. The regulation may have to be revised for better protection of those already sensitized.

Classification and characteristics of periorbital hyperpigmentation

INTRODUCTION

Periorbital hyperpigmentation (POH) is among the commonest esthetic and dermatological complaints. Despite its frequency, there are inadequate information detailing its incidence and prevalence. This subsequently leads to lack of comprehensive POH classification and stratification of impact on an individual's general well'being. Malaysia, a multiracial country with an expansive expatriate population, provides a unique opportunity to identify demographics of POH and subsequently attempts to group this esthetic and dermatological entity.

OBJECTIVE

This study aims to develop a new and clinically relevant POH classification system and to measure impact on quality of life of POH individuals.

METHODS

One hundred patients with POH were enrolled, of which all underwent clinical assessment by a clinician. Objective assessment with mexameter and digital analysis were performed. All recruited patients also completed a questionnaire based on dermatology life quality index (DLQI).

RESULTS

Assessments noted the commonest type of POH among the subjects was vascular (51%) with the least being pigmentary (6%). The location of POH majority involved both the upper and lower eyelids (65%). DLQI scoring shows that a majority (58%) did not disrupt their quality of life.

CONCLUSION

Vascular type POH was the frequent most form observed, and involvement tends to occur on both eyelids. A majority of noted that POH does not affect they QOL, but the due consideration must be given in those whom are moderately and minimally affected. A thorough and comprehensive holistic approach is required in managing POH despite its focal presentation as it does affect a patient's quality of life.

Quality of life outcomes in adults with moderate-to-severe plaque psoriasis treated with dimethylfumarate (DMF): a post hoc analysis of the BRIDGE study

BACKGROUND

Psoriasis is a chronic inflammatory skin disease associated with quality of life (QoL) impairment. BRIDGE was a randomized, double-blind, phase III study comparing the efficacy and safety of dimethylfumarate (DMF) with a fixed combination of fumaric acid esters (FAE) or placebo for the treatment of moderate-to-severe psoriasis.

OBJECTIVES

This post hoc analysis investigated treatment effect on QoL overall and by patient subgroups categorized by disease severity. Week 8 efficacy responses were also investigated as possible predictors of Week 16 Dermatology Life Quality Index (DLQI) outcomes.

METHODS

Patients were randomized to receive a maximum daily dose of 720 mg of DMF, FAE (gradual up-titration) or placebo for 16 weeks. Psoriasis Area Severity Index, Body Surface Area, Physician's Global Assessment and DLQI were assessed at baseline, Weeks 8 and 16. DLQI 0-1 indicated 'no effect on patient life'. Associations between baseline severity, Week 16 DLQI and Week 8 efficacy (as observed cases) were also examined.

RESULTS

At baseline, 671 patients were included in the full analysis set (267 randomized to DMF, 273 to FAE and 131 to placebo). DMF was superior to placebo (P < 0.001) and not significantly different to FAE regarding Week 16 DLQI outcomes (P > 0.05). Baseline disease severity did not impact DLQI outcomes at Week 16. In DMF- and FAE-treated patients, Week 8 PASI 50/75 responders reported better DLQI responses at Week 16 vs non-responders (P < 0.05). Week 8 PASI ≤ 3 and/or PGA 0-1 responders were also more likely to report DLQI 0-1 at Week 16 vs non-responders (P < 0.05).

CONCLUSION

Dimethylfumarate significantly improved DLQI outcomes vs. placebo and was not affected by baseline disease severity. Efficacy responses (PASI 50/75, PASI ≤3 and PGA 0-1) as early as Week 8 were predictive of QoL outcomes at Week 16 in DMF- and FAE-treated patients.

A review of the impact of occupational contact dermatitis on quality of life

Occupational contact dermatitis (OCD) is the most common occupational skin disease in many countries. We reviewed the current evidence on how OCD impacts on quality of life (QoL). The three commonly used QoL questionnaires in OCD were the Short-Form Health Survey (SF-36), the Dermatology Life Quality Index (DLQI), and the Skindex. Despite the availability of a variety of validated QoL instruments, none of them is specific to OCD or entirely adequate in capturing the impact of OCD on QoL. Nonetheless, the results of this paper do suggest a significant impact. Use of QoL measures in clinical settings will provide patients with an opportunity to express their concerns and assist clinicians to evaluate the effectiveness of management beyond the clinical outcomes. This paper also highlights the lack of a disease-specific QOL instrument and the importance of developing a validated measure to assess QOL in OCD, enabling comparison across countries and occupational groups.

The localized scleroderma skin severity index and physician global assessment of disease activity: a work in progress toward development of localized scleroderma outcome measures

OBJECTIVE

To develop and evaluate a Localized Scleroderma (LS) Skin Severity Index (LoSSI) and global assessments' clinimetric property and effect on quality of life (QOL).

METHODS

A 3-phase study was conducted. The first phase involved 15 patients with LS and 14 examiners who assessed LoSSI [surface area (SA), erythema (ER), skin thickness (ST), and new lesion/extension (N/E)] twice for inter/intrarater reliability. Patient global assessment of disease severity (PtGA-S) and Children's Dermatology Life Quality Index (CDLQI) were collected for intrarater reliability evaluation. The second phase was aimed to develop clinical determinants for physician global assessment of disease activity (PhysGA-A) and to assess its content validity. The third phase involved 2 examiners assessing LoSSI and PhysGA-A on 27 patients. Effect of training on improving reliability/validity and sensitivity to change of the LoSSI and PhysGA-A was determined.

RESULTS

Interrater reliability was excellent for ER [intraclass correlation coefficient (ICC) 0.71], ST (ICC 0.70), LoSSI (ICC 0.80), and PhysGA-A (ICC 0.90) but poor for SA (ICC 0.35); thus, LoSSI was modified to mLoSSI. Examiners' experience did not affect the scores, but training/practice improved reliability. Intrarater reliability was excellent for ER, ST, and LoSSI (Spearman's rho = 0.71-0.89) and moderate for SA. PtGA-S and CDLQI showed good intrarater agreement (ICC 0.63 and 0.80). mLoSSI correlated moderately with PhysGA-A and PtGA-S. Both mLoSSI and PhysGA-A were sensitive to change following therapy.

CONCLUSION

mLoSSI and PhysGA-A are reliable and valid tools for assessing LS disease severity and show high sensitivity to detect change over time. These tools are feasible for use in routine clinical practice. They should be considered for inclusion in a core set of LS outcome measures for clinical trials.

Oral health-related quality of life in children: part III. Is there agreement between parents in rating their children's oral health-related quality of life? A systematic review

OBJECTIVE

One issue that receives a great deal of attention is the comparison between measurement of children's oral health-related quality of life (OHRQoL) reports with those of their parents. However, the extent to which parents understand the effects of ill-health on their children's lives remains unanswered. The purpose of this systematic review was to identify the literature on the nature, extent and the pattern of agreement/disagreement between parent and child reports about child OHRQoL and assess the association between them.

MATERIALS AND METHODS

The literature was searched using MEDLINE, ISI, Lilacs and Scielo, from January 1985 to March 2007. The selected studies used well-validated instruments and provided children's and parent's perceptions of child OHRQoL.

RESULTS

A total of 87 articles were retrieved and five were selected for the review, which showed that children and parents do not necessarily share similar views about child OHRQoL. Some parents may have limited knowledge about their children's OHRQoL, particularly the impact on social and emotional well-being.

CONCLUSIONS

Valid and reliable information can be obtained from parents and children using appropriate questionnaire techniques. Although the parents' reports may be incomplete due to lack of knowledge about certain experiences, they still provide useful information.

Patient preference quality of life measures in dermatology

Patient quality of life (QOL) is an important aspect of health care. It is crucial that we continue to develop instruments to assist in detecting burden of disease, interpreting outcomes of clinical trials, determining cost effectiveness of therapies, and guiding clinical decision making. The measurement of patient preferences, specifically utilities and contingent valuation, for health states provides data that can assist in the aforementioned endeavors. Patient preferences have been measured in many areas of medicine. However, it is relatively new to the field of dermatology. The present authors provide an overview of the basic concepts of patient preference measures and how they compare to the widely used health status instruments. Various techniques that have been used to elicit patient preferences are discussed, including standard gamble, time trade-off, willingness-to-pay, rating scales, health utilities index, and EuroQol (EQ-5D). In addition, the present authors review the current literature reporting utilities relevant to dermatology.

Arabic version of Skindex-16: translation and cultural adaptation, with assessment of reliability and validity

BACKGROUND

Quality-of-life is increasingly recognized as an important measure in dermatology; however, most currently available dermatologic quality-of-life measures were originally created for the English language. Skindex-16 being one, is a self-administered questionnaire covering the symptoms, emotions and functioning aspects.

OBJECTIVES

Our aim was to translate into Arabic and culturally adapt Skindex-16 following the international guidelines for cross-cultural adaptation of health-related quality-of-life measures. Moreover, its validity and reliability would be assessed.

METHODS

Translation and transcultural adaptation of Skindex-16 were performed. Subsequently, a cross-sectional study was conducted where 678 persons (338 patients and 340 healthy people) responded to the Arabic version of Skindex-16. Evaluations of the semantic equivalence of back-translated items, reliability, construct validity, and content validity of the Arabic version were the main outcome measures.

RESULTS

Two problematic items as well as the introductory (header) statement required a second translation and back-translation to achieve satisfactory agreement with the original instrument. The final Arabic version of Skindex-16 was internally reliable (Cronbach's alpha-range for the scales 0.81-0.92). The instrument demonstrated both construct and content validity. As hypothesized, the scores for dermatologic patients were higher than those for healthy persons (mean 31.5 vs. 21.1, P < 0.001, respectively). Similarly, scores for patients with inflammatory dermatosis were higher than those for patients with isolated skin lesions (mean 32.99 vs. 25.3, P < 0.05), indicating a poorer quality-of-life. However, greater than 63% of the patients' responses to an open-ended question about their skin disease were addressed by items in the instrument.

CONCLUSION

We have developed a semantically equivalent translation with cultural adaptation of Skindex-16 into Arabic. The assessment of its measurement properties shows that it is quite reliable and a valid measure of the effects of skin diseases on the quality-of-life in Saudi patients.

Cross validation of the Turkish version of dermatology life quality index

BACKGROUND

The aim of this study was to test the linguistic validation of the Turkish version of the Dermatology Life Quality Index (DLQI) for Turkish speaking dermatology patients.

METHODS

The DLQI is a 10-item dermatology specific index developed originally in English. The methodology of this study consists of four consecutive sections: Translation, cognitive debriefing, field testing and statistical analysis. Translation steps: (a) Two forward independent translations into Turkish, (b) reconciliation of these translations by a dermatologist, (c) backward translation of the consensus Turkish version by a bilingual person into its original language (English), (d) and comparing the original questionnaire with the backward translated one. Cognitive debriefing: Sessions were performed on five patients from each of the seven different dermatological diagnosis groups. Field testing: The final Turkish version on which the face validity was approved by specialists on a total of 79 inpatients/outpatients with various dermatological diagnoses treated at Celal Bayar University Hospital.

STATISTICAL ANALYSIS

Internal consistency (using Cronbach a) and item-total score correlations (Pearson correlation) were used for reliability analysis. Validity analysis was carried out by construct testing (principal components factor analysis), convergent (Pearson correlation) and (discriminate Student's t-test and Mann-Whitney U-test) validity, and SF-36 was used in parallel with DLQI in order to test convergent validity. The data were analyzed by the SPSS version 10.0 (SPSS Inc., Chicago, IL, USA) statistical package.

RESULTS

The mean age of the patients in the study was 30.77+/-15.91 years; the mean score of DLQI was 7.61+/-6.12. The median of item-total correlation coefficient was found to be 0.66, within a range of 0.48-0.81. The internal consistency of the index was found to be highly sufficient (alpha=0.85). The DLQI was found to be highly related to the physical domain of SF-36. Life quality score was found to be significantly low for the inpatients compared with outpatients (differential validity).

CONCLUSION

It was found that the Turkish version of the DLQI was an acceptable index for dermatologists and dermatology patients and, moreover, to be valid and reliable in a cross-sectional level. The responsiveness of the Turkish version of the DLQI needs to be tested further on a variety of dermatological conditions with different severities.

Psychosocial effects of vitiligo

A limited number of studies have paid attention to the psychosocial well-being of patients affected with vitiligo. We review the psychosocial effects of vitiligo, how patients deal with them and the psychiatric morbidity in vitiligo patients. Given the appreciable comorbidity, it is important to consider these observations in the management of patients, for example in patient-physician interaction but also in treatment strategies and evaluation of treatments. The effects of the psychological state on the disease itself together with the potential therapeutic implications are reviewed. Based on these data, we suggest how to further improve patient's management.

Parent gender and assessment of infant life quality

OBJECTIVES

The primary objective was to examine the influence of parents' gender on the assessment of quality of life among infants with atopic dermatitis. The secondary objective was to examine the psychological factors affecting the assessment.

METHODS

Questionnaires were completed by 28 couples, as a basis for gender comparison. Data were gathered on disease severity, confidence of treatment, Major Depression Index (MDI), Spielberger Trait Anxiety Inventory (STAI) and the Infants' Dermatitis Quality of Life Index (IDQOL).

RESULTS

The mothers' scores were higher than those of fathers for all assessments, although differences were not statistically significant. Significant correlations were found between MDI and severity assessment for mothers only and between MDI and STAI for both genders. Multiple linear regression analysis suggested gender differences in the proposed model, where only depression was appearing statistically significant (P = 0.029).

CONCLUSION

Our data presented suggest that no significant gender-dependent differences occur in parents' overall severity assessment of the eczema in their children, but the influence of the different factors studied is not equal in the two sexes. Future instruments aimed at surrogate assessment of disease severity in children by their parents should take this into account and provide explicit testing of possible gender differences.

Correlates of health-related quality of life in women with severe facial blemishes

BACKGROUND

Facial appearance plays a large role in self-perception and interaction with others. Visible facial skin lesions are a common condition. Purpose This study assessed factors associated with health-related quality of life (HRQOL) in women with visible facial skin lesions.

METHODS

The study included 73 women with one or more of the following conditions: acne, dermatosis papulosis, hypopigmentation, lentigenes, melasma, rosacea, vascular proliferations and other facial scars. The Skindex-16 was used as a measure of HRQOL. Fear of negative evaluation (FNE) was assessed to determine whether self-perception characteristics relate to HRQOL.

RESULTS

There were strong correlations in both bivariate and multivariate analyses among increased FNE, heightened perception of QOL without the facial condition and lower overall HRQOL (P< 0.05 and P< 0.01, respectively). There were no differences in HRQOL by type of facial condition, as well as no effects of the area covered by the condition on HRQOL. Interestingly, women not using foundations represented only 10% of the study population and had better HRQOL than women who did use foundations.

CONCLUSIONS

Severe facial blemishes of any cause have a significant impact on women's QOL, and the effect of these lesions is mediated in part by psychological characteristics related to self-perception and self-presentation.

Measuring quality of life of patients with different clinical types of psoriasis using the SF-36

BACKGROUND

Different specific and generic instruments are used to evaluate quality of life in dermatology, but their interrelationship is not well known.

OBJECTIVES

To describe the quality of life in patients with different clinical types of psoriasis using the 36-item short form of the Medical Outcomes Study questionnaire (SF-36), and to study its correlation with dermatology-specific instruments.

METHODS

We conducted a cross-sectional study of 380 inpatients with psoriasis. SF-36 mean scores were compared with the norms for medical and psychiatric disorders. Quality of life was also measured by both dermatology-specific (Skindex-29 and Dermatology Life Quality Index, DLQI) and psoriasis-specific instruments (Psoriasis Disability Index, PDI, and the Impact of Psoriasis Questionnaire, IPSO). A specific (Psoriasis Life Stress Inventory, PLSI) and a generic (12-item General Health Questionnaire, GHQ-12) measure of psychological distress was also used. A cluster analysis was performed to study the relationship among the different questionnaires.

RESULTS

Our study population showed SF-36 physical health scores similar to minor medical conditions (e.g. physical functioning 79 for psoriasis, 80 for minor medical conditions, and 57 for severe medical conditions), but mental health scores quite similar to psychiatric illnesses (e.g. mental health 57 for psoriasis, 81 for minor medical conditions, 79 for severe medical conditions, and 53 for psychiatric conditions). The SF-36 showed two distinct patterns of impairment of quality of life, with a greater burden of disease for palmoplantar, pustular and arthropathic psoriasis. SF-36 scales tended to form separate clusters from the other dermatology-specific quality of life instruments.

CONCLUSIONS

A generic quality of life instrument (e.g. the SF-36) provides information that is complementary to that derived from dermatological questionnaires, and may give further insight in the evaluation of the burden of psoriasis.

Quality of life and acne in Scottish adolescent schoolchildren: use of the Children's Dermatology Life Quality Indexc (CDLQI) and the Cardiff Acne Disability Indexc (CADI)

BACKGROUND

Acne vulgaris is known to adversely affect all aspects of quality of life. However, although acne is thought to occur in the majority of adolescents, there are few data currently available on the impact of acne in this age group.

OBJECTIVES

Measurement of the impairment of health-related quality of life (HRQoL) in teenage Scottish schoolchildren in a comparative study using two HRQoL questionnaires. A secondary objective was to collect data on the use and perceived efficacy of medical and over-the-counter (OTC) preparations.

STUDY DESIGN

An anonymous cross-sectional survey of 200 adolescent (15-18 years) Dundee schoolchildren was conducted by means of two self-reported questionnaires: the Children's Dermatology Life Quality Index (CDLQI) and the Cardiff Acne Disability Index (CADI). Data on demographics and therapeutic modalities and their perceived efficacy were also collected.

ANALYSIS

Statistical analysis was performed using the package Stata 7.0.

RESULTS

Self-reported acne was present in 83% of teenagers (147/178), with similar sex distribution (54% male, 46% female). The overall mean CDLQI score (max. 30) was low 1.7 {6% impairment} (CI -1 to 0), range 0-19. Nine pupils scored between 5 and 9 {17-30% impairment} suggesting moderate HRQoL impairment and three scored > 10 {> 33% impairment} indicating severe impairment. The overall mean CADI score (max. 15) of 1.9 {13% impairment}, CI 0 to 1 (range 0-15) was also low, but 12 pupils scored between 5 and 9 {33-60% impairment}, one scoring 10 + {> 67% impairment} and one scoring the maximum, 15 {100% impairment}. There was no significant difference in mean scores between the sexes in either questionnaire (P = 0.5). There was good correlation between the results from the two questionnaires (Spearman's rho = 0.62). Three-quarters (75%) had used OTC products, of which only a third (33%) felt they helped 'a lot'. Fifteen per cent were receiving prescribed treatment from their doctors of which 66% found it helpful.

CONCLUSIONS

Self-reported acne occurred in 83% (147/178) of the Scottish teenagers involved in this study, which confirms previous reports of a high prevalence of acne in teenagers. Cross-validation of the CLDQI and CADI demonstrated good correlation and both scales were easy to administer and identified 11% (16/147) of teenagers who perceive their lives to be significantly affected by their acne (8% moderately to severely, 3% severely). It is important to identify and treat such teenagers early to reduce the future socio-economic burden of their acne.

Narrow-band UVB311 nm vs. broad-band UVB therapy in combination with topical calcipotriol vs. placebo in vitiligo

BACKGROUND

Recently, it has been shown that UVB phototherapy may be more effective than UVA in the treatment of vitiligo. Currently, however, no studies have compared the efficacy of UVB311 nm and broad-band UVB therapy. Calcipotriol has recently been reported to be effective adjunctive treatment for vitiligo, enhancing the efficacy of 8-methoxypsoralen plus UVA (PUVA) therapy.

METHODS

Ten patients were enrolled in the study; nine completed the 12 months of therapy. The upper part of the body was treated twice weekly with UVB311 nm and the lower part with broad-band UVB. Calcipotriol was applied onto the vitiligo lesions of the right side of the body and placebo on the left side. Repigmentation was documented by photography, planimetry, and Vitiligo Disease Activity (VIDA) score. The quality of life was measured by the Dermatology Life Quality Index (DLQI).

RESULTS

After 7-16 weeks, six of the nine patients showed initial repigmentation on the side treated with UVB311 nm. After 6 months of treatment, none of the patients showed repigmentation on the areas treated with broad-band UVB, which prompted us to apply UVB311 nm all over the body. At the end of 12 months, two patients showed > 75% repigmentation, two showed 51-75%, two showed 26-50%, and three showed 0-25%. In all patients with progressive vitiligo (seven of the nine patients), disease activity was stopped. Remarkably, vitiligo lesions treated with calcipotriol initially showed delayed repigmentation compared with control areas; however, there was no therapeutic difference between calcipotriol and placebo, both in combination with UVB311 nm, by the end of the study. The DLQI score improved significantly by an average of 28%. Conclusion UVB311 nm therapy was effective in the treatment of vitiligo, whereas broad-band UVB had no effect. Combination with calcipotriol ointment was not superior to UVB311 nm monotherapy. The quality of life significantly improved with narrow-band UVB311 nm phototherapy.

Quality of life instrument for Turkish people with skin diseases

BACKGROUND AND OBJECTIVE

To develop a new, short, self-administrated subjective quality of life (QOL) instrument for Turkish people with skin diseases.

PATIENTS AND METHODS

The 11-item questionnaire of QOL instrument was developed from 200 consecutive dermatological patients' replies. The reliability and validity of the instrument was tested on data gathered from 278 patients with skin diseases attending a dermatology outpatient department and 49 normal subjects. Construct validity was assessed by an exploratory factor analyses and comparisons between patients rated severe and not severe, as well as between normal and patient groups. Reliability was assessed from the internal consistency of the scales and the correlations were made between scores from a 7-10-day retest by using intraclass correlation coefficient.

RESULTS

Factor analyses found six separate dimensions of QOL involving skin disease: social life, emotional life, daily activity, symptoms, cognitive life and sexual life. In addition, 81.3% of common variance was explained by the above factors, all of which correlated with the scale scores of the instrument. The instrument scales were internally consistent (Cronbach's alpha= 0.77-0.84) and scale scores were reproducible after 7-10 days (ICC = 0.63-0.88). Significantly, correlations between scale scores and physician's assessment of the severity of the skin disease were found. Significant differences between diagnostic groups were observed with higher scores for patients with psoriasis, urticaria and acne than those with eczema in the emotional life domain (P < 0.05). In the sexual life domain, however, the eczema group had higher scores than patients with psoriasis, urticaria or acne (P < 0.01).

CONCLUSION

The instrument provides valid and reliable assessments of QOL in Turkish patients with skin disease.

Does enough quality of life-related discussion occur during dermatology outpatient consultations?

BACKGROUND

Dermatologists' assessments of how their patients' lives are affected by the skin disease are of importance for informing clinical decisions. However, there is no information about how often quality of life (QoL) issues are discussed in outpatient consultations.

OBJECTIVE

To examine the relationship between the extent of QoL-related discussion during dermatology outpatient consultations, and the current impact of the disease on patients' lives.

PATIENTS AND METHODS

A total of 238 consultations were observed in a teaching dermatology outpatient department for QoL-related discussion initiated by either the clinician or the patient. Following the consultation, all patients were posted a Dermatology Life Quality Index (DLQI) questionnaire to complete and return within 1 week.

RESULTS

QoL discussion was absent in 40% of consultations. Consultants initiated the fewest QoL discussions with patients, and nurses the most (P < 0.0001). One hundred and twenty-eight (54%) patients returned the DLQI, 114 (48%) of which were evaluable. The mean score was 5.6, SD +/- 6.6, median 3, range 0-29. The mean DLQI score for the patients with whom there was no QoL discussion was 4.0 +/- 4.7, n = 55, compared with the mean DLQI score for patients with whom QoL was discussed 6.8 +/- 7.2, n = 59 (P < 0.001).

CONCLUSION

This study demonstrates that little information concerning QoL is elicited during dermatology outpatient consultations.

A two-compound product containing calcipotriol and betamethasone dipropionate provides rapid, effective treatment of psoriasis vulgaris regardless of baseline disease severity

BACKGROUND

A two-compound product containing calcipotriol and betamethasone dipropionate (Daivobet/Dovobet) has been evaluated in a large clinical trial programme, providing a wealth of data on the treatment of psoriasis vulgaris.

OBJECTIVE

To determine the effectiveness of the two-compound product in patients with mild, moderate and severe psoriasis vulgaris.

METHODS

Data from over 1,534 patients with psoriasis vulgaris who received the two-compound product once daily for at least 4 weeks in four randomised, double-blind studies were pooled. A meta-analysis of the pooled data is presented. Severity of psoriasis at baseline was determined by investigator assessment and Psoriasis Area and Severity Index (PASI) score.

RESULTS

For patients with severe disease defined by PASI score (PASI baseline > or = 17), the mean reduction in PASI after up to 4 weeks of treatment was 71.6% compared with 68.9 and 67.2% for those with moderate (PASI baseline 5.1-16.0) and mild disease (PASI baseline < or = 5). Corresponding reductions for investigator-assessed severity were 72.6, 69.1 and 68.7%, respectively.

CONCLUSION

Although the meta-analysis of the data from these four studies was performed post hoc, we may conclude that the two-compound product provided highly effective treatment of psoriasis, regardless of the category of baseline disease severity.

An assessment of the quality of life in older patients with skin disease

BACKGROUND

There are few data regarding quality of life in older people with skin disease, particularly concerning those with skin cancer. Access to U.K. secondary care dermatological services is increasingly focusing on skin cancer, which may have a negative effect on waiting times for patients with rashes.

OBJECTIVES

To assess the quality of life in patients aged 65 years and over and to determine how this relates to type and extent of skin disease.

METHODS

One hundred consecutive new dermatology patient referrals aged 65 years and above had quality of life assessed by the Dermatology Life Quality Index (DLQI), the Hospital Anxiety and Depression Scale (HADS) and the Illness Perception Questionnaire. Patients were examined for type and extent of skin disease.

RESULTS

There were 49 men (mean age 75.1 years) and 51 women (mean age 75.0 years). Fifty-five per cent of patients had been referred with one or more lesions (76% premalignant or malignant) and 45% had rashes. There was no significant difference between the quality of life scores of men vs. women regarding all three of the questionnaires. However, patients with rashes scored significantly higher (i.e. poorer quality of life) on all but one of the questionnaire parts compared with patients with lesions. Patients with more extensive disease had significantly higher DLQI scores.

CONCLUSIONS

Older people suffering from rashes had significantly poorer quality of life than patients with lesions, even those with skin cancer. The quality of life is negatively associated with extent of skin disease. Access to specialist dermatological care should take into account the suffering caused by extensive skin diseases. DLQI and a general quality of life questionnaire such as the HADS are quick to deliver and to score, particularly in the setting of a busy outpatient department. They provide an excellent screening tool for psychological problems in older people with skin disease.

Effect of vitiligo on self-reported health-related quality of life

BACKGROUND

Vitiligo is a pigmentary disorder affecting at least 1% of the total population. Although the disease does not produce direct physical impairment, it may considerably influence the psychological well-being of the patients. It has been suggested that patients suffer from low self-esteem, poor body image and a poor quality of life. The majority of the studies on the psychosocial impact of vitiligo were conducted in the U.S.A. and England.

OBJECTIVES

This study aims to quantify the burden of vitiligo by estimating health-related quality of life in the Dutch-speaking Belgian population (Flanders). This is compared with the level of disability caused by psoriasis in a similarly recruited population. It is also our purpose to detect those at risk of experiencing a poor quality of life and to identify variables that might predict this impairment.

PATIENTS AND METHODS

Patients with vitiligo (n = 119) and 162 patients with psoriasis were included in a postal survey. In order to obtain a patient-based measurement of quality of life we used the Dermatology Life Quality Index (DLQI), a widely validated questionnaire that is easy to use and allows comparison between several skin disorders. Other survey questions were related to demographic data and disease-related characteristics.

RESULTS

We obtained excellent response rates in both patient groups. The overall mean DLQI score for vitiligo (4.95) was lower than that for psoriasis (6.26) (P = 0.01). Patients with vitiligo experienced significantly less impairment of life quality from the symptoms and treatment of the disease (P < 0.001). The highest individual mean scores in vitiligo were found for Q2 (feelings), Q4 (clothing), Q5 (social and leisure activities) and Q3 (daily routine). The interaction of disease and sex on the DLQI score was highly significant (P = 0.001). While men with vitiligo scored significantly lower than men with psoriasis (P < 0.001), we found a comparable overall DLQI score for women in these disease groups. The number of consultations (P = 0.005) and severity of the disease (P < 0.001) were independently related to the DLQI.

CONCLUSIONS

Our study quantifies the burden on the quality of life caused by vitiligo and indicates specific areas of patients' lives which are most affected by the disease. Sex, number of consultations and subjective disease severity independently predict the quality of life. The quality of life impairment in women affected with vitiligo equals the impairment caused by psoriasis in our study population. These results should awake the interest of physicians in this 'cosmetic' disease, since appropriate treatment is likely to improve the quality of life of vitiligo patients.

Two Decades Experience of the Psoriasis Disability Index

The Psoriasis Disability Index (PDI) was formed 20 years ago. Since its introduction it has been used widely as a tool for assessment of quality of life in psoriasis. This paper reviews its use in 23 peer-reviewed articles and over 35 published abstracts, and describes its use in conjunction with other general and psoriasis-specific quality of life assessments, and with a range of physical and psychological measures. The PDI is effective in demonstrating the effects of interventions, both of treatments and in health service research. The PDI has been translated into at least 16 languages and has been used in published research in 20 countries.

Comparative study of the impact of chronic urticaria, psoriasis and atopic dermatitis on the quality of life

BACKGROUND

A better management of chronic skin disorders (CSDs) requires a knowledge of their impact from the patient's point of view.

OBJECTIVES

To determine which aspects of the patient's life are mainly impaired in the different CSDs, and provide comparative references to estimate better the real impact of the different CSDs.

PATIENTS AND METHODS

A prospective cross-sectional and matched study of 1356 adult outpatients to compare the health-related quality of life (HRQL) profile in chronic urticaria (466 CU), psoriasis (464 PSO) and atopic dermatitis (426 AD), using the VQ-Dermato, a multidimensional instrument in French validated for CSDs.

RESULTS

After adjustment for confounders, HRQL dimensions were differently affected in the three CSDs. The 'physical discomfort' dimension was more degraded in AD and CU than in PSO (P < 0.001), and 'leisure activities' more in PSO than in CU (P < 0.001). 'Self-perception' and 'treatment-induced restrictions' dimensions were much less affected in CU than in PSO and AD (P < 0.001). In PSO, the 'daily living activities' dimension was much less impaired than in CU and AD (P < 0.001). No aspect of HRQL was really spared in AD.

CONCLUSIONS

The comparison shows that CU, PSO and AD are characterized by completely different qualitative profiles of impact on HRQL, which are influenced by their clinical characteristics and usual treatment options. It underlines the severe impairment of CU which is often underestimated.

Lebensqualitat und Berufsdermatosen - Entwicklung und Uberprufung eines Fragebogens zur Lebensqualitat bei Berufsdermatosen (LIOD - Life Quality Index Occupational Dermatoses). Quality of life and occupational dermatoses - Development and evaluation of a questionnaire assessing quality of life with in patients with occupational dermatoses (LIOD - Life Quality Index Occupational Dermatoses)

BACKGROUND

Quality of life (QOL) is an established parameter in dermatology; it is known that skin diseases can affect QOL adversely. There are no specific questionnaires that consider the consider the effect of occupational factors as triggers for work-related diseases, even though such a questionnaire could link QOL specifically with the work situation.

PATIENTS AND METHODS

Based on a literature search and the analysis of existing study instruments, a questionnaire reflecting "Life Quality Index Occupational Dermatoses (LIOD)" was developed and studied in four different groups of persons (N = 228) with and without dermatological diseases.

RESULTS

Using the "Guidelines for QOL-assessment in dermatological studies", a test comparing LIOD to established instruments showed a reliability quotient of 0.804. Cronsbach's alpha was 0.898. The logical and discriminate validity were tested and found to be significant. Hypotheses that had been devised while developing the test were confirmed.

CONCLUSIONS

The validated LIOD questionnaire is a valuable addition to existing instruments in dermatology. LIOD may be used to gain data reflecting the efficacy of therapeutic strategies comparable to medical data.

The place of botulinum toxin type A in the treatment of focal hyperhidrosis

BACKGROUND

Hyperhidrosis (primary or secondary) is excessive sweating beyond that required to return body temperature to normal. It can be localized or generalized, commonly affecting the axillae, palms, soles or face, and can have a substantial negative effect on a patient's quality of life.

IMPACT OF DISEASE

Objective evaluation comprising quantitative assessment (gravimetric and Minor's iodine starch test) and subjective evaluation (Dermatology Quality of Life Index and Hyperhidrosis Impact Questionnaire) allow accurate assessment of the impact of hyperhidrosis on patients.

BOTULINUM TOXIN TYPE A

Botulinum toxin type A acts by inhibiting the release of acetylcholine at the presynaptic membrane of cholinergic neurones. It has proved useful in treating a number of diseases relating to muscular dystonia and is now proving beneficial in treating hyperhidrosis. Clinical trials investigating botulinum toxin type A use in axillary and palmar hyperhidrosis show significant benefits with few side-effects reported, with a favourable impact also being seen on patient quality of life. Botulinum toxin type A injections are generally well-tolerated with beneficial results lasting from 4 to 16 months.

CONCLUSIONS

Botulinum toxin type A injections are an effective and well-tolerated treatment for hyperhidrosis. This paper proposes a positioning of this treatment along with current established treatments, and highlights the role of botulinum toxin type A as a valuable therapy for the treatment of hyperhidrosis.

Quality of life and disease severity are correlated in children with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) in children may affect their daily activities and normal development. It can have a negative impact on the child's behaviour. Little is known about the quality of life (QOL) in children and its relationship to disease severity, especially from a community-based study.

OBJECTIVES

To document the impact of AD on children's QOL and its relationship to disease severity.

METHODS

The targeted population, before recruitment, comprised children with AD aged 5-10 years from a primary care setting. Their general practitioners identified potential patients and the U.K. diagnostic criteria for AD were used to verify the diagnosis. Eczema severity was assessed using the SCORAD (SCORing Atopic Dermatitis) index. The Children's Dermatology Life Quality Index (CDLQI) was used to quantify the impact of AD on children's QOL. These two parameters were evaluated on two occasions 6 months apart. The Spearman correlation coefficient and multiple regressions were used in statistical analysis.

RESULTS

Of the 116 children attending the first QOL assessment visit, 78 (mean age 8.6 years, 44 girls and 34 boys) were able to complete the CDLQI. Of these 78 children, 71 (91%) attended the second visit, and were included in the analysis. The children's QOL was affected in 65 (92%) and 55 (77%) children attending the first and second visits, respectively. The CDLQI was significantly correlated with the SCORAD at the first and second visits (r=0.52, P<0.001 and r=0.59, P<0.001, respectively). Each unit change in the SCORAD was associated with a 0.12 (95% confidence interval 0.04-0.19, P=0.004) unit change in the children's QOL.

CONCLUSIONS

We have shown a positive correlation between children's QOL and disease severity on cross-sectional and over time observation. This highlights the impact of AD on children's life. It also draws attention to the long-term effect on children's behaviour and development. In addition, these findings may imply that the CDLQI could be used as an extra measure of disease assessment in clinical practice and research studies.

Validation of a Cantonese version of the Children's Dermatology Life Quality Index

My goal was to assess the validity and reliability of a Cantonese version of the Children's Dermatology Life Quality Index (CDLQI). To do so, I invited four translators to produce a proper Cantonese translation of the CDLQI. I asked five children to complete this version and made adjustments as necessary. I then requested 30 children with skin problems and 30 children consulting for problems unrelated to the skin in a primary care setting to complete the questionnaire before their consultation. A physician assessed the severity of the skin problem using a visual analog scale. Some children from both groups completed the questionnaire again 7 days later. The CDLQI scores are strongly (gammas = 0.850) and significantly (p < 0.01) correlated with physician-rated disease severity. The Cantonese CDLQI scores were similar to those of the English version for individual skin problems. Correlation of test-retest results is strong (gammas = 0.958, p < 0.01). Cronbach's alpha is 0.83. I concluded that the Cantonese CDLQI is a valid and reliable tool for assessing the effects of skin problems on quality of life in children.

Self-reported skin complaints: validation of a questionnaire for population surveys

BACKGROUND

Estimation of skin diseases in the community is challenging because we do not easily have access to the nonhealthcare-seeking population. A potential tool is a questionnaire asking for self-reported skin complaints. Such an instrument has not yet been developed.

OBJECTIVES

To validate a simple instrument assessing skin morbidity in the general adult population, to predict clinical skin morbidity from self-reported skin complaints.

METHODS

A questionnaire was drawn up in Norwegian and validated against clinical signs in two samples of an urban population, 100 healthcare-seeking adults in a dermatological clinic, and 100 nonhealthcare-seeking adults. A total self-reported score was calculated and validated against severity of clinical signs (no sign, trivial, moderate or severe). The inter-rater agreement was assessed in a small study including 16 patients from a dermatological clinic.

RESULTS

The participation rate was 98%. The sensitivity was 61%, the specificity 69% and the positive predictive value 82% when the caseness criterion was any clinical sign of skin disease. The agreement was good between the two observers for clinical skin morbidity, with kappa = 0.67.

CONCLUSIONS

This questionnaire is a simple tool to evaluate skin morbidity in an adult population. The use of self-reported complaints to predict clinical morbidity may be of value in quantifying and exploring skin diseases at the population level. Further studies are needed to improve the instrument. It is our intention to demonstrate the potential usefulness of this questionnaire in a forthcoming population survey in Norway.

Development and validation of a health-related quality of life instrument for women with melasma

BACKGROUND

Melasma can have significant emotional and psychological effects on those affected with the condition. In the past, the impact of melasma on health-related quality of life (HRQoL) has been assessed using general measures of skin disease that equally weigh both the physical and psychosocial distress arising from the presence of a dermatological condition.

OBJECTIVES

Our purpose was to develop and validate a disease-specific HRQoL instrument to identify the areas of the patient's life most impaired by melasma as well as the effects of the condition on their level of functioning in correlation with disease severity: the Melasma Quality of Life scale (MELASQOL).

PATIENTS AND METHODS

A random sample of 102 women identified by an investigator as having melasma were evaluated by the investigator using the Melasma Area and Severity Index (MASI). The patients were then anonymously surveyed with the SKINDEX-16, the Fear of Negative Evaluation scale, the Dermatology Life Quality Index (DLQI), a skin discoloration evaluation questionnaire, and a measure of perceived life quality difference without melasma. The 10-item MELASQOL scale was devised from the comprehensive HRQoL assessment battery.

RESULTS

The psychometric properties of the MELASQOL were comparable with the properties of the DLQI and the SKINDEX-16. The MELASQOL scores were highly correlated with the other HRQoL measures. The discriminatory ability of the MELASQOL is superior to the SKINDEX-16 and the DLQI for melasma. The three life domains most adversely affected by melasma (social life, recreation/leisure and emotional well-being) were highlighted by this instrument. These were the same three areas of life that patients believed would improve the most if they no longer were affected by the disease.

CONCLUSIONS

The MELASQOL can be used to evaluate objectively the effect of melasma on a patient's HRQoL. The high correlation with the DLQI, the SKINDEX-16 and the skin discoloration questionnaire suggests that the new scale is a valid instrument, which can be used to monitor the level of impairment individuals suffer due to their melasma. The MELASQOL scores can help guide treatment methods as well as track the improvement of patients' HRQoL.

Willingness to pay and time trade-off: sensitive to changes of quality of life in psoriasis patients?

BACKGROUND

Willingness to pay (WTP) and time trade-off (TTO) have been used successfully as quality of life (QOL) measurements in dermatology. However, until now there have been no studies available individually comparing these measures pre- and post-treatment.

OBJECTIVES

To check sensitivity to changes for WTP and TTO (i). pre- to post-treatment, and (ii). to a 6-month follow-up period.

METHODS

We performed a prospective multicentre study in outpatients with psoriasis vulgaris treated with synchronous balneo-phototherapy (simultaneous application of narrowband ultraviolet B and bathing in 10% Dead Sea salt solution). Besides WTP and TTO, the Psoriasis Disability Index (PDI) and the Psoriasis Area and Severity Index (PASI) were monitored.

RESULTS

One hundred and ninety-four patients participated in the pretreatment survey, of whom 138 (71%; 84 men, 54 women; mean age 43.9 years) also returned the post-treatment questionnaire. WTP (percentage of monthly income) was shown to be independent of patients' income. During treatment, mean +/- SD WTP fell from 13.8 +/- 19.2% to 11.5 +/- 15.9% (relative improvement 16.7%; P < 0.05), TTO (h per day) from 2.7 +/- 3.8 to 2.3 +/- 3.6 (relative improvement 15%; P < 0.001), PDI improved from 29.8 +/- 18.6 to 23.5 +/- 18.9 (relative improvement 21.1%; P < 0.001) and PASI (available for 113 patients) from 14.9 +/- 7.7 to 5.6 +/- 5.0 (relative improvement 62.4%; P < 0.001). Changes in WTP, PDI and PASI were statistically significantly correlated. Ninety-one of 138 patients (66%) also completed a third survey after a follow-up period: no further changes in PDI, WTP and TTO were found, indicating a stable QOL post-treatment.

CONCLUSIONS

Correlation analysis indicated that WTP, assessed as percentage of monthly income, seems to be an appropriate way to measure QOL, unbiased by income of patients. WTP, TTO and PDI were correlated and were sensitive to changes during treatment. WTP and TTO therefore also seem to be appropriate tools for assessment of QOL in interventional studies, especially for pharmacoeconomic analyses.

Satisfaction of patients after treatment with botulinum toxin for dynamic facial lines

OBJECTIVE

To gain first evidence on the patient satisfaction after treatment with botulinum toxin type A (BTX-A) and to check for differences in satisfaction with respect to clinical, psychologic, and sociodemographic parameters.

METHODS

In this pilot study, 30 patients who had been treated with BTX-A within the last 3 months answered a standardized questionnaire (the Freiburg questionnaire on aesthetic dermatology and cosmetic surgery). The items assessed were attitudes on beauty and body, satisfaction with treatment outcome, and general quality of life. A prospective study consisting of the same items runs parallel and will be published later.

RESULTS

More than 80% of the patients answered that the treatment had been beneficial to them. All patients would recommend treatment completely or mostly. Only a very small part of the patients was moderately stressed by the treatment.

CONCLUSION

Injections with BTX-A is a satisfying and well-tolerated treatment of dynamic facial lines for all patients in this pilot study.

Acne and hirsuties in teenagers

Acne and body hair are both cutaneous responses to androgenic stimulation. They are normal events in adolescent girls. There is considerable variation in the evolution of the two conditions. The sebaceous gland is exquisitely sensitive to androgens, and acne appears with the onset of puberty, peaks in prevalence in the teenage years and gradually improves thereafter. Hair growth on the face, trunk and limbs develops more slowly and generally peaks in the 20s. Indications for endocrine investigation include very severe acne, onset of acne and hirsuties in the very early stage of puberty (Tanner stage 3) and systemic virilism. Treatment for acne and hirsuties can be either topical or systemic. The choice of therapy is based on the severity of the disease rather than the results of endocrine investigation. Further, since PCO is related to impaired glucose tolerance, advice relating to lifestyle changes should be offered to prevent the development of diabetes.

The Children's Dermatology Life Quality Index: validation of the cartoon version

BACKGROUND

In 1995 the Children's Dermatology Life Quality Index (CDLQI) was developed as a tool to allow quality of life assessment of children with skin conditions. This initial questionnaire was in a written format.

OBJECTIVES

Using the same validated questions, a full-colour cartoon version has been developed. The aim of this study was to validate this against the initial written questionnaire in a three-part study.

METHODS

The first part of the study piloted the use of both versions in an outpatient setting. One hundred and one children completed both versions of the CDLQI in a random order. A further 66 children completed the cartoon CDLQI in outpatients, and subsequently completed the cartoon version on the same day at home, which was returned by post. The scores were compared. In the second part, in more controlled conditions to eliminate parental and investigator bias, 107 children with current dermatological problems were administered both versions of the CDLQI in a random order. The scores were analysed, and time to complete each version, and the child and parental preferences, were recorded. The third part assessed compliance by asking 546 children recently reviewed in dermatology clinics to return a single completed postal CDLQI. Half of the children were given the text, and half the cartoon version.

RESULTS

The median age of participating children was 11 years. There was no significant difference in scores between the two versions in both parts 1 and 2, but the cartoon version was completed faster (median 90 s) than the written version (median 120 s) (P < 0.0001). Both children and their parents significantly preferred the cartoon version and found it easier to use. Forty-six per cent of the postal CDLQI questionnaires were returned; there was no difference in compliance between the two versions.

CONCLUSIONS

The cartoon CDLQI is equivalent to the previously validated written CDLQI version, but is faster and easier for children to use, and is preferred by both children and parents.

Effect of botulinum toxin type A on quality of life measures in patients with excessive axillary sweating: a randomized controlled trial

BACKGROUND

Botulinum toxin type A (BTX-A) has been shown to be a safe and effective treatment for primary focal hyperhidrosis. However, the effect of BTX-A therapy on quality of life (QOL) in patients with this condition has only recently begun to be studied in controlled clinical trials.

OBJECTIVES

To assess the impact on QOL of BTX-A treatment in patients with bilateral primary axillary hyperhidrosis.

METHODS

A multicentre, randomized, double-blind, placebo-controlled trial enrolled 320 patients who exhibited persistent, bilateral, primary axillary hyperhidrosis sufficient to interfere with daily activities. These patients were treated with either 50 U BTX-A (Botox, Allergan, Inc., Irvine, CA, U.S.A.) or placebo in each axilla. QOL was assessed using the Hyperhidrosis Impact Questionnaire (HHIQ) at baseline and 1, 4, 8, 12 and 16 weeks post-treatment, as well as the Medical Outcomes Trust Short Form-12 Health Survey(SF-12) at baseline and 16 weeks post-treatment.

RESULTS

At baseline, participants reported a marked negative impact of hyperhidrosis on various measures, including emotional status, ability to participate in daily and social activities, productivity at work and number of clothing changes per day. During the post-treatment period, statistically and clinically significantly greater improvements in all of these parameters were observed for the BTX-A group compared with the placebo group (P < 0.01). The BTX-A group improvements were observed within 1 week of treatment, and were sustained with little or no decline throughout the 16-week follow-up period. Compared with the baseline HHIQ responses regarding treatment history, BTX-A treatment resulted in a greater level of overall treatment satisfaction than did many other hyperhidrosis treatments. In addition, patients treated with BTX-A exhibited statistically significantly greater improvement in the physical component summary score of the SF-12 at 16 weeks than did placebo-treated patients (P < or = 0.019).

CONCLUSIONS

Hyperhidrosis is associated with a substantial QOL burden; however, QOL is markedly improved with BTX-A treatment.

Self-reported dermatological problems and use of prescribed topical drugs correlate with decreased quality of life: an epidemiological survey

BACKGROUND

Skin problems are common in the population. Although a substantial fraction of the population suffers from skin conditions, we still have little information on how this affects the everyday life of the individuals concerned.

OBJECTIVES

To evaluate the impact of skin disease on health-related quality of life (HRQOL) measured with the Short Form-36 (SF-36), a multidimensional generic HRQOL instrument, from an epidemiological perspective. A further aim was to study differences in HRQOL by use of non-prescription and prescription dermatological drugs.

METHODS

The survey was carried out in the county of Uppland, Sweden in a random sample of 8000 individuals aged 20-84 years, of whom 5404 (68%) answered the questionnaire.

RESULTS

A large part of the population (20.5%) reported dermatological problems and/or use of topical dermatological drugs, with a higher frequency among women (23.3%) than men (17.3%). Persons reporting dermatological problems scored lower on all eight dimensions of the SF-36. This pattern, although weaker, persisted after adjusting for comorbid somatic as well as psychiatric diseases and complaints. Those using topical dermatological drugs on prescription generally scored lower than the other groups with skin problems: in particular, they evaluated personal health as poorer (general health perceptions), perceived more limitations in daily activities (role limitation because of emotional health problems) and felt more tired and worn out (vitality).

CONCLUSIONS

The study shows that skin disorders constitute a substantial problem in the population and cause a significant decrease in HRQOL. Furthermore, the results of this population survey point out the need for further population-based studies more specifically aimed at dermatological problems and HRQOL.

Topical corticosteroid therapy for acute radiation dermatitis: a prospective, randomized, double-blind study

BACKGROUND

Radiation dermatitis is a common side-effect of radiation therapy, but there is no current consensus about its appropriate therapy.

OBJECTIVES

To compare treatment with topical 0.1% methylprednisolone vs. 0.5% dexpanthenol in a cohort of patients undergoing fractionated radiation therapy for breast cancer.

METHODS

In a randomized, double-blind design, treatment was initiated at the beginning of radiation therapy and continued for 2 weeks after termination of radiation. Outcomes were compared by three different measures: clinical (symptom score), functional (transepidermal water loss, TEWL) and subjective (quality of life, QOL).

RESULTS

In a preliminary cohort of untreated patients undergoing radiation therapy, clinical signs and TEWL levels increased progressively during radiation therapy, reaching highest values at 5 and 4 weeks, respectively. Although neither topical treatment reduced the incidence of radiation dermatitis, both delayed the emergence of greatest clinical and TEWL scores until approximately 6 and 5 weeks, respectively. With topical corticosteroids, clinical symptoms and TEWL were less pronounced than with dexpanthenol. Whereas general QOL improved after completion of radiation therapy, skin-related QOL declined. However, the skin-related QOL decline could be at least in part reversed by use of topical corticosteroid vs. dexpanthenol-containing emollient.

CONCLUSIONS

We provide evidence that prophylactic and ongoing use of topical therapy with either topical corticosteroid or a dexpanthenol-containing emollient ameliorates, but does not prevent radiation dermatitis. Our data suggest, but do not prove, a benefit of a topical corticosteroid vs. a dexpanthenol-containing emollient. Further controlled studies with larger cohorts will be needed to determine optimal forms of topical therapy for radiation dermatitis.

Eczema: quality of life by body site and the effect of patch testing

BACKGROUND

Patients with dermatitis are known to have impaired quality of life. Whether this varies according to body site has not been evaluated. Patch tests have previously been shown to influence quality of life, although no previous studies have shown if this is dependent on the results of the patch tests.

OBJECTIVES

To evaluate the impact of patch testing on quality of life according to the outcome of the investigations and to determine how quality of life varies according to eczema body site.

METHODS

One hundred and sixty consecutive adult patients with active eczema were selected from a patch test clinic for inclusion into the study. Quality of life was determined using the Dermatology Life Quality Index (DLQI) and the SF-36, prior to patch testing and 2 months later. Perceived eczema severity at each time point was also noted, along with the outcome of patch testing. Baseline comparison of quality of life was performed between four body site groups (face, hand, generalized, other).

RESULTS

Patients confirmed as having relevant positive contact allergens were shown to have a significant improvement in both perceived eczema severity (P = 0.0004) and DLQI score (P = 0.0015) at 2 months after patch testing. No significant changes were noted in the SF-36 score, other than a borderline improvement in the pain score (P = 0.048). The improvement in quality of life and eczema severity was not noted in patients with negative patch tests. Eighty-nine per cent of patients diagnosed as having contact allergy were able to comply with avoidance advice. No significant variation was noted in quality of life according to body site affected by eczema. There was a positive correlation between DLQI score and perceived eczema severity (P < 0.0001).

CONCLUSIONS

Patients confirmed as having contact allergy show a subsequent improvement in eczema severity and an improvement in quality of life.

Patient satisfaction with teledermatology is related to perceived quality of life

BACKGROUND

There is a lack of good data about patient satisfaction with teledermatology and about its potential interaction with quality-of-life factors.

OBJECTIVES

To assess the association between perceived skin-related quality of life and patient satisfaction with a nurse-led teledermatology service.

METHODS

In a mobile nurse-led teledermatology clinic located in four inner city general practices in Manchester, the teledermatology service used digital cameras to capture and store images of skin conditions for remote diagnosis by dermatologists. One hundred and twenty-three adult patients, non-urgent dermatology referrals from primary care, completed the Dermatology Life Quality Index (DLQI) and a 15-item patient satisfaction questionnaire.

RESULTS

In common with other studies of patient satisfaction, subjects reported highly favourable views of 'hotel' aspects of the service (93%) and found it 'convenient' (86%). However, 40% of patients would have preferred to have had a conventional face-to-face consultation with a dermatologist, and 17% felt unable to speak freely about their condition. Patient satisfaction with the service was related to quality of life. Patients reporting lower quality of life as measured by the DLQI were more likely to prefer a face-to-face encounter with a dermatologist (r = 0.216, P < 0.05), and to evince anxiety about being photographed (r = 0.223, P < 0.05).

CONCLUSIONS

Patient acceptance and satisfaction with telemedicine services is complicated by patients' subjective health status. Telehealthcare providers need to recognize that patients with poor quality of life may want and benefit from face-to-face interaction with expert clinicians.

Factors associated with patient satisfaction with care among dermatological outpatients

BACKGROUND

It has been shown that poor patient satisfaction can lead to poor adherence to treatment with consequently poor health outcomes. In order to improve the quality of care perceived by the patient and thus the health outcome, it is important to understand which are the main factors influencing patient satisfaction.

OBJECTIVES

To examine factors associated with patient satisfaction with care among dermatological out-patients.

METHODS

This longitudinal study is based on a sample of dermatology out-patients. The independent effects on patient's satisfaction of patient characteristics (sociodemographic characteristics, disease severity, quality of life) and of specific aspects of provided health care (the time the physician spent with patients, physician's interpersonal skills, etc.) were examined by multiple logistic regression.

RESULTS

A total of 1389 out-patients were selected at random and invited to participate. Of the 722 patients who agreed to participate, 424 fulfilled the inclusion criteria and 396 of these patients (93.4%) completed the study. Overall satisfaction was reported by 60.0% of patients. The likelihood of overall satisfaction was found to be significantly and independently increased by the physician's ability to give explanations and to show empathy for the patient's condition, and by the older age of patients. The likelihood of satisfaction also increased with increasing disease severity, but decreased with symptom-related poor quality of life. The lowest level of satisfaction was found among patients whose symptom-related quality of life was worse than the clinical severity rated by the dermatologist.

CONCLUSIONS

Improving the physician's interpersonal skills can increase patient satisfaction, which is likely to have a positive effect on treatment adherence and health outcomes. Dermatologists succeeded better in establishing a good relationship with clinically more severely affected patients than with patients who were clinically mildly affected despite their quality of life being impaired. Thus, the inclusion of a patient-rated quality of life can be a useful measure in dermatology, as it enables clinicians to perceive the patients' perception of their health status.

Differences in efficacy between intention-to-treat and per-protocol analyses for patients with psoriasis vulgaris and atopic dermatitis: clinical and pharmacoeconomic implications

BACKGROUND

Pharmacoeconomic outcome research is based on three criteria: (i) evaluation of objective therapeutic effects; (ii) quality of life; and (iii) treatment costs. Evaluation of therapeutic effect is mainly based on the results of clinical trials using objective clinical measures, e.g: Psoriasis Area and Severity Index (PASI) (score for psoriasis vulgaris) and the Severity Scoring of Atopic Dermatitis (SCORAD) (score for atopic dermatitis). In most studies, only results for a treatment-optimized subpopulation (patients treated according to the protocol) are presented in publications. The relevance of such data for daily routine therapy is doubtful.

OBJECTIVES

Our purpose was to investigate the expected loss of effectiveness of switching from a clinical trial to daily routine therapy for the synchronous application of narrow-band ultraviolet (UV) B phototherapy (311 nm) and bathing in 10% Dead Sea salt solution (synchronous balneophototherapy) for patients with psoriasis vulgaris and atopic dermatitis.

METHODS

We conducted a multicentre, uncontrolled observational study of outpatients. To achieve data for 'clinical trial' and 'daily routine' situations, two populations were compared: (i) all patients strictly treated according to the protocol (ATP) with no protocol deviations (data published in clinical trials), and (ii) all patients participating in the study who received active treatment at least once, despite treatment irregularities, non-compliance, early withdrawal or other protocol violations [intention-to-treat-population (ITT), model for 'daily routine'].

RESULTS

A total of 2526 patients were included in the ITT analysis for psoriasis vulgaris (n = 487 for atopic dermatitis), of which 818 patients could be analysed according to protocol (n = 104 for atopic dermatitis). Striking differences in the therapeutic effect between both groups (ITT and ATP) were found using relative PASI and SCORAD score improvement: 11% (57% 'daily routine' vs. 68% in 'clinical trial') for psoriasis vulgaris and 16% (39% 'daily routine' vs. 55% 'clinical trial') for atopic dermatitis. The main reasons for excluding patients from the 'clinical trial' group were early study withdrawal in 29% (atopic dermatitis, 47%) of patients and fewer treatments per week than planned in the protocol in 24% (atopic dermatitis, 52%).

CONCLUSIONS

Our data clearly indicate that for the prediction of the therapeutic effect for daily routine therapy the ITT data appear to be more relevant than the ATP results (i.e. those presented in clinical trials). Although these data are only a first step for evaluating the 'real' therapeutic effect of a treatment modality in daily routine, they seem to support the requirements for ITT analyses in efficacy studies and demonstrate the necessity of ITT data for pharmacoeconomic evaluation.

Botulinum A toxin improves life quality in severe primary focal hyperhidrosis

Focal hyperhidrosis is a condition that may disturb emotional, social and professional life. Treatment options for severe cases are surgical sympathectomy and local chemical sweat gland denervation by intradermal injections of botulinum toxin A (Btx A). The Dermatology Life Quality Index (DLQI) is a simple validated questionnaire designed to measure and compare disability in different skin diseases. The aim of this study was to assess quality of life with the DLQI before and after treatment with botulinum toxin injections in a group of patients with severe hyperhidrosis. DLQI was administered to 58 randomly chosen patients before and after treatment. All patients answered the DLQI questionnaire prior to treatment and 53/58 at mean 5.2 months after treatment. The mean DLQI score in the 58 patients before treatment was 10.3 (2-23). In the group of 16/53 patients who had a relapse of sweating when answering the DLQI a second time, no significant improvement was seen [score 10.6 before and 8.8 after treatment (P = 0.21)]. In patients without relapse, a 76% improvement was obtained (DLQI was reduced from 9.9 to 2.4; P < 0.0001). The study showed that focal hyperhidrosis may considerably reduce life quality and the disability experienced by the patients can be largely reversed by botulinum toxin injections.

Morbidity in patients with hidradenitis suppurativa

BACKGROUND

Although skin diseases are often immediately visible to both patients and society, the morbidity they cause is only poorly defined. It has been suggested that quality-of-life measures may be a relevant surrogate measure of skin disease. Hidradenitis suppurativa (HS) leads to painful eruptions and malodorous discharge and is assumed to cause a significant degree of morbidity. The resulting impairment of life quality has not previously been quantitatively assessed, although such an assessment may form a pertinent measure of disease severity in HS.

OBJECTIVES

To measure the impairment of life quality in patients with HS.

METHODS

In total, 160 patients suffering from HS were approached. The following data were gathered: quality-of-life data (Dermatology Life Quality Index, DLQI questionnaire), basic demographic data, age at onset of the condition and the average number of painful lesions per month.

RESULTS

One hundred and fourteen patients participated in the study. The mean +/- SD age of the patients was 40.9 +/- 11.7 years, the mean +/- SD age at onset 21.8 +/- 9.9 years and the mean +/- SD duration of the disease 18.8 +/- 11.4 years. Patients had a mean +/- SD DLQI score of 8.9 +/- 8.3 points. The highest mean score out of the 10 DLQI questions was recorded for question 1, which measures the level of pain, soreness, stinging or itching (mean 1.55 points, median 2 points). Patients experienced a mean of 5.1 lesions per month.

CONCLUSIONS

HS causes a high degree of morbidity, with the highest scores obtained for the level of pain caused by the disease. The mean DLQI score for HS was higher than for previously studied skin diseases, and correlated with disease intensity as expressed by lesions per month. This suggests that the DLQI may be a relevant outcome measure in future therapeutic trials in HS.