Vitiligo and Psychiatric Morbidity: A Profile from a Vitiligo Clinic of a Rural-based Tertiary Care Center of Eastern India

Exploratory axis factoring for identifying the self-esteem latent factors and their correlation with the life quality of persons suffering from vitiligo

Objective

Our research aimed to measure the importance of self-esteem in assessing the disease burden in patients with vitiligo, which, according to our knowledge, had not been studied earlier. The purpose of this research study was to expand the state of knowledge regarding the influence of vitiligo on the quality of patients' life, with a particular focus on their self-esteem. We have formulated the following two hypotheses which include H1: two latent factors characterize the self-esteem of patients with vitiligo; H2: the self-esteem of the patients with Vitiligo is correlated with their life quality, by influencing it to a high degree.

Methods

We have used two validated questionnaires called Rosenberg (Q1), for the evaluation of self-esteem (for proving H1), and Dermatology Life Quality Index (DLQI) (Q2), to measure the health-related quality of life of patients (for proving H2). Both questionnaires with 10 questions were applied to the same set of 114 carefully selected patients with no missing values to questions. An in-depth statistical and reliability analysis was performed on the outcomes provided by Q1, applying a scale and subscale reliability analysis, using the Cronbach's alpha reliability indicator (Cα). An exploratory analysis called Principal Axis Factoring (PAF) with Oblimin with Kaiser Normalization rotation was applied to prove H1, verifying the assumptions regarding the average variance extracted (AVE) and convergent and discriminant validity (CDV). A scale reliability analysis of outcomes provided by Q2 was performed for proving H2, by calculating Cα. Additionally, a nonparametric correlation analysis was performed, by calculating the Spearman r correlation coefficient between the Rosenberg index and DLQI index, and the 95% confidence interval (CI).

Results

Based on the provided data, the value of Cα obtained in Q1 was 0.84. As a result of applying PAF on Q1, H1 has been proven and two latent factors of self-esteem have been extracted. These factors were named competence (eigenvalue = 4.126; 41.258% of total variance explained) and value (eigenvalue = 1.857; 18.57% of total variance explained). For the two subscales determined by the two factors, we have obtained the Cα values of 0.848 and 0.8, all indicating good reliability. For testing H2, on Q2 data we obtained Cα = 0.914. The Spearman correlation coefficient r = -0.734 (p < 0.0001), between the self-esteem questionnaire evaluation result and the life-quality index result indicated the existence of a strong negative correlation, which is significant according to 95% CI [-0.81, -0.63].

Discussion

The study focused on analyzing the self-esteem of patients with vitiligo. In addition, the psychometric properties of the Q1 questionnaire were analyzed and Q1 proved to have good internal consistency. PAF indicated a two-factorial structure, with factors called competence and value, proving H1, with a moderate correlation of 0.427 between the two latent constructs. The competence factor includes motivation, self-efficacy, initiative, and persistence in action. The value factor is much more complex, indicating a feeling, a personal evaluation, or a positive or negative attitude toward one's person, which better captures the entire phenomenology of self-esteem. The statistical analysis of the results provided by the self-esteem questionnaire included questions that proved to be internally consistent. The AVE and CDV assumptions were met. Q2 was proved to have excellent scale reliability. H2 proved a statistically significant strong negative correlation between the Rosenberg score and DLQI score.

Psychiatric morbidity among patients suffering from Vitiligo

Background

Vitiligo is a chronic acquired, stigmatizing disease characterized by discoloration of skin and mucous membranes. Patients suffering from this condition suffer from a lack of confidence and psychological stress.

Aim

To assess depression, anxiety, and social anxiety among patients suffering from vitiligo.

Material and Method

This hospital-based cross-sectional, observational, descriptive study was carried out in a tertiary care center on 100 patients suffering from vitiligo, who were consecutively enrolled after informed consent from the outpatient department (OPD) of the dermatology department. Permission was obtained from the institutional ethics committee Diagnosis of vitiligo was made by two consultants from the department of dermatology. Sociodemographic variables were recorded in the sociodemographic form. The General Health Questionnaire-12 (GHQ-12) was applied to all 100 patients. Patients who scored >3 on GHQ-12 were further subjected to the Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), and Social Interaction Anxiety Scale. Results were statistically analyzed on SPSS-22.0 (IBM, Armonk, USA).

Results

Of all the patients, 55% (n = 55) had a GHQ score >3 (i.e., Psychiatric morbidity was present in 55% of patients.). Out of 50 patients in the age group of 18-25 years, 41 patients in the age groups of 26-35 years, and 9 patients in the age groups of 36-45 years, 22 (44%), 17 (42.1%), and 6 patients had psychiatric morbidity, respectively. Of the total number of patients, 46% had depression according to the HAM-D scale. Of all the patients, 18% had mild, 22% had moderate, and 6% had severe depression. Age-wise analysis showed that out of 50 patients in the age group of 18-25 years, 41 patients in the age group of 26-35 years, and 9 patients in the age group of 36-45 years, 22 (44%), 20 (48.7%), and 4 patients had depression, respectively. Of the patients who had depression, 39% were male and 58% were female. On HAM-A, 47% of the patients had anxiety; 33% had mild, 12% had moderate, and 2% had severe anxiety. Age-wise analysis showed that out of 50 patients in the age group of 18-25, 41 patients in the age group of 26-35 years, and 9 patients in the age group of 36-45 years, 20 (40%), 23 (56.1%), and 3 patients had anxiety, respectively. On SIAS, 36% of the patients had social anxiety. Out of 50 patients in the age group of 18-25 years, 41 patients in the age group of 26-35 years, and 9 patients in the age group of 36-45 years, 23 (46%), 9 (7.8%) and 4 patients had social anxiety, respectively. According to gender-wise distribution, 17% of male and 63% of female patients had social anxiety.

Conclusion

A high prevalence of anxiety, depression, and social anxiety has been observed in this present study. Therefore, importance should be given to psychiatric evaluation of such patients and, if required, necessary interventions should be undertaken to improve their quality of life.

Current Status of Cell-Based Therapies for Vitiligo

Vitiligo is a chronic pigmentary disease with complex etiology, the signs of which are caused by the destruction of melanocytes in the epidermis, leading to the lack of melanin pigment responsible for skin coloration. The treatment of vitiligo, which aims at repigmentation, depends both on the clinical characteristics of the disease as well as on molecular markers that may predict the response to treatment. The aim of this review is to provide an overview of the clinical evidence for vitiligo cell-based therapies taking into account the required procedures and equipment necessary to carry them out as well as their effectiveness in repigmentation, assessed using the percentage of repigmentation of the treated area. This review was conducted by assessing 55 primary clinical studies published in PubMed and ClinicalTrails.gov between 2000 and 2022. This review concludes that the extent of repigmentation, regardless of the treatment method, is highest in stable localized vitiligo patients. Moreover, therapies that combine more than one cell type, such as melanocytes and keratinocytes, or more than one method of treatment, such as the addition of NV-UVB to another treatment, increase the chances of >90% repigmentation. Lastly, this review concludes that various body parts respond differently to all treatments.

The association between social support and depression among patients with vitiligo in China

Vitiligo is a common depigmenting skin disease with profound psychosocial impacts. Depression is one of the most common mental distress. Social support has a significant impact on the psychological status of patients. The aim of this study is to investigate the depression and social support status of patients with vitiligo in China, and further explore the correlation between social support and depression. The outpatients with vitiligo were investigated face to face with SDS (Self-rating depression scale) and SSRS (Social support rate scale). The mean SDS score of the patients was 44.05 ± 6.76, which was significantly higher than Chinese norms (p = 0.000). Female patients, unmarried, disease at rapid progressive stage and skin lesions at the exposed site had higher SDS scores (all p < 0.05). The scores of total social support, subjective support, objective support and support availability were lower than Chinese norms (all p < 0.01), and all were negatively correlated with SDS scores (all p < 0.001). In conclusion, low social support is one of the risk factors for depression in patients with vitiligo in China. More support and acceptance should be given to the patients.

Patients with vitiligo have a distinct affective temperament profile: A cross-sectional study using Temperament Evaluation of Memphis, Paris, and San Diego Auto-Questionnaire

Background

Vitiligo is a skin disease associated with significant psychiatric comorbidities. Affective temperaments represent the inherited foundation of personality and represent the biologically stable part of emotional reactivity. Studies assessing the temperament profile of patients with vitiligo are still scarce.

Method

This was a cross-sectional study enrolling 34 patients with vitiligo and 34 age and sex-matched healthy controls. Affective temperament profile was investigated using the Temperament Evaluation of Memphis, Paris, and San Diego Auto-questionnaire. Dermatology life quality index was used to evaluate disease impact on patients' quality of life.

Results

We found significant differences with vitiligo patients scoring higher in anxious (11.5 ± 4.76 vs. 9.06 ± 6.22; p = 0.036) and lower in hyperthymic (5.79 ± 3.82 vs. 7.5 ± 3.64; p = 0.027) temperaments. Vitiligo worsening reported by patients was associated with recent psychological stressors in 18 cases (52.9%) and Koebner phenomenon in 20 cases (58.8%). Koebner phenomenon was more frequently associated with the hyperthymic temperament (p = 0.035). Cyclothymic temperament was positively correlated with Dermatology life quality index (rho = 0.417, p = 0.014).

Conclusions

This study demonstrated that patients with vitiligo have a distinct premorbid temperament profile. Having low hyperthymic and high anxious temperament traits seem to predispose patients to be less resilient to psychological stressors. A better understanding of the affective traits of vitiligo patients would be vital in personalising and adapting the management of this chronic skin disease.

Psychosocial Effects of Vitiligo: A Systematic Literature Review

Background

Patients with vitiligo experience reduced quality of life.

Objective

To comprehensively describe the available evidence for psychosocial burden in vitiligo.

Methods

A systematic review of observational studies and clinical trials identified using PubMed, EMBASE, Scopus, and the Cochrane databases was performed through 1 March, 2021, to assess psychosocial comorbidities in vitiligo. Two independent reviewers performed an assessment of articles and extracted data for qualitative synthesis.

Results

Included studies (N = 168) were published between 1979 and 1 March, 2021; 72.6% were published since 2010. Disorders including or related to depression (41 studies, 0.1–62.3%) and anxiety (20 studies, 1.9–67.9%) were the most commonly reported. The most prevalent psychosocial comorbidities were feelings of stigmatization (eight studies, 17.3–100%), adjustment disorders (12 studies, 4–93.9%), sleep disturbance (seven studies, 4.6–89.0%), relationship difficulties including sexual dysfunction (ten studies, 2.0–81.8%), and avoidance or restriction behavior (12.5–76%). The prevalence of most psychosocial comorbidities was significantly higher vs healthy individuals. Factors associated with a significantly higher burden included female sex, visible or genital lesions, age < 30 years (particularly adolescents), and greater body surface area involvement, among others. The most commonly reported patient coping strategy was lesion concealment.

Limitations

Available studies were heterogeneous and often had limited details; additionally, publication bias is possible.

Conclusions

The results of this systematic review show that vitiligo greatly affects psychosocial well-being. The extent of psychosocial comorbidities supports the use of multidisciplinary treatment strategies and education to address the vitiligo-associated burden of disease.

Protocol Registration

PROSPERO (CRD42020162223).

Graphic Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40257-021-00631-6.

Stress, anxiety, and depression in patients with vitiligo

Background

Vitiligo has a significant effect on patients’ quality of life; they feel stigmatized and disturbed by their condition. A lot of vitiligo patients, according to reports, suffer from psychological disturbances. The aim of the study is to find the relation between vitiligo and stress, anxiety, and depression and to measure how vitiligo affects the quality of life index. This study included 50 vitiligo patients and 50 matched healthy control groups. All patients were assessed by the Depression Anxiety Stress Scale (DASS) to determine the severity of anxiety, depression, and stress symptoms and the Dermatology Life Quality Index (DLQI) scale to evaluate their quality of life while the control group underwent only the Depression Anxiety Stress Scale.

Results

The prevalence of stress was 76% (n=38), anxiety was 78% (n=39), and depression was 80% (n=40); the difference was statistically significant between patient group and control group regarding stress, anxiety, and depression. Gender had a significant relationship with stress, anxiety, and depression (p < 0.05) (female affected more than male). Also, there was a statistically significant relation between the degree of vitiligo and anxiety (p < 0.05). Vitiligo has a moderate to very severe effect on the quality of life index. There was a statistically significant positive correlation between stress and feeling of embarrassment from vitiligo and clothes choice.

Conclusion

Vitiligo is a psychcutaneous disease that does not only affect the patient’s physical status, but also his mental and psychological status.

Meta-Analytic Review of High Anxiety Comorbidity among Patients with Vitiligo

Background

Vitiligo is a disfiguring skin disease with profound psychosocial impacts, such as anxiety, but the reported effect sizes of associations vary. We aimed to conduct a meta-analysis to quantify the strength of association between anxiety and vitiligo and to estimate the prevalence of anxiety among individuals with vitiligo.

Methods

A systematic literature search was performed in five online databases (MEDLINE, Embase, Web of Science, Cochrane Library, and PsycINFO) from inception until March 20, 2020. All of the eligible studies were comprehensively reviewed, and all of the available data were analyzed according to our predefined criteria.

Results

Twenty-one studies involving 3259 patients in 11 countries were included in this meta-analysis. Compared with the healthy control group, patients with vitiligo often had concomitant anxiety (OR = 6.14 [95% CI: 3.35–11.24], I² = 30.1%). The pooled prevalence of anxiety in female patients was significantly higher than that in males (OR = 2.24 [95% CI: 1.31–3.84], I² = 0.0%). Subgroup analysis showed that the pooled prevalence of clinical anxiety disorder and anxiety symptoms was 12% (95% CI: 7%–16%, I² = 76.3%) and 34% (95% CI: 21%–46%, I² = 94.7%), respectively. No publication bias has been detected by Begg's funnel plot and Egger's test.

Conclusion

Patients with vitiligo have high anxiety comorbidity, with female predominance. Dermatologists and psychiatrists should be vigilant to the presence of anxiety, apply appropriate interventions to reduce the psychological impacts in a timely manner, and thus promote recovery in vitiligo patients. However, due to some objective limitations (poor information about the OR and diversity in assessment tools among included studies), findings should be interpreted with caution.

The Impact of Vitiligo on Quality of Life and Psychosocial Well-Being in a Nepalese Population

The authors collected demographics and assessed the impact of vitiligo using Vitiligo Quality of Life (VitiQoL) and Vitiligo Impact Scale (VIS), followed by a focused survey and semistructured interviews with 22 participants in midwestern Nepal. VitiQoL and VIS scales did not indicate a large impact on quality of life; however, through interviews/focused surveys, participants expressed unhappiness/worry, problems in finding partners, securing employment, and social discrimination due to their skin lesions. These stressors are highlighted along with lack of proper physician counseling and vitiligo-related myths, which create psychosocial distress that may not be given priority in underdeveloped countries like Nepal.

Psychodermatology of vitiligo: Psychological impact and consequences

Vitiligo is an autoimmune dermatologic disorder that causes chronic skin depigmentation, which affects an estimated 1% of the world's population. This disfiguring condition can have devastating psychological consequences on its sufferers. The field of psychodermatology examines psychiatric manifestations of dermatologic conditions. Although previous research in this area has been done on other skin disorders, no large-scale review exists on the dermatologic-psychiatric connection in vitiligo specifically. The current article will discuss the psychodermatology of vitiligo with an emphasis on depression, stress, and low self-esteem. The social and cultural considerations will also be explored. Finally, the implications of these psychiatric manifestations on treatment will be discussed, with the goal of implementing early psychiatric intervention for those with vitiligo.

Evaluating prevalence of depression, anxiety and hopelessness in patients with Vitiligo on an Iranian population

INTRODUCTION

Vitiligo is caused by partial or complete destruction of melanocytes in the affected skin area and influences the patient's quality of life. Besides physical involvement, vitiligo patients experience a high level of stress. Depression and Anxiety are common psychiatric disorders in vitiligo patients.

AIM

This study, as the first study, evaluates hopelessness, anxiety, depression and general health of vitiligo patients in comparison with normal controls in an Iranian population.

METHOD

Hundred patients with vitiligo and hundred healthy controls were examined. General health, depression, hopelessness and anxiety were evaluated based on general health questionnaire. Anxiety, depression and hopelessness levels were analyzed using Chi-Square, and the mean value of general health was evaluated through t-test.

RESULTS

The results showed that anxiety and hopelessness levels were significantly higher in vitiligo patients than those who are in healthy controls. This significant difference refers to high levels of anxiety and hopelessness among women with vitiligo. It was also found that the single patients were more anxious, hopeless and depressive, while the married patients were only more anxious and hopeless than those who are in the control group, respectively. General health of patients was significantly worse than in healthy controls. The low level of general health in patients was related to poorer level of general health among women with vitiligo.

CONCLUSION

It seems that women with vitiligo are more mentally stressed than men with vitiligo. Both singles and married vitiligo patients suffer from anxiety and hopelessness.

Association of Functional Polymorphism in Protein Tyrosine Phosphatase Nonreceptor 22 (PTPN22) Gene with Vitiligo

The protein tyrosine phosphatase nonreceptor 22 (PTPN22) is associated with susceptibility to autoimmune diseases. The functional polymorphism in PTPN22 at 1857 is a strong risk factor for vitiligo susceptibility in Europeans; however, controversy exits in other populations. Present study was aimed to determine whether the PTPN22 C1857T polymorphism confers susceptibility to vitiligo in Saudi Arabians. Genomic DNA was extracted and amplified using tetra primer amplification-refractory mutation system polymerase chain reaction (ARMS-PCR) method. The frequencies of allele T and genotype CT of PTPN22 C1858T polymorphism were significantly higher, whereas those of allele C and genotype CC were lower in patients as compared with controls (P < 0.0001). The genotype TT was absent in both the patients and controls. It is concluded that PTPN22 C1858T polymorphism is strongly associated with vitiligo susceptibility. However, additional studies are warranted using large number of samples from different ethnicities and geographical areas.

The color of skin: psychiatric ramifications

Skin color is one of the major attributes that defines both individual distinctiveness and differences between groups. There is a preference for lighter skin world-wide, among both light- and dark-skinned individuals, further leading to skin-color bias based upon skin-color hierarchy within certain ethnoracial groups. The psychiatric and psychosocial ramifications of skin color are important in several situations, including (1) disorders of skin discoloration (eg, vitiligo), which can significantly affect the psychosocial development of the patient especially when it has its first onset during adolescence; (2) widespread use of skin-lightening products, which are used despite knowledge about serious toxicity from inorganic mercury and potent corticosteroids that are some of their main constituents; (3) indoor tanning, which is a recognized carcinogen and practiced by over 50% of university-age adults and 20% of adolescents. Educating about photocarcinogenicity does not change tanning behaviors, which is strongly driven by peer pressure; and (4) when a psychiatric disorder, such as body dysmorphic disorder or major depressive disorder, is the primary basis for skin color dissatisfaction. Despite the role of complex sociocultural and psychiatric factors in clinical manifestations involving skin color, a supportive relation with the dermatologist can significantly aid the patient in managing their disease burden.

RNA-seq Reveals Dysregulation of Novel Melanocyte Genes upon Oxidative Stress: Implications in Vitiligo Pathogenesis

Oxidative stress is known to induce melanocyte death, but the underlying mechanisms are incompletely understood. To identify oxidative stress-induced global gene expression changes in melanocytes, we treated PIG1 melanocytes with H₂O₂ in a dose- and time-dependent manner and performed RNA-seq. This approach allowed us to capture the events occurring early as well as late phase after treatment with H₂O₂. Our bioinformatics analysis identified differentially expressed genes involved in various biological processes of melanocytes which are known to contribute to the vitiligo development, such as apoptosis, autophagy, cell cycle regulation, cell adhesion, immune and inflammatory responses, melanocyte pluripotency, and developmental signaling such as WNT and NOTCH pathways. We uncovered several novel genes that are not previously described to be involved in melanocytic response to stress nor in vitiligo pathogenesis. Quantitative PCR and western blot analysis of selected proteins, performed on PIG1 and primary human epidermal melanocytes, confirmed the RNA-seq data. Interestingly, we discovered an aberrant regulation of several transcription factors that are involved in diabetes, neurological, and psychiatric diseases, all of which are comorbid conditions in patients with vitiligo. Our results may lead to a better understanding of the molecular mechanisms underlying vitiligo pathogenesis and help developing new drug targets for effective treatment.

Gender Differences in Depression, Coping, Stigma, and Quality of Life in Patients of Vitiligo

Though vitiligo is one of the psychodermatological disorders which do not cause direct physical impairment, it is cosmetically disfiguring leading to serious psychological problems in daily life. We undertook this research to study patients of vitiligo the prevalence of depression, coping, stigma, and quality of life and comparison of the same in both genders. Patients diagnosed clinically as having vitiligo by consultant dermatologist were enrolled after informed consent and ethics approval. 156 patients were screened, of which 100 satisfying criteria were taken up for the study. A semistructured proforma was designed to collect the necessary information with administration of Beck's depression inventory, participation scale, dermatology life quality index, and adjustment to chronic skin diseases questionnaire. Depression prevalence was 63.64% in females and 42.86% in males (p<0.0457); the total mean BDI scores were significant with females having higher scores than males (p<0.0083). No significant differences were seen on participation scale though 52% females felt stigmatized as compared to 45% males (p <0.5779). While almost 97% of our patients had impaired quality of life there was no significant difference in both genders on the total score (p<0.3547). Females had significantly higher faulty coping style than males with significant differences on all domains and total scores (p< 0.0094). There was a strong association of depression with faulty coping and stigma (p< 0.0001) in both genders. Also association of stigma with quality of life showed highly significant findings in both genders (p< 0.0001) on all the domains of DLQI. This study helps in early identification of psychological problems in vitiligo patients and planning their future course of management, hence improving the prognosis and quality of life.