Evolution of the questionnaire used in the study.
Sensitivity and specificity of self-reports of skin-pigmentation conditions compared with findings of physical examination. PIH indicates postinflammatory hyperpigmentation. Sensitivity and specificity are reported as mean (SD) percentages.
Wuu A, Haley RW, Pandya AG. Validation of a Questionnaire for Self-reporting of Hyperpigmentation Disorders in Chinese-Speaking Women of Chinese Descent. Arch Dermatol. 2009;145(2):202-203. doi:10.1001/archdermatol.2008.561
Disorders of hyperpigmentation are more common in darker-skinned individuals1 such as the Chinese.2 A few studies have been performed in dermatology clinics attempting to determine the prevalence of lentigines, postinflammatory hyperpigmentation (PIH), and melasma.3,4 However, the prevalence of these conditions in most populations is unknown. The goal of the present study was to develop and validate a questionnaire for self-reporting of hyperpigmentation disorders in Chinese women.
A series of questions was first developed in English and then translated into Chinese. Some questions were reworded based on the rules of Chinese syntax. The resulting translations were reviewed by a panel of Chinese teachers for accuracy and comprehensibility. After approval was obtained from the institutional review board, an initial test with a focus group was carried out with a group of 6 Chinese women aged 18 to 55 years. They were sampled randomly from the waiting room of a Chinese-speaking primary care physician. Only women were chosen for this study because disorders of hyperpigmentation in Asians, such as melasma, are more common in women.2 Furthermore, in our experience, women are more concerned about facial disorders of hyperpigmentation than men.
After obtaining feedback from the focus group, we evaluated the questions and altered them to improve comprehension. These were then back-translated to English and then reviewed by one of us (A.G.P.), who confirmed that the meaning of the original English question was not lost (Figure 1). The questionnaire was then administered to women at the 2006 Chinese Health Fair in Houston, Texas. After they completed the questionnaire, the women were examined individually for the presence or absence of melasma, lentigines, and PIH by an examiner experienced in the diagnosis of these disorders. The examiner was blinded to the results of the questionnaire at the time of the examination. All patients in the focus group as well as those at the health fair gave written informed consent prior to participation.
The number of people who entered the health fair was 172, with 73 fitting the inclusion criteria (Chinese women aged 18-55 years). The total number of subjects who answered the questionnaire and were examined was 69; therefore, the participation rate was 95%. The average age of the participants was 42 years. A total of 67 of the 69 were born outside the United States, with an average age of immigration of 32 years. The 2 American-born Chinese women had their questionnaires read to them owing to their lack of Chinese reading skills, and both expressed full understanding. Most of the women were from China (70%) and Taiwan (17%), while the remaining were from Vietnam, Singapore, Cambodia, and Malaysia. The sample contained 44 and 31 cases of lentigines and PIH, respectively, but only 11 cases of melasma (Figure 2). The question regarding self-report of lentigines had a mean (SD) sensitivity of 93.2% (3.8%) and specificity of 96.0% (3.9%). For PIH, sensitivity was 100.0%, and specificity was 92.1% (4.4%), whereas the question on melasma had a sensitivity of 81.8% (11.6%) and a specificity of 93.1% (3.3%).
A Spanish language instrument to determine the prevalence of melasma has been developed and successfully administered to a large population of Hispanic women.3 However, the prevalence of melasma, lentigines, and PIH is largely unknown in other populations. We attempted to validate a tool that can be used to determine the prevalence of hyperpigmentation disorders in Chinese women. We refined the language and syntax by consulting with Chinese teachers, and then we administered the questionnaire to a focus group to maximize comprehensibility. The results of the study in 69 female Chinese subjects show that this questionnaire is valid for self-reporting of lentigines and PIH.
Limitations include lack of a broad sample (most of the patients were middle-aged women) and the use of only 1 examiner. Reliability testing (test-retest) was not performed in this study by the subjects or the examiner. The focus of the study was to determine concordance between the subject and the examiner. Because of the low number of subjects with melasma, more Chinese women with melasma must be evaluated to determine the validity of this questionnaire for melasma. In addition, the melasma question specifically related melasma to pregnancy. This question may need to be refined, since many women develop melasma without any relation to pregnancy. The lentigines and PIH questions may be used in future studies to determine prevalence of these disorders in Chinese women. Determining the prevalence of pigmentary disorders and their impact on quality of life will assist in understanding the full impact of these disorders in various populations worldwide.
Correspondence: Dr Pandya, Department of Dermatology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9190 (firstname.lastname@example.org).
Author Contributions: Drs Wuu and Pandya had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Wuu, Haley, and Pandya. Acquisition of data: Wuu. Analysis and interpretation of data: Wuu, Haley, and Pandya. Drafting of the manuscript: Wuu and Pandya. Critical revision of the manuscript for important intellectual content: Haley and Pandya. Statistical analysis: Haley. Administrative, technical, or material support: Pandya. Study supervision: Pandya.
Financial Disclosure: None reported.
Funding/Support: This study was supported by the Department of Dermatology, University of Texas Southwestern Medical Center.
Previous Presentation: This study was presented in poster form at the annual meeting of the Society for Investigative Dermatology; May 9-12, 2007; Los Angeles, California.