Association of Quality of Life and Location of Lesions in Patients With Vitiligo

Vitiligo is a chronic depigmenting disorder of multifactorial etiology affecting 0.5% to 1% of the population. The white macules characteristic of vitiligo have been shown to have a profound impact on quality of life (QOL) in affected individuals.^1,2 The goal of this cross-sectional study was to determine the location(s) of vitiligo lesions that has the greatest effect on QOL.

All patients enrolled in the Dallas Vitiligo Registry (DVR) at the University of Texas Southwestern (UTSW) Medical Center from April 2013 to August 2015 were reviewed. The DVR was approved by the UTSW Medical Center institutional review board and all patients gave informed consent. They were not compensated for their participation. A total of 184 patients were examined. It was determined that a total sample size of 184 would provide 80% power with a type 1 error of .05. The location of each affected area of skin was documented and the total body surface area affected as well as the vitiligo area severity index was calculated. Each participant also completed the VitiQoL, a vitiligo-specific QOL instrument.³ The VitiQoL contains 16 questions divided into 3 domains: participation limitation, stigma, and behavior. Questions in the participation limitation domain include those asking about the patient’s ability to perform daily activities and social and leisure activities. Stigma includes questions about embarrassment and worrying about what others are thinking about the patient. Behavior includes questions on grooming practices and how vitiligo affects the choice of clothing worn by the patient.

The mean (SD) age of participants was 40.3 (17.2) years and the male to female ratio was 1.4:1. Race and ethnicity were self-reported. Results are as follows: 60 (33%) participants were white, non-Hispanic, 50 (27%) Hispanic, 32 (17%) black, and 42 (23%) Asian. VitiQol results are shown in the Table. A Wilcoxon rank sum test comparing QOL in patients with exposed (hands, neck, face) vs nonexposed lesions revealed that patients with hand involvement had worse quality of life in all domains than patients without hand involvement (stigma: median [range], 19 [0-30] vs 16 [0-30]; P = .04; participation: 10 [0-42] vs 5.5 [0-42]; P = .03; behavior: 9 [0-18] vs 7 [0-17]; P = .02; total: 39 [0-94] vs 31 [0-93]; P = .01). The only other significant result was a single QOL domain (behavior) for those with neck involvement vs those without neck involvement (median [range], 9 [0-18] vs 7 [0-18]; P = .04).

A previous study validating the VitiQOL found that QOL was worse in subjects with vitiligo on exposed areas compared with those with lesions in nonexposed areas.³ Our study suggests that the hands in particular are the most bothersome location (Figure). A possible explanation for this finding is the difficulty in camouflaging hand lesions compared with face and neck lesions. Fear of greeting others may be a factor as well, because personal interactions often start with a hand shake, which is important in making a good first impression. Indeed, 1 study⁴ showed that a handshake preceding social interaction enhanced the positive impact of approach and diminished the negative impact of avoidance behavior on the evaluation of social interaction. Individuals with vitiligo of the hands may find that others avoid shaking their hand because of the contrast between normal and depigmented skin, contributing to a lower QOL.

Although this study was performed in only 1 center, our results suggest that hand involvement with vitiligo is associated with a significant negative effect on quality of life. Unfortunately, hands are one of the most difficult areas to treat. Similar studies should be performed in other parts of the world. If confirmed, research should focus on hand involvement in patients with vitiligo as one of the most important sites for which effective treatments should be developed.

Corresponding Author: Amit G. Pandya, MD, Department of Dermatology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9190 (amit.pandya@utsouthwestern.edu).

Accepted for Publication: October 9, 2016.

Published Online: January 11, 2017. doi:10.1001/jamadermatol.2016.4670

Author Contributions: Ms Florez-Pollack and Dr 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.

Concept and design: Florez-Pollack, Pandya.

Acquisition, analysis, or interpretation of data: Florez-Pollack, Jia, Zapata, Rodgers, Hernandez, Hynan.

Drafting of the manuscript: Florez-Pollack.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Florez-Pollack, Jia, Hynan.

Administrative, technical, or material support: Zapata, Hernandez, Pandya.

Conflict of Interest Disclosures: None reported.

Funding/Support: The database program used in this study, REDCap, is funded at the University of Texas Southwestern Medical Center. Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award Number UL1TR001105.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.