Living with vitiligo: results from a national survey indicate differences between skin phototypes.

DEAR EDITOR, Vitiligo, an acquired, idiopathic skin disease characterized by a generally progressive loss of inherited skin colour, has an estimated worldwide prevalence of 0 5–1%. Although vitiligo is more noticeable in individuals with dark skin, the prevalence is similar to that in the overall population. Despite not being life threatening, vitiligo is a serious skin disorder and the overall disease burden in individuals with vitiligo is often underestimated. The current study determined the burden, in the broadest sense (including impact on quality of life, self-perceived stress and self-image) of vitiligo on daily life and, in particular, assessed differences in the perception of vitiligo and its management in fair vs. dark skin phototypes. We conducted a cross-sectional monocentric study in 300 patients with vitiligo, within the framework of developing a new specific vitiligo burden questionnaire. Consulting dermatologists recorded patient demographic/clinical characteristics, and classified patients as having ‘fair skin’ (phototype I–III) or ‘dark skin’ (phototype IV–VI). This study was approved by the Commission Nationale Informatique et Libert es and by the local ethics committee of the University Hospital of Bordeaux. The burden of vitiligo was evaluated via a conceptual vitiligo-burden-specific questionnaire (developed by the authors) and several validated assessment tools: Short Form-12, Dermatology Life Quality Index (DLQI), PCV-Metra (Pr evention Cardio-Vasculaire en M edecine du Travail) and Body Image States Scale. The conceptual vitiligo questionnaire, created after conducting face-to-face interviews between patients with vitiligo (n = 25), experts in questionnaire design and psychology, and physicians involved in vitiligo, consisted of 35 questions, each with seven possible responses: ‘all the time’, ‘very often’, ‘often’ (collectively ‘yes’), ‘sometimes’, ‘rarely’, ‘never’ and ‘not applicable’ (collectively ‘no’). Three hundred individuals with vitiligo (72% female; mean age 48 9 16 2 years, range 15–87) were classified as having fair (n = 234) or dark (n = 66) skin. The majority of patients classified with dark skin were of Middle Eastern, Caribbean or Indian ethnicity. Vitiligo most commonly affected the hands (85% of patients), wrists (69%), armpits (62%), feet (62%), elbows (61%) and mouth (59%). The face (76%) and hands (54%) were the most troublesome body areas affected by vitiligo. Overall, respectively 29%, 42%, 22%, 6% and 2% of patients reported < 5%, 5–10%, 10–25%, 25–50% and > 50% of their body area affected by vitiligo. There were no between-group differences for these parameters. More patients with dark skin than fair skin reported being satisfied with their support/management (34% vs. 20%, P = 0 046). However, 47% of fair-skinned patients replied ‘undecided/don’t know’ in response to ‘are you satisfied with your treatment?’; 73% of all patients were ‘undecided/not treated’, with < 10% of respondents answering ‘yes’. The majority (91%) of patients reported following their physician’s prescription ‘most often/occasionally’, with < 20% of patients self-medicating. Patients in both groups demonstrated impaired quality of life, self-perceived stress levels and self-image (Table 1). Patients with dark skin reported higher DLQI scores than those with fair skin (Table 1; P = 0 049). The responses obtained with the conceptual vitiligo questionnaire are shown by skin phototype in Table S1 (see Supporting Information). Twenty-two of 42 factors assessed by univariate analysis were retained at the predetermined P < 0 15 level (Table S2; see Supporting Information). Multivariate analysis demonstrated three factors that were significantly associated with skin phototype (Table 2). For patients with dark skin, significant factors were ‘my vitiligo has repercussions on my physical appearance’ [odds ratio (OR) 3 41, 95% confidence interval (CI) 1 04–11 13; P = 0 042] and ‘managing my vitiligo on a daily basis is a burden’ (OR 3 09, 95% CI 1 07–8 95; P = 0 037). In contrast, ‘my vitiligo puts me at greater risk for skin cancer’ (OR 0 37, 95% CI 0 15–0 95; P = 0 039) was significantly associated with a higher burden in fairskinned individuals. The latter perception is interesting in light of studies indicating that patients with vitiligo have a decreased risk of melanoma and nonmelanoma skin cancer; improved patient education by physicians may be warranted in this area. This study demonstrates that, regardless of skin phototype, patients with vitiligo experience significant disease-related burden and self-perceived stress. Furthermore, although patients with dark skin phototypes perceived some significant differences in the burden of vitiligo on daily life compared with their fair-skinned counterparts, and vice versa, overall self-perceived stress associated with vitiligo was generally similar in patients regardless of skin type. The current study reinforces outcomes from previous studies, while providing new insights into differences in the