Knowledge, beliefs, and perceptions of Turkish vitiligo patients regarding their condition*

BACKGROUND Vitiligo is an acquired pigmentary skin disorder that affects 0.5% to 2.0% of the population. OBJECTIVE Patients' knowledge, opinions, and attitudes about vitiligo were evaluated. METHODS The team conducted a cross-sectional, descriptive, prospective study between June 2014 and May 2015. The study included 100 patients aged over 12 years who were diagnosed with vitiligo. A questionnaire including items on knowledge, opinions, and beliefs about vitiligo and the Illness Perception Questionnaire (IPQ) were filled out by the patients, and the results were analyzed. RESULTS In total, 100 (58 female, 42 male) patients were included in the study. Of them, 74% knew the name of their disease, 90% thought that vitiligo was not contagious, 48% reported that they obtained information on the disease from a doctor, and 69% believed they had adequate information on vitiligo. Eighty percent reported no negative effects from vitiligo on relationships with friends or family. It was believed that stress, excessive sun exposure, and heredity were causes of vitiligo, according to 84%, 37%, and 22% of the patients, respectively. Thirty-six patients (36%) believed that their illness was a serious disease and 35% deemed that it did not have a major impact on their lives. CONCLUSIONS Our results show that vitiligo patients were generally highly aware of their condition. The disease did not negatively affect patient opinions or attitudes about vitiligo. The authors believe that improving patient-physician communication will impact positively on the course of the disease.


INTRODUCTION
Vitiligo is a common depigmenting skin disorder characterized by acquired, idiopathic, progressive, circumscribed hypomelanosis of the skin and hair. It occurs worldwide, with an incidence of 0.5% to 2.0%. 1 Skin diseases are often visible to others, and many skin disorders may entail significant psychosocial consequences. Vitiligo is a social stigma and is associated with a decreased quality of life, especially when lesions are located over the face; thus, it may affect the quality of social and personal life depending on the patient's perception. 2 Some studies on the anxiety and depression associated with vitiligo were performed in Turkey. 3 In one of them, the rate of psychiatric morbidity was higher in vitiligo patients than in healthy control subjects. 4 However, no reported study has evaluated the beliefs, knowledge, and opinions about vitiligo among affected patients. This study aimed to evaluate affected patients' knowledge, attitudes, perceptions, and opinions about vitiligo.

Participants, questionnaire and data collection
A cross-sectional, descriptive, prospective study was conducted at the dermatology outpatient clinic of the Okmeydani Training and Research Hospital from June 2014 to May 2015. In total, 100 consecutive patients who had a diagnosis of vitiligo confirmed by a dermatologist were included in the study. A questionnaire including items on knowledge, opinions and attitudes about vitiligo was filled out by the patients, and the results were analyzed statistically.
Patients were subdivided into the following three subgroups, according to age: the young adult group <30 years of age (n = 41),the adult group aged between 30 and 49 years (n = 39) and the elderly group >50 years (n = 20).
Of the patients, 63 (63%) were married, while 37 (37%) were unmarried; 85 (85%) patients had a high school education or lower level, while 15 (15%) patients had a college education or higher (Table 1). Table 2 shows the percentage of patients "agreeing" with each cause item. The most common belief regarding the cause of the disease was stress (84%), followed by excessive sun exposure (37%) and heredity (22%). Patients who had a higher level of education believed more commonly than those with lower educational levels (p = 0.014) that vitiligo developed because of altered immunity. Male patients were more likely to think that vitiligo developed because of excessive work than female patients (p = 0.010). Table 3 displays the percentage of patients "agreeing" with different consequence items. Thirty-six (36%) patients believed that their illness was a serious disease, and 35% believedthat their illness did not have a major impact on their lives. No association was found between the beliefs about consequences and educational level or age (p > 0.05). Female patients were more likely to think that vitiligo was a serious disease (p = 0.031). Male vitiligo patients thought that their illness had no major impact on their lives (p = 0.041).

Beliefs about recurrence or chronicity
Among the patients, 44% believed their illness was likely to be a long-term condition. However, there was no association between this belief and the patients'educational level or sex. Sixty-six percent of the patients in the young adult group deemed that their illness was likely to be a long-term condition (p < 0.001). Twenty-four patients thought that their illness would last a short time.
The patients who believed their illness was likely to be a long-term condition were more likely to experience a longer duration of disease (60 months (1-360 months), p = 0.015) ( Table 4). Sixty percent of the patients in the elderly group thought that their illness would be permanent (p = 0.009). Table 5 presents the data on the patients' opinions about cures and control. Forty-seven percent believed their vitiligo would improve with time, while 18% believed very little could be done to improve their illness. However, these patients were more likely to experience a longer duration of disease (84 months (12-360 months), p = 0.006) ( Table 4). Forty-five percent of the patients in the elderly

Emotional effects
Forty-six percent of the patients reported that their illness made them feel anxious. However, there was no significant association between reports of anxiety and patients' sex or level of education. In addition, 28% reported that having the illness did not make them feel anxious. This finding was more prevalent in males than females (p = 0.032). Twenty-nine percent reported that the illness made them feel angry, while 12% indicated that they became depressed when thinking about their illness.  Arabian vitiligo patients, where most patients (84%) believed in fate as a cause of vitiligo; stress, altered immunity, and heredity were reported as the other causes (33%, 26%, and 24% of the patients, respectively). A significant proportion of their patients (28%) believed that "evil eye" was responsible for their illness. 13 Our patients deemed that the most common causes of the disease were stress (84%), excessive sun exposure (37%), heredity (22%) and excessive work (20%). Patients with higher educational levels believed more often than those with lower levels (p = 0.014) that altered immunity could cause vitiligo. The percentages of patients who thought that fate and evil eye could be causes of vitiligo were only 13% and 7%, respectively. These lower ratios may be due to cultural and regional differences. The authors think that despite the lower ratio of college education and higher among our patients, the ratios for Internet use and consulting a doctor were high, while the percentages of patients with beliefs about fate and evil eye as causes of vitiligo were therefore lower.

DISCUSSION
Similarly to the study by AlGhamdi et al., beliefs about the contagiousness of vitiligo were striking; in our study, 90% of the patients thought that it was not contagious. 13 There was no statistically significant difference between patients with lower versus higher educational levels (P > 0.05).
Firoozet al. 12 reported that half of the vitiligo patients (49%) deemed their illness had a strong impact on their lives. Similarly, AlGhamdi et al. 13 found this ratio to be 42%. Unlike these studies, our ratio was lower (27%).
Thirty-five percent of all patients said their illness did not have a major impact on their lives. Male vitiligo patients thought this more frequently than female patients (P = 0.041), who were more likely to think that vitiligo was a serious disease (P = 0.031).
Studies carried out by Noh et al. 10 showed that the quality of life of vitiligo patients was significantly impaired compared with that of healthy subjects. Females exhibited greater private body consciousness than males. 10 This may be explained by women's greater awareness of cosmetic disfigurement. Thus, they may consider that vitiligo is an important disease. Our finding is consistent with previous psychological literature, which demonstrated a higher level of concern with physical appearance and the seriousness of the illness.
Regarding disease duration,the team found that 24 (24%) anxious. This finding was more prevalent in males than females (p = 0.032). Al Robaee noted that women were more embarrassed and self-conscious about their disease than men because it impaired their social life and personal relationships. 16 Similar findings have been observed in several studies, concluding that disturbances in social lives and psychiatric morbidity are more frequent in female patients. 17 Our findings are consistent with these reports.
In the UK, the results of a recent survey from a patient support group showed that most respondents obtained information about their disease from non-medical sources (83.0%), 12.5% from dermatologists, and 7.1% from their general practitioners. 16 In our study, information on vitiligo was obtained most frequently from a doctor (48%) or the Internet (46%). Of our patients, 69% believed that information on vitiligo from these sources was adequate. Furthermore, more than half of our patients knew the name of their illness. Although we found that the proportion was lower for patients with higher educational levels, they had information about the disease and had visited a physician.
When the impact of the self-image of vitiligo was questioned, 80% of patients indicated that vitiligo did not have a serious impact on their relationships with family or friends. Moreover, vitiligo did not have a significant impact on work/school performance (91%).

CONCLUSION
In conclusion, our results suggest that a majority of the patients had knowledge about their illness. They were also aware of the causes. In recent years, sources of information such as the Internet and medical publications have increased, so patients have more knowledge about their disease. It is known that vitiligo is not life-threatening. Thus, although some patients were anxious, they had positive ideas on cures and disease control. As physicians, attending to patients should improve their outlook on the prognosis and cure of the disease. Improving patient-physician communication will impact positively on the course of the disease.q