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Print version ISSN 0365-0596
An. Bras. Dermatol. vol.85 no.1 Rio de Janeiro Jan./Feb. 2010
Maria Laura TabordaI; Magda Blessmann WeberII; Kelly Abreu Machado TeixeiraIII; Alice Paixão LisboaIV; Elisângela de Quevedo WelterV
ICurrently enrolled in the Masters Degree program in Medical Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA). Specialist Certificate in Dermatology awarded by the Brazilian Society of Dermatology, Porto Alegre, RS, Brazil
IIAdjunct Professor of Dermatology, Federal University of Health Sciences of Porto Alegre (UFCSPA). Doctorate in Dermatology awarded by the Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
IIICurrently enrolled in the Masters Degree program in Pathology, Federal University of Health Sciences of Porto Alegre (UFCSPA). Specialist Certificate in Dermatology awarded by the Brazilian Society of Dermatology, Porto Alegre, RS, Brazil
IVPhysician, Porto Alegre, RS, Brazil
VPhysician. Specialist Certificate in Dermatology awarded by the Brazilian Society of Dermatology, Porto Alegre, RS, Brazil
BACKGROUND: Some dermatoses affect the personal, professional and social lives of patients as a result of their unsightliness. It is important to pay appropriate attention in the overall evaluation of these individuals in order to implement a more effective therapeutic approach.
OBJECTIVES: To evaluate the quality of life and the incidence of psychological distress in patients receiving care at a dermatology clinic.
METHODS: A cross-sectional study. Following consultation, the Dermatology Life Quality Index (DLQI) and the Self Report Questionnaire (SRQ-20) were applied.
RESULTS: One thousand patients were interviewed, 77.2% of whom were women. Most patients were in the 4160 year age-group. Dermatoses had no effect at all on the quality of life of 21.5% of patients, a small effect in 34.2% of cases, a moderate effect in 21.6%, a very large effect in 19.3% and an extremely large effect in 3.4% of patients. No statistically significant correlation was found between psychological distress and dermatoses. Comparison of the two questionnaires showed a statistically significant association between the presence of psychological distress and poorer quality of life (p<0.001). Patients with psychological distress reported that their skin condition had a very large or extremely large effect on their quality of life.
CONCLUSION: This study highlights the fact that many skin diseases affect the quality of life and psychological state of the sufferer, affecting his/her health in general, the progression of the skin condition and the patient's response to therapy.
Keywords: Dermatology; Psychological stress; Quality of life
Various dermatoses affect the emotional state of patients, their social relationships and their daily routine activities as a result of the stigmas provoked by the unsightliness of the lesions.1 Statistics indicate that at least one-third of patients with skin diseases suffer emotional repercussions as a consequence of their dermatoses.2 Therefore, it is important to assess the distress of patients with respect to these skin conditions and also to evaluate any alterations in their quality of life (QOL). Various factors modify the degree to which diseases affect patients' QOL: the individual characteristics of the patient, the natural history of the disease, the region of the body affected and the duration of the disease prior to diagnosis.3
Studies have shown that dermatoses with low morbidity may cause an impact similar to that of diseases such as asthma and epilepsy,4 confirming that skin diseases are detrimental to the sufferer's self-image and may lead to depression and anxiety just as much as severe systemic diseases. Although they are not life-threatening or physically debilitating, they may severely affect the psychological and social functioning of patients.5
Since dermatoses are perceptible, they often result in repercussions in the personal, professional and social lives of patients. Attention should thus be paid to this aspect in order to carry out a comprehensive evaluation of these individuals and enable a more complete and effective therapeutic approach to be implemented. Therefore, the objective of the present study was to evaluate the quality of life and the frequency of psychological distress in patients in a referral dermatology center in southern Brazil.
MATERIAL AND METHODS
The sample enrolled to this cross-sectional study was composed of all eligible patients attending the clinic between January and July, 2007. Exclusion factors were: age < 18 years and having any disease that could affect cognition. Following a routine dermatological consultation, the Dermatology Life Quality Index (DLQI) was applied. This instrument has been validated for use in Brazil and consists of 10 items divided into six domains: symptoms and feelings, daily activities, leisure, work and school, personal relationships and treatment. Answers are awarded scores ranging from 0 to 3 and the final overall result is the simple sum of these scores, higher indexes indicating poorer disease-related quality of life.
The Self-Report Questionnaire (SRQ-20), a screening instrument for mental disease consisting of 20 questions that has been used in primary healthcare sites, was applied at the same consultation. The score generated by the SRQ-20, a continuous variable, ranged from 0 to 20 and was dichotomized using cut-off points of 7/8 for men and 8/9 for women. Scores above the cut-off points were indicative of psychological distress. This instrument was developed by the World Health Organization and has been validated for use in Brazil. The following variables were analyzed: the type of dermatosis, the age and gender of the patient, time of the disease course and the time since initial diagnosis. Analysis of the variables was performed using Student's t-test and Pearson's' chi-square test. Statistically significant association was defined as p < 0.05. The study protocol was approved by the Internal Review Board of the Federal University of Health Sciences of Porto Alegre (UFCSPA). The patients' data were stored in an anonymous database and analyzed using the SPSS statistical software program, version 12.
One thousand patients were evaluated during the study period. The sample was predominantly composed of women (77.2%) and the predominant age-group was 41-60 years, with a mean age of 47.3 ± 16.5 years. The mean duration of the disease was 6.2 ± 9.7 years. The most prevalent types of dermatosis were superficial mycoses (13.5%), benign skin tumors (11.9%), melasma and acquired melanosis (9.3%), premalignant dermatoses (8.0%), melanocytic nevi (5.9%), acne (5.2%) and malignant skin tumors (5.0%).
The median overall DLQI score was 5.0 (2.0 - 10. 0), which is indicative of a small effect of the skin condition on the patient's quality of life. The mean overall score was 6.5 ± 6.0, which also indicates a small effect. In 21.5% of the patients (n=215), the dermatological disease had no effect at all on their QOL. In the remaining patients, the dermatosis was found to exert some effect: in 34.2% of cases, this effect was small; in 21.6% moderate, in 19.3% it was very large and in 3.4% of cases the effect of the condition on the patient's QOL was extremely large, as shown by a DLQI score >20.
When the six domains of the DLQI were analyzed separately, the patients with the highest scores were found only in the symptoms and feelings domain. The other domains were associated with scores indicative of no effect at all (Table 1).
No statistically significant association was found between the patient's gender and overall DLQI score; nevertheless, there was a trend for women to be associated with scores indicative of a small effect of the disease on QOL.
When the scores obtained in the specific DLQI domains were compared between men and women, statistically significant differences were found in the treatment and work/school domains. Treatment of the skin condition had no effect on the QOL of women (p=0.036), while men were most affected in the work/school domain (p=0.025).
When the DLQI was correlated with the dermatological disease, it was found that alopecia, viral skin infections and malignant skin tumors exerted no effect at all on the QOL of patients, while melanocytic nevi and benign skin tumors had a small effect on QOL. Bacterial infections were associated with a moderate effect; contact eczema, psoriasis, pruritus and urticaria with a very large effect; and collagenoses with an extremely large effect on the QOL of the study participants (p < 0.001).
With respect to each one of the domains in the DLQI and the alterations caused by the different forms of dermatosis, in the symptoms and feelings domain there was a statistically significant association between altered QOL and contact eczema, superficial mycoses and psoriasis (p < 0.001). In the daily activities domain, this association occurred with collagen diseases, atopic eczema, contact eczema, pruritus, urticaria and psoriasis (p < 0.001). Psoriasis, contact eczema and collagen diseases also affected the leisure domain (p=0.002). Bacterial infections, collagen diseases, contact eczema and psoriasis affected the work and school domain (p < 0.001), while pruritus, urticaria, contact eczema and bacterial infections were found to have an effect on the personal relationships domain (p < 0.001).
In the general analysis of the SRQ-20 instrument, no statistically significant association was found with gender (p>0.05); however, the minimum significance achieved could be considered borderline.
When the results of the SRQ-20 were analyzed according to age-group, a statistically significant association was found in the women (p < 0.05). No psychological distress was found in the women in the 18-25 year or 26-40 year age-groups; however, in women in the 41-60 year age-group and those over 60 years of age an association was found with psychological distress (Table 2). No statistically significant association was found in the men. However, following adjusted residual analysis, a brief trend of association was found between the over-61 year age-group and SRQ values above the cut-off point.
When psychological distress, as measured by the SRQ, was related to dermatoses in general, no statistically significant association (p>0.05) was found for the sample as a whole, irrespective of gender. Nevertheless, trends of association were found with some of the diseases, superficial mycoses and vitiligo being associated with an absence of distress, while acne, contact eczema and psoriasis were associated with the presence of psychological distress.
When the patients were analyzed according to gender, a trend of association was found between psychological distress and psoriasis and eczemas in general in women, whereas in the case of women with acne no distress was found. With respect to the men, a trend of association was found between psychological distress and atopic eczema, pruritus and urticaria; however, in the case of men with acne, malignant skin tumors, vitiligo or melasma no distress was detected.
Comparing the findings from the two questionnaires revealed a statistically significant association between the presence of psychological distress and poorer quality of life (p < 0.001) (Table 3). The patients with psychological distress reported a very large or an extremely large effect of their skin condition on their QOL, whereas the patients with no psychological distress were found to be associated with scores indicative of no effect at all or a small effect of their dermatosis on QOL. When the two variables were analyzed according to gender, it was found that both the men and the women who had psychological distress also reported poorer QOL. In the men, an association was found between psychological distress and scores indicative of a moderate, very large or extremely large effect on QOL, while in the women this association was related to scores indicative of a very large or extremely large effect on QOL.
In the analysis of the DLQI, it was found that 78. 5% of the patients reported some effect of the disease on their quality of life and that in 22.7% of these cases this effect was either very large or extremely large. Contact dermatitis was the skin condition that had the worst effect on quality of life in the following domains: symptoms and feelings, daily activities, leisure, work and school and personal relationships. In addition, a trend of association was found between contact dermatitis and psychological distress. This finding corroborates that reported by Agner et al., who showed that QOL is significantly affected in individuals with contact eczema on their hands, irrespective of gender.6 The recurrent and debilitating nature of this type of dermatosis may have contributed towards these findings. Moreover, the treatment of contact dermatitis often requires changes in life habits and time away from work, negatively affecting the household budget and the patient's QOL.
Psoriasis was also found to negatively affect the sufferers' quality of life, probably because it is a chronic dermatosis that is often stigmatizing; however, no data were found in the literature on this subject.
Analysis of the association between the SRQ-20 questionnaire and the dermatological diseases included in this study showed no statistically significant correlation; however, a trend of association was found between acne, contact eczema and psoriasis and the presence of psychological distress. Acne and psoriasis are skin conditions that generally occur on visible areas of the body, tending to generate negative feelings since they are unsightly and lead to changes in the patient's daily habits such as going out with friends and attending social events. Therefore, the patient's self-esteem may be affected and his/her daily activities significantly hampered. A study published recently by Abdel-Hafez et al. also reported that acne vulgaris has a significant impact on QOL and on the psychological state of the patient despite not constituting a life-threatening condition.5 It may, nevertheless, be prudent to take the degree of acne into consideration in order to establish the actual effect of this condition on the patient.4 Kaymac et al. reported that satisfactory topic or systemic treatment reduced symptoms of depression and anxiety in patients and improved their QOL.7
Since superficial mycoses are easily treated diseases, it would be reasonable to believe that they have little effect on the life of the sufferer. However, vitiligo may be devastating to the patient depending on the extent of the affected areas, since, although not life-threatening, it is an extremely unsightly disease. It is possible that in the majority of the patients in the study, the disease may have been confined to small areas of the body covered by the patient's clothes, such as the genital area for example, thereby causing no social or psychological repercussions.
When the SRQ-20 was analyzed according to gender, no statistically significant differences were found between women and men. However, following adjusted residual analysis, a trend of association was found between being female and the presence of psychological distress. This finding may have occurred due to the fact that psychiatric disorders such as depression are more common in women than in men.8 The fact that older age-groups were associated with greater psychological distress in women is curious. It is reasonable to speculate that this may have resulted from the effect of other factors such as the menopause or conditions such as diabetes, hypercholesterolemia, hypertension or others that could have increased the patient's perception of their discomfort and their impression that they were really ill. The finding that the patients with the poorest QOL were also those in whom psychological distress was greatest, irrespective of gender, was very interesting. Both questionnaires were found to be equally capable of detecting the individuals in whom the effect of the dermatoses on their lives was greatest.
The results of this study highlight the importance of performing a comprehensive evaluation of the patient so as to obtain a better understanding of the ways in which the skin condition may be interfering in the quality of life and mental health of individuals. The psychological effect caused by the dermatosis should be carefully evaluated and treated individually, since it will doubtless influence the course of the dermatosis and the therapeutic response of the patient.
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7. Kaymak Y, Taner E, Taner Y. Comparison of depression, anxiety and life quality in acne vulgaris patients who were treated with either isotretinoin or topical agents. Int J Dematol. 2009:48:41-6. [ Links ]
8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000. [ Links ]
Mailing Address: This article was submitted to the SGP (Sistema de Gestão de Publicações) of the Anais Brasileiros de Dermatologia on August 20, 2009 and approved on December 17, 2009 12:35:15.
Maria Laura Taborda
Vila Assunção. Bororó - 55
91900 540 Porto Alegre, RS
Tel: 51 3395-5716 Celular: 51 9944 8620
Conflict of interest: None
Financial funding:: Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA)
This article was submitted to the SGP (Sistema de Gestão de Publicações) of the Anais Brasileiros de Dermatologia on August 20, 2009 and approved on December 17, 2009 12:35:15.