Separated, n (%)                            4 (12.9)                                        4(13.8)                                                                                                               0

Number of siblings	1, n (%)	4 (12.9)	3(10.3)	4(13.3)	.56
	2, n (%)	12 (38.7)	17(58.6)	18(60)
	3, n (%)	10 (32.3)	7(24.1)	6(20)
	4, n (%)	3 (9.7)	2(6.9)	2(6.1)
	5, n (%)	2 (6.5)	0	0

TABLE 2 Comparison of groups’ psychological test scores and presence of stressful life event

Groups	P-value
Alopecia areata                       Vitiligo                                          Controls	AA-Vi                         AA-C                         Vi-C

Stressful life event, n (%)                        19 (61.3)                                      25 (86.2)                                      9 (30)                                                                               .041                                               .014                                         <.0001

RCADS-Child, mean ± SD Separation Anxiety	55.61 ± 12.94	50.21 ± 9.6	48.83 ± 9.9	.116	.026	.291
Generalized Anxiety	48.61 ± 11.37	45.14 ± 9.09	42.5 ± 7.41	.195	.021	.261
Panic	49.65 ± 12.3	47.31 ± 10.9	44.67 ± 8.17	.454	.177	.470
Social Phobia	46.19 ± 12.48	43.66 ± 8.72	39.93 ± 8.34	.625	.050	.069
Obsessive-Compulsive	48 ± 12.58	48.03 ± 11.56	46.93 ± 8.89	.935	.874	.952
Depression	49.68 ± 12.21	47.38 ± 14.3	41.07 ± 7.55	.314	.006	.162
Total Anxiety	49.03 ± 12.96	45.69 ± 10.5	42.43 ± 7.88	.287	.057	.295
Total	49.13 ± 12.9	45.86 ± 11.63	41.47 ± 7.95	.245	.010	.261

RCADS-Parent, mean ± SD

Separation Anxiety	57.55 ± 15.3	54.38 ± 9.8	51.03 ± 8.43	.700	.167	.181
Generalized Anxiety	54.81 ± 9.64	52.9 ± 11.55	51.6 ± 10.8	.415	.133	.660
Panic	55.06 ± 12.64	54.24 ± 11.82	48.57 ± 9.9	.795	.014	.030
Social Phobia	49.26 ± 12.09	49.45 ± 10.91	45.83 ± 8.47	.900	.291	.199
Obsessive-Compulsive	57.39 ± 11.18	55.86 ± 11.17	54.97 ± 11.18	.573	.422	.558
Depression	58.74 ± 14..95	56.24 ± 14.15	47.37 ± 8.23	.529	.001	.014
Total Anxiety	55.06 ± 10.92	53.9 ± 12.39	50.2 ± 10.65	.569	.041	.316
Total	56.32 ± 11.1	54.72 ± 12.24	49.43 ± 10.22	.428	.012	.074
Parents’ BAI, mean ± SD	11.71 ± 8.78	11.45 ± 10.21	8.97 ± 8.71	.667	.169	.235
Parents’ BDI, mean ± SD	10 ± 6.72	9.83 ± 5.79	7.53 ± 5.78	.906	.110	.093

Abbreviations: AA, Alopecia Areata; Vi, Vitiligo; C, Controls; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; RCADS-Child, Revised Child Anxiety and Depression Scales, Child Version; RCADS-Parent, Revised Child Anxiety and Depression Scales, Parent Version.

 

significant (P < .0001). Furthermore, this parameter was statistically significantly higher in the vitiligo group compared to the AA and control groups (P = .014 and P < .0001, respectively) (Table 2).

1.1                | Evaluation of the scales related to psychological parameters and QoL

The mean CDLQI score was 5.1 ± 5.13 (0-22) in the AA group and

2.76 ± 2.39 (0-8) in the vitiligo group; the mean DeFIS score was 12.19 ± 11 (0-54) in the AA group and 14.45 ± 9.33 (0-45) in the vitiligo group, indicating no significant difference (P = .245, P = .102, respectively).

In the AA group, the scores in the RCADS-C subscales of SAD

(P = .026), GAD (P = .021), SP (P = .049) and MDD (P = .006), and the total (P = .010) scores were significantly higher compared to the control group. According to the results of RCADS-P, the scores in the subscales of PD (P = .015) and MDD (P = .001), and the total anxiety (P = .041) and total (P = .012) scores were significantly higheramong the patients in the AA group compared to the control group (Table 2). While there was no significant difference in the vitiligo group in terms of the RCADS-C scale scores, according to RCADS-P, the PD (P = .030) and MDD (P = .014) subscores of the patients were significantly higher than the controls (Table 2). There was no significant difference between the AA and vitiligo groups in relation to the RCADS-C and RCADS-P scores. Similarly, no significant difference was observed between the AA, vitiligo, and control groups in terms of the parents’ BAI and BDI scores (Table 2).

Concerning the relationship between disease severity and total anxiety and depression scores, in the AA group, the SALT score had a positive correlation with RCADS-C depression (P = .014) and total anxiety (P = .032) and RCADS-P depression (P = .023) and total anxiety (P = .014) scores. However, in this group, no significant correlation was detected between the parents’ BAI (P = .321) and BDI (P = .161) scores. In the vitiligo group, there was no significant correlation between the VASI score and the total anxiety and depression scores, but the VASI score was found to be positively correlated with the RCADS-P SAD score (P = .048). There was no significant relationship between the parents’ BAI (P = .829) and BDI (P = .981) scores in the vitiligo group (Table 3).

In the AA group, the CDLQI score was positively correlated with the scores obtained from SALT (P = .008), RCADS-C depression (P = .012) and total anxiety (P = .041), DeFIS (P = .010), parental BAI (P = .011), and parental BDI (P = .022). In the vitiligo group, the CDLQI score had a positive correlation with the scores of RCADS-C depression (P = .001) and total anxiety (P = .007), and RCADS-P

TABLE 3 Correlation between SALT, VASI, CDLQI, DeFIS, RCADS-C, RCADS-P, BAI, and BDI scores in patients with alopecia areata and vitiligo (Spearman rho) Separation Anxiety .383* .271 .195 .256 .350 .489** Generalized Anxiety .387* .307 .409* −.132 .299 .361 Panic .381* .342 .431* .104 .481** .377* Social Phobia .236 .317 .313 −.114 .281 .162 Obsessive-Compulsive .428* .370* .330 .197 .571** .477** Depression .438* .443* .377* .164 .589** .325 Total Anxiety .386* .370* .378* .067 .491** .455* Total .448* .445* .425* .102 .570** .440* RCADS-Parent Separation Anxiety .292 .310 .242 .371* .230 .574** Generalized Anxiety .455* .365* .495** .061 .318 .368* Panic .157 .127 .372* .142 .310 .396* Social Phobia .398* .169 .428* .096 .167 .203 Obsessive-Compulsive .382* .336 .482** .238 .344 .688** Depression .407* .228 .400* −.003 .383* .394* Total Anxiety .435* .309 .553** .144 .332 .462* Total .454* .331 .522** .053 .389* .424* Parents’ BAI .184 .452* .515** −.042 .169 .262 Parents’ BDI .258 .410* .643** −.005 .255 .185 SALT .466** .602** VASI .048 .184 CDLQI .466** .455* .048 .130 DeFIS .602** .455* .184 .130 Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CDLQI, Children’s Dermatology Life Quality Index; DeFIS, Dermatological Family Impact Scale; RCADS-Child, Revised Child Anxiety and Depression Scales, Child Version; RCADS-Parent, Revised Child Anxiety and Depression Scales, Parent Version; SALT, Severity of Alopecia Tool; VASI, Vitiligo Area Severity

Index.

*P < .05.

**P < .01.

depression (P = .040); however, CDLQI did not have a significant relationship with parental BAI (P = .379), parental BDI (P = .183), VASI (P = .804), and DeFIS (P = .500) (Table 3).

In the AA group, the DeFIS score had a positive correlation with the SALT score (P < .0001), the RCADS-C depression (P = .037) and total anxiety (P = .036) scores, the RCADS-P depression (P = .026) and total anxiety (P = .001) scores, the parental BAI score (P = .03), and the parental BDI score (P < .0001). In the vitiligo group, the DeFIS score was positively correlated with the scores of RCADS-C total anxiety (P = .013), and RCADS-P depression (P = .035) and total anxiety (P = .012); however, no significant correlation was observed between the DeFIS score and the parental BAI (P = .169), parental BDI (P = .337), and VASI (P = .340) scores (Table 3).

2       | DISCUSSION

Psychiatric symptoms are very common in dermatology patients, and an undetected psychiatric disorder can significantly reduce the patient’s QoL since it can delay treatment or recovery. We designed this study to better understand the impact of AA and vitiligo on children and their parents. Therefore, we have attempted to study the dimensions of anxiety disorders, that is, SAD, SP, GAD, OCD, and PD. Furthermore, in the current study, the anxiety and depression scales were directly evaluated in addition to the DeFIS scale, which indirectly measures the psychological status of the parents. Present results suggest differences between AA and vitiligo pediatric patients. The presence of stressful life events before the onset of both AA and vitiligo in the pediatric group and emphasized its greater importance for the latter. In addition, anxiety symptoms were more common in AA patients than those with vitiligo.

In a study by Bilgiç et al, AA was shown to have a positive correlation with higher state and trait anxiety and depression scores in children.¹¹ In another study examining children with AA aged nine to 11 years, the patients were found to have significantly higher levels of psychopathology than the controls.⁷ In our study, we observed a significant difference between the pediatric patients with AA and the control group in terms of the RCADS-C subscales scores in SAD, GAD, SP, and depression, as well as the total scale score, which contributes to and supports previous research. In addition, PD and total anxiety scores were significantly higher in children with AA in the RCADS-P scale. While no significant difference was found in any of the subscales of RCADS-C in the evaluation of vitiligo patients, according to RCADS-P, the PD and depression scores of the patients in the vitiligo group were significantly higher compared to the control parents. The results of studies investigating depression and anxiety scores in patients with vitiligo are variable. In a study evaluating children and adolescents with vitiligo, depression scores were found to be higher than the control groups only in the children (8-12 years) group.¹⁶ In another study, children’s level of anxiety and depression symptoms did not significantly differ from the control group.¹⁵ However, Ucuz et al reported that the state and trait anxiety scores of children with vitiligo were different from those of the controls.¹⁷ The awareness that pediatric patients with alopecia areata and vitiligo are closely related to psychological factors is essential and psychiatric evaluation is important in the management of this population. Such patients should be directed to the child and adolescent psychiatrist, and treatment of the psychological condition can contribute to the medical treatment of dermatological disease.

In a recent study involving the parents of children with vitiligo, the depressive symptoms of the parents were higher than those of the control group, but the authors did not observe a similar link for anxiety symptoms.¹⁵ In another study evaluating depression and anxiety symptoms among the carers of patients with different types of dermatoses (vitiligo, atopic dermatitis, and psoriasis), higher levels of anxiety and depression were observed compared to the general population, but no difference was observed between disease groups.¹⁸ To the best of our knowledge, there is no study in the literature examining the psychiatric state of the parents of children with AA. In the current study, there was no difference between the anxiety and depression levels of the parents of the patients with AA and vitiligo and those in the control group. Similarly, no significant difference was observed between the vitiligo and AA groups in terms of the DeFIS scores, through which we evaluated the QoL of the parents.

A small number of studies related to the pediatric cases have shown the presence of stressful life events before the onset of AA as a potential trigger of the disease at a rate of 9.5% to 81%.^31-34 In studies conducted with children with vitiligo, a history of stressful life events before the onset of the disease was reported at the rates of 48.8%¹⁵ and 77%.¹⁷ In our study, 61% of children with AA and 86.2% of children with vitiligo had a history of stressful life events in the year prior to the onset of the disease.

There is only one study in the literature that evaluated the severity of AA together with psychological state in children, and the results did not show a significant relationship.¹¹ In contrast, in our study, there was an increase in the depression and anxiety scores of the patients with AA with the increasing severity of the disease, although a positive correlation of disease severity and anxiety and depression levels was not detected for the parents. In the evaluation of patients with vitiligo, Önen et al did not report a relationship between the severity of the disease and anxiety and depression scores in parents or children.¹⁵ In other studies in which children and adolescents were examined, no significant relationship was observed between vitiligo severity and anxiety^16,17 and depression¹⁶ scores. In our study, only the level of SAD was increased with the increasing severity of vitiligo, but there was no positive correlation between disease severity and parental anxiety and depression levels.

In a previous study examining the effect of AA on QoL, it was shown that the QoL of the parents decreased as the severity of the disease increases in the child.³⁵ In a study by Bilgiç et al, AA severity was shown to have a negative effect on the QoL of children.¹¹ Similarly, in our study, impairment in the QoL of both patients and their parents increased with the increasing disease severity in the AA group. However, there are conflicting results in studies investigating the effect of the severity of vitiligo on QoL. For example, in one study, the severity of vitiligo in adolescents was observed to affect QoL negatively¹⁶ while two other studies including children and adolescents reported no relationship between QoL and the body surface area³⁶ and vitiligo severity.¹⁵ According to another study in which the effect of childhood vitiligo on parents’ QoL was examined, as the area of involvement of vitiligo increased, the parental QoL decreased.³⁷ In the current study, we found no correlation between disease severity and the QoL of patients or parents.

The main limitation of this study is the small sample size and cross-sectional design, and the lack of a structured interview and psychiatric evaluation can be considered as another limitation.

The results of the study indicated that the presence of stressful life events was more common in pediatric patients with vitiligo than those with AA. On the other hand, anxiety symptoms were more prevalent in patients with AA than those with vitiligo. While the severity of AA was correlated with the QoL of the affected children and their parents, there was no such correlation in vitiligo. The QoL of the patients affected the anxiety and depression levels of their parents in the AA group, but not in the vitiligo group. It is important to identify pediatric patients with alopecia areata and vitiligo who need extra psychological support and refer them to the child and adolescent psychiatrist. In conclusion, providing a psychological evaluation and support for both patients and their parents will not only help them better cope with chronic dermatoses that cause cosmetic disorders such as vitiligo and AA but also contribute to the improvement of their QoL.

ACKNOWLEDGMENTS

We thank Esma İnan Yüksel, MD, for her valuable contribution.

DATA AVAILABILITY STATEMENT

Data openly available in a public repository that issues datasets with DOIs.

ORCID

Sevil Savaş Erdoğan               https://orcid.org/0000-0002-4392-4671

Tuğba Falay Gür              https://orcid.org/0000-0002-3233-9610

Bilal Doğan              https://orcid.org/0000-0002-0855-5209

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