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In Vitiligo, Vitiligo research, vitiligo treatment

Anxiety and depression in pediatric patients with vitiligo and alopecia areata and their parents: A cross-sectional controlled study Part 2

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 anxiety16,17 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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VIPOC
In Vitiligo, Vitiligo research, vitiligo treatment

Factors affecting quality of life in patients with vitiligo Part 2

Patients and methods

Participants and settings

A nationwide questionnaire-based study was conducted in 21 hospitals and clinics in Korea from July 2015 to June 2016. All patients aged ≥ 20 years diagnosed with vitiligo by dermatologists, and who provided written informed consent prior to the survey were enrolled. We restricted the participants to adult patients, because different questionnaires should be applied to children and adults. We explored demographic characteristics and vitiligo phenotypes and determined Skindex-29 scores. All patients first completed the questionnaires in paper-and-pencil format, and dermatologists then confirmed the clinical profiles after interviewing and examining the patients. The study protocol was designed in accordance with the Declaration of Helsinki and was approved by the institutional review board of each hospital.

Demographic characteristics

Demographic characteristics recorded included age, sex, marital status (single or married) and educational background (elementary school graduate, middle school graduate, high school graduate or college graduate).

Vitiligo phenotypes

The vitiligo phenotypes included subtype (segmental or nonsegmental), disease duration (< 1, 1–4, 5–9 or ≥ 10 years), affected body surface area (BSA; < 05, 05–09, 1–4, 5–9, 10–19 or ≥ 20%), involvement of visible body parts (yes or no) and the particular body parts involved (face and neck, scalp, upper extremities, lower extremities, trunk and genital area).

The Skindex-29 questionnaire

QoL was assessed using the Korean version of Skindex-29. This instrument is employed extensively to measure the effects of skin disease on a patient’s life;8,9 the Korean version was cross-culturally adapted by Ahn et al.10 The semantic equivalence of all back-translated items has been confirmed,10 and the Korean version has been validated by several previous studies.11–13 The questionnaire contains 29 items exploring the influence of skin disease on daily life using a five-point scale: 0 (never), 1 (rarely), 2 (sometimes), 3 (often) and 4 (all the time). The responses were transformed into linear scores varying from 0 (no effect) to 100 (effect always experienced). Each item belongs to one of three domains (symptoms, functioning and emotions); the scores of the three domains were calculated as the mean score of the items included in each domain.

The major items affecting patients with vitiligo

The proportions of patients affected by each item (sometimes, often and all the time) were calculated. The items of most concern were identified based on the answers.

Quality-of-life impairment

The outcomes of the study were mild or severe impairment of QoL, as determined by each domain (symptoms, functioning and emotions) of Skindex-29. Mild and severe QoL impairments were defined using the cut-off scores suggested by Prinsen et al.:14,15 ≥ 39 (mild) and ≥ 52 (severe) for symptoms, ≥ 21 (mild) and ≥ 37 (severe) for functioning, and ≥ 24 (mild) and ≥ 39 (severe) for emotions.

Statistical analyses

Absolute and percentage frequencies were determined for categorical variables, and position (mean and median) and scattering (SD, range) were described for continuous variables. Univariate and multivariate logistic regression analyses were sequentially performed to identify the factors independently associated with QoL impairment in each domain of Skindex29. All analyses were performed using R 3.3.1 (R Foundation for Statistical Computing, Vienna, Austria).

Results

In total, 1123 patients with vitiligo were recruited from 21 hospitals and clinics. Of the participants, 609 (542%) were male and 514 female (458%), with a mean age of 498  152 years (range 20–84). The median duration of disease was 30 years (range 0–60). The detailed clinical characteristics of the enrolled patients are summarized in Table 1.

The results of Skindex-29

The Skindex-29 items of most concern to patients with vitiligo were as follows: no. 13: I worry that my skin condition may get worse (746% of patients); no. 3: I worry that my skin condition may be serious (629%); no. 22: My skin condition is a problem for the people I love (556%); and no. 6: My skin condition makes me feel depressed (535%) (Table 2).

Impaired quality of life and associated factors in terms of the symptoms domain

Of the patients with vitiligo, 146% (164 of 1123) had mild and 52% (58 of 1123) had severe QoL impairment in terms of the symptoms domain (Fig. 1). On multivariate logistic

Table 1 The clinical characteristics of the 1123 patients with vitiligo included in the present study

 

 

 

 

 

 

regression modelling, the involvement of visible body parts (OR 153) and a larger affected BSA (compared with < 05%; 5–9%: OR 278, 10–19%: OR 284 and ≥ 20%: OR 469) were associated with mild symptom impairment (Table 3). A larger affected BSA was also associated with severe symptom impairment (compared with < 05%; ≥ 20%: OR 810).

Impaired quality of life and associated factors in terms of the functioning domain

Of the patients with vitiligo, 488% (548 of 1123) had mild and 282% (317 of 1123) had severe QoL impairment in terms of the functioning domain. The factors associated with

Table 2 The Skindex-29 items that affected > 25% of patients with vitiligo

Affected

Items (in order of frequency)                        patients     Domain

13. I worry that my skin condition may          746%         Emotions get worse

3. I worry that my skin condition may            629%         Emotions be serious

22. My skin condition is a problem for          556%                Functioning the people I love

6. My skin condition makes me feel               535%         Emotions depressed

9. I worry about getting scars from my           498%         Emotions skin condition

12. I am ashamed of my skin condition        497%       Emotions

28. I am annoyed by my skin condition        476%       Emotions

5. My skin condition affects my social           450%                Functioning life

15. I am angry about my skin condition        448%       Emotions

24. My skin is sensitive                                 433%          Symptoms

4. My skin condition makes it hard to            427%                Functioning work or do hobbies

21. I am embarrassed by my skin 410%         Emotions condition

19. My skin is irritated                                  379%          Symptoms

23. I am frustrated by my skin condition      356%       Emotions

20. My skin condition affects my 354%         Functioning interactions with others

11. My skin condition affects how close       328%       Functioning

I can be with those I love

17. My skin condition makes showing           305%                Functioning affection difficult

26. I am humiliated by my skin    296%         Emotions condition

10. My skin itches                                         291%          Symptoms

14. I tend to do things by myself  275%         Functioning because of my skin condition

30. My skin condition makes me tired          264%       Functioning

8. I tend to stay at home because of my          263%                Functioning skin condition

 

Source

 

VIPOC
In Non classé, Vitiligo, Vitiligo research, vitiligo treatment

Anxiety and depression in pediatric patients with vitiligo and alopecia areata and their parents: A cross-sectional controlled study Part 1

Department of Dermatology, University of

Health Sciences, Sultan Abdulhamid Han

Training and Research Hospital, Istanbul,

Turkey

Correspondence

Sevil Savaş Erdoğan, Department of

Dermatology, Sultan Abdulhamid Han Training and Research Hospital, Tıbbiye Street., 34668, Usküdar, Istanbul, Turkey. Email: doktorsevilsavas@gmail.com

2232  |   © 2020 Wiley Periodicals LLC                                                       wileyonlinelibrary.com/journal/jocd       J Cosmet Dermatol. 2021;20:2232–2239.

 

1       | INTRODUCTION

Anxiety and depressive disorders are the most common psychopathologies in children and adolescents.1 Alopecia areata (AA) is a common hair disorder characterized by a sudden-onset non-cicatricial but has a great negative effect on cosmetic appearance. Several studies have estimated the prevalence of AA worldwide to be 1%-2%, and in the majority, the first patch presents before the age of 20 years.2 Vitiligo is characterized by the partial or complete absence of melanocytes that cause the development of white macules or patches in various parts of the body.3,4 The worldwide prevalence of vitiligo is estimated to be 0.5%-2%, and approximately 50% of patients experience vitiligo before the age of 20 years.5,6 Since their visibility, chronic and disfiguring nature, and lack of curative therapy, AA and vitiligo may have high psychosocial effects on patients. AA and vitiligo are associated with various psychiatric comorbidities. In different studies, high anxiety and depressive disorder rates have been reported in children and adolescents with AA.7-11 Studies have shown that vitiligo patients suffer more from depression and anxiety.12-14 However, there are only a limited number of studies investigating the relationship between vitiligo and psychiatric state in children and adolescents.15-17

Skin diseases have a negative effect on family life,18-20 and the care of a child with AA or vitiligo may be associated with higher anxiety and depression in their parents than that of healthy children. Unlike other studies, in the current work, children and adolescents with AA and vitiligo and their parents were compared with each other and also with the healthy control group. Therefore, we aimed to identify psychiatric findings in children and adolescent groups with AA and vitiligo and to evaluate the levels of anxiety and depression in their parents. We also aimed to investigate the quality of life (QoL) of patients, and the impact of the disease on their parents.

2       | MATERIAL AND METHOD

2.1      | Study design and subjects

This is a prospective cross-sectional study conducted in our dermatology outpatient clinic between October 2018 and December 2019. The study was approved by the institutional ethical committee and carried out in accordance with the principles of the Declaration of Helsinki. Patients, controls, and their parents, who agreed to participate in the study, provided informed consent.

The study included children and adolescents aged seven to 17 years and their parents. Of the patients, 31 had AA and 29 had vitiligo. In addition, 30 age- and gender-matched healthy controls without any dermatological disease and their parents with a similar education level to that of the patients’ parents were included as a reference group. The following exclusion criteria were used for both the patient and control groups: systemic treatment (systemic steroid, cyclosporin and/or neuropsychiatric drugs) within the last three months prior to the study and any other chronic disease.

2.2      | Demographic variables and clinical severity

Demographic data (patient age and gender, and parental age and education level) and medical information (disease duration, disease severity, and presence of stressful life events within the past year from the onset of disease) were noted in separate forms for the patients. In addition, through a clinical examination, the Severity of Alopecia Tool (SALT) score21 was calculated for the patients with AA, and the Vitiligo Area Severity Index (VASI)22 for those with vitiligo.

The questionnaires explained below were administered in a single interview. The patients and controls completed the Revised Child Anxiety and Depression Scales-Child version (RCADS-C), and their parents completed the parent version (RCADS-P) to support the results of the child version. The parents also completed the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI). Lastly, the Children’s Dermatology Life Quality Index (CDLQI) scale was completed by the patients, and the Dermatological Family Impact Scale (DeFIS) by their parents.

2.3      | Scales on psychological parameters and QoL

CDLQI is a four-point Likert scale that evaluates the state of the patients and can be used in children aged four to 17 years. Higher scores indicate a greater level of deterioration in QoL. In this study, we used the Turkish version of this scale, for which validity and reliability studies have been previously conducted.23

RCADS-C and RCADS-P are self-report questionnaires, each containing 47 items designed to assess DSM-IV depression and anxiety disorders in children and adolescents. Response options are based on four-point Likert scales. Both versions have six subscales [separation anxiety disorder (SAD), social phobia (SP), obsessive-compulsive disorder (OCD), panic disorder (PD), generalized anxiety disorder (GAD), and major depressive disorder (MDD)] and provide a total anxiety score (sum of the score in five anxiety scales) and a total internalizing score (sum of the six scores in subscales).24 In this study, we used the Turkish versions of these questionnaires. The validity and reliability studies of the Turkish versions have been previously conducted.25,26

DeFIS is a 15-item, five-choice response scale to investigate how the family QoL of patients with chronic dermatosis has been affected within the last month and produces a score of 0-4. Higher scores indicate greater impairment in QoL. The scale was developed for the Turkish society by Turan et al, and the validity and reliability studies have been undertaken by the same authors.27

BAI is a 21-item self-report scale that was used to measure parents’ anxiety levels in this study. The items include symptoms of anxiety and higher total scores indicating greater anxiety levels. BAI was previously adapted to the Turkish society, and the Turkish version of the scale was in the current study.28

BDI is a 21-item self-report scale that was used to measure the level of depression in parents. There are four statements for each symptom, and a higher total score indicates a higher level of depression. The validity and reliability studies of the Turkish adaptation of the 1979 version of BDI have been undertaken.29,30

2.4      | Statistical analysis

As the statistical method, descriptive analyses (frequency distributions, percentage, mean, and standard deviation) were used. For the analysis of continuous data, conformance to normal distribution was checked using the Kolmogorov-Smirnov test. For the data that were normally distributed, the comparison of more than two groups was undertaken with ANOVA and the post hoc Bonferroni test and the comparison of two groups using the t-test.

In the absence of normal distribution, Kruskal-Wallis and MannWhitney U tests were performed, the chi-square test was used for discrete data, and Fisher’s exact test was conducted depending on the data compatibility. Relationships were investigated by the

TABLE 1 Characteristics of patients and controls

Spearman rho correlation coefficient. The results were evaluated at the 95% confidence interval and P < .05 significance level.

3       | RESULTS

3.1                | Demographic and clinical characteristics of the study groups

Thirty-one patients with AA, 29 patients with vitiligo, and 30 age- and gender-matched controls were included in the study. The mean (± standard deviation) ages of the in the AA, vitiligo, and control groups were 12.5 ± 3.6, 13 ± 3, and 12.6 ± 3.1 years, respectively. There was no statistically significant difference between the patient and control groups in terms of age, gender, number of siblings, parental education level, and parental marital status (Table 1). All patients with AA had the patchy type, and their mean SALT score was 6.3 ± 13.1. In the vitiligo group, the type of disease was vulgaris in 51.7% (n = 15), focal in 44.8% (n = 13), and segmental in 3.4% (n = 1). The mean VASI score of the vitiligo group was 3.6 ± 7.4. The mean disease duration was 6.5 ± 15.5 (range, 1-84) months in the AA group and 31.4 ± 35.5 (range, 2-132) months in the vitiligo group.

The difference between the AA, vitiligo, and control groups in terms of the presence of stressful life events was statistically

 

Groups

Alopecia areata

 Vitiligo Controls P-value
Age, mean ± SD 12.54 ± 3.56 13 ± 3.03 12.6 ± 3.06 .85
Sex Female, n (%) 14 (45.16) 13(44.82) 14(46.66) .98
Male, n (%) 17 (54.83) 16(55.17) 16(53.33)
Mother’s educational level Illiterate, n (%) 1 (3.2) 3(10.3) 0 .56
Primary school, n (%) 12 (38.7) 9(31) 12(40)
Middle School, n (%) 5 (16.1) 5(17.2) 8(26.7)
High school, n (%) 9 (29) 6(20.7) 7(23.3)
University, n (%) 4 (12.9) 6(20.7) 3(10)
Father’s educational level Illiterate, n (%) 11 (35.5) 6(20.7) 13(43.3) .6
Primary school, n (%) 5 (16.1) 6(20.7) 4(13.3)
Middle School, n (%) 8 (25.8) 11(37.9) 9(30)
High school, n (%) 7 (22.6) 5(17.2) 4(13.3)
University, n (%) 0 1(3.4) 0

Parental marital status                                         Married, n (%)                                 27 (87.1)                                   25(86.2)                       30(100)                                                                    .11

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).

VIPOC
In vitiligo treatment

Vitiligo treatment updates

Dr. John Harris discusses the current and future landscape for vitiligo treatment.

Vitiligo Treatment Updates – The Dermatology Digest (thedermdigest.com)

John E. Harris, MD, PhD, is Professor and Chair, Department of Dermatology, as well as Director of the Vitiligo Research Center at University of Massachusetts Medical School in Worcester, Mass.

“We’ve been using the same [vitiligo] treatments for about 3400 years: sunlight and light-activated chemicals, while now we use narrowband UVB, which is a small improvement,” said John E. Harris, MD, PhD, who discussed vitiligo treatment updates at the 4th Inflammatory Skin Disease Summit.

“We have good treatments for vitiligo, but they’re really cumbersome. They take a long time. Patients have to really commit to 12 to 14 months of treatment to get decent improvement.”

However, research over the past decade into what causes vitiligo has led to new treatment opportunities, said Dr. Harris. There are two signaling cytokine pathways that can be targeted for vitiligo: JAK inhibitors for interferon gamma signaling and biologics to target IL-15 signaling.

“A phase II and then phase III clinical trial have now been conducted using topical ruxolitinib [Opzelura] to treat vitiligo, and both showed that it was very effective….1 The FDA has approved it for atopic dermatitis and now we’re hoping in the next few months it will be approved for vitiligo. That would be the first FDA-approved treatment for vitiligo, ever.”

In terms of biologics, a clinical trial is currently recruiting patients to address disease relapse, which is about 40% within a year of stopping any treatment, said Dr. Harris.

“We wanted to know why—why does vitiligo come back? And importantly, why does it come back in exactly where it was before?”

According to Dr. Harris, they found that resident memory T cells form within vitiligo lesions.

“You can take a JAK inhibitor or any other treatment and turn off these cells, and everything gets better. But then if you stop the treatment, they’re still there. They wake back up and reinitiate everything.”

Those memory T cells require IL-15 signaling for long-term maintenance and survival, said Dr. Harris.

“When we blocked IL-15 signaling, not only did vitiligo get better in a mouse model, but those… memory T cells were erased from the skin. Short-term treatment gave us long-term effects. We’re hoping that blocking IL-15 with an antibody… will last not just for a short period of time but actually give a durable, long-term response.”

In their research, Dr. Harris and colleagues also have found hundreds of other activated pathways to potentially target for vitiligo treatment.2 

“We’re pursuing those. There’s some promise that that maybe someday we’ll have even better [treatments]. Could the cure for vitiligo be in that data somewhere? We’re hoping so.”

According to Dr. Harris, treatments under consideration include a bi-specific antibody and RNA interference (RNAi).

“We know we can treat psoriasis [and] atopic dermatitis with an antibody. We showed some data… [with] a bi-specific antibody, where one antibody targets two different things. We can bring the treatment into the skin, tether it there, and create a high local concentration that might be both safer and have higher efficacy for patients.”

RNAi may also be an option for treating vitiligo and other inflammatory skin diseases, said Dr. Harris.

“It’s a new way to turn off proteins in different tissues, and we found a way to deliver this specifically to the skin.”

Despite all these up-and-coming treatments, Dr. Harris has a key message for dermatologists who may believe they do not currently have viable treatment options for their vitiligo patients.

“There’s plenty you can do even now with the tools that we have, the drugs, the treatment approaches…. It’s just cumbersome and difficult and not everybody has access.”

Current off-label treatment options include tofacitinib (Xeljanz XR) and ruxolitinib, said Dr. Harris.

“Oral tofacitinib works for vitiligo. It’s tough to get because it’s not FDA approved for vitiligo. It’s very expensive. So, trying to get that approved for use in patients can be difficult, although not impossible.”

The oral JAK inhibitor also recently received a black box warning for safety concerns.

According to Dr. Harris, he has topical ruxolitinib compounded at a compounding pharmacy.

“I’ve used [ruxolitinib] over the last few years. But as soon as that gets FDA approved for vitiligo, we’ll have it from the pharmacy and be able to prescribe it on label which would be exciting.”

References

  1. Rosmarin D, Pandya AG, Lebwohl M, et al. Ruxolitinib cream for treatment of vitiligo: a randomised, controlled, phase 2 trial. Lancet. 2020 Jul 11;396(10244):110-120. doi: 10.1016/S0140-6736(20)30609-7. PMID: 32653055.
  2. Gellatly KJ, Strassner JP, Essien K, et al. scRNA-seq of human vitiligo reveals complex networks of subclinical immune activation and a role for CCR5 in Treg function. Sci Transl Med. 2021 Sep 8;13(610):eabd8995. doi: 10.1126/scitranslmed.abd8995. Epub 2021 Sep 8. PMID: 34516831; PMCID: PMC8686160.

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