To the Editor: Vitiligo is associated with significant negative psychologic effects, which have been found
to be worse in Eastern cultures than in Western cultures, likely due to the stigma associated with the
disease.1-3 We sought to assess differences in the quality of life (QoL) of South Asian patients according
to the degree of acculturation in the Western culture to determine if integration into the Western
culture is associated with an improved QoL.
South Asian patients with vitiligo, aged 18 years and above, were recruited from a tertiary care
academic dermatology clinic in this institutional review board-exempted study. African American
patients with vitiligo and matching skin types were recruited as controls. South Asian patients from
Hyderabad, India, were also recruited from a vitiligo specialty clinic. The severity of vitiligo was determined using body surface area measurement. All the patients completed the Dermatology Life Quality
Index questionnaire and the 36-Item Short Form survey (SF-36). The South Asian patients were also
given an acculturation questionnaire with the authors’ permission.4 The degree of integration of
South Asians into the Western culture of the United States of America (USA) was assessed using a series
of questions, including the frequency of the use of native language, consumption of native foods,
observation of native cultural or religious holidays, and cultural self-identification. All subjects who
scored 50% or greater were designated as acculturated. The Chi-square or Fisher’s exact test was used
to compare the ethnic groups based on sex and the presence of acculturation. The Dermatology Life
Quality Index, as well as the component and domain scores of the SF-36, were analyzed using 2-way analysis of variance.
The patients’ demographics are presented in Table I. There were no differences between the
groups in terms of the Dermatology Life Quality Index scores or the SF-36 general health domain.
Regarding the SF-36 physical component scores, women in the USA-acculturated group had significantly higher (better QoL) scores than women from Hyderabad. Men scored significantly higher than women, and the USA-acculturated group scored significantly higher than the Hyderabad group
(Table II). The means were significantly higher in African Americans than in the Hyderabad group for
the physical functioning domain, higher in the USAacculturated group than in the Hyderabad group for
the role physical domain, and higher in men than in women for the bodily pain domain (Supplemental
Tables I to III available via Mendeley at https://doi.org/10.17632/fhfzrwnvmx). For the mental component domain scores, men had significantly higher means than women in the vitality domain.
Our results suggest that patients with greater integration into the South Asian culture experience
a more negative effect on QoL, likely due to the stigma associated with vitiligo. There was a significant
QoL impairment seen in the patients from Hyderabad compared with that in the South Asian
patients in the USA, indicating that moving to the USA may have conferred a protective effect. This
effect was the most significant in acculturated South Asian patients integrated into the American culture.
Furthermore, women perceived greater impairment compared with men. The limitations of this study
include its small sample size, recruitment from only 2 centers, and a referral bias because the patients were recruited from specialty clinics. Future, larger studies on acculturation should be performed to confirmour findings. The results of our study suggest that individuals with vitiligo integrated into the South Asian culture, particularly women, experience an increased burden from their disease. Understanding these differences may help providers in managing South Asian patients with vitiligo.
| Demographic characteristics | African American | South Asian, nonacculturated | South Asian acculturated | South Asian from
Hyderabad, India |
| Total | 20 | 31 | 21 | 30 |
| Men, n (%) | 8 (40%) | 12 (39%) | 13 (62%) | 13 (43%) |
| Mean age in years | 50.4 | 42 | 40.2 | 34.4 |
| Median age in years | 41.5 | 41 | 41 | 30 |
| Mean duration of vitiligo in years | 10.8 | 8.65 | 12.66 | 10.33 |
| Median duration of vitiligo in years | 7.0 | 4.0 | 10.0 | 4.5 |
| Nonsegmental type, n (%) | 20 (100%) | 29 (94%) | 18 (86%) | 27 (90%) |
| Median BSA, % (IQR) | 7.05 (0.44, 16.25) | 1.00 (0.25, 3.00) | 1.88 (0.48, 5.00) | 0.70 (0.25, 2.98) |
Table II. SF-36 physical component scores based on sex and ethnic groups
| Ethnicity | Sex | n | Mean | 95% confidence interval
Lower bound |
Upper bound | ANOVA model P values | ||
| Ethnicity | Sex | Interaction of ethnicity and sex | ||||||
| USA-acculturated | Male | 13 | 55.05 | 51.49 | 58.61 | .030 | .034 | .025 |
| Female | 8 | 59.79 | 55.26 | 64.33 | ||||
| USA-nonacculturated | Male | 12 | 56.49 | 52.79 | 60.19 | |||
| Female | 19 | 51.14 | 48.20 | 54.09 | ||||
| African American | Male | 8 | 57.05 | 52.51 | 61.58 | |||
| Female | 12 | 51.79 | 48.09 | 55.49 | ||||
| Hyderabad | Male | 13 | 54.53 | 50.97 | 58.09 | |||
| Female | 17 | 48.92 | 45.81 | 52.03 | ||||
interaction: women in USA-acculturated group versus women in Hyderabad group, P ¼ .0046; P values \.05 were statistically significant.
ANOVA, Analysis of variance; SF-36, 36-item short form survey; USA, United States of America.
recruited from specialty clinics. Future, larger studies on acculturation should be performed to confirm our findings. The results of our study suggest that individuals with vitiligo integrated into the South Asian culture, particularly women, experience an increased burden from their disease. Understanding these differences may help providers in managing South Asian patients with vitiligo.
Amrita Hans, MD,a Keerthi A. Reddy, MD,a Samantha M. Black, BS,a Jamael Thomas, MD, MPH,a Orlando Martinez-Luna, BSA,a Jacqueline McKesey, MD, MS,a Linda S. Hynan, PhD,b and Amit G. Pandya, MDa
From the Department of Dermatology, University of Texas Southwestern Medical Centera and Departments of Population & Data Sciences (Biostatistics) and Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas.b
Funding sources: None.
IRB approval status: This study was reviewed by the Institutional Review Board of the University of Texas Southwestern Medical Center, Dallas, Texas, and determined to be exempt from review.
Reprints not available from the authors.
Correspondence to: Amit G. Pandya, MD,
Department of Dermatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9069
E-mail: amit.pandya@utsouthwestern.edu
Conflicts of interest None disclosed.
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- Ongenae K, Van Geel N, De Schepper S, Naeyaert JM. Effect of vitiligo on self-reported health-related quality of life. Br J Dermatol. 2005;152(6):1165-1172.
- Bharmal N, Hays RD, McCarthy WJ. Validity of temporal measures as proxies for measuring acculturation in Asian Indian survey respondents. J Immigr Minor Health. 2014;16(5): 889-897.
