BASIC/CLINICAL SCIENCE
Treatment of Vitiligo Patients by Excimer Laser Improves Patients’ Quality of Life Hani A. Al-Shobaili Background: Vitiligo can negatively affect patients’ quality of life (QoL). Assessment of QoL provides relevant information about treatment benefits. Objectives: To examine the effects of excimer laser treatment on vitiligo patients’ QoL and to identify overall patient satisfaction. The literature review failed to show any study concerning the same field. Methods: A total of 134 vitiligo patients (with 386 lesions) were studied. The Dermatology Life Quality Index (DLQI) was used to assess the effect of excimer laser treatment on patients’ QoL. A visual analogue scale (VAS) was used to rate patients’ overall life satisfaction and disturbance. Results: Excimer laser treatment significantly improved QoL in vitiligo patients, with improvement observed in five of six DLQI domains. Treatment-induced changes in the VAS score showed a significant decline in life disturbance and improvement in life satisfaction. Multivariate analysis revealed that sex and treatment duration were independent factors influencing treatment outcomes. Conclusions: Treatment of vitiligo with excimer laser can positively influence patients’ QoL. Patients with multiple focal lesions should be treated by excimer laser even if some lesions may not show significant clinical improvement. Contexte: Le vitiligo peut alte´rer la qualite´ de vie (QV) des personnes atteintes. Aussi l’e´valuation de la QV fournit-elle des renseignements pertinents sur les avantages du traitement. Objectifs: L’e´tude visait a` examiner les effets du traitement par le laser a` excime`res sur la QV des patients atteints de vitiligo et a` e´valuer le degre´ ge´ne´ral de satisfaction. L’examen de la documentation n’a pas permis de relever d’e´tude se rapportant au meˆme domaine. Me´thode: Au total, 134 patients atteints de vitiligo (386 le´sions) ont participe´ a` l’e´tude. Nous avons utilise´ le Dermatology Life Quality Index (DLQI) pour e´valuer l’effet du traitement par le laser a` excime`res sur la QV des patients. Quant au degre´ ge´ne´ral de satisfaction et de malaise a` l’e´gard de la vie, ils ont e´te´ e´value´s a` l’aide d’une e´chelle visuelle analogue (EVA). Re´sultats: Le traitement par le laser a permis d’ame´liorer conside´rablement la QV chez les patients atteints de vitiligo; en effet, une ame´lioration a e´te´ note´e dans cinq domaines sur six e´value´s dans le questionnaire DLQI. Par ailleurs, les changements releve´s dans les re´sultats obtenus sur l’EVA et attribuables au traitement ont re´ve´le´ une diminution importante du malaise devant la vie et une ame´lioration sensible du degre´ de satisfaction a` l’e´gard de la vie. Par ailleurs, les analyses plurifactorielles ont aussi re´ve´le´ que le sexe et la dure´e du traitement e´taient des facteurs inde´pendants qui avaient une incidence sur les re´sultats du traitement. Conclusions: Le traitement du vitiligo par le laser a` excime`res peut ame´liorer la QV des patients. Ceux qui pre´sentent de nombreuses le´sions focales devraient eˆtre traite´s par le laser a` excime`res, meˆme si certaines le´sions peuvent ne pas montrer d’atte´nuation importante sur le plan clinique.
ITILIGO is a common acquired pigmentation disorder, affecting at least 1% of the world population, regardless of age or sex. Although vitiligo does not
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From the Department of Dermatology, College of Medicine, Qassim University, Qassim, Saudi Arabia. Address reprint requests to: Hani A. Al-Shobaili, MD, Department of Dermatology, College of Medicine, Qassim University, PO Box 5578, Unaizah 51911, Saudi Arabia; e-mail: [email protected].
DOI 10.2310/7750.2014.14002 # 2014 Canadian Dermatology Association
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cause direct physical impairment, it can produce significant psychosocial burden.1,2 Several studies have demonstrated that patients with vitiligo suffer from poor body image and low self-esteem and experience a considerable level of psychosocial disability3 and that this poor self-image of vitiligo patients can lead to depression.4 Many vitiligo patients show significant distress, especially in relation to social activities or negative reactions with others,5 and most patients with vitiligo report feelings of embarrassment, which can lead to low self-esteem and further social isolation.6 Moreover, many patients experience discrimination from
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others and feel stigmatized,7 and it has also been reported that the disease may have a negative effect on sexual relationships.8 In general, all currently available data demonstrate a negative impact of vitiligo on patients’ overall quality of life. Excimer laser treatment for vitiligo patients has been previously reported to improve the degree of repigmentation.9 However, assessment of quality of life will provide more important and relevant information on the benefits of the treatment. Several general validated questionnaires and diagnostic structured interviews have already been introduced.10–12 However, due to the shortcomings of these questionnaires in a dermatologic setting, only a few diseasespecific questionnaires have been found to display a good correlation between quality of life and treatment response for vitiligo.13–16 In 1994, Finlay and Khan proposed the Dermatology Life Quality Index (DLQI), which can be used to evaluate the quality of life of patients in dermatologic outpatient settings and to compare the quality of life between different chronic dermatologic diseases.17 The objective of this study was to determine the effect of excimer laser treatment on vitiligo patients’ quality of life and on their overall life satisfaction and disturbance after treatment.
Methodology Recruitment of Patients This study was performed at the Dermatology Clinics of Qassim University–affiliated hospitals in Saudi Arabia between July 2012 and April 2013. A total of 162 vitiligo patients with vitiliginous lesions at different body sites were enrolled. After explaining the treatment procedure and the expected benefits and risks, informed consent was obtained from all patients. Patients were included if they had vitiligo affecting # 5% of the body and had not been receiving any treatment for the last 8 weeks. Pregnant or breast-feeding women, patients with a history of photosensitive disorders or skin cancer, or those who had used systemic and/or topical immunosuppressive treatments within the last 8 weeks were excluded from the study. Patients were also excluded if they had been exposed extensively to sunlight or phototherapy in the 8 weeks before entering the study. Information about the demographics of the patients, the type of vitiligo, the site of lesions, and the duration of the disease was collected. Ethical approval was obtained from the Institutional Review Board of the College of Medicine, Qassim University.
Excimer Laser Treatment All patients were treated with a monochromatic 308 nm xenon-chloride excimer laser (XTRAC, PhotoMedex, Horsham, PA). The fixed technical parameters were as follows: pulse frequency of 200 Hz, with a maximal output of 600 mW/cm2 per pulse; pulse width of 30 nanoseconds; and laser energy of 20 mJ. Beam transmission was achieved by liquid light guide, with variable spot size diameters of 15, 20, and 25 mm that were changed according to the size of the lesions. The minimal erythema dose (MED) was determined for each patient, and treatment was started with one MED, which was repeated twice a week on nonconsecutive days. The dose given at each session depended on the extent of the erythema observed after the previous treatment. If the erythematous response was severe and/or other signs of phototoxic side effects (eg, burning/stinging, edema, and/or blisters) were present, the subsequent session was cancelled. If the erythematous response was moderate or slight, the dose was increased by 50 mJ/cm2. If there was no erythematous response, the dose was increased by 100 mJ/cm2. The eyes of the patients were protected with ultraviolet light–protective goggles. The end point was 32 treatments, or 100% repigmentation, whichever was achieved first. DLQI and Visual Analogue Scale The DLQI questionnaire was used according to the instructions given by Finlay and Khan.17 This is a widely validated questionnaire that is simple, self-explanatory, easy to use, and well accepted by patients. It provides quantifiable measurement of quality of life and allows comparison between several chronic skin disorders. The questionnaire includes 10 questions, each with a maximum score of 3 and a minimum score of 0, resulting in a cumulative score ranging between 0 and 30. The higher the score, the more the quality of life is impaired. The DLQI has six domains, concerning different aspects of life: (1) symptoms and feelings; (2) daily activities; (3) leisure; (4) work and school; (5) personal relationships; and (6) treatment. Domains 1, 2, 3, and 5 consist of two questions each, with a maximum domain score of 6. The other two domains (4 and 6) have one question each, with a maximum domain score of 3. Every patient completed the DLQI questionnaire at the beginning of the study, as well as after the completion of the treatment, approximately 16 weeks later. Additionally, all patients were also requested to rate their overall life satisfaction and their overall life
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disturbance before and after treatment on a visual analogue scale (VAS) of 0 to 10, where 0 represents no satisfaction or no disturbance and a score of 10 represents complete satisfaction or maximum disturbance. Statistical Analysis Data were analyzed using SPSS for Windows version 16.0 (SPSS Inc., Chicago, IL). The results are expressed as mean 6 standard deviation unless stated otherwise. Data were tested for normality prior to the t-test and analysis of variance (ANOVA). Paired two-tailed t-tests were used to compare mean scores of the DLQI before and after treatment. One-way ANOVA was used to measure the correlation between mean scores and different sociodemographic and clinical variables. Multivariate analysis was used to identify significant independent factor(s) that affected the mean DLQI scores. A p value , .05 was considered significant.
Results Characteristics of the Study Patients The results from 134 of 162 subjects (64 men, 70 women) were analyzed. Twenty-eight patients (17.3%) left the clinics without completing the questionnaire and therefore were excluded from the study; however, their social, demographic, and clinical characteristics were analyzed, and the improvement was significantly similar to that of those who participated and completed their questionnaires. The total number of lesions treated by excimer laser was 386. The demographic and clinical characteristics of the patients are summarized in Table 1. DLQI Scores As evident in Figure 1, the overall improvement in the DLQI score was statistically significant after excimer treatment (p , .001). The means (6 SD) of the DLQI scores before and after the treatment were 10.6 6 4.3 and 4.5 6 3.9, respectively. The majority of patients (123; 91.8%) demonstrated improvement in their quality of life, whereas 11 patients (8.2%) showed no significant improvement. The reported scores at baseline and the end of treatment among the vitiligo patients on the six domains of the DLQI questionnaire are summarized in Table 2. A majority of patients demonstrated significant improvement in five of six DLQI domains (p , .001) except for the treatment domain. As far as the patient’s 52
Table 1. Demographic and Clinical Characteristics of the Study Subjects Characteristic Number of patients (M:F) Mean age in years (SD, range) Gender, n (%) Male Female Education, n (%) No education Up to secondary education University Postgraduate Social status, n (%) Single Married Divorced/widowed Occupation, n (%) Manual work Clerk Business Professional Student Housewife Type of vitiligo lesions, n (%) Focal Vulgaris Segmental Mean duration of disease, years (SD, range) Mean age at onset, years (SD, range) Distribution of lesions (N 5 386), n (%) Face Neck Trunk Upper limb Lower limb
n 134 (64:70) 32.5 (11.8, 16–50) 64 (47.8) 70 (52.2) 6 63 54 11
(4.5) (47.0) (40.3) (8.2)
52 (38.8) 75 (56.0) 7 (5.2) 4 23 20 19 34 34 176 193 17 5.3
(3.0) (17.2) (14.9) (14.1) (25.4) (25.4) (45.6) (50.0) (4.4) (5.3, 1–42)
26.8 (11.0, 3–53)
52 32 73 124 105
(13.5) (20 M, 32 F) (8.3) (10 M, 22 F) (18.9) (43 M, 30 F) (32.1) (50 M, 74 F) (27.2) (55 M, 50 F)
Figure 1. Vitiligo patients’ quality of life measured by the Dermatology Life Quality Index questionnaire before and after excimer laser treatment.
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Table 2. DLQI Scores in the Six Domains before and after Excimer Laser Treatment in Vitiligo Patients DLQI Score (mean 6 SD) Domain (maximum DLQI score) Symptoms and feelings (6) Daily activities (6) Leisure (6) Work and school (3) Personal relationships (6) Treatment (3)
Before Treatment 2.35 3.09 2.40 1.46 1.25 0.04
6 6 6 6 6 6
0.43 0.61 0.42 0.26 0.23 0.01
After Treatment 1.08 1.21 1.07 0.60 0.49 0.03
6 6 6 6 6 6
0.19 0.22 0.20 0.14 0.07 0.01
Difference (mean 6 SD)
p Value
6 6 6 6 6 6
.001 .001 .001 .001 .001 .48
1.27 1.88 1.33 0.86 0.76 0.01
0.23 0.34 0.24 0.15 0.14 0.002
DLQI 5 Dermatology Life Quality Index.
gender was concerned, women showed a higher quality of life index, but both men and women showed significant improvement in their quality of life after the excimer laser treatment. The mean DLQI scores did not differ significantly between different education, social class, and occupation groups after treatment ( p5 .87, .42, and .33, respectively). When the patients were divided into three age groups (, 20 years, 20–39 years, and $ 40 years), the mean DLQI scores before and after treatment were not influenced by age group (p 5 .30 and .43, respectively). However, data on the duration of disease (, 1 year, 1–3 years, and . 3 years), the location of the lesions, and the type of vitiligo significantly influenced the DLQI score before and after treatment (p , .05). The highest score, indicating the highest impairment in quality of life, was observed among patients with a disease duration of . 3 years. The improvement in DLQI scores distributed by site of lesions is shown in Figure 2. In short, the improvement in DLQI scores was greatest for patients with lesions on the face and neck, followed by the legs and arms, and, lastly, the abdomen and back. In contrast, patients with lesions on the hands and feet did not report significant improvement in quality of life. The association between
DLQI scores and the type of vitiligo lesions was also investigated (Figure 3). Our data demonstrated a clear reduction in the DLQI scores in all types of vitiligo lesions after excimer laser treatment, with the highest improvement in quality of life being achieved in patients with focal-type vitiligo. Furthermore, we observed that patients with multiple lesions suffered significantly greater impairment in their quality of life before treatment compared to patients with a single lesion (p 5 .02). Conversely, patients with multiple lesions showed significantly greater improvements in their DLQI scores after treatment compared to patients with a single lesion (p , .01). In addition, the quality of life of patients with exposed lesions (face, neck, and upper arm) was more impaired before treatment and was more improved after treatment compared to patients with covered lesions (p , .01), except for patients with lesions on the hands and feet. For further validation, multivariate analysis was performed to determine the independent factors influencing the DLQI scores on excimer treatment. The analysis revealed that being a female, having longer disease duration, and having lesions on the face and neck
Figure 2. The Dermatology Life Quality Index scores distributed by site of lesion before and after excimer laser treatment.
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Figure 3. The Dermatology Life Quality Index scores in different types of vitiligo before and after excimer laser treatment.
demonstrated significantly better improvement in DLQI scores (p , .01). VAS Scores Patients responded to two questions about their perceived life disturbance and overall life satisfaction before and after treatment. These questions used a VAS of 0 to 10. The mean (6 SD) VAS scores of patients before and after excimer treatment are shown in Figure 4. Comparing VAS scores before and after treatment revealed that life disturbance was significantly reduced by 45.6% (8.1 vs. 3.7), whereas life satisfaction was significantly improved (2.0 vs. 6.8) (p , .001) after the treatment. Table 3 summarizes the vitiligo patients’ life satisfaction and disturbance before and after excimer laser treatment, sorted by the different sites of the vitiligo lesions. Patients with multiple lesions showed a significant decline in life disturbance and significant improvement in life satisfaction after treatment with excimer laser. The only exception
was patients with lesions on the hands and feet, who did not show any significant differences in either their life disturbance or life satisfaction score. The effect of education, social class, and occupation on the life disturbance and satisfaction scores before and after treatment was not statistically significant (p . .05). On the other hand, there was a significantly greater improvement in life satisfaction and a decline in the life disturbance score after treatment in patients with longer disease duration (. 3 years) (p 5 .01 and p 5 .02, respectively) compared to patients with a disease duration # 3 years. Patients who achieved higher rates of repigmentation of vitiligo lesions showed significantly less life disturbance and more life satisfaction after treatment. Multivariate analysis was used to determine the factors influencing life disturbance and satisfaction. Female patients were generally less satisfied and more disturbed than male patients (p 5 .02 and p 5 .01, respectively). Similarly, patients with longer disease duration were less satisfied (p 5 .01) and more disturbed (p 5 .01). Other
Figure 4. Visual analogue score measurement before and after laser treatment.
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Table 3. Effect of Excimer Laser Treatment on Patients’ Overall Life Satisfaction and Disturbance: Correlation with Sites of Vitiligo Lesions Life Disturbance Score (mean 6 SD) Lesions Treated n (%)
Site Face and neck Abdomen Back Legs Thighs Foot Upper arm Lower arm Elbows Hand Total
84 42 31 36 39 30 30 18 26 50 386
(21.8) (10.9) (8.0) (9.3) (10.1) (7.8) (7.8) (4.7) (6.7) (12.9) (100)
Before Treatment 9.8 6.9 6.6 7.6 7.8 8.1 7.9 8.5 7.9 8.6 8.1
6 6 6 6 6 6 6 6 6 6 6
1.47 1.38 1.33 1.54 1.17 1.22 1.42 1.28 1.19 1.29 1.14
After Treatment 2.3 1.7 1.3 2.1 2.8 7.6 2.5 3.1 2.3 7.9 2.7
6 6 6 6 6 6 6 6 6 6 6
0.35 0.26 0.19 0.32 0.42 1.14 0.38 0.47 0.35 1.27 0.41
Life Satisfaction Score (mean 6 SD) p Value Before Treatment .001 .001 .001 .001 .001 .140 .001 .001 .001 .15 .001
1.5 2.4 2.6 1.9 2.1 1.6 2.3 1.4 2.1 1.6 2.0
6 6 6 6 6 6 6 6 6 6 6
0.23 0.38 0.41 0.29 0.32 0.24 0.32 0.21 0.31 0.23 0.33
After Treatment
p Value
6 6 6 6 6 6 6 6 6 6 6
.001 .001 .001 .001 .001 .21 .001 .001 .001 .24 .001
7.9 7.0 7.2 7.4 7.5 3.1 7.5 6.6 7.8 2.9 6.8
1.42 1.19 1.17 1.33 1.13 0.46 1.20 1.06 1.18 0.41 1.05
DLQI 5 Dermatology Life Quality Index.
sociodemographic and clinical variables did not influence life disturbance or satisfaction significantly.
Discussion Most previous studies on vitiligo have demonstrated the negative impacts of the disease on patients’ social and psychological quality of life,5,8,16 but only a few studies have focused on the impact of any treatments on the patients’ quality of life.18 Impaired quality of life, which is common in people with chronic skin diseases, may not necessarily relate to disease severity. Therefore, this study included other factors that may be related to quality of life, such as social and demographic aspects. The response rate in this study was 82.7%, which provided a representative impression of the study population. In this study, the mean DLQI score before treatment was higher than that obtained by other studies. However, it is well documented that different studies showed different DLQI scores.5,17,19 This study found no relationship between DLQI score and the occupation, education, social class, or age of patients. Conversely, sex, duration of the disease, location of the lesion, and the type of vitiligo were found to significantly affect the DLQI score. Improvements in DLQI scores were observed in five of six domains of the DLQI. The only domain that did not show significant improvement was the treatment domain. However, it did not affect the overall improvement in patient quality of life. The study also revealed that female vitiligo patients experienced significantly more impairment in their quality of life than male patients. However, Kent and al-Abadie
and Parsad and colleagues found no relationship between the DLQI and sex.19,20 Our data revealed that patients with vitiligo on the exposed areas of the body were predominantly women, and this may partly explain why the quality of life of women was more disturbed. This study also showed that women were more impaired in their daily routine activities and in personal relationships and more influenced in the choice of clothing. Altogether, the data clearly indicated that the impact of vitiligo on the quality of life of women was markedly higher compared to the impact on the quality of life of male patients. These results are well supported by many published reports on other dermatologic conditions.21 This study also demonstrated that quality of life in patients with exposed lesions was significantly improved after treatment. In other studies, where quality of life has been demonstrated to be improved after the use of camouflage treatment for disfiguring exposed skin conditions, similar results have been observed, clearly indicating the importance of treatment, specifically of exposed lesions.22,23 However, in a recent study on coping and stigmatization in vitiligo, Schmid-Ott and colleagues reported that the location of vitiligo plays no role in the overall stigmatization experience.7 Furthermore, this study also determined that longer disease duration and multiple lesions were important factors for predicting impairment in quality of life. It can thus be hypothesized that therapeutic strategies to reduce the number of affected sites could improve patients’ quality of life. It has also been reported that the social life of vitiligo patients is impaired by the tendency of these patients to withdraw from friends
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and to avoid going out.24,25 In this regard, the present study also determined that daily activities, leisure, work, and personal relationships were all significantly improved after treatment.
Conclusion Treatment of vitiligo patients by excimer laser shows positive impacts on patients’ quality of life. To the best of my knowledge, this is the first study that compares vitiligo patients’ quality of life before and after excimer laser treatment. The data also revealed that the excimer laser failed to treat some of the lesions, especially on the hands and feet. However, the study found that this treatment improved patients’ overall life satisfaction. Therefore, the results of the present study conclude that vitiligo patients should be treated by excimer laser regardless of the poor response of some vitiliginous lesions.
Acknowledgments Financial disclosure of author and reviewers: None reported.
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9. Alhowaish AK, Dietrich N, Onder M, Fritz K. Effectiveness of a 308-nm excimer laser in treatment of vitiligo: a review. Lasers Med Sci 2013;28:1035–41, doi:10.1007/s10103-012-1185-1. 10. Goldberg DP. The detection of psychiatric illness by questionnaire. Maudsley Monograph 21. Oxford (UK): Oxford University Press; 1972. 11. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SP-36). I. Conceptual framework and item selection. Med Care 1992;30:473–83, doi:10.1097/00005650-199206000-00002. 12. Chren MM, Lasek RJ, Quinn LM, et al. Skindex, a quality-of-life measure for patients with skin disease: reliability, validity, and responsiveness. J Invest Dermatol 1996;107:707–13, doi:10.1111/ 1523-1747.ep12365600. 13. Lundberg L, Johannesson M, Silverdahl M, et al. Quality of life, health-state utilities and willingness to pay in patients with psoriasis and atopic eczema. Br J Dermatol 1999;141:1067–75, doi:10.1046/j.1365-2133.1999.03207.x. 14. Schmid-Ott G, Kuensebeck HW, Jaeger B, et al. Validity study for the stigmatization experience in atopic dermatitis and psoriatic patients. Acta Derm Venereol 1999;79:443–7, doi:10.1080/0001555 99750009870. 15. Ghren MM, Lasek RJ, Flocke SA, et al. Improved discriminative and evaluative capability of a refined version of Skindex, a qualityof-life instrument for patients with skin diseases. Arch Dermatol 1997;133:1433–40, doi:10.1001/archderm.1997.03890470111018. 16. Kent G, al-Abadie M. Psychologic effects of vitiligo: a critical incident analysis. J Am Acad Dermatol 1996;35:895–8, doi:10.1016/ S0190-9622(96)90112-7. 17. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210–6, doi:10.1111/j.1365-2230.1994.tb01167.x. 18. Maroti M, Ulff E, Wijma B. Quality of life before and 6 weeks after treatment in a dermatological outpatient treatment unit. J Eur Acad Dermatol Venereol 2006;20:1081–5, doi:10.1111/j.1468-3083. 2006.01704.x. 19. Kent G, Al-Abadie MSK. Factors affecting responses on Dermatology Life Quality Index among vitiligo sufferers. Clin Exp Dermatol 1996; 21:330–3, doi:10.1111/j.1365-2230.1996.tb00116.x. 20. Parsad D, Pandhi R, Dogra S, et al. Dermatology Life Quality Index score in vitiligo and its impact on the treatment outcome. Br J Dermatol 2003;148:363–84, doi:10.1046/j.1365-2133.2003.05097_ 9.x. 21. Harlow D, Poyner T, Finlay AY, Dykes PJ. Impaired quality of life of adults with skin disease in primary care. Br J Dermatol 2002;143: 979–82, doi:10.1046/j.1365-2133.2000.03830.x. 22. Holme SA, Beattie PE, Fleming CJ. Cosmetic camouflage advice improves quality of life. Br J Dermatol 2002;147:946–9, doi:10. 1046/j.1365-2133.2002.04900.x. 23. Boehncke WH, Ochsendorf F, Paeslack I, et al. Decorative cosmetics improve the quality of life in patients with disfiguring skin diseases. Eur J Dermatol 2002;12:577–80. 24. Teovska Mitrevska N, Eleftheriadou V, Guarneri F. Quality of life in vitiligo patients. Dermatol Ther 2012;25 Suppl 1:S28–31, doi: 10.1111/dth.12007. 25. Linthorst Homan MW, Spuls PI, de Korte J, et al. The burden of vitiligo: patient characteristics associated with quality of life. J Am Acad Dermatol 2009;61:411–20, doi:10.1016/j.jaad.2009.03.022.
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Treatment of Vitiligo Patients by Excimer Laser Improves Patients’ Quality of Life Hani A. Al-Shobaili Background: Vitiligo can negatively affect patients’ quality of life (QoL). Assessment of QoL provides relevant information about treatment benefits. Objectives: To examine the effects of excimer laser treatment on vitiligo patients’ QoL and to identify overall patient satisfaction. The literature review failed to show any study concerning the same field. Methods: A total of 134 vitiligo patients (with 386 lesions) were studied. The Dermatology Life Quality Index (DLQI) was used to assess the effect of excimer laser treatment on patients’ QoL. A visual analogue scale (VAS) was used to rate patients’ overall life satisfaction and disturbance. Results: Excimer laser treatment significantly improved QoL in vitiligo patients, with improvement observed in five of six DLQI domains. Treatment-induced changes in the VAS score showed a significant decline in life disturbance and improvement in life satisfaction. Multivariate analysis revealed that sex and treatment duration were independent factors influencing treatment outcomes. Conclusions: Treatment of vitiligo with excimer laser can positively influence patients’ QoL. Patients with multiple focal lesions should be treated by excimer laser even if some lesions may not show significant clinical improvement. Contexte: Le vitiligo peut alte´rer la qualite´ de vie (QV) des personnes atteintes. Aussi l’e´valuation de la QV fournit-elle des renseignements pertinents sur les avantages du traitement. Objectifs: L’e´tude visait a` examiner les effets du traitement par le laser a` excime`res sur la QV des patients atteints de vitiligo et a` e´valuer le degre´ ge´ne´ral de satisfaction. L’examen de la documentation n’a pas permis de relever d’e´tude se rapportant au meˆme domaine. Me´thode: Au total, 134 patients atteints de vitiligo (386 le´sions) ont participe´ a` l’e´tude. Nous avons utilise´ le Dermatology Life Quality Index (DLQI) pour e´valuer l’effet du traitement par le laser a` excime`res sur la QV des patients. Quant au degre´ ge´ne´ral de satisfaction et de malaise a` l’e´gard de la vie, ils ont e´te´ e´value´s a` l’aide d’une e´chelle visuelle analogue (EVA). Re´sultats: Le traitement par le laser a permis d’ame´liorer conside´rablement la QV chez les patients atteints de vitiligo; en effet, une ame´lioration a e´te´ note´e dans cinq domaines sur six e´value´s dans le questionnaire DLQI. Par ailleurs, les changements releve´s dans les re´sultats obtenus sur l’EVA et attribuables au traitement ont re´ve´le´ une diminution importante du malaise devant la vie et une ame´lioration sensible du degre´ de satisfaction a` l’e´gard de la vie. Par ailleurs, les analyses plurifactorielles ont aussi re´ve´le´ que le sexe et la dure´e du traitement e´taient des facteurs inde´pendants qui avaient une incidence sur les re´sultats du traitement. Conclusions: Le traitement du vitiligo par le laser a` excime`res peut ame´liorer la QV des patients. Ceux qui pre´sentent de nombreuses le´sions focales devraient eˆtre traite´s par le laser a` excime`res, meˆme si certaines le´sions peuvent ne pas montrer d’atte´nuation importante sur le plan clinique.
ITILIGO is a common acquired pigmentation disorder, affecting at least 1% of the world population, regardless of age or sex. Although vitiligo does not
V
From the Department of Dermatology, College of Medicine, Qassim University, Qassim, Saudi Arabia. Address reprint requests to: Hani A. Al-Shobaili, MD, Department of Dermatology, College of Medicine, Qassim University, PO Box 5578, Unaizah 51911, Saudi Arabia; e-mail: [email protected].
DOI 10.2310/7750.2014.14002 # 2014 Canadian Dermatology Association
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cause direct physical impairment, it can produce significant psychosocial burden.1,2 Several studies have demonstrated that patients with vitiligo suffer from poor body image and low self-esteem and experience a considerable level of psychosocial disability3 and that this poor self-image of vitiligo patients can lead to depression.4 Many vitiligo patients show significant distress, especially in relation to social activities or negative reactions with others,5 and most patients with vitiligo report feelings of embarrassment, which can lead to low self-esteem and further social isolation.6 Moreover, many patients experience discrimination from
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others and feel stigmatized,7 and it has also been reported that the disease may have a negative effect on sexual relationships.8 In general, all currently available data demonstrate a negative impact of vitiligo on patients’ overall quality of life. Excimer laser treatment for vitiligo patients has been previously reported to improve the degree of repigmentation.9 However, assessment of quality of life will provide more important and relevant information on the benefits of the treatment. Several general validated questionnaires and diagnostic structured interviews have already been introduced.10–12 However, due to the shortcomings of these questionnaires in a dermatologic setting, only a few diseasespecific questionnaires have been found to display a good correlation between quality of life and treatment response for vitiligo.13–16 In 1994, Finlay and Khan proposed the Dermatology Life Quality Index (DLQI), which can be used to evaluate the quality of life of patients in dermatologic outpatient settings and to compare the quality of life between different chronic dermatologic diseases.17 The objective of this study was to determine the effect of excimer laser treatment on vitiligo patients’ quality of life and on their overall life satisfaction and disturbance after treatment.
Methodology Recruitment of Patients This study was performed at the Dermatology Clinics of Qassim University–affiliated hospitals in Saudi Arabia between July 2012 and April 2013. A total of 162 vitiligo patients with vitiliginous lesions at different body sites were enrolled. After explaining the treatment procedure and the expected benefits and risks, informed consent was obtained from all patients. Patients were included if they had vitiligo affecting # 5% of the body and had not been receiving any treatment for the last 8 weeks. Pregnant or breast-feeding women, patients with a history of photosensitive disorders or skin cancer, or those who had used systemic and/or topical immunosuppressive treatments within the last 8 weeks were excluded from the study. Patients were also excluded if they had been exposed extensively to sunlight or phototherapy in the 8 weeks before entering the study. Information about the demographics of the patients, the type of vitiligo, the site of lesions, and the duration of the disease was collected. Ethical approval was obtained from the Institutional Review Board of the College of Medicine, Qassim University.
Excimer Laser Treatment All patients were treated with a monochromatic 308 nm xenon-chloride excimer laser (XTRAC, PhotoMedex, Horsham, PA). The fixed technical parameters were as follows: pulse frequency of 200 Hz, with a maximal output of 600 mW/cm2 per pulse; pulse width of 30 nanoseconds; and laser energy of 20 mJ. Beam transmission was achieved by liquid light guide, with variable spot size diameters of 15, 20, and 25 mm that were changed according to the size of the lesions. The minimal erythema dose (MED) was determined for each patient, and treatment was started with one MED, which was repeated twice a week on nonconsecutive days. The dose given at each session depended on the extent of the erythema observed after the previous treatment. If the erythematous response was severe and/or other signs of phototoxic side effects (eg, burning/stinging, edema, and/or blisters) were present, the subsequent session was cancelled. If the erythematous response was moderate or slight, the dose was increased by 50 mJ/cm2. If there was no erythematous response, the dose was increased by 100 mJ/cm2. The eyes of the patients were protected with ultraviolet light–protective goggles. The end point was 32 treatments, or 100% repigmentation, whichever was achieved first. DLQI and Visual Analogue Scale The DLQI questionnaire was used according to the instructions given by Finlay and Khan.17 This is a widely validated questionnaire that is simple, self-explanatory, easy to use, and well accepted by patients. It provides quantifiable measurement of quality of life and allows comparison between several chronic skin disorders. The questionnaire includes 10 questions, each with a maximum score of 3 and a minimum score of 0, resulting in a cumulative score ranging between 0 and 30. The higher the score, the more the quality of life is impaired. The DLQI has six domains, concerning different aspects of life: (1) symptoms and feelings; (2) daily activities; (3) leisure; (4) work and school; (5) personal relationships; and (6) treatment. Domains 1, 2, 3, and 5 consist of two questions each, with a maximum domain score of 6. The other two domains (4 and 6) have one question each, with a maximum domain score of 3. Every patient completed the DLQI questionnaire at the beginning of the study, as well as after the completion of the treatment, approximately 16 weeks later. Additionally, all patients were also requested to rate their overall life satisfaction and their overall life
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disturbance before and after treatment on a visual analogue scale (VAS) of 0 to 10, where 0 represents no satisfaction or no disturbance and a score of 10 represents complete satisfaction or maximum disturbance. Statistical Analysis Data were analyzed using SPSS for Windows version 16.0 (SPSS Inc., Chicago, IL). The results are expressed as mean 6 standard deviation unless stated otherwise. Data were tested for normality prior to the t-test and analysis of variance (ANOVA). Paired two-tailed t-tests were used to compare mean scores of the DLQI before and after treatment. One-way ANOVA was used to measure the correlation between mean scores and different sociodemographic and clinical variables. Multivariate analysis was used to identify significant independent factor(s) that affected the mean DLQI scores. A p value , .05 was considered significant.
Results Characteristics of the Study Patients The results from 134 of 162 subjects (64 men, 70 women) were analyzed. Twenty-eight patients (17.3%) left the clinics without completing the questionnaire and therefore were excluded from the study; however, their social, demographic, and clinical characteristics were analyzed, and the improvement was significantly similar to that of those who participated and completed their questionnaires. The total number of lesions treated by excimer laser was 386. The demographic and clinical characteristics of the patients are summarized in Table 1. DLQI Scores As evident in Figure 1, the overall improvement in the DLQI score was statistically significant after excimer treatment (p , .001). The means (6 SD) of the DLQI scores before and after the treatment were 10.6 6 4.3 and 4.5 6 3.9, respectively. The majority of patients (123; 91.8%) demonstrated improvement in their quality of life, whereas 11 patients (8.2%) showed no significant improvement. The reported scores at baseline and the end of treatment among the vitiligo patients on the six domains of the DLQI questionnaire are summarized in Table 2. A majority of patients demonstrated significant improvement in five of six DLQI domains (p , .001) except for the treatment domain. As far as the patient’s 52
Table 1. Demographic and Clinical Characteristics of the Study Subjects Characteristic Number of patients (M:F) Mean age in years (SD, range) Gender, n (%) Male Female Education, n (%) No education Up to secondary education University Postgraduate Social status, n (%) Single Married Divorced/widowed Occupation, n (%) Manual work Clerk Business Professional Student Housewife Type of vitiligo lesions, n (%) Focal Vulgaris Segmental Mean duration of disease, years (SD, range) Mean age at onset, years (SD, range) Distribution of lesions (N 5 386), n (%) Face Neck Trunk Upper limb Lower limb
n 134 (64:70) 32.5 (11.8, 16–50) 64 (47.8) 70 (52.2) 6 63 54 11
(4.5) (47.0) (40.3) (8.2)
52 (38.8) 75 (56.0) 7 (5.2) 4 23 20 19 34 34 176 193 17 5.3
(3.0) (17.2) (14.9) (14.1) (25.4) (25.4) (45.6) (50.0) (4.4) (5.3, 1–42)
26.8 (11.0, 3–53)
52 32 73 124 105
(13.5) (20 M, 32 F) (8.3) (10 M, 22 F) (18.9) (43 M, 30 F) (32.1) (50 M, 74 F) (27.2) (55 M, 50 F)
Figure 1. Vitiligo patients’ quality of life measured by the Dermatology Life Quality Index questionnaire before and after excimer laser treatment.
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Table 2. DLQI Scores in the Six Domains before and after Excimer Laser Treatment in Vitiligo Patients DLQI Score (mean 6 SD) Domain (maximum DLQI score) Symptoms and feelings (6) Daily activities (6) Leisure (6) Work and school (3) Personal relationships (6) Treatment (3)
Before Treatment 2.35 3.09 2.40 1.46 1.25 0.04
6 6 6 6 6 6
0.43 0.61 0.42 0.26 0.23 0.01
After Treatment 1.08 1.21 1.07 0.60 0.49 0.03
6 6 6 6 6 6
0.19 0.22 0.20 0.14 0.07 0.01
Difference (mean 6 SD)
p Value
6 6 6 6 6 6
.001 .001 .001 .001 .001 .48
1.27 1.88 1.33 0.86 0.76 0.01
0.23 0.34 0.24 0.15 0.14 0.002
DLQI 5 Dermatology Life Quality Index.
gender was concerned, women showed a higher quality of life index, but both men and women showed significant improvement in their quality of life after the excimer laser treatment. The mean DLQI scores did not differ significantly between different education, social class, and occupation groups after treatment ( p5 .87, .42, and .33, respectively). When the patients were divided into three age groups (, 20 years, 20–39 years, and $ 40 years), the mean DLQI scores before and after treatment were not influenced by age group (p 5 .30 and .43, respectively). However, data on the duration of disease (, 1 year, 1–3 years, and . 3 years), the location of the lesions, and the type of vitiligo significantly influenced the DLQI score before and after treatment (p , .05). The highest score, indicating the highest impairment in quality of life, was observed among patients with a disease duration of . 3 years. The improvement in DLQI scores distributed by site of lesions is shown in Figure 2. In short, the improvement in DLQI scores was greatest for patients with lesions on the face and neck, followed by the legs and arms, and, lastly, the abdomen and back. In contrast, patients with lesions on the hands and feet did not report significant improvement in quality of life. The association between
DLQI scores and the type of vitiligo lesions was also investigated (Figure 3). Our data demonstrated a clear reduction in the DLQI scores in all types of vitiligo lesions after excimer laser treatment, with the highest improvement in quality of life being achieved in patients with focal-type vitiligo. Furthermore, we observed that patients with multiple lesions suffered significantly greater impairment in their quality of life before treatment compared to patients with a single lesion (p 5 .02). Conversely, patients with multiple lesions showed significantly greater improvements in their DLQI scores after treatment compared to patients with a single lesion (p , .01). In addition, the quality of life of patients with exposed lesions (face, neck, and upper arm) was more impaired before treatment and was more improved after treatment compared to patients with covered lesions (p , .01), except for patients with lesions on the hands and feet. For further validation, multivariate analysis was performed to determine the independent factors influencing the DLQI scores on excimer treatment. The analysis revealed that being a female, having longer disease duration, and having lesions on the face and neck
Figure 2. The Dermatology Life Quality Index scores distributed by site of lesion before and after excimer laser treatment.
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Figure 3. The Dermatology Life Quality Index scores in different types of vitiligo before and after excimer laser treatment.
demonstrated significantly better improvement in DLQI scores (p , .01). VAS Scores Patients responded to two questions about their perceived life disturbance and overall life satisfaction before and after treatment. These questions used a VAS of 0 to 10. The mean (6 SD) VAS scores of patients before and after excimer treatment are shown in Figure 4. Comparing VAS scores before and after treatment revealed that life disturbance was significantly reduced by 45.6% (8.1 vs. 3.7), whereas life satisfaction was significantly improved (2.0 vs. 6.8) (p , .001) after the treatment. Table 3 summarizes the vitiligo patients’ life satisfaction and disturbance before and after excimer laser treatment, sorted by the different sites of the vitiligo lesions. Patients with multiple lesions showed a significant decline in life disturbance and significant improvement in life satisfaction after treatment with excimer laser. The only exception
was patients with lesions on the hands and feet, who did not show any significant differences in either their life disturbance or life satisfaction score. The effect of education, social class, and occupation on the life disturbance and satisfaction scores before and after treatment was not statistically significant (p . .05). On the other hand, there was a significantly greater improvement in life satisfaction and a decline in the life disturbance score after treatment in patients with longer disease duration (. 3 years) (p 5 .01 and p 5 .02, respectively) compared to patients with a disease duration # 3 years. Patients who achieved higher rates of repigmentation of vitiligo lesions showed significantly less life disturbance and more life satisfaction after treatment. Multivariate analysis was used to determine the factors influencing life disturbance and satisfaction. Female patients were generally less satisfied and more disturbed than male patients (p 5 .02 and p 5 .01, respectively). Similarly, patients with longer disease duration were less satisfied (p 5 .01) and more disturbed (p 5 .01). Other
Figure 4. Visual analogue score measurement before and after laser treatment.
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Table 3. Effect of Excimer Laser Treatment on Patients’ Overall Life Satisfaction and Disturbance: Correlation with Sites of Vitiligo Lesions Life Disturbance Score (mean 6 SD) Lesions Treated n (%)
Site Face and neck Abdomen Back Legs Thighs Foot Upper arm Lower arm Elbows Hand Total
84 42 31 36 39 30 30 18 26 50 386
(21.8) (10.9) (8.0) (9.3) (10.1) (7.8) (7.8) (4.7) (6.7) (12.9) (100)
Before Treatment 9.8 6.9 6.6 7.6 7.8 8.1 7.9 8.5 7.9 8.6 8.1
6 6 6 6 6 6 6 6 6 6 6
1.47 1.38 1.33 1.54 1.17 1.22 1.42 1.28 1.19 1.29 1.14
After Treatment 2.3 1.7 1.3 2.1 2.8 7.6 2.5 3.1 2.3 7.9 2.7
6 6 6 6 6 6 6 6 6 6 6
0.35 0.26 0.19 0.32 0.42 1.14 0.38 0.47 0.35 1.27 0.41
Life Satisfaction Score (mean 6 SD) p Value Before Treatment .001 .001 .001 .001 .001 .140 .001 .001 .001 .15 .001
1.5 2.4 2.6 1.9 2.1 1.6 2.3 1.4 2.1 1.6 2.0
6 6 6 6 6 6 6 6 6 6 6
0.23 0.38 0.41 0.29 0.32 0.24 0.32 0.21 0.31 0.23 0.33
After Treatment
p Value
6 6 6 6 6 6 6 6 6 6 6
.001 .001 .001 .001 .001 .21 .001 .001 .001 .24 .001
7.9 7.0 7.2 7.4 7.5 3.1 7.5 6.6 7.8 2.9 6.8
1.42 1.19 1.17 1.33 1.13 0.46 1.20 1.06 1.18 0.41 1.05
DLQI 5 Dermatology Life Quality Index.
sociodemographic and clinical variables did not influence life disturbance or satisfaction significantly.
Discussion Most previous studies on vitiligo have demonstrated the negative impacts of the disease on patients’ social and psychological quality of life,5,8,16 but only a few studies have focused on the impact of any treatments on the patients’ quality of life.18 Impaired quality of life, which is common in people with chronic skin diseases, may not necessarily relate to disease severity. Therefore, this study included other factors that may be related to quality of life, such as social and demographic aspects. The response rate in this study was 82.7%, which provided a representative impression of the study population. In this study, the mean DLQI score before treatment was higher than that obtained by other studies. However, it is well documented that different studies showed different DLQI scores.5,17,19 This study found no relationship between DLQI score and the occupation, education, social class, or age of patients. Conversely, sex, duration of the disease, location of the lesion, and the type of vitiligo were found to significantly affect the DLQI score. Improvements in DLQI scores were observed in five of six domains of the DLQI. The only domain that did not show significant improvement was the treatment domain. However, it did not affect the overall improvement in patient quality of life. The study also revealed that female vitiligo patients experienced significantly more impairment in their quality of life than male patients. However, Kent and al-Abadie
and Parsad and colleagues found no relationship between the DLQI and sex.19,20 Our data revealed that patients with vitiligo on the exposed areas of the body were predominantly women, and this may partly explain why the quality of life of women was more disturbed. This study also showed that women were more impaired in their daily routine activities and in personal relationships and more influenced in the choice of clothing. Altogether, the data clearly indicated that the impact of vitiligo on the quality of life of women was markedly higher compared to the impact on the quality of life of male patients. These results are well supported by many published reports on other dermatologic conditions.21 This study also demonstrated that quality of life in patients with exposed lesions was significantly improved after treatment. In other studies, where quality of life has been demonstrated to be improved after the use of camouflage treatment for disfiguring exposed skin conditions, similar results have been observed, clearly indicating the importance of treatment, specifically of exposed lesions.22,23 However, in a recent study on coping and stigmatization in vitiligo, Schmid-Ott and colleagues reported that the location of vitiligo plays no role in the overall stigmatization experience.7 Furthermore, this study also determined that longer disease duration and multiple lesions were important factors for predicting impairment in quality of life. It can thus be hypothesized that therapeutic strategies to reduce the number of affected sites could improve patients’ quality of life. It has also been reported that the social life of vitiligo patients is impaired by the tendency of these patients to withdraw from friends
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and to avoid going out.24,25 In this regard, the present study also determined that daily activities, leisure, work, and personal relationships were all significantly improved after treatment.
Conclusion Treatment of vitiligo patients by excimer laser shows positive impacts on patients’ quality of life. To the best of my knowledge, this is the first study that compares vitiligo patients’ quality of life before and after excimer laser treatment. The data also revealed that the excimer laser failed to treat some of the lesions, especially on the hands and feet. However, the study found that this treatment improved patients’ overall life satisfaction. Therefore, the results of the present study conclude that vitiligo patients should be treated by excimer laser regardless of the poor response of some vitiliginous lesions.
Acknowledgments Financial disclosure of author and reviewers: None reported.
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