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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 31-35

Validation of vitiligo impact scale-22 among North Karnataka population


1 Department of Dermatology, Venereology and Leprosy, Shri B.M. Patil Medical College, Hospital and Research Center, BLDE University, Bijapur, Karnataka, India
2 Department of Dermatology and Venereology, AIIMS, Bhubaneswar, Odisha, India

Date of Submission28-Nov-2018
Date of Acceptance03-Feb-2019
Date of Web Publication06-Jan-2020

Correspondence Address:
Aparna Palit
Department of Dermatology and Venereology, AIIMS, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_55_18

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  Abstract 


Background: Vitiligo is known to have major psychosocial impact among the sufferers. “Vitiligo impact scale-22 (VIS-22)” is a recently developed specific scale to measure quality of life (QOL) in these patients. It was found effective in evaluating QOL among north Indian patients with vitiligo. Since the effect of vitiligo on QOL is variable, it is prudent to validate VIS-22 in various populations. Aim: This study aims to validate VIS-22 among south Indian patients with vitiligo. Methods: Vitiligo patients with education up to 10th standard were included as cases. Patients suffering from short-term illnesses served as controls. Cases and controls were given visual analog scale (VAS), dermatology life quality index (DLQI), Skindex-16 and VIS-22 to respond at 1st, 2nd, and 12th weeks. The criterion and construct validities of the scales were evaluated using Spearman's correlation coefficient (r). Student's t-test was used for disease specificity of VIS-22. Spearman's rank coefficient, paired t-test, and ANOVA were used to estimate first, second, and third measures of responsiveness, respectively. Results: A total of 153 cases and 155 controls were enrolled. The criterion validity showed strongest correlation with Skindex-16 (r = 0.832) and convergent validity with both DLQI (r = 0.752) and Skindex-16 (r = 0.832). It also showed strong correlation with emotional and functioning domain of Skindex-16 at baseline (r = 0.713 and 0.702, respectively) and at 12 weeks (r = 0.770 and 0.789, respectively). The scales were reliable at baseline and 2 weeks with excellent correlation between scores (r = 0.954). The VIS-22 scores were responsive at week 12 and similarly in VAS, DLQI, and Skindex-16. Conclusion: VIS-22 has vitiligo-specific questions and better QOL measurement properties compared to DLQI and Skindex-16. This study results found VIS-22 to be a valid, highly reliable, and responsive QOL-measurement tool among south Indian patients with vitiligo.

Keywords: Quality of life, vitiligo, vitiligo impact scale-22


How to cite this article:
Shivaswamy A, Palit A, Inamadar AC. Validation of vitiligo impact scale-22 among North Karnataka population. Clin Dermatol Rev 2020;4:31-5

How to cite this URL:
Shivaswamy A, Palit A, Inamadar AC. Validation of vitiligo impact scale-22 among North Karnataka population. Clin Dermatol Rev [serial online] 2020 [cited 2020 Feb 23];4:31-5. Available from: http://www.cdriadvlkn.org/text.asp?2020/4/1/31/275249




  Introduction Top


Vitiligo is known to have major psychosocial impact upon the sufferers.[1] It is particularly stigmatizing in the dark-skinned population due to visible contrast.[2] The general appearance of the vitiligo-sufferers may affect their self-image and cause major depression.[3] A marked reduction of quality of life (QOL) has been observed among these patients irrespective of the extent of the disease.[1] It is particularly distressing when the lesions are located on the exposed body parts such as face and extremities.[4],[5]

Various study results have demonstrated that vitiligo causes emotional, social, and occupational impact on affected patients.[6] Peer pressure among children and adolescents and discrimination at workplaces have been observed.[2] The particularly stressful situations are difficulty in getting married and marital disharmony in young adult sufferers.[3],[7] Many studies have been conducted to estimate the QOL in vitiligo patients. The results showed that psychological abnormalities frequent among these patients include embarrassment, anxiety, depression, suppressed interpersonal and social behavior, poor body image, sleep disturbances, and suicidal tendencies.[3] These observations indicate that the psychological impact of vitiligo need to be evaluated so that early preventive measures can be instituted and help the patients to have a better QOL.

There are various scales to measure the QOL in patients with vitiligo, such as general health measures (visual analog scale [VAS]) and skin disease-specific questionnaires.[8],[9] Three important nonspecific skin disease questionnaires are the dermatology life quality index (DLQI), Skindex-29, and Skindex-16.[9] The available vitiligo-specific scales are vitiligo life quality index, VitiQol, and vitiligo impact scale (VIS).[10],[11],[12] These vitiligo-specific scales have an advantage of having disease-relevant questions and thus, higher acceptability among patients and dermatologists.[1]

VIS-22 is a modified version of VIS.[8] VIS consisted of 27 questions where five were specifically for married individuals and only one for unmarried. To minimize the chances of discrepancy in final scoring among married and unmarried patients Gupta et al. have designed VIS-22 by equalizing the number of questions for both groups.[1] Thus, the scale consists of 22 questions and has been found to be effective to assess the QOL in patients with vitiligo among a group of North Indian patients.[1] Since the impact of vitiligo on QOL of patients may vary depending on the region, social status, level of education, existing beliefs and taboos, and skin type, it is important to validate the effectiveness of VIS-22 in various population. The validation of VIS-22 was done among a segment of South Indian population residing in North Karnataka.


  Methods Top


A total of 153 vitiligo patients and 155 controls attending the dermatology outpatient department of a tertiary care hospital in North Karnataka were included.

Vitiligo patients aged more than 16 years with educational status of at least secondary level, irrespective of gender, and clinical type of disease were taken up. The enrolled controls fulfilled the same criteria but suffering from short-term skin diseases unlikely to cause psychological impact.

Three assessment visits for both patients and controls were planned over a period of 12 weeks; the 1st visit (0 week), 2nd visit (2 weeks), and 3rd visit (12 weeks). A detailed history was taken on the first visit, and clinical examination of the patients was done to note the type, distribution, and severity of vitiligo and subsequent improvement or worsening during all three visits.

Total 4 scales were selected for assessment of the patients; VAS, two non-specific scales DLQI and Skindex-16, and VIS-22. The original VIS-22, which was in English language and translated to Hindi by Gupta et al.,[1] was re-translated to the Kannada language for easy comprehensibility of the study population [Figure 1]. During each visit, the patients and controls were given VAS, DLQI, Skindex-16, and VIS-22 to respond.[1]
Figure 1: Translation of VIS-22 in Kannada language

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Each patient was given appropriate treatment depending on disease type, severity and tendency to progress. These included topical corticosteroids and/or tacrolimus (0.1%), oral mini-pulse therapy with betamethasone, narrowband ultraviolet-B phototherapy, targeted phototherapy, and mini-punch and suction blister grafting. The controls were treated adequately for respective illnesses. The clinical improvement of the vitiligo patients was graded as follows:

  1. Mild improvement - 25%
  2. Moderate improvement - 25%–49%
  3. Good improvement - 50%–74%
  4. Excellent improvement - ≥75%.


Institutional Ethics Committee approval was undertaken, and consent was obtained from each case and control.

Statistical analysis

Clinico-epidemiological data collected from the patients were calculated with mean ± standard deviation (SD). The criterion and construct validities were evaluated using Spearman's correlation coefficient. Student's t-test was used for disease specificity of VIS-22. Spearman's rank coefficient, paired t-test, and ANOVA were used to estimate first, second, and third measures of responsiveness, respectively.


  Results Top


Among 153 cases who were enrolled, 124 (81.04%) continued to follow-up till 12 weeks. The clinical details of the cases and controls have been presented in [Table 1].
Table 1: Demographic characteristics of cases and controls

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Criterion validity

The mean (±SD) scores at the 1st visit for the VAS, DLQI, Skindex-16, and VIS-22 were 5.1 (±2.5), 5.6 (±4.6), 22.07 (±14.0), and 19.1 (±10.8), respectively. The VAS (correlation coefficient [r] =0.676, P < 0.001) showed moderate correlation with VIS-22. The DLQI showed strong correlation (r = 0.752, P < 0.001), and Skindex-16 showed the strongest correlation (r = 0.832, P < 0.001) with VIS-22. Similar strengths of correlations were found between the scales at week 12.

Convergent validity

The VIS-22 showed a strong correlation with DLQI and Skindex-16 (P < 0.001). The total scores of VIS-22 showed poor correlation with the symptom domain of Skindex-16 (r = 0.462), but a strong correlation with emotion and social functioning domains (r = 0.713 and 0.702, respectively) at baseline. At week 12, moderate correlation was found with symptom domain (r = 0.613) and strong correlation with emotion and social functioning domain (r = 0.770 and 0.789, respectively).

The correlation between VAS, DLQI, Skindex-16, and VIS-22 at baseline, week 2 and week 12 have been presented in [Table 2].
Table 2: Correlation of visual analog scale, dermatology life quality index, skindex-16, vitiligo impact scale-22 at baseline and week 12

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Test retest reliability

The scores of VAS, DLQI, Skindex-16 (%), and VIS-22 at baseline and 2nd visit showed a strong correlation (r = 0.954 and P < 0.001), indicating that all the four scales are reliable at 2 weeks' interval.

Clinical response of patients with vitiligo

Among 153 patients with vitiligo, 91 (73.4%) showed improvement of their skin lesions, whereas 27 (21.0%) showed no clinically significant change. Seven patients (5.6%) had worsening of their skin lesions characterized by minimal or no re-pigmentation and appearance of new depigmented lesions.

Correlation with degree of clinical response

Among the 91 patients, who showed clinical response to the treatment provided, 45 (49.5%) had mild, 15 (16.5%) had moderate, 22 (24.2%) had good, and 9 (9.9%) showed excellent improvement.

Correlation of change in scores with change in disease status

A statistically significant correlation was found (P < 0.001) between scores of each individual scale at baseline and 3rd visit in relation to changes in disease status (either worsening of disease status or clinically good/excellent response). However, there was no significant correlation between these two parameters when there was mild-to-moderate response to therapy. The correlations between the individual scores and change in disease status of vitiligo patients have been presented in [Table 3] and [Figure 2], [Figure 3].
Table 3: Correlation of change in individual scores and disease status

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Figure 2: Correlation of change in baseline individual scores and disease status

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Figure 3: Correlation of change in 3rd visit individual scores and disease status

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  Discussion Top


Vitiligo is known to cause a great psychosocial impact on affected patients. Indians are particularly susceptible to vitiligo-related psychological morbidity due to their darker skin shade producing a strong contrast.[1],[2] It is associated with an enormous social stigma, psychological distress, and affects the interpersonal relationships.[7] Many of the vitiligo patients feel that they are the victims of impolite remarks and ridicule, and discriminated because of their abnormal skin color. These feelings are more among the young and active group of patients. Indian women probably have the greatest impairment of QOL as compared to men because of the prevalent custom of gender discrimination in the society.[3]

The mean (±SD) DLQI score among vitiligo patients was 5.6 (±4.6) showing a moderate effect on QOL of vitiligo patients and is comparable to the results from earlier studies.[13] The mean (±SD) scores of DLQI, Skindex-16, and VIS-22 are 5.6 (±4.6), 22.0 (±14.0), and 19.1 (±10.8), respectively. In the study by Gupta et al., the mean (±SD) scores of DLQI, Skindex-16, and VIS-22 were 8.25 (±6.93), 31.98 (±23.11), and 26.50 (±14.47), respectively.[1] It was observed that the emotional status of Skindex-16 was the most affected domain among vitiligo patients (38.2%) followed by social functioning (11.3%) and symptoms (6%) whereas the symptoms domain was most affected among controls (20.66%).

The criterion validity showed a strong correlation of VIS-22 with Skindex-16 (r = 0.832, P < 0.001), followed by DLQI (r = 0.752, P < 0.001) and a moderate correlation was found with VAS (r = 0.676, P < 0.001) at baseline. Similar results were noticed at 12th week. The results were comparable to that of Gupta et al., where VIS-22 showed a strong correlation with Skindex-16 (r = 0.761, P < 0.001) and VAS (r = 0.7076, P < 0.001) and a moderate correlation with DLQI (r = 0.5889, P < 0.001).[1]

The convergent validity in the population was evident by a strong correlation of VIS-22 with DLQI and Skindex-16 (P < 0.001). The total scores of VIS-22 showed poor correlation with the symptom domain of Skindex-16 (r = 0.462), while there was a strong correlation with emotion and social functioning domains (r = 0.713 and 0.702, respectively) at baseline. At week 12, moderate correlation was found with symptom domain (r = 0.613) and strong correlation with emotion and social functioning domains (r = 0.770 and 0.789, respectively). Similar observations were made by Gupta at al where the convergent validity was evident by strong correlation of VIS-22 with DLQI and Skindex-16 (P < 0.001).[1] The total scores of VIS-22 showed poor correlation with symptom domain of Skindex-16 (r = 0.36), but a moderate-to-strong correlation with emotion and social functioning domains (r = 0.63 and 0.74, respectively). Similar results were noted between baseline and at 12th week.

A statistically significant difference (P < 0.001) was found in mean (±SD) VIS-22 scores of cases 19.1 (±10.8) and controls 6.8 (±7.0), similar to the findings by Gupta et al. where the VIS-22 scores were significantly higher compared to the controls.[1] The test-retest reliability of VAS (r = 0.955), DLQI (r = 0.974), Skindex-16 (r = 0.93), and VIS-22 (r = 0.957) at baseline and 2nd visit showed a strong correlation (P < 0.001) which was comparable to the study results of Gupta et al.,[1] with a high reliability of 0.9053 for VIS-22 followed by DLQI (r = 0.8242) and Skindex-16 (r = 0.7166).

VIS-22 showed a significantly higher scores in clinically nonresponders (mean change = 4.7, P < 0.001) similar to the study results of Gupta et al., which also showed a significant high scores (mean change = 10.412, P = 0.01).[1] Skindex-16 also showed a significant higher scores (mean change = 4.6, P < 0001) in clinical nonresponders whereas DLQI showed a statistically nonsignificant difference (mean change = 0.6, P = 0.016). This was in contrast to the study results of Gupta et al., where DLQI showed a significant difference (mean change = 3.391, P = 0.01) whereas the difference of Skindex-16 was not statistically significant (mean change = 5.476, P = 0.27) in clinical nonresponders.[1]

From the results, it is evident that VIS-22 is a valid, reliable, and responsive QOL instrument in patients with vitiligo. It was established by Gupta et al. among a group of North Indian patients with vitiligo.[1] Their finding was validated among a group of South Indian patients indicating efficacy of VIS-22 in determining QOL among vitiligo patients from varied background. However, it requires further validation in other parts of India among the different population to label it as a widely effective QOL determinant in patients with vitiligo.

Although the sample size was adequate to assess and validate VIS-22, a larger sample size would have been helpful to estimate the interpretability of the scores. Another limitation was that like the earlier study this population also belonged to the Indian society where vitiligo is already associated with enormous stigma and hence, certain degree of impaired QOL among the sufferers was expected.


  Conclusion Top


Gross impairment of the QOL in vitiligo patients is known in the Indian society. These patients require thorough counseling and early intervention to reduce psychological morbidity so that they can return to a normal life. The invention of a disease-specific scale for this purpose was long pending. The results established that VIS-22 is a valid, reliable, and responsive instrument for the measurement of QOL in vitiligo patients residing at southern India as well. Further validation in other geographical regions in India and various other countries is required to accept it as a standard vitiligo-specific scale for the measurement of QOL. In future, the widespread use of VIS-22 for patients with vitiligo at both institutional and community levels would be a boon in their effective management.

Declaration of patient consent

The informed consent was obtained for participation in the study and publication of data and images for research and educational purposes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Gupta V, Sreenivas V, Mehta M, Khaitan BK, Ramam M. Measurement properties of the vitiligo impact scale-22 (VIS-22), a vitiligo-specific quality-of-life instrument. Br J Dermatol 2014;171:1084-90.  Back to cited text no. 1
    
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