Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2024;14(2):e2024112 1 Dermatology Quality of Life and Depression, Anxiety, and Stress Scale-42 in Scabies Patients Serap Köran Karadoğan1, Berna Ulgen Altay2 1 İzmir Metropolitan Municipality Esrefpasa Hospital, Konak/İzmir, Turkey 2 Department of Dermatology, Izmir Democracy University Medical Faculty, Buca Seyfi Demirsoy Training and Research Hospital, Konak/ İzmir, Turkey Key words: Scabies, quality of life, depression, anxiety, stress Citation: Karadoğan SK, Ulgen Altay B. Dermatology Quality of Life and Depressıon Anxiety and Stress-42 Scale in Scabies Patients. Dermatol Pract Concept. 2024;14(2):e2024112. DOI: https://doi.org/10.5826/dpc.1402a112 Accepted: November 12, 2023; Published: April 2024 Copyright: ©2024 Karadoğan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: Both the authors have contributed significantly to this publication. Corresponding Author: Serap Köran Karadoğan, İzmir Metropolitan Municipality Esrefpasa Hospital Depratment of Dermatology, Gaziler Street, No:315, 35170, Konak/İzmir, Turkey Email address: gafkaradogan@yahoo.com Introduction: Scabies is a pruritic skin infestation with a globally increasing prevalence. Sleep prob- lems and impaired social and personal interactions, mainly due to itching, have been reported. Objectives: We aimed to determine the influence of scabies on quality of life and psychosocial health using Dermatology Life Quality Index (DLQI) and Depression Anxiety and Stress Scale-42 (DASS-42) and analyze whether there is a correlation between the two scales and any sociodemographic and clinical characteristic. Methods: Scabies patients (>16 years) who presented to our outpatient clinics were enrolled. Age, sex, occupation, marital status, and education level and clinical features were recorded. DLQI and DASS-42 were used. Possible influence of demographic and clinical characteristics on total scores were analyzed. The Spearman coefficient analysis was performed to determine whether there is a correlation between these scores. Results: Of 92 patients (mean age:37.76±15.355, Female/Male: 1.09/1), 63% were married and 35.9% were high-school graduates; 27.2% and 23.9% were housewives and officers, respectively. Disease was generalized in 57.6% and duration of disease was mostly <4 weeks. Mean DLQI and DASS-42 scores were 13.16±7.638 and 42.10±30.644, respectively. Symptoms/feelings were affected predominantly. DLQI was affected ‘severely’ in 41.3% of patients. Conclusions: Impairment of DLQI is a significant predictive parameter for higher DASS levels. Scabies is not only associated with impairment in DLQI but may also lead to psychosocial problems. All scabies patients should be evaluated and consulted–if needed–for possible problems of psychosocial status, including depression, anxiety, and stress, as well as clinical symptoms and secondary complications. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2024;14(2):e2024112 Introduction Scabies is a pruritic skin infestation caused by an ectopara- site Sarcoptes scabiei var. hominis presenting with itchy le- sions characteristically located on the web spaces of fingers, volar surfaces of wrists, inner thighs, umbilicus, areolae in women, and genitalia in men. Prolonged skin contact, usu- ally more than 10 minutes, particularly among family mem- bers and/or sexual partners, is the most common mode of transmission. Handshakes, hugging, and casual touching are very rare modes of transmission. Diagnosis is usually made clinically. Dermoscopic and/or microscopic evaluation to de- tect feces, eggs, or even mites may be used to confirm the diagnosis [1,2]. The disease has been reported to cause 71 disability- adjusted life years (DALY)/100,000 people, contributing to 0.21% DALYs from all of the 315 conditions studied by the Global Burden of Disease in 2015 worldwide [2]. The protective skin barrier may be impaired due to severe pru- ritus, and secondary cutaneous bacterial infections and even some life-threatening conditions, including renal and cardiac diseases, have been reported particularly among immuno- compromised patients [3]. Scabies not only causes pruritus and cutaneous signs but may also lead to impairment in the quality of life (QOL) of patients and even lead to social and psychological problems. Insomnia, a decrease in the qual- ity of sleep, and negative influence on daily activities due to pruritus have been reported. Patients cannot go to work or school, may be stigmatized or excluded, or may face commu- nication problems with friends and/or partners throughout the therapy period due both to the symptoms and to thera- peutic methods including topical ointments with an unpleas- ant odor [3-4]. Dermatology Life Quality Index (DLQI) has increas- ingly been used in many dermatological conditions recently. It gives very important data both to predict the therapeutic results and the prognosis of the dermatoses [5]. The Depres- sion, Anxiety and Stress Scale-42 (DASS-42) is a scale mea- suring three subscales–depression, anxiety and stress–both dimensionally and categorically and discriminates each in the same questionnaire [6]. DASS-42 or its shorter version (DASS-21) have previously been used in a few dermatoses, including oral lichen planus, eczema, and atopic dermatitis, as well as in specific populations such as employees, der- matologists, secondary school girls, and adolescent refu- gees [7-16]. There are only three studies investigating the relation- ship between QOL and psychological status of scabies pa- tients using various scales, including Beck’s Depression Scale (BDS), Beck’s Anxiety Inventory (BAI), Hamilton Anxi- ety Rating Scale (HAM-A), Zung Self-Rating Depression Scale (SDS), and Zung Self-Reporting Anxiety Scale (SAS) [17-20]. In this study, we aimed to investigate the psycho- logical burden of this disease using DASS-42 Scale and its possible correlation with DLQI results and also to determine whether any sociodemographic and clinical characteristics of the patients are related with these results. Methods We conducted a prospective and descriptive survey study after obtaining ethical clearance from the local ethics com- mittee. All the patients who presented to our dermatology outpatient clinics between January and June 2023, aged ≥16 years, capable of writing, reading, and understanding a given questionnaire, and diagnosed as having scabies clinically and/or dermoscopically were enrolled. The exclusion crite- ria were pregnancy/lactation, any doubt about the clinical diagnosis, atypical forms of scabies (Norwegian Gale), be- ing <16 years, chronic dermatological and systemic diseases (diabetes, hypertension, asthma, epilepsy, acne and psoria- sis), or using any mood-altering drugs. Patients’ age, sex, education level, marital status, occu- pation, and clinical characteristics such as distribution of lesions and duration of symptoms were recorded. The dis- ease was categorized as ‘localized’ if lesions were located on <3 regions and ‘generalized’ if lesions were located on ≥3 regions. After an informed consent form was signed by the pa- tients and sociodemographic parameters were recorded, the patients were asked to complete the questionnaires of the Dermatology Life Quality Index (DLQI) and the Depression Anxiety and Stress Scale-42 (DASS-42). DLQI was first developed by Finlay et al. as a question- naire consisting of 10 items; it has been validated in more than 40 dermatological disease [5]. We used the validated Turkish version of this index [21]. There are 10 questions about the patient’s symptoms/feelings (questions 1–2), daily activities (questions 3–4), leisure and sports activities (questions 5–6), work and/or school (question 7), personal interactions (questions 8–9), and therapeutic challenges (question 10). The patient is asked to choose one of the 4 or 5 answers for every question. The answers are catego- rized as follows: very much-3, much-2, little-1, not much-0, not relevant-0, and unanswered question-0. All the points are summed, and a total score ranging from between 0 and 30 is achieved. The higher the score, the more the patient’s quality of life (DLQI) is impaired. The range of scores are categorized as follows: 0–1= DLQI is not affected, 2–5= DLQI is mildly affected, 6–10= DLQI is moderately af- fected, 11–20=DLQI is severely affected, and 21–30=DLQI is very severely affected. Original Article | Dermatol Pract Concept. 2024;14(2):e2024112 3 The DASS-42 is a 42-item questionnaire consisting of three subscales within 14 items, and a Likert-type evaluation is made (0=never, 1=sometimes, 2=very often, 3=always). It is an easy, short self-report questionnaire designed to evaluate the presence and severity of depression, anxiety, and stress in patients ≥ 16 years of age [6]. The patients are asked to reply to the questions considering the previ- ous week. The total score is achieved after summing all the scores. Normal range is 0–9 for depression, 0–7 for anxiety, and 0–14 for stress. We used the Turkish version of the scale, which was modified slightly for the Turkish population [22]. Sample and Sample Size Sample size was determined using PASS (NCSS Corp. Re- leased 2011. Power Analyzes Sample Size for Windows, Ver- sion 11.0. Utah, USA) Pocket Programme. The average score of DLQI in the reference trial is 14.5±4.5. A sample size of 91 achieves 90% power to detect a difference of -1.6 be- tween the null hypothesis mean of 15.0 and the alternative hypothesis mean of 16.5, with an estimated standard devia- tion of 4.5 and with a significance level (alpha) of 0.05000 using a two-sided one-sample t-test. Statistical Methods Collected data were analyzed using IBM Statistical Pack- age for the Social Sciences (SPSS) for Windows 23.0 (IBM Corp, Armonk, NY). Frequency and percentages for cate- gorical data, and mean, standard deviation, median, and minimum and maximum descriptive values were used for continuous data. Kolmogorov-Smirnov Test was used to analyze normality test of data. The independent samples t-test for comparison of two groups with normal distri- bution, the Mann Whitney-U test for comparison of two groups without normal distribution, the ANOVA Test for comparison of more than two groups with normal distri- bution, and the Kruskal-Wallis H test for comparison of more than two groups without normal distribution were used. In the comparison of categorical variables, Fisher’s exact test or the chi-squared test, and Pearson or Spear- man’s correlation test” in determination of interaction be- tween scale scores were used. Level of significance was set at P<0.05. Results Ninety-two patients were enrolled in the study. The median age of participants was 36 years (min-max, 18-84 years), with a slight predominance of females (n=48, 52.2%). The majority of the patients were aged between 16 and 35 years (48.9%), and 63% of the patients were married. The pa- tients were mostly high school (35.9%, n=33) and university graduates (22.8%, n=21). Housewives and officers were the largest groups (27.2%, n=25 and 23.9%, n=22, respectively) (Table 1). Generalized disease was noted more than localized dis- ease (57.6% vs 42.4%, respectively). Duration of the disease was mostly less than four weeks (46.7%) (Table 2). The mean DLQI was 13.16±7.638. DLQI was ‘affected severely’ in 41.3% (n=38) of patients. The most affected do- main of DLQI was symptoms/feelings (mean 3.89±1.593), followed by difficulties at work/school (mean 2.25±2.058). The mean±SD of the total DASS score was 42.10±30.644 (with subgroups of depression 13.11±11.595, anxiety 12.13±9, and stress 16.95±11.291) (Table 3). Although not statistically significant, DLQI was af- fected more in patients >55 years, males (13.68±7.172), singles (13.47±6.934), officers (14.91±6.921), and those with higher education level (14.21±7.749) in comparison to other groups of age, sex, occupation, and education Table 1. Demographic characteristics of patients. Variable N % Age (years) 16-35 45 48.9 36-55 29 31.5 >55 18 19.6 Sex Male 44 47.8 Female 48 52.2 Marital status Single 34 37 Married 58 63 Occupation Officer 22 23.9 Student 9 9.8 Worker 17 18.5 Housewife 25 27.2 Other 19 20.7 Education level Lit.- primary 19 20.7 Middle 19 20.7 High 33 35.9 University 21 22.8 Table 2. Clinical characteristics of patients. Variable n % Involvement Generalized 53 57.6 Localized 39 42.4 Duration >12 weeks 21 22.8 4-12 weeks 28 30.4 <4 weeks 43 46.7 4 Original Article | Dermatol Pract Concept. 2024;14(2):e2024112 Table 3. Statistics of total and subgroups of DASS-42 and domains and subgroups of DLQI. Variables Mean±SD DASS-42 Total 42.10±30.644 Depression 13.11±11.595 Anxiety 12.13±9.216 Stress 16.95±11.291 DLQI (domains) Total 13.16±7.638 Symptoms and feelings 3.89±1.593 Daily activities 2.09±1.954 Leisure 1.98±1.898 Relationships 1.64±1.289 Work-school 2.25±2.058 Therapeutic challenge 1.32±1.119 DLQI (subgroups) n (%) Very severely affected 18 (19.6) Severely affected 38 (41.3) Moderately affected 18 (19.6) Mildly affected 13 (14.1) Unaffected 5 (5.4) levels. On the other hand, it was found that DLQI was significantly affected in patients with general involvement (16.06±7.159) and >12 weeks of duration (17.81±7.012) (P<0.05) (Table 4). For total DASS-42 score, depression, anxiety, and stress levels were significantly higher in patients >55 years (P=0.035), patients with generalized involvement (P<0.001), and patients with a duration of >12 weeks (P<0.001), re- spectively. However, no significant difference was observed among other demographic and clinical characteristics, in- cluding sex, marital status, occupation, and education level (Table 5). DLQI of patients were mostly affected severely (median 42) and very severely (median 77). DLQI of patients who ex- perienced very severe depression (15.2%), anxiety (17.4%), and stress (12%) were affected very severely (64.3%, 50%, and 63.6%, respectively) (Table 6). Patients with very severe depression, anxiety, and stress had higher scores of DLQI in comparison with other groups (21.43±4.735, 18.88±7.710 and 21.91±5.088, respectively) (Table 7). Spearman correlation coefficient analysis revealed a pos- itive and significant correlation between total DLQI score and total (rs =0.582) and subgroups of DASS-42 (depression (rs=0.618), anxiety (rs =0.508), and stress level (rs =0.553) scores, respectively) (P<0.001) (Table 8). Discussion Scabies is a pruritic and contagious dermatosis which has been reported to have affected 2.8% of the population in the year 2015. A total increase of 6.6% in the incidence of scabies between the years of 2005-2015 has been estimated [24]. In a recent study, it was emphasized that movements of people, including tourists and immigrants in Croatia, may have had a possible influence on scabies movements [25]. An approximate 30-fold increase in prevalence comparing the years 2017 and 2019 has been noted in our country [26]. Ural et al. reported that the COVID-19 pandemic period has also contributed [27]. We think this may have been even more prominent during recent months probably due to low socioeconomic level and poor hygiene conditions, which may have unfortunately worsened after the increasing number of immigrants and the earthquake in southeastern, leading to thousands of victims. Skin diseases are important risk factors for emotional stress, acute anxiety, and mood disorders, sometimes even affecting the therapeutic response and course of the disease. Shahbaz et al. [28] demonstrated that QoL in patients with various dermatoses on exposed parts is impaired. The nega- tive influence of both symptoms and therapeutic challenges on the quality of life of scabies patients and/or their family members has also been well-established [1, 3, 4, 17, 29]. The psychological burden of many dermatoses, including psoriasis, vitiligo, acne, atopic dermatitis, seborrheic derma- tosis, psoriasis, eczema, hidradenitis suppurativa, oral lichen planus, alopecia, steroid-resistant dermatitis, and chronic pruritus, has been thoroughly investigated previously [7-11, 19, 23]. There are only three studies analyzing the cor- relation between DLQI and psychological consequences of scabies, in which DLQI and various psychometric, including BDS/ BAS, HAM-A and SAS/ SDS, were used [17, 18, 20]. Here, we investigated the impact of this disturbing disease on the patients’ psychological health using DASS-42 and an- alyzed its possible correlation with DLQI results. Bilal et al. [1] stated that the feeling of embarrassment and shopping were the most affected domains in their male patients (58.9%). The domains affected predominantly were shopping, clothing, and work activities, which they concluded may reflect the young, active age group living in urban areas. In a study of 102 scabies patients, Nair et al. [3] concluded that scabies can affect DLQI in the form of work, sleep disturbances, and psychosocial problems both in patients and their family members. The most common age group was 21-40 years, with a predominance of students and housewives, and the major domain affected was work activity (74.2%), followed by feeling of embarrassment (64.5%). In another study of 120 scabies patients, difficulty at work was mostly experienced, followed by feelings of Original Article | Dermatol Pract Concept. 2024;14(2):e2024112 5 factors influencing QoL, depression and anxiety of patients with skin diseases, and the correlation between the three using DLQI, and SAS, and SDS. They concluded that pso- riasis, acne, atopic dermatitis, steroid- dependent dermatitis, and alopecia have a certain impact on QoL of most patients and may cause different degrees of anxiety and depression. Sun et al. [19] observed a strong correlation between skin diseases-neurodermatitis, eczema, and psoriasis and anxiety using HAM-A scale and concluded that the likelihood of anxiety decreases as age increases. Although we also found a similar positive correlation between scabies and DASS-42 scores, patients older than 55 years were significantly more affected and had higher DASS-42 scores in our study. It is well established that certain populations including immu- nocompromised patients, children, the elderly, and patients with developmental disabilities have a higher risk of acquir- ing the disease and experiencing the complications. This may be attributed to the late onset of symptoms, particularly itching, leading to a delay in seeking medical care until the lesions are generalized since type 1 and delayed type 4 im- mune response, which normally develops in weeks 1–4 after infestation, may be impaired in these patients [2]. Indeed, it is postulated that the stress surrounding COVID-19 and embarrassment and social relationships. The patients were aged mostly 18–30 years [4]. Similarly, in the present study, the majority of the patients were aged between 16 and 35 years (48.9%), with a predominance of housewives and officers, and the most affected domain was symptoms and feelings (mean: 3.89±1.593), followed by difficulties at work and school (mean 2.25±2.058). The mean DLQI score of our study population was 13.16±7.638. This value was in concordance with the previ- ous studies of DLQI in scabies, which reported mean DLQI values of between 10.09 and 14.95±4.5 [1, 17, 30]. There have been studies reporting a small-to- moderate effect of scabies on DLQI [3, 30, 32-34]. On the other hand, in one study, DLQI in 72.2% of patients was moderate- to-extremely affected. DLQI was ‘affected severely’ in 41.3% (n=38) of our patients, similar to most of the previous stud- ies [1,17]. A mild effect was reported only in one study per- formed in rural areas, and the authors concluded that this may be attributable to the fact that the QoL is so poor that people do not consider scabies as a problem at all [32]. The mean±SD DASS-42 score in our study was 42.10±30.644 (depression 13.11±11.595, anxiety 12.13±9.216, and stress 16.95±11.291). Guo et al. [23] investigated the Table 4. Distribution of demographic and clinical characteristics according to means of DLQI. Variables Categories n (%) DLQI Mean±SD P* Age 16-35 45 (48.9) 13.76±7.517 0.473 36-55 29 (31.5) 11.72±8.293 >55 18 (19.6) 14±6.894 Sex Male 44 (47.8) 13.68±7.172 0.536 Female 48 (52.2) 12.69±8.088 Marital status Single 34 (37) 13.47±6.934 0.488 Married 58 (63) 12.98±8. 075 Occupation Officer 22 (23.9) 14.91±6.921 0.651 Student 9 (9.8) 11.22±6.723 Worker 17 (18.5) 12.29±7.769 Housewife 25 (27.2) 12.28±8.106 Other 19 (20.7) 14±8.731 Education level Lit.-Primary 19 (20.7) 13.16±8.995 Middle 19 (20.7) 11.53±6.266 0.688 High 33 (35.9) 14.21±7.749 University 21 (22.8) 13±7.537 Involvement Generalized 53 (57.6) 16.06±7.159 <0.001 Localized 39 (42.4) 9.23±6.483 Duration >12 weeks 21 (22.8) 17.81±7.012 4-12 weeks 28 (30.4) 13.29±7.049 0.002 <4 weeks 43 (46.7) 10.81±7.388 6 Original Article | Dermatol Pract Concept. 2024;14(2):e2024112 status, and duration of disease and DLQI in most dermato- ses on exposed parts, including acne, hirsutism, melasma, vitiligo, and eczema. Yıldırım et al. [17] found no relation- ship between BDS/BAS and age, sex, education level, and duration of scabies. Similarly, Bilal et al. [1] reported a large effect of scabies on DLQI without any significant as- sociation with sociodemographic characteristics, including social isolation can have negative effects on mental stress in older people. Psychological stress has an impact on many skin diseases and can play a substantial role in exacerbating disease activity [31]. There are various studies on the demographic char- acteristics of patients with dermatoses and DLQI scores. Shahbaz et al. [28] reported a relation between sex, marital Table 5. Distribution of demographic characteristics according to total and subgroups of DASS-42 Score. Variable DASS-42 n % Total DASS Depression Anxiety Stress Age 16-35 45 48.9 46.62±29.529 14.42±11.766 13.71±9.067 18.67±10.717 36-55 29 31.5 30.14±27.248 8.79±9.329 8.62±8.436 12.72±10.306 >55 18 19.6 50.06±34.374 16.78±12.941 13.83±9.691 19.44±12.858 P* 0.035 0.039 0.045 0.049 Sex Male 44 47.8 38.61±32.407 12.20±12.320 10.48±9.586 16.16±12.069 Female 48 52.2 45.29±28.905 13.94±10.953 13.65±8.687 17.67±10.604 P* 0.229 0.477 0.100 0.525 Marital status Single 34 37 48.65±33.189 15.26±12.745 14.59±10.284 19.09±11.948 Married 58 63 38.26±28.651 11.84±10.780 10.69±8.285 15.69±10.795 P* 0.117 0.173 0.052 0.165 Occupation Officer 22 23.9 35.05±21.588 10.27±8.419 9.32±6.121 15.36±9.016 Student 9 9.8 57.00±41.728 18.44±16.569 16.67±13.416 23.00±13.711 Worker 17 18.5 38.41±29.424 11.76±10.651 11.47±8.449 15.18±11.706 Housewife 25 27.2 46.64±29.627 14.36±11.324 14.44±8.996 17.84±10.617 Other 19 20.7 40.53±35.692 13.42±13.234 10.79±10.228 16.32±12.966 P* 0.393 0.447 0.178 0.462 Education Lit-primary 19 20.7 48.26±32.844 15.95±12.376 13.68±9.621 18.63±11.781 Middle 19 20.7 31.58±24.885 9.26±8.491 9.53±7.479 12.79±10.003 High 33 35.9 47.30±34.645 14.91±13.347 14.18±10.510 18.21±12.328 University 21 22.8 37.86±24.882 11.19±9.647 9.86±7.411 17.19±10.003 P* 0.23 0.20 0.17 0.34 Involvement Generalized 53 57.6 58.62±27.093 18.64±11.016 17.06±8.570 23.08±9.579 Localized 39 42.4 19.64±18.596 5.59±7.429 5.44±4.800 8.62±7.489 P* <0.001 <0.001 <0.001 <0.001 Duration >12 weeks 21 22.8 64.33±31.614 21.33±11.573 18.76±10.554 24.24±10.881 4-12 weeks 28 30.4 51.29±31.037 17.25±12.447 13.93±8.726 20.39±11.519 <4 weeks 43 46.7 25.26±18.587 6.40±6.044 7.72±6.162 11.14±8.093 P* <0.001 <0.001 <0.001 <0.001 TOTAL 92 100 42.10±30.644 13.11±11.595 12.13±9.216 16.95±11.291 Original Article | Dermatol Pract Concept. 2024;14(2):e2024112 7 environmental cleaning, may have contributed to the ex- traordinary impairment of DLQI in the elderly. Although there is limited evidence concerning the rela- tion between duration of disease and DLQI in scabies pa- tients, eight weeks of disease has been reported to influence the DLQI and burden of the disease in two studies [17, 31]. Although most of our patients had a duration less than four weeks, we observed a significant difference of DLQI in pa- tients with longer duration. Patients with generalized disease and longer duration usually have more pruritus and second- ary skin changes, including excoriations and cutaneous in- fections, possibly explain the greater impairment of DLQI. For total DASS-42 score, depression, anxiety, and stress levels were significantly higher in patients > 55 years (P=0.035), with generalized involvement (P<0.001), and age group, education level, and occupation. In the present study, although not significant statistically, DLQI was af- fected more in patients > 55 years, males (13.68±7.172), singles (13.47±6.934), officers (14.91±6.921), and those with higher education level (14.21±7.749) in comparison with other groups of age, sex, occupation, and education level. On the other hand, it was found that DLQI was sig- nificantly affected in patients with generalized involvement (16.06±7.159) and >12 weeks of duration (17.81±7.012) (P<0.05). Since older patients constituted a small group in our population, it is worth observing the greater impair- ment of DLQI in these patients. Increased and prolonged social isolation during the whole COVID-19 pandemic in addition to the unpleasant and impractical topical therapy of scabies, including long hours of ointments and self- and Table 6. Distribution of subgroups of DLQI and DASS-42. DLQI DASS-42 n (%) Unaffected n (%) Mildly affected n (%) Moderately affected n (%) Severely affected n (%) Very severely affected n (%) Total Median (Min-Max) 92 (100) 10 9-33 9 0-61 26 1-80 42 4-95 77 19-126 Depression Very severe 14 (15.2) 0 0 0 5 (35.7) 9 (64.3) Severe 10 (10.9) 0 0 2 (20) 6 (60) 2 (20) Moderate 12 (13) 0 1 (8.3) 3 (25) 6 (50) 2 (16.7) Mild 10 (10.9) 0 0 1 (10) 7 (70) 2 (20) Normal 46 (50) 5 (10.9) 12 (26.1) 12 (26.1) 14 (30.4) 3 (6.5) Anxiety Very severe 16 (17.4) 0 0 3 (18.8) 5 (31.3) 8 (50) Severe 20 (21.7) 0 1 (5) 3 (15) 12 (60) 4 (20) Moderate 14 (15.2) 1 (7.1) 1 (7.1) 3 (21.4) 7 (50) 2 (14.3) Mild 9 (9.8) 0 2 (22.2) 0 4 (44.4) 3 (33.3) Normal 33 (35.9 4 (12.1) 9 (27.3) 9 (27.3) 10 (30.3) 1 (3) Stress Very severe 11 (12) 0 0 0 4 (36.4) 7 (63.6) Severe 14 (15.2) 0 1 (7.1) 3 (21.4) 7 (50) 3 (21.4) Moderate 14 (15.2) 1 (7.1) 0 3 (21.4) 6 (42.9) 4 (28.6) Mild 11 (12) 0 1 (9.1) 3 (27.3) 5 (45.5) 2 (18.2) Normal 42 (45.7) 4 (9.5) 11 (26.2) 9 (21.4) 16 (38.1) 2 (4.8) Table 7. Mean DLQI scores according to subgroups of DASS-42.  Variable DASS-42 P*Very severe Severe Moderate Mild Normal DLQI (total score) Depression 21.43±4.735 16±5.963 12.92±6.417 17.50±7. 059 9.15±6.6.377 <0.001 Anxiety 18.88±7.710 15.40±6.303 12.71±6.911 14.89±7.184 8.76±6.462 <0.001 Stress 21.91±5.088 15. 07±6.719 15.07±7.509 13.91±7.595 9.40±6.267 <0.001 8 Original Article | Dermatol Pract Concept. 2024;14(2):e2024112 variable affecting the DLQI independently from other demo- graphic and clinical characteristics of scabies patients. Sca- bies is not only associated with impairment in quality of life, but it also may lead to psychosocial problems. All scabies patients should be evaluated and consulted, if needed, for possible problems of psychosocial life, including depression, anxiety, and stress, as well as clinical symptoms and other secondary complications. References 1. Bilal K, Othman SM, Asaad YA. Quality of life in patients with scabies in Erbil, Iraq. Zanco J Med Sci. 2021 Dec; 25(3): 638-48. https://doi.org/10.15218/zjms.2021.030 2. Leung AKC, Lam JM, Leong KF. Scabies: a neglected global dis- ease. Current Pediatric Reviews. 2020;16:33-42. doi:10.2174/15 7339631566629071141131. 3. Nair PA, Vora RV, Jıvani N, Gandhi SS. A study of clinical pro- file and quality of life in patients with scabies at a rural tertiary care centre. J Clin Diag Res. 2016 Oct; 10(10):WC01-WC05. doi:10.7860/JCDR/2016/20938.8703 4. Bindushree R, Hosthoata A. A study of clinical profile and qual- ity of life in patients with scabies. Int J Res Dermatol. 2021 Jul;7(4):1-5. https://dx.doi.org/10.18203/issn.2455-4529 5. Finlay AY. Quality of Life Indices. Indian J Dermatol Venereol Leprol. 2004;70:143-148. 6. Lovibond SH, Lovibond PF. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995;33:335-43. 7. Hon KL, Pong NH, Poon TCW, et al. Quality of life and psycho- social issues are important outcome measures in eczema treat- ment. J Dermatol Treat. 2015 Feb;26(1):83-9. doi:10.3109/095 46634.2013.873762 8. Duran S, Atar E. Determination of depression, anxiety and stress (DAS) levels in patients with atopic dermatitis: a case- control study. Psychology, Health and Medicine. doi.org/10180 /13548506.2019.1710545 9. Kalkur C, Sattur AP, Guttal KS. Role of depression, anxiety and stress in patients with oral lichen planus: a pilot study. Indian J Dermatol. 2015 Sep-Oct;60(5):445-9. doi:10.4103/0019 -5154.158625 10. Manczyk B, Golda J, Biniak A, et al. Evaluation of depression, anxiety and stress levels in patients with oral lichen planus. J Oral Sci. 2019; Vol 61(3):391-7. doi.org/10.2334/josnusd.18-0113 11. Porras-Carrique T, Gonzales-Moles MA, Warnakulasuriya S, Ramos-Garcia P. Depression anxiety, and stress in oral lichen planus: a systematic review and meta-analysis. Clin Oral Invest. 2022;26:1391-1408. doi.org/1007/s00784-021-0414-0 12. Nieuwenhujiijsen K, de Boer AGEM, Verbeek JHAM, Blonk RWB, van Dijk FJH. The depression Anxiety Stress Scales (DASS): detecting anxiety disorder and depression in employees absent from work because of mental health problems. Occup Environ Med. 2003 Jun; 60 Suppl1 (Suppl 1): i77-82. doi:10.1136/oem .60.supple_1.i77. 13. Karadağ M, Ogutlu H. Prevalance of psychiatric symptoms among refugee adolescents in Turkey: a controlled study. Braz J Psychiatry. 2021 Jan-Feb;43(1):55-60. doi.org/10.1590/1516 -4446-2020-0916 with duration of >12 weeks (P<0.001) in comparison with other age, involvement, and duration groups, respectively. However, no significant difference was observed among other demographic and clinical characteristics (sex, mar- ital status, occupation, and education level). Although the mean duration of disease was predominantly <4 weeks, we observed that patients with >12 weeks of duration tended to have higher levels of depression, anxiety, and stress. In a recent cross-sectional study with a much longer mean dura- tion of symptoms (5.9 months) than all previous studies and ours, scabies patients had more anxiety, depression, and im- paired QoL and tended to have moderate-to-severe depres- sion in comparison to controls [20]. DLQI of patients was mostly affected severely (median 42) and very severely (median 77). DLQI of patients with very severe depression (15.2%), anxiety (17.4%), and stress (12%) were affected very severely (64.3%, 50%, and 63.6%, respectively) and had higher scores of DLQI (21.43±4.735, 18.88±7.710, and 21.91±5.088, respectively). Spearman correlation coefficient analysis revealed a positive and sig- nificant correlation between total DLQI score and total (rs =0.582) and subgroups of DASS-42 (depression (rs=0.618), anxiety (rs =0.508), and stress level (rs =0.553) scores, respec- tively) (P<0.001). All these findings suggest that the more DLQI is impaired, the higher the level of depression, anxiety, and stress in scabies patients. The limitations of our study are the small size of the pop- ulation and the lack of a control group and pediatric patients. Conclusion We conclude that impairment of DLQI is a statistically sig- nificant predictive parameter for an increase in depression, anxiety, and stress levels. DASS-42 score is an important Table 8. Spearman rho analysis demonstrating the relationship between DLQI and DASS-42 (total and subgroups). DLQI DASS-42 Total Correlation coefficient .582** P** .000 Depresssion Correlation coefficient .618** P** .000 Anxiety Correlation coefficient .508** P** .000 Stress Correlation coefficient .553** P** .000 DLQI Correlation coefficient 1.000 P** ** Correlation is significant at the 0.01 level (2-tailed). Original Article | Dermatol Pract Concept. 2024;14(2):e2024112 9 Study 2015. Lancet. 2016;388:1545-602. doi:10.1016/S0140 -6736(16)31678-6 25. Lugovic-Mihic L, Azdajic MD, Filipovic SK, et al. An increasing scabies incidence in Croatia: a call for coordinated action among dermatologists. Zdr Varst. 2020;59(4):264-72. doi:10.2478/sjph -2020-0033 26. Özden MG, Ertürk K, Kartal SP, et al. An extraordinary out- break of scabies in Turkey. J Eur Acad Dermatol Venereol. 2010; 34(12):e818-20. doi:10.1111/JDV16699 27. Ural ZK, Çatak B, Ağaoğlu E. Prevalence of scabies in the Covid-19 pandemic period and determination of risk factors for scabies: a hospital based cross-sectional study in Northeast Turkey. Acta Parasitol. 2022 Jun;67(2):802-808. https://doi. org/10.1007/s11686-022-00524-6. 28. Shahbaz H, Shabbir S, Maryam J, Amir S, Humayun A. Quality of life in patients with skin diseases on exposed parts- a study in two teaching hospitals of Lahore. Proceeding SZPGMI. 2017;Vol:31(2):103-110. 29. Chowdhry S, Sheoran P, D-Souza P, Yadav MK, Rathore S. As- sessment of the quality of life in patients with scabies in an urban tertiary care centre in North India. Serbian J of Dermatol Vene- reol. 2020;12(2):41-6. Doi:10.2478/sjdv-2020-0007 30. Jin-Gang A, Sheng-Xiang X, Sheng-Bin X, et al. Quality of life of patients with scabies. J Eur Acad Dermatology and Venereol (Internet). 2010 Oct;24(10):1187-91. Doi:10.1111/j.1468-3083 .2010.03618.x. 31. Golpanian RS, Yosipovitch G. J Am Geriatr Soc. 2020 Aug;68(8):1680-1682. doi:10.1111/jgs.16627. Epub 2020 Jun 7. 32. Worth C, Heukelbah J, Fengler G, Walter B, Liesenfeld O, Felmeier H. Impaired quality of life in adults and children with scabies from an impoverished community in Brazil. Int J Dermatol. 2012;51(3):275-82. doi:10.1111/J 1365-4632.2011 .05017.x 33. Lake SJ, Engelman D, Sokana O, et al. Health-related quality of life impact of scabies in Solomon Islands. Trans R Soc Trop Med Hyg. 2022;116(2):148-56. doi:10.1093/trstmh/trab096. 34. Collinson S, Timothy J, Zayzay SK, et al. The prevalence of sca- bies in Monrovia, Liberia: a population-based survey. PLoS Negl Trop Dis. 2020 Dec 7;14(12):e008943. doi:10.1371/journal. pntd.0008943. 14. Al-Gelban KS, Al-Amri HS, Mostafa OA. Prevalence of depres- sion, anxiety and stress as measured by the Depression, Anxi- ety, and Stress Scale (DASS-42) among secondary school girls in Abha, Saudi Arabia. SQU Med J. 2009;9(2):140-7. 15. Elsaie ML, Hasan MS, Zaky MS, Hussein SM, Kadah AS, Omar AM. Implication of COVID-19 on the mental health of Egyp- tian dermatologists: A cross-sectional study. J Cosmet Dermatol. 2021;20:3066-3073. https://doi.org/10.1111/jocd.14390 16. Kaner G, Yurtdaş-Depboylu G, Çalık G, et al. Evaluation of perceived depression, anxiety, stress levels and emotional eating behaviours and their predictors among adults during COVID-19 pandemic. Public Health Nutrition. 2022;26(3):674-83. doi:10.1017 /S1368980022002579 17. Yıldırım SK, Ogut ND, Erbagcı E, C.  Scabies affects quality of life in correlation with depression and anxiety. Dermatol Pract Concept. 2023 Apr 1;13(2):e2023144. https://doi.org/10.21203 /rs.3.rs-1486167/v1 18. Ali D. Impact of scabies on quality of life and correlation to depression and anxiety. J Psych. 2022; 25:509. doi:10.35248 /2378-5756.22.509 19. Sun C, Ren Y, Zhang W. Association between skin diseases and anxiety: a logistic analysis and prediction. Ann Transl Med. 2023;11(2):115. doi.org/10.21037/atm-22-6511 20. Seetan K, Khamees A, Abusohyon B, et al. Scabies is associated with more anxiety, depression, and impaired quality of life: a cross-sectional comparative study. J Pharma Neg Results. 2022; 13(7): 6314-20. doi:10.47750/pnr.2022.13.507.768 21. Öztürkcan S, Ermertcan AT, Eser E, Şahin MT. Cross validation of the Turkish version of dermatology life quality index. Int J Dermatol. 2006;45:1300-1307. 22. Bilgel N, Bayram N. Depresyon Anksiyete Stres Ölçeğinin (DASS-42) Türkçeye uyarlanmış şeklinin psikometrik özellikleri. Nöropsikiyatri Arşivi. 2010; 47(2): 118-126. 23. Guo F, Yu Q, Liu Z, et al. Evaluation of life quality, anxiety, and depression in patients with skin diseases. Medicine. 2020;99: 44(e22983). http://dx.doi.org/10.1097/MD.0000000000022984 24. GBD 2015 Disease and Injury Incidence and Prevalence, Col- laborators. Global, regional, and national incidence, prevalence and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease