Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2024;14(2):e2024075 1 Impact of Vitiligo on Quality of Life in Patients of Skin of Color and Its Correlation With Clinical Severity Assessment Scores Utilizing Disease Specific Scores: A Cross-Sectional Study Guneet Awal1, Navleen Kaur1, Guramrit Singh1, Nishant Sharma2 1 Department of Dermatology,Venereology and Leprosy, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, India 2 Department of Community Medicine, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, India Key words: vitiligo, quality of life, skin of color, VIS-22, VitiQoL Citation: Awal G, Kaur N, Singh G, Sharma N. Impact of Vitiligo on Quality of Life in Patients of Skin of Color and Its Correlation With Clinical Severity Assessment Scores Utilizing Disease Specific Scores: A Cross-Sectional Study. Dermatol Pract Concept. 2024;14(2):e2024075. DOI: https://doi.org/10.5826/dpc.1402a75 Accepted: October 18, 2023; Published: April 2024 Copyright: ©2024 Awal 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: All authors have contributed significantly to this publication. Corresponding Author: Dr. Guneet Awal, 469,East Mohan Nagar, Opp. DSP Park,Amritsar, Punjab 143001. Phone numbers- 9988834379,9115703086 E-mail: guneetawal@gmail.com Introduction: Assessment of disease severity of vitiligo is exigent as it is a psychosomatic ailment. VIDA (vitiligo disease activity score) and VASI (vitiligo area severity index) were previously used for this evalu- ation. Recently, the introduction of two vitiligo specific tools, vitiligo impact scale (VIS)-22 and Vitiligo Quality of Life Index (VitiQoL) has aided in assessing the quality of life (QOL) in a pertinent manner. Objectives: To measure the QOL in vitiligo using disease specific indices (VitiQoL and VIS-22), to as- sess their relationship with disease severity (VASI and VIDA) and to determine the correlation between QOL scores (VIS-22 and VitiQoL). Methods: This observational cross-sectional study included 195 patients with vitiligo, and their dis- ease severity was calculated using VASI and VIDA scoring. Patients were asked to fill questionnaires for assessing the QOL using validated tools i.e. VIS-22 and VitiQoL. Results: Significant correlation was demonstrated between both QOL scores and VASI score (P value 0.001) with slightly higher values for VitiQoL (r = 0.824) than with VIS 22 (r = 0.693). Both scores exhibited a significant association with VIDA score (P value < 0.001). Moreover, statistically signifi- cant correlation was found between VIS-22 and VitiQoL, thereby proving the concordance between these scores. Conclusions: The study infers that QOL seemed to be remarkably dependent on the clinical severity scores and that higher disease activity corresponds to poorer QOL. It is imperative to precisely assess burden of vitiligo and the impairments caused by it in order to aid multi-modality management and allow more standardized research. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2024;14(2):e2024075 Introduction Vitiligo, a pigmentary disorder with loss of melanocytes, although predominantly asymptomatic, is a cause of great cosmetic and psychological concern [1]. There is an in- creasing prevalence of vitiligo affecting up to 1%-4% of the world population. In India, vitiligo has been known as “sweta kustha,” which translates as “white leprosy”[2]. Individuals with vitiligo may be treated with stigma due to false belief of having Hansen disease, which can be ac- quired by contact, thereby causing low self-esteem, poor body image and depression [3]. They face difficulty in finding jobs and getting married as a result of social dis- crimination and cultural beliefs, leading to anxiety and distress. Vitiligo can be classified as a psychosomatic ailment, with both psychological and physical elements contribut- ing to disease development, relapses and remissions [4]. Assessment of disease severity is imperative since it affects patients psychological well-being. Vitiligo Area Scoring In- dex (VASI) is a quantitative score given by Hamzavi et al in which hand units are used to calculate percentage of vitil- igo involvement [5]. Vitiligo disease activity score (VIDA) is another assessment tool which is based on subjective as- sessment of disease activity [6]. Earlier there was no specific quality of life (QOL) as- sessment tool for vitiligo and it was measured by using nonspecific tools such as Dermatology Life Quality Index (DLQI), Skindex-26 and SF-36 [2,7-9]. However, it is in- creasingly recognized that vitiligo has a greater impact on QOL owing to psychological concerns such as lack of self-confidence, unfavorable body views, and failed social interactions, rather than physical problems [7,8,10,11]. Hence, two vitiligo specific tools have been developed, which are Vitiligo impact scale (VIS)-22 and Vitiligo Qual- ity Of Life index (VitiQoL) [12,13]. VitiQoL is an objec- tive, vitiligo specific measure of disease status, burden and treatment outcome for patients. It is substantiated using disease-specific items from in-depth open-ended patient in- terviews, clinical input and literature review [14]. Similarly, VIS-22, another disease-specific questionnaire, consists of 22 easily understandable questions: 19, common to all patients and one each for patients who are married, un- married, working, or studying. Objectives In this article we have assessed and analyzed the QOL of vitiligo patients using disease specific indices, and its rela- tionship with clinico-demographic patterns and severity of vitiligo as there is paucity of data on their correlation in In- dian patients. Methods Study Site and Population A total of 195 clinically diagnosed patients of vitiligo attend- ing the dermatology department of a tertiary care hospital were included in this cross-sectional, questionnaire-based study after obtaining informed consent. Study Period It was conducted over a period of 2 years from August 2019 to July 2021. Inclusion Criteria All consenting patients aged ≥18 years with clinical diagno- sis of vitiligo were included. Exclusion Criteria Patients less than 18 years of age or with other disorders and disabilities associated with social stigma. Study Procedure Demographic details including the patients name, age, sex, occupation, marital status, duration, onset and progres- sion of the disease were recorded. Patients were diagnosed clinically and the findings were corroborated with dermos- copy. The severity of disease was calculated by using VASI and VIDA scoring and their correlation with VIS-22 and VITIQoL scores was evaluated. Study Measurement Tools VASI score is a quantitative severity evaluation score that is evaluated in the same way as the Psoriasis Area and Severity Index (PASI) score. The magnitude of residual depigmen- tation is indicated as: 100%-depigmented area exceeds the pigmented area; 50%-depigmented and pigmented areas are equal; 25%-pigmented area exceeds the depigmented area; and 10%-specks of depigmentation are present [5]. Each body site (Hands, upper extremities, trunk, lower extremi- ties and feet) VASI is calculated. The cumulative body VASI is determined as (range of 0-100): VASI = Σ(all body sites) (hand units)×(residual depigmentation) Njoo et al utilized the VIDA score for the first time in 19996. It is a six-point scale based on patient perception of disease activity over time and is graded as follows-VIDA score + 4: activity lasting 6 weeks or less; score +3: activ- ity lasting 6 weeks to 3 months; score 2: activity lasting 3-6 months; score1: activity lasting 6-12 months; score 0: stable for 1 year or more; score -1: stable with spontaneous Original Article | Dermatol Pract Concept. 2024;14(2):e2024075 3 re-pigmentation for 1 year or more. A low Vitiligo disease activity score indicates less vitiligo activity. Lilly et al in 2013 proposed VitiQoL, which is a disease specific instrument based on three factors: stigma, participa- tion limitation and behavior [14]. It comprises of 15 questions with a seven-point Likert scale (0-6) and the total scores rang- ing from 0 to 90.Individuals with higher scores indicate a poorer QOL. VIS-22, the modified version of VIS, comprises of 22 items encompassing areas of self-confidence, anxiety, depression, marriage, family worries, social interactions, school/college related, occupation related, treatment related and attitude. Individual responses were scored from 0 to 3; a higher score denoting worse QOL [12,15]. Gupta et al graded the VIS-22 scores as: 0-5: no impact; 6-15: mild impact; 16-25: mod- erate impact; 26-40: large impact and 41-66: very large impact [16]. Ethical clearance for the study was obtained from the Institutional Ethics committee. Required permissions were obtained before the use of these assessment scores for the present study. The patients were asked to fill the question- naires to assess the QOL using validated tools ie VIS-22 and VitiQoL. A bilingual dermatologist translated the English versions of both the questionnaires into Punjabi language. Backward translations were done by a different bilingual dermatologist. The validity of translations was cross-checked by the evaluators. Statistical Analysis Data was analyzed using Statistical Package for the Social Sciences version 26 software (SPSS Inc.). Qualitative data were described using number and percentages. Descriptive statistics, mean and SD were calculated for quantitative vari- ables. For assessment of correlation between QOL and vitil- igo severity scores, Pearson correlation coefficient was used. For comparison of demographic profile, independent t test and analysis of variance (ANOVA) test was used. Probability value (P value) of less than 0.05 was considered significant. Intra class correlation coefficient was used to find agreement between the two quality of life scores. Results A total of 195 patients were recruited in the study. The mean age was 35.64 ± 14.76 years. Vitiligo was most commonly seen in patients aged 30 to 39 years (34.35%) with mean du- ration of 6.7 years and maximum (39.49%) patients present- ing within 3 years of onset. Family history of a first-degree relative with vitiligo was positive in 34 patients (17.43%). Mostly, patients belonged to Fitzpatrick skin type 3(39.48%) and 4(51.28%). 115 patients were married whereas 72 were single and 8 divorced. The most common occupational group was laborer (40%) followed by student (18.5%), household worker (17.95%), semiskilled worker (13.84%), skilled worker (6.67%), and unemployed (3.04%). Both ex- posed and nonexposed sites were involved in 42.56%, only non-exposed sites in 36.4% and exposed sites in 21.02% patients. Of these, upper limbs constituted 24.1% followed by lower limbs (15.89%). A maximum number of patients (27.17%) had VIDA score of +2, 24.61% of +3 whereas 15.38% had VIDA score of 0. The mean VASI score in this study was 12.63±8.06 and it was significantly associated with duration of disease ( P < 0.05). There was significant association between VASI score and VIDA score, with highest VASI score in patients with a VIDA score of +4. Overall, the mean VIS-22 score of our study population was 27.25±11.19, reflecting altogether a large impact on QOL with the mean score in females (27.76±11.86) being higher than males (26.91±10.82), though not statistically significant. Patients within age group 18-29 years and dis- ease duration of 7-12 years had the highest VIS-22 score of 29.65±14.07 and 28.32±11.96 respectively. Skilled pa- tients had the lowest VIS-22 score (23.15±9.51) while the household workers and laborers had higher VIS-22 scores (29.52±12.57 and 28.02±11.39 respectively). VIS-22 scores were higher among divorced patients (33.25±13.71), indi- viduals with skin type V (29.11±12.7) and who had lesions on exposed parts of the body (27.92±11.31). The score was highest in patients with lesions on face (33.64±14.82) followed by chest (31.24±12.43) (Table 1). Out of 195 patients, most patients had moderate im- pact (45.4 %) and large impact (33.7 %) with fewer hav- ing mild impact (8.6%) and very large impact (12.2%) in their QOL (Figure 1A). Maximum number (47%) of males had moderate impact on QOL with respect to VIS-22 scores whereas maximum number of females (49%) had large im- pact (Figure 1B). Statistically significant strong correlation was observed between VIS-22 and VASI scores (r 0.693, P value < 0.001) as shown in Figure 2A. Overall, mean VASI scores were highest (25.91±11.84) in patients who had large impact followed by those who had moderate impact on their QOL (13.18±4.77) (Table 2). While ascertaining the strength of relationship between VIS-22 and VIDA score using Pearson correlation coefficient, a weak positive correlation was determined be- tween these scores (P value<0.001) (Figure 2B). The questions related to social interactions (3, 12 and 13) and anxiety (2,11) domains were the major contributors to VIS-22 scores in our study. A higher VitiQoL score was seen in females (25.75±14.15) as compared to males (24.34±12.98) (P > 0.05). A significant association (P value< 0.05) was seen between VitiQoL scores and age of patient (18-29 years; 29.77±17.97) as well as 4 Original Article | Dermatol Pract Concept. 2024;14(2):e2024075 Table 1. Correlation of VIS-22 Score With Demographic Variables in patients of vitiligo VIS22 N VIS22 mean Standard deviation of VIS22 P value Gender F 118 26.9153 10.82145 0.606 M 77 27.7662 11.86647 Age 18-29 48 26.3958 11.58271 0.567 30-39 66 27.0000 9.78067 40-49 46 26.6739 10.46062 >50 35 29.6571 14.07113 Duration of disease <3 78 28.3205 11.96802 0.757 3-6 56 26.8214 11.13080 7-12 31 25.2581 9.67460 13-15 18 27.9444 12.52044 >15 12 26.4167 8.94893 Family history Positive 57 27.1930 10.22329 0.963 Negative 138 27.2754 11.64673 Marital status Divorce 8 33.2500 13.70870 0.304 Single 70 27.1000 11.60104 Married 117 26.9316 10.80128 Occupation Student 35 27.0857 11.89259 0.388 Labour 78 28.0256 11.39603 Household worker 36 29.5278 12.75816 Semiskilled 27 24.7407 7.96914 Skilled 13 23.1538 9.51180 Unemployed 6 24.6667 10.30857 Skin type Type III 75 28.1333 11.71201 0.436 Type IV 103 26.3010 10.56338 Type V 17 29.1176 12.97537 Sites Exposed 41 27.9268 11.31457 0.977 Covered 70 26.2714 11.54440 Exposed+covered 84 27.3929 11.03883 Individual sites Scalp 7 22.8571 9.90671 0.065 Face 17 33.6471 14.82793 Chest 25 31.2400 12.43074 Abdomen 28 24.1429 7.88207 Back 26 29.1154 11.76206 UL 47 25.7872 10.75808 LL 31 26.0645 9.81813 Genital 6 23.6667 7.22957 Mucosal 8 25.7500 12.98075 VIS = vitiligo impact scale. longer duration of disease (>15 years; 29.91±15.03). Higher scores were observed in divorced patients (29.00±10.81), those with skin type V (28.64+-15.61) and who had le- sions on exposed parts (25.68+-14.66) especially facial (29.52±20.11) and mucosal lesions (28.25±15.53). Scores were lowest in skilled workers (19.07±5.34) as compared to other occupational groups (Table 3). Figure 3A represents scatter plot depicting correlation of VASI score (12.63±8.06) with VitiQoL score (24.89±13.40) in which both the scores were found to have very strong correlation(r value 0.824 and P value < 0.001).On further analysis of the VitiQoL questionnaire, it was observed that female patients had statistically more significant limited social participation(4.21±1.34) and changes in behavioral Original Article | Dermatol Pract Concept. 2024;14(2):e2024075 5 Figure 1. (A) Percentage of patients according to severity grade of impact of VIS-22. (B) Comparison of impact of VIS-22 severity scores in males and females. VIS = vitiligo impact scale. patterns (4.46±1.22) as compared to males(P value < 0.05). Similarly, the stigma and behavior domains of VitiQol score were statistically significant in the age group of 18-29 years (P value < 0.001) as shown in Table 4. Figure 3B demonstrates statistically significant weak cor- relation between VitiQoL and VIDA score with the scores being highest in patients with VIDA score of +4. Furthermore, Intra class Correlation Coefficient (ICC) was used to evaluate the agreement between VIS-22 and Vi- tiQoL scores (Table 5). A value of 0.842 was obtained which was interpreted as good concordance between the two QOL scores, thereby implicating that both the scores were equiva- lent in terms of evaluation of QOL in vitiligo. Conclusions There is dearth of data regarding association of QOL indi- cators in vitiligo with the disease activity and area scores in patients of skin of color, particularly in the Indian scenario, in spite of the fact that highest incidence of the disease has been established in India [17]. Kim et al. and Kostopoulou et al. in their studies, have highlighted the fact that in vitil- igo, subjective severity is more relevant than physician-rated severity in predicting QOL [18,19]. Therefore, through this study, we attempted to reprise the existing high incidence of impact on QOL using valid disease specific questionnaires among patients with variable demographics. 6 Original Article | Dermatol Pract Concept. 2024;14(2):e2024075 Figure 2. (A) Scatter plot demonstrating the correlation between VIS-22 and VASI score; association of the parameters is shown by solid line (r value-0.693; P value 0.001). (B) Scatter plot demonstrating positive association and significant correlation of VIS-22 with VIDA score; solid line represents the trend line and dotted lines represent the scatter points (r value 0.366; P value < 0.001). VASI = vitiligo area severity index; VIDA = vitiligo disease activity score; VIS = vitiligo impact scale. Table 2. Correlation of VASI score with VIS-22 score Mean VIS-22 (27.25±11.19) VIS-22 0-5 (N=0) VIS-22 6-15 (N=17) VIS-22 16-25 (N=89) VIS-22 26-40 (N=65) VIS-22 41-66 (N=24) P value R value Mean VASI (12.63±8.06) 0 09.54±5.26 13.18±4.77 25.91±11.84 08.00±2.48 0.001 0.693 VASI = vitiligo area severity index; VIS = vitiligo impact scale. Original Article | Dermatol Pract Concept. 2024;14(2):e2024075 7 Table 3. Correlation of VitiQoL score with various demographic variables VitiQoL N VitiQoL mean Standard deviation of VitiQoL P value Gender F 118 24.3390 12.97942 0.474 M 77 25.7532 14.15437 Age 18-29 48 26.6042 14.20330 0.034 30-39 66 22.3485 9.88004 40-49 46 23.0652 12.16991 >50 35 29.7714 17.97398 Duration of disease <3 78 27.1154 15.16317 0.021 3-6 56 23.3214 10.84956 7-12 31 18.8387 7.16518 13-15 18 27.2778 16.73603 >15 12 29.9167 15.03002 Family history Positive 57 26.0000 13.82027 0.463 Negative 138 24.4420 13.30058 Marital status Divorce 8 29.0000 10.81005 0.564 Single 70 25.5000 14.94798 Married 117 24.2564 12.65807 Occupation Student 35 23.2857 12.15723 0.374 Labour 78 25.5385 13.89075 Household worker 36 27.7222 16.52982 Semiskilled 27 23.4444 8.89829 Skilled 13 19.0769 5.34574 Unemployed 6 28.1667 21.02776 Skin type Type III 75 26.1733 15.46782 0.186 Type IV 103 23.3495 11.20899 Type V 17 28.6471 15.61626 Sites Exposed 41 25.6829 14.66874 0.782 Covered 70 25.3571 14.49541 Exposed+covered 84 24.1310 11.94140 Individual sites Scalp 7 27.1429 20.41591 0.283 Face 17 29.5294 20.11566 Chest 25 28.4800 14.23060 Abdomen 28 21.1071 9.08943 Back 26 26.4615 11.84308 UL 47 23.0213 13.18842 LL 31 24.4516 11.45961 Genital 6 17.6667 3.61478 Mucosal 8 28.2500 15.53567 LL = lower limbs; UL = upper limbs; VitiQoL =Vitiligo Quality of Life Index. Despite earlier research done by Hedyat et al, Borimne- jad et al and Hammam et al2 establishing that females had a substantially greater influence on QOL, our study found comparable results with no significant differences between the genders in overall mean VIS-22 and VitiQol scores [13,20,21]. This emphasizes the fact that the psychological burden of chronic disorders like vitiligo is alike regardless of gender. This is comparable to the studies done by Aghaei et al in Iran, Patvekar et al and Kota et al in India, who found insignificant variance in QOL impairment between men and women using DLQI scores [22-24]. These variable results might be due to cultural and religious differences between various countries. 8 Original Article | Dermatol Pract Concept. 2024;14(2):e2024075 Figure 3. (A) Scatter plot demonstrating correlation among VitiQol and VASI scores; association of the parameters is shown by the solid line. (r value-0.824; P value 0.001). (B) Scatter plot demonstrating positive association and significant correlation of VitiQol with VIDA score; solid line represents the trend line and dotted lines represent the scatter points (r value 0.352; P value <0.001). VASI = vitiligo area severity index; VIDA = vitiligo disease activity score; Vitiligo Quality of Life Index. Nonetheless, gender-wise impact of VIS-22 in the present study reflected maximum proportion of females (48.7%) to have a large impact on their QOL, unlike maximum pro- portion of males (46.7%) who had moderate impact. Like- wise, upon assessment of the individual VitiQoL domains, it was established that females had higher affliction in two individual domains , participation limitation (P value 0.03) and behavior (P value 0.012). Questions 4, 6, 9 and 14 con- tributed maximum to the participation limitation scores and questions 8,12 to behavior scores. Considering that vitiligo generates obvious lesions on the skin, this relatively poor QOL in female patients based on behavior component was logically anticipated as they are socially more pressurized, tend to get coerced behaviorally and strive to disguise their patches with camouflage and/or clothing. Furthermore, they exhibit a greater emotional agitation, and the condition has a significant influence on their self-esteem [13,25,26,27,28]. The higher scores of participation limitation found in the present study are contrary to most of the studies done be- forehand [13,25,28]. This discrepancy between genders with Original Article | Dermatol Pract Concept. 2024;14(2):e2024075 9 Table 4. Descriptive statistics of various domains of Vitiligo Quality of Life Index score according to gender and age groups Limited social participation Stigma Behavior Variables Mean Standard deviation Mean Standard deviation Mean Standard deviation Sex Males 3.80 1.21 4.18 1.92 4.02 1.13 Females 4.21 1.34 4.56 1.27 4.46 1.22 P value 0.03 0.09 0.012 Age 18-29 3.63 1.67 4.92 1.45 3.72 1.57 30-39 3.41 1.04 4.19 1.73 2.94 1.03 40-49 3.28 1.22 3.27 1.66 2.48 1.27 >50 3.10 1.12 2.43 1.25 2.14 1.02 P value 0.282 0.001 0.001 Table 5. Intra-class Correlation Coefficient for VIS-22 and VitiQoL scores (Statistically Significant at p<0.05; CI- Confidence Interval) Scores Mean + SD Intra Class Correlation 95% CI P Value VIS 22 27.25+11.19 0.842 0.784-0.884 0.000 VitiQoL 24.89+13.40 CI = confidence interval; SD = standard deviation; VIS = vitiligo impact scale VitiQoL =Vitiligo Quality of Life Index. regards to participation limitation can be explained by the increased constraints on women in terms of aesthetics, which restrain them to carry out daily and leisure activities as freely as men due to myths pertaining to the disease. Various other factors that were independent predictors of poor QOL in the present study were early adulthood (18-29 years; statistically significant), prolonged disease duration (>15 years; statistically significant), unskilled pro- fession, single and divorced individuals, skin type V and those having lesions on exposed sites. Among early adult- hood patients, the behavior and stigma domains were sig- nificantly affected in this study. Most of these results seemed to be consistent with various previous studies done on QOL in vitiligo using various scores wherein the frequently ob- served indicators of worse QOL were prolonged duration of lesions [18,19], having darker skin type [7,25,30] and lesions on exposed sites apart from other factors such as ex- tensive vitiligo, having psychiatric morbidity and previously treated vitiligo [2,7,14,31]. Poorer QOL in individuals hav- ing prolonged disease duration is probably attributable to the chronic nature of disease, relapsing and remitting course, non-compliance to treatment along with the cultural influ- ences pertaining to indigenous practices of medicine and as- sumptions about incurability of vitiligo. Both men and women with white patches over skin have been considered inappropriate for marriage since time immemorial, and emergence of patches have been cited as grounds for divorce [29,32]. Five out of eight divorced pa- tients professed to vitiligo being the ground for divorce in this study. It is noteworthy that vitiligo impacts not only the diseased individual but also the QOL of their family members including partners [17]. L Al-Mubarak et al in their study in- ferred that married people QOL was not as poorly influenced as that of single people, similar to the present study wherein both VIS-22 and VitiQoL scores were higher in single pa- tients as the disease probably instils a fear of rejection and decreased future prospects of marriage [33]. Higher values of both QOL scores in household workers and laborers in this study, as compared to lower scores in patients with skilled oc- cupations, signifies the importance of education in reducing the impact of chronic diseases on the individual psychological impairment. Both the VIS-22 and VitiQoL scores exhibited a statisti- cally significant association with VIDA score (P value<0.001, r value 0.367 and 0.353 respectively), asserting that higher disease activity corresponds to poorer QOL. The only other study done so far comparing VIDA with QOL scores showed statistically insignificant, weakly positive association be- tween VIDA score and DLQI [34]. Gupta et al grouped the questions of VIS 22 in 10 domains comprising attitude, anxiety, social interaction, occupation and so forth [12]. While assessing these individual domains, 10 Original Article | Dermatol Pract Concept. 2024;14(2):e2024075 graded impact scales. Preliminary psychological screening may assist in timely engagement with multidisciplinary ap- proaches and mental health experts to mitigate the health burdens for these patients. Future prospective studies should focus on identifying inherent fundamental factors in mental health in order to bridge gaps in psychological support to the patients. Acknowledgement We thank Dr. M Ramam and Dr. Vishal Gupta, Department of Dermatology, AIIMS, New Delhi, for granting us permis- sion for using VIS-22. References 1. Njoo MD, Westerhof W. Vitiligo pathogenesis and treatment. Am J Clin Dermatol. 2001;2(3):167-181. DOI: 10.2165/00128071 -200102030-00006. PMID: 11705094. 2. Parsad D, Dogra S, Kanwar AJ. Quality of life in patients with vitiligo. Health Qual Life Outcomes. 2003;1:58. DOI: 10.1186/1477-7525 -1-58. PMID: 14613564. PMCID: PMC269995. 3. Amer AA, Gao XH. Quality of life in patients with vitiligo: an analysis of the dermatology life quality index outcome over the past two decades. Int J Dermatol. 2016;55(6):608-614. DOI: 10.1111/ijd.13198. PMID: 26749040. 4. Malhotra N, Dytoc M. The pathogenesis of vitiligo. J Cutan Med Surg. 2013;17(3):153-172. DOI: 10.2310/7750.2012.12005. PMID: 23673299. 5. Hamzavi I, Jain H, McLean D, Shapiro J, Zeng H, Lui H. Parametric modeling of narrowband UV-B phototherapy for vit- iligo using a novel quantitative tool: the Vitiligo Area Scoring Index. Arch Dermatol. 2004;140(6):677-683. DOI: 10.1001 /archderm.140.6.677. PMID: 15210457. 6. Njoo MD, Das PK, Bos JD, Westerhof W. Association of the Koebner phenomenon with disease activity and therapeutic responsiveness in Vitiligo Vulgaris. Arch Dermatol. 1999;135(4):407-413. DOI: 10.1001/archderm.135.4.407. PMID: 10206047. 7. Mattoo SK, Handa S, Kaur I, Gupta N, Malhotra R. Psychi- atric morbidity in vitiligo: prevalence and correlates in India. J Eur Acad Dermatol Venereol. 2002;16(6):573-857. DOI: 10.1046/j.1468-3083.2002.00590.x. PMID: 12482039. 8. Porter JR, Beuf AH, Lerner A, Nordlund J. Psychosocial effect of vitiligo: a comparison of vitiligo patients with ‘‘normal’’ control subjects, with psoriasis patients, and with patients with other pig- mentary disorders. J Am Acad Dermatol. 1986;15(2 Pt 1):220- 224. DOI: 10.1016/s0190-9622(86)70160-6. PMID: 3745526. 9. Wang KY, Wang KH, Zhang ZP. Health-related quality of life and marital quality of vitiligo patients in China. J Eur Acad Dermatol Venereol. 2011;25(4):429-435. DOI: 10.1111/j.1468 -3083.2010.03808.x. PMID: 20666878. 10. Talsania N, Lamb B, Bewley A. Vitiligo is more than skin deep: a survey of members of the Vitiligo Society. Clin Exp Dermatol. 2010;35(7):736-739. DOI: 10.1111/j.1365-2230.2009.03765.x. PMID: 20015281. 11. Kent G, al-Abadie M. Factors affecting responses on Dermatology Life Quality Index items among vitiligo sufferers. Clin Exp Dermatol. 1996;21(5):330-333. PMID: 9136149. the questions related to social interactions (3,  12, 13) and anxiety (2, 11) were found to be the major contributors to the scores in the present study, specifically among those who had lesions on the exposed sites. Upon severity assessment of VIS-22, 45.4 % patients re- flected moderate impact and 33.7 % had large impact on their QOL, both comprising of the largest burden (79.1%) of the study group, hence reiterating that vitiligo has consid- erable affliction on QOL. Likewise, Gupta et al, in a study of cohort of 391 vitiligo patients, noted 49.7% patients had large impact on QOL followed by mild impact in 27.7 % patients using VIS 22 scores [16]. Higher mean values of VASI score observed in patients who had moderate to large impact on their QOL (P value 0.001; r value 0.693)according to VIS-22 score, demon- strated that more the disease severity, higher the impact on QOL. Similar results were seen by Hammam at al in study done on QOL using DLQI scores [21]. Statistically significant correlation demonstrated in this study between both VIS-22 and VitiQoL with VASI scores (P value 0.001) infers that QOL seemed to be remarkably de- pendent on the clinical severity scores. Correlation of VitiQoL score with VASI score was slightly higher (r value 0.824,very strong correlation) than with VIS 22 score (r value 0.693,s trong correlation). Studies done antecedently corroborating this relationship between QOL and area severity scores are Hammam et al (DLQI and VASI), Patvekar et al (VASI and VIS-22), Hedyat et al (VASI and VitiQol) and several others [9,13,19,21,22,,24,35,36,37,38]. Contrarily, Kota et al in their study established significant correlation of VASI with DLQI but poor correlation with VIS-22 scores [23]. Since neither of the two QOL scores (VIS-22 and VitiQoL) was determined to be superior to the other (ICC 0.842), each of these scores is viable for utilization in skin of color to measure the impact of vitiligo on QOL. Since it was a hospital-based study, extrapolation of this data at community level may not be representative of the ac- tual disease burden. Moreover, it was a questionnaire-based study lacking any control group. Furthermore, the study population was representative of a group where cultural be- liefs and myths pose a greater psychological burden which may not coincide with global figures. The scoring was per- formed at one point in time and test-retest measurements could not be performed. In this study, both disease specific QOL scores were com- pared and correlated with disease severity assessment tools in Indian patients. Additionally, our study emphasizes the importance for dermatologists to integrate QOL assessments in management of vitiligo, in order to assess the extent of activity limitation and psychological burden. 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