Quality of life in patients with acquired pigmentation: An observational study

Sir, Pigmentary disorders are cosmetically very disfiguring for patients and affect their quality of life. Acquired pigmentation in females can be caused by various dermatological conditions. Pigmented contact dermatitis (PCD), lichen planus pigmentosus (LPP), macular amyloidosis (MA), postinflammatory hyperpigmentation (PIH) prurigo pigmentosa, etc. can lead to diffuse as well as reticular pigmentation. Quality of life (QOL) indices assess the effects of disease on patients’ well-being. Originally, QOL instruments were created to address information about patient's biologic and psychosocial health, including ability to perform routine activities such as walking up and down stairs. The Dermatology Life Quality Index (DLQI) is a simple, practical, and self-administered questionnaire designed to assess limitations caused by the impact of skin disease.1 It is a health quality of life scale comprised of 10 items which focus on 6 dimensions: “symptoms,” “daily activities,” “leisure,” “work,” “personal relationships,” and “treatment.” The total score is calculated by adding the score of each question and ranges from a minimum of “0” to a maximum of “30,” with higher scores representing greater impairment of quality of life.1, 2 Interpretation of DLQI scores is done as: no effect at all on patient's life (0-1), small effect on patient's life (2-5), moderate effect on patient's life (6-10), very large effect on patient's life (11-20), and extremely large effect on patient's life (21-30). We assessed the quality of life in females presenting with acquired pigmentation involving exposed areas. Fifty-two adult females (19-48 years) who presented with such pigmentation on exposed sites, e.g face (n = 3), neck (n = 1), chest (n = 2), arms and forearms (n = 22), back (n = 18), and legs (n = 6) (with or without nonexposed sites), over a period of 1 year, were included in the study after getting a written informed consent. About 34.6% females had presented only because of cosmetic concerns, while rest had pruritus in addition. Diagnosis was made on the basis of clinical history, skin biopsy findings, direct immunofluorescence, and patch testing. Maximum number of females were diagnosed as PIH (n = 18), followed by MA (n = 15), PCD (n = 10), LPP (n = 7), confluent and reticulate papillomatosis (n = 1), and systemic sclerosis (n = 1). DLQI was measured by giving questionnaire-based proforma to the patients. Most of the patients (38.5%) showed moderate effects on their quality of life followed closely by very large effects on quality of life in 34.6% of patients. No effect on quality of life was seen in 3.8% of the patients (Figure 1). On analyzing individual conditions, in PIH moderate effect on quality of life was found in 50% patients. In MA, very large effect on patient's quality of life was found in 40% patients, which was closely followed by moderate effect in 33.3% of patients. In LPP and PCD very large and moderate effect on quality of life was found in of patients (40%) and (42.9%) (Figure 2). Overall, minimum score of quality of life was zero and maximum score was 25. Total mean score was 9.67 ± 5.313. Various studies regarding quality of life have been done in pigmentary disorders such as melasma, vitiligo, lentigo, postinflammatory hyperpigmentation, and idiopathic guttate hypomelanosis and have shown a significant negative impact on a person's health-related quality of life. DLQI had been studied in various dermatological disorders including hyperpigmentation disorders such as melasma, postinflammatory hyperpigmentaion, and vitiligo. In a study, of patients with diagnosed pigmentary disorders, using quality of life assessment questionnaire, majority of patients (53%) were not at all bothered by the skin's appearance. However, 47.3% of patients admitted, feeling self-conscious about their skin to some degree, 21.8% felt others focused on their skin, 32.7% felt unattractive because of their skin, 32.7% put effort into hiding pigmentary changes, and 23.6% felt their skin affected their activities. Majority of patients of postinflammatory hyperpigmentation did not show any significant effect on their quality of life in this study in contrast to our study which could be due to different inclusion criteria as we included female patients with hyperpigmentation involving exposed areas.3 In another study of health-related quality of Life in patients with primary cutaneous amyloidosis, cosmetic disfigurement and severe pruritus dramatically affected patient's quality of life in MA, which led to psychosocial stress and the impairment of emotional functioning.4 Patients with primary cutaneous amyloidosis experienced a significant impairment of life quality in terms of feelings, clothing, social, and leisure activities and daily routine. Strong impact of primary cutaneous amyloidosis was seen on patients’ quality of life both for dermatology-specific (using the DLQI) and for general health perceptions (using the SF-36). We suggest that quality of life measurements can be used in evaluation of patients presenting with pigmentation as this can be an important tool to assess the response to various therapeutic modalities.