QUALITY OF LIFE OF VITILIGO PATIENTS ATTENDING THE DERMATOLOGY CLINIC OF THE UNIVERSITY COLLEGE HOSPITAL IBADAN, NIGERIA

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QUALITY OF LIFE OF VITILIGO PATIENTS ATTENDING THE DERMATOLOGY
CLINIC OF THE UNIVERSITY COLLEGE HOSPITAL IBADAN, NIGERIA.
Ehiaghe L. Anaba1*, Adekunle O. George2 and Adebola O. Ogunbiyi2
1Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria.
2Department of Medicine, University College Hospital, Ibadan, Nigeria.
Article Received on 13/12/2019 Article Revised on 03/02/2019 Article Accepted on 24/02/2019
INTRODUCTION
Vitiligo is an important skin disease having a major
impact on quality of life (QOL) of patients,[1,2] many of
whom feel distressed and stigmatized by their
condition.[3,4] Vitiligo patients experience various
degrees of psychosocial impairment and psychiatric
morbidity with resultant altered QOL despite the fact that
the condition does not lead to a severe physical
illness.[3,4]
Various factors have been documented in vitiligo to
affect QOL; the mere presence of the vitiligo lesions,[5]
vitiligo lesions on visible parts of the body like the face
and hands,[2] age,[2,4] gender,[2,6] family history of
vitiligo,[7] marital status,[2,8] duration of disease.[7]
location[1] and severity of vitiligo.[2,8,9-11,12] Vitiligo
causes emotional pain, low self-esteem, poor body
image, depression, suicidal ideation and self-harm.[3,9]
Difficulty with sexual relationships especially in patients
who have their lesions in the genital area is reported by
vitiligo patients.[10-12] Vitiligo patients tend feel more
stigmatized than patients with other skin disorders.[13,14]
Vitiligo patients are treated regularly in the dermatology
clinics in Nigeria.[15] However, QOL studies in Nigerian
vitiligo patients are few. The objective of this study
therefore, is to assess the QOL of people living with
vitiligo and to determine the clinical (location, severity,
class of vitiligo) and socio-demographic factors (age,
sex, marital status, level of education) that affect the
QOL in the patients in this center using the dermatology
life quality index (DLQI) questionnaire and the general
health questionnaire (GHQ-12).
MATERIALS AND METHODS
This was a Prospective comparative study conducted
over a one year period at the University College Hospital
(UCH) Ibadan Dermatology Outpatient Clinic. Ethical
clearance was given for the study by the research and
ethics committee of the hospital. Permission to use the
DLQI was obtained from Finlay AY its developer.
The QOL of 57 vitiligo patients was compared with the
QOL of 57 controls (non-skin disease patients) using the
GHQ-12. The QOL items on the DLQI of 42 newly
diagnosed vitiligo patients was compared with that of 15
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Research Article
ISSN 2394-3211
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EUROPEAN JOURNAL OF PHARMACEUTICAL
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ejpmr, 2019,6(3), 495-504
*Corresponding Author: Anaba L. Ehiaghe
Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria.
ABSRACT
Background: In Nigeria, vitiligo is prevalent with a consequent impairment of quality of life. However, studies on
quality of life impairment, the clinical and socio-demographic factors which impair this quality of life are few.
Aims and Objectives: To determine quality of life of the adult vitiligo patients, the socio-demographic factors
(age, sex, marital status, level of education) and the clinical characteristics (location, severity, class of vitiligo) that
could impact on their quality of life. Also, to compare quality of life in newly diagnosed vitiligo patients to patients
who were already being treated. Methodology: This was a cross-sectional study, over a one year period. The QOL
of 57 adult patients (42 newly diagnosed and 15 follow up) was assessed using the Dermatology Life Quality Index
(DLQI) and the General Health Questioonnaire-12 (GHQ-12). Also, the QOL of 57 controls was assessed using the
GHQ-12. These patients were clinically assessed and a study protocol was used. Data was analyzed using SPSS 16.
Results: Quality of Life was found to be impaired, mean DLQI score was 5.7 ± 6.8. Quality of life comparisons
between the newly diagnosed and the follow up respondents did not reveal any statistically significance difference
(P=0.581). Embarrassment, choice of clothing, problems with work and friendship were the main items of QOL
impairment on the DLQI. Significant association was not found between gender, age at presentation, level of
education and QOL impairment. Marital status was significantly associated with QOL impairment. Conclusion:
Vitiligo significantly impairs QOL irrespective of when patients are diagnosed. In each patient‟s treatment
modality, QOL should be taken into consideration.
KEYWORDS: Vitiligo, Quality of Life, Nigeria, Marital Status.

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vitiligo patients already attending the clinic. Also, the
effect of clinical and socio-demographic factors on QOL
in the 42 new patients was studied. Sample size was
calculated using the formula for comparing means of two
samples.16 Fifty seven age, gender and level of education
matched controls who attend the eye clinic for refraction,
who did not have vitiligo or other skin lesions and had no
recognizable mental illness were recruited into the study.
A detailed history was obtained and physical
examination performed on each new vitiligo patient. A
proforma which had been developed for this study and
has items on sociodemographic characteristics (sex, age,
level of education, marital status), clinical history of
vitiligo (duration of vitiligo, age at onset of vitiligo,
family history of vitiligo, activity/spreading of lesions)
and findings on physical examination (clinical type of
vitiligo, severity, visibility of lesions) was used for this
study.
Classification of vitiligo in this study was based on the
Nordlund‟s classification; vulgaris, segmental, acral,
acrofacial and focal.[17] The extent/severity of vitiligo
was based on the rule of nine.[18]
Two instruments; the Dermatology Life Quality Index
(DLQI)[19] and the General Health Questionnaire (GHQ)-
12[19] were used in the assessment of QOL.
The DLQI an instrument for the measurement of QOL in
skin disease patients has ten questions covering
symptoms and feelings, daily activities, leisure, work and
school, personal relationships and treatment over the
previous one week. Each question has four possible
responses: „„not at all,‟‟ „„a little,‟‟ „„a lot,‟‟ or „„very
much,‟‟ with scores of 0, 1, 2, and 3, respectively. „„Not
relevant‟‟ is also scored as 0, giving a maximum score of
30 and a minimum of 0. The higher the score, the greater
the level of impairment of QOL.[19,21] The DLQI scores
are interpreted as follows; scores of 0-1 mean no effect
on the patient‟s life, 2–6 mean a small effect, 7–12,
moderate effect, 13–18 very large effect and 19- 30
extremely large effect on patient‟s QOL.[22]
The GHQ-12 is an instrument of well-being
measurement.[20] The GHQ measures common mental
health problems of depression, anxiety, somatic
symptoms and social withdrawal.[20] The GHQ allows
simple comparison between studies of assessment of
wellbeing and detects minor non-psychotic psychiatric
disorders.
The GHQ-12 which has twelve questions was chosen for
this study due to its brevity, ease of use and time
consideration. Each question has four possible answers
ranging from, not at all to much more than usual with
scores of 0,1,2,3 respectively. Scores range from 0 to 36.
Scores greater than fifteen (15) shows evidence of stress
and greater than twenty (20) suggests severe problems
and psychological stress. A score of above 3 is usually
used as the cut off score implying psychological
impairment.[20]
Vitiligo patients filled out both the DLQI and GHQ-12
while controls filled out only the GHQ-12 questionnaire.
Socio-dermographic characteristics (age, sex, level of
education) of controls were obtained using a proforma.
Data was analysed using SPSS version 16.[20]
Quantitative variables were summarized using means,
median, standard deviation and range while frequencies
and proportions were used for categorical variables. The
agreement between two scales for assessment of quality
of life, the DLQI and GHQ-12 was assessed using
Cronbach‟s alpha. The relationship between two
quantitative variables was tested using the Pearson‟s
correlation coefficient when data was normally
distributed and the Spearman‟s correlation analysis when
not normally distributed. Comparison of mean quality of
life scores was done using t-test and analysis of variance
for comparing 2 or 3 groups respectively. When not
normally distributed the Mann Whitney U test and
Kruskal Wallis tests were used respectively. Associations
between qualitative variables were tested using the chi
square test. The level of significance was at 5%.
TESTING VALIDITY AND RELIABILITY OF
INSTRUMENTS
The DLQI and GHQ-12 questionnaires were validated by
studying a sub sample of each group (12 patients with
vitiligo and 12 of the control group). The instrument was
re-administered after about two weeks of initial
interview. Internal consistency and reliability (to assess
extent to which items comprising each scale measures
the same construct) was assessed by the Cronbachs‟
alpha statistics.[16] and item-total correlations. A value
of >0.70 for the former and >0.30 for the latter were
conventionally considered acceptable.
Test-retest reliability was determined by an intra-class
correlation coefficient (ICC) of individual patient scores
2 week apart. Construct validity was examined by means
of correlations of scales for DLQI with relevant scales of
the GHQ-12.
RESULTS
A total of 42 new vitiligo patients were attended to
during the study period, 21 males and 21 females. The
mean age of the patients was 43.1 ± 18.8 years. An equal
number of respondents had their age at onset between 18
– 29 years and 30 – 39 years. The commonest area of
onset was the face/scalp. Vitiligo was active in 48.7% of
the patients. Level of education was tertiary in 64.3%,
secondary in 19%, primary in 9.5% and no formal
education in 7.1%. Majority of the respondents (63.4%)
presented after their 1st year of onset. Only 2.4% had a
family history of vitiligo, 33.3% reported self-
medication, 42.9% had hospital treatment and 73.8% of
respondents were asymptomatic. Treatment for other
medical conditions was reported in 40.5%; hypertension

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in 52.9%, diabetes mellitus in 11.8%, respiratory
diseases in 17.7%. The distribution of the socio- demographic variables is shown in table 1.
Table 1: Distribution Of Socio-Demographic Variables.
Male (21)
Female(21)
Total (n=42)
Age at presentation (years)
18 – 29
30 – 39
40 – 49
50 – 59
≥60
8(38.1)
6(28.6)
2(9.5)
2(9.5)
3(14.3)
4(19.2)
4(19.0)
4(19.0)
3(14.3)
6(28.6)
12(28.5)
10(23.8)
6(14.3)
5(11.9)
9(21.4)
Marital status
Single never married
Currently married
Divorced
Widowed
12(57.1)
9(42.9)
0(0.0)
0(0.00
5(23.8)
10(47.6)
0(0.0)
6(28.6)
17(40.5)
19(45.2)
0(0.0)
6(14.3)
Age at onset of vitiligo (years)
0 – 9
10 – 17
18 – 29
30 – 39
≥40
1(4.8)
4(19.0)
6(28.6)
5(23.8)
4(19.0)
1(4.8)
1(4.8)
4(19.2)
5(24.0)
10(48)
2(4.8)
5(11.9)
10(23.8)
10(23.8)
14(33.3)
Area of onset
Anterior trunk
Face/scalp
Gluteal
Lower limb
Neck
Upper limb
4(19.0)
10(47.6)
0(0.0)
2(9.5)
0(0.0)
5(23.8)
0(0.0)
14(66.7)
1(4.8)
1(4.8)
1(4.8)
4(19.0)
4(9.5)
24(57.1)
1(2.4)
3(7.1)
1(2.4)
9(21.4)
Clinical characteristics are shown in table 2. Using the
“rule of nine”, 71.4% of respondents had a vitiligo
severity of <9%. Leukotrichia was absent in all the
respondents. Majority had their vitiligo in a
visible/exposed part of the body. Re-pigmentation was
reported in 54.5% of patients. Half of the adults had
acrofacial vitiligo.
Table 2: Distribution Of Clinical Variables.
Male
Female
Total (n=42)
Re-Pigmentation
Yes
No
5(45.5)
6(54.5)
7(63.6)
4(36.4)
12(54.5)
10(45.5)
Actual severity score
<1
1 – 3
4 – 9
>9
7(33.6)
5(24.0)
7(33.6)
2(9.6)
7(33.6)
4(19.2)
3(14.4)
7(33.6)
14(33.3)
9(21.4)
10(23.8)
9(21.4)
Visibility (lesion in exposed parts)
Yes
No
18(85.7)
3(14.3)
19(90.5)
2(9.5)
37(88.1)
5(11.9)
Classification of vitiligo
Segmental
Vulgaris
Focal
Acrofacial
Acral
1(4.8)
7(33.3)
2(9.5)
8(38.1)
3(14.3)
1(4.8)
5(23.8)
1(4.8)
13(61.9)
1(4.8)
2(4.8)
12(28.6)
3(7.1)
21(50.0)
4(9.5)
CONTROL GROUP ANALYSIS
Analysis of the control group is shown in table 3. The
mean age of the control group was 40.5 ± 16.5 with a
range of 18-80 years. Males constituted 56.1% of the
respondents in this group. Most persons (57.9%) were
currently married, 38.6% were single and 3.5% were
widowed. Level of education was tertiary in 68.4%,
secondary in 15.8%, primary in 10.5% and no formal
education in 5.3%.

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Table 3: Demographic Distribution of Control
Respondents.
Variable
Frequency
Percentage
Age (years)
18 – 19
20 – 29
30 – 39
40 – 49
50 – 59
≥60
4
12
15
7
9
10
7
21
26.3
12.3
15.8
17.5
GHQ-12 score
No impairment
impairment
1
56
1.8
98.2
The DLQI and GHQ-12 scales were validated by
assessment of their internal consistency using the
Cronbach‟s alpha. The Cronbach‟s alpha for the
dermatology scale (10 items) was 0.79 and for the GHQ-
12 scale (12 items) 0.89. The correlation coefficient for
the test-retest reliability analysis of the GHQ-12
instrument was high at 0.805 while that for the DLQI
was fair at 0.511.
There was no impairment of QOL in 98.2% of the
control group while QOL was impaired in 61.9% of the
newly diagnosed and in 66.7% of the old vitiligo
patients.
In the new patients; the mean GHQ-12 score was 10.6 ±
6.2, with the highest and lowest scores being 30 and 1
respectively and the mean DLQI score was 4.2 ± 4.6,
with the highest and lowest scores being 16 and 0
respectively. For the old patients; mean GHQ-12 score
was 12.3 ± 7.5 with the highest and lowest scores being
30 and 7 respectively. The mean DLQI score was 5.7 ±
6.8 with the highest and lowest scores being 21 and 0
respectively.
The quality of life comparisons between control and new
patients showed a statistically significant difference. The
median GHQ-12 score for control respondents was 7,
while that for the new vitiligo patients was 9. This was
significant at P=0.001. Quality of life comparisons
between the new and the old vitiligo patients did not
reveal any statistically significance difference, P=0.581
(median DLQI score was 2 in both groups).
A mild effect on QOL was observed in 26.7% of old
patients and in 31.0% of new patients. Moderate
affectation of QOL was reported in 26.7% of old patients
and in 23.8% of new patients. Large to extremely large
effects was seen in 13.3% of old patients and in 30.9% of
new patients. See figure 1.
Figure 1: Specific Level of Qol Impairment Using The Dlqi.
The responses to the individual items on the DLQI scale
are shown in figure 2 for newly diagnosed and old cases.
Amongst the newly diagnosed; on the 1st item, 16.7% of
persons reported varying degrees of itchiness, pain or
stinging sensation over the last one week.
Embarrassment or self-consciousness was reported in
61.9% of respondents. Interference with going to the
market or farm was reported in 38.1% of persons. Of all
respondents, 47.6% reported influence on the choice of
clothes worn due to the vitiligo and the same percentage
reported effects on social or leisure activities.
Interference with sports was reported in 38.0%. The
proportion of persons that reported interference with
work or study by the vitiligo was 95.2%. Affectation of
relationship with friends, partner or relatives was seen in
47.6%. Sexual difficulties due to vitiligo were seen in
26.2%. Problems with treatment were reported in 26.2%.
Amongst the old patients; on the first item, 80% of the
respondents said their skin had not been itchy at all. On
the second item on embarrassment or self-consciousness,
73.3% of the patients had various degrees of affectation.
On the third item, interference with going to the market
and on the fourth item, influence on the type of clothes

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worn 40% gave a positive response. Interference with
social or leisure activities was reported in 33.3% of
respondents. On the aspect of sports, to varying degrees,
the life of 26.7% of respondents was affected by vitiligo.
On the seventh item, affectation of work or study, the
quality of life in 93.3% of respondents was not affected.
Relationship with friends, partner or relatives was
affected in 40%. Sexual difficulties was reported by
20%. On the tenth item, 26.7% reported impairment of
QOL by treatment of vitiligo.
The relationship between the DLQI and variables is
shown in tables 4a and 4b. Amongst the newly diagnosed
cases, significant associations were found for age, history
of spreading, marital status, and visibility of vitiligo At
P=0.008, the age was significantly associated with the
DLQI with a spearman‟s coefficient of -0.404. All other
variables were not significantly associated (level of
education, severity, gender, re-pigmentation, class of
vitiligo).
Amongst the old cases, no significant associations were
found with the socio-demographic and vitiligo related
variables. The socio-demographic variables tested
included age, gender, marital status, tribe and
educational status. The vitiligo related variables tested
include the age at onset, duration before presentation,
family history, a history of re-pigmentation, history of
spreading, visibility of lesion, class of vitiligo and
severity of vitiligo.
Figure 2: Distribution of Responses To The Individual Items on The Dlqi Scale.
DISCUSSION
This study revealed an impairment of quality of life in
majority of the vitiligo patients compared to controls.
Also, median QOL score was significantly different
between the vitiligo patients and the controls. The
presence of lesions on the skin which had a great colour
difference from the normal skin, uncertainty about the
nature of the lesions with queries from friends, family
and passersby may have been responsible for this
impairment in QOL. In India, Sangma et al found a
similar difference QOL between vitiligo patients and
controls.[24]
However, there was no difference in median QOL scores
between the newly diagnosed and the old vitiligo
patients. This result shows that, the duration of the
presence of vitiligo lesions have no effect on QOL
impairment. Rather it is the presence of the vitiligo
lesions which impaired QOL. This result of lack of
influence of duration of lesion on QOL is in keeping
with the report from Holland25 but at variance with the
report from Korea, where a long duration of vitiligo
lesions negatively impacted on QOL.[7] Other studies
have also shown QOL of vitiligo patients to be
negatively impaired by the mere presence of vitiligo.[5,26]
The highest score on the DLQI questionnaire was 16 out
of a possible maximum score of 30 in these vitiligo
patients. This high score may have been as a result of the
long time it takes for lesions to re-pigment, frequent
clinic attendance or problems of drug procurement. A
similar high score was reported by Sangma et al their
study of vitiligo and QOL impairment.[24]
Looking at the level of impairment of QOL of patients as
classified by Hongbo et al,[22] >60% of both old and
newly diagnosed patients had impaired QOL. This study
shows that QOL is impaired in a lot of vitiligo patients
though the level of impairment was mostly mild/
moderate. This mild/ moderate level of QOL impairment
was an unexpected finding in this study; more so, as
majority of the patients in this study had their lesions in
exposed areas of the body. Vitligo patients tend to be
self-conscious and embarrassed by their lesions
especially when the de-pigmented lesions contrast with
dark coloured skin as in this study. This study is in
consonance with studies from Korea and India, where a
similar mild QOL impairment in vitiligo patients was
observed.[2,24,27]

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All items on the DLQI were negatively affected by
vitiligo and there were also differences in QOL
impairment between newly diagnosed and old cases.
Itchiness/soreness of the skin was not a major item of
impairment of QOL in this study because most of the
patients were asymptomatic. Vitiligo is mainly an
asymptomatic skin lesion with occasional itch or
soreness from sun burn.[28]
Embarrassment or self-consciousness as a result of
having vitiligo was a major item that impacted
negatively on QOL. The old patients were even more
embarrassed than the new patients. Vitiligo lesions are
very striking against the background of a dark coloured
skin. Most patients would have been starred at and asked
questions by friends and relations about the colour
change of their skin with resultant embarrassment and
self-consciousness. Similar reports of embarrassment as
a result of having vitiligo have been documented by
other authors.[2,13,14] Patients in these studies were found
to be embarrassed because they were starred at and
frequently asked questions regarding their skin lesions.
On the item on interference with going to the market,
about 40% of both old and new patients reported an
interference with market attendance. One lady, a shop
owner had actually closed her shop because she had
vitiligo and refused to be seen outside her house. This
interference with market attendance is due to lesions
being present on exposed parts of the body with its
attendant comments and questions. Also, patients may
fear stigmatization since the spotted lesions are similar to
that of leprosy. The old patients seem to also be worse
off in this item. Stigmatization and avoidance of public
places like the market has also been documented by other
authors.[3,4,14] Patients in these studies reported being
subjected to rude remarks and starred at.
On the item of influence of vitiligo on choice of clothes
worn, more than 40% of both old and new patients
reported an influence on choice of clothes worn and this
influence was worse in the old old patients. Patients
would have had to wear clothes which cover their lesions
to prevent comments being passed on their lesions or
being starred at. These patients were specifically asked if
they would wear clothes which reveal their body parts
and they were not willing to. Lesions on exposed skin
would be quite striking against the background dark
coloured skin. A similar influence of vitiligo on choice
of clothing was reported in Belgium, though they did not
compare their new patients with old patients.[25] Also, the
Belgian patients had to choose clothes which would
protect them from UV rays because their depigmented
lesions were susceptible to sunburn and this was
inconveniencing to the patients.
Social or leisure activities item was affected by vitiligo
in both new patients and old patients although the effect
is little. Only a minority had a severe affectation and they
were mainly old patients. Social or leisure activities may
have been little affected because, these activities are
carried out with friends and relations who usually are the
support group of patients. Also, these friends and
relations usually show more understanding of the disease
process and will not probably stigmatize the patient.
Other reports on the influence of vitiligo on social or
leisure activities have the same conclusions as in this
study. In Belgium, where the DLQI was used as in this
study, social or leisure activities was slightly negatively
affected by the presence of vitiligo.[25] A previous study
from this center using a self-designed questionnaire,
reported interference of vitiligo with social life.[29] The
authors of this study came to the conclusion that, this
affectation of social life was due to unkind remarks from
strangers and being starred at.[29]
Participation at sporting activities does not appear to be
much affected by having vitiligo from this study as it
was observed in about one third of the patients. This
study did not specifically lookout for how many people
participate in sporting activities. It is not known if this
low report of influence of vitiligo on sporting activities is
due to a low participation in sporting activities. Sporting
activities usually involved dressings which expose the
extremities leading to exposure of lesions. Exposure of
lesions leads to embarrassment which would impair
QOL. Participation at sporting activities was similarly,
minimally affected by having vitiligo in Belgium.[25] This
study did not however report how many of the patients
participated in sporting activities.
On the item on “if having vitiligo has prevented them
from working or studying” almost all the newly
diagnosed patients had problems with going to work
because of having vitiligo while this was a problem in a
negligible proportion of old patients. Problems with
going to work as a result of having vitiligo seems to be
dependent on how long patients have had their lesions.
The old patients don‟t appear to have a problem with
going to work, probably because they and their
colleagues over time had become used to their lesions.
The new patients appear to be severely affected by
having vitiligo. This may be because of being questioned
by colleagues about the sudden appearance of de-
pigmented lesions. This is especially as the vitiligo
lesions would be quite striking against their dark skin.
A study on the effect of vitiligo on willingness to go to
work by other authors revealed a minimal effect similar
to that of the old patients in this study.[25] This study was
in Caucasians in whom vitiligo lesions are not so
striking. It is not known if this contributed to the minimal
effect on these Caucasians. In a Nigerian study of
psychosocial problems in patients with vitiligo, patients
were found to be unwilling to go to work because their
relationship with fellow workers was impaired by
vitiligo.[29] The colleagues of these patients may have
avoided them due to fear of developing the lesions
following physical contact with the patients.

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When asked if having vitiligo had affected their
relationship with their friends and relations; about one
third of the old and new patients reported some
affectation of their relationships. Two young men
reported losing their partners because they had vitiligo
and were not willing to start any other relationships until
their lesions were gone.
Majority of the vitiligo patients in this study had no
relationship problems because of having vitiligo. In the
few patients who had relationship problems, it seems to
be a major problem. Problems with relationships may not
have been a major problem in this study because Nigeria
is a closely knit society where friends and relations serve
as support group of patients. A similar minimal negative
effect of vitiligo on social relationships has previously
been documented in Belgium and Nigeria.[25,29]
Vitilgo from this study does not seem to cause sexual
difficulty in the majority of patients and this is
independent of how long patients have had the lesions.
Majority of the patients may not have had difficulties in
their sexual relationships, as the lesion in most patients
in this study was not extensive and mostly extragenital.
In the few patients who have sexual difficulty as a result
of having vitiligo, this was not a major problem. This
study shows that embarrassment is major item affecting
QOL of these vitiligo patients. This may be the reason
for the sexual difficulty in the few patients affected. Also
it is hypothesized, that, with the long duration of lesions,
patients may begin to lose self-confidence and feel
unappealing.
Vitiligo has been noted in other studies to have a variable
effect on the sexual life of patients.[1,10,29] A previous
study from Nigeria reported no effect of vitiligo on
patient‟s sexual life.[29] Morales-Sanchez et al following
their study, concluded that, vitiligo does affect the sexual
life of patients especially if the lesions are located in the
genital area.[1] A study specifically comparing QOL
impairment in women who had vitiligo with no genital
lesions to women who had no vitiligo revealed impaired
sexual satisfaction especially with increasing body
surface area involvement.[10] These different studies
point out the sexual difficulties that vitiligo patients
encounter irrespective of the location of the vitiligo
lesions.
On the question of “how messy treatment was or how
much time is taken up by treatment”, the newly
diagnosed patients in this study were not yet on
treatment, this may be the reason for the minimal report
of problems with treatment. However, the old patients
reported impairment on this item. The main modality of
treatment in this center is PUVASOL (topical meladinine
and sunlight exposure). The process of this treatment
modality could be inconveniencing. This may be the
reason for this high report of problems with treatment
amongst the old patients, most of who were on treatment.
Problems with treatment regimens for vitiligo has been
documented as in this study to affect QOL and this effect
was not in a lot of patients.[25]
There was a significant association between age and
QOL impairment, with QOL worse with increasing age.
Older age is usually associated with more self-
consciousness and a need to look good. This is the age
that needs to go out to work and interact with colleagues;
this may be the reason for the worse QOL with
increasing age. This study was also a dermatology clinic
based study, with patients concerned enough about their
skin to seek specialist treatment. The result of this study
is at variance with that in other studies. In some studies
age had no influence on QOL impairment in vitiligo[8,27]
and in others a younger age was associated with QOL
impairment[2,4]
The males in this study had a worse QOL compared to
the females though it was not statistically significant.
This was an unexpected finding. The reason for the
worse QOL in the males is not known as the general
opinion with no documentary evidence in Nigeria is that,
males are usually not as self-conscious as females. Both
males and females had lesions in exposed parts. This
result is at variance with other studies on QOL
impairment and gender in vitiligo patients, where QOL
in females is reported to be worse.[4,6,24,30,31] In Iran
where pigmentary changes could be obvious as in
Nigeria, more females had QOL impairment.[4] This is
despite this country being a country where the dress code
of females involves being all covered up. In India,
gender had no impact on QOL impairment.[27]
Single patients in this study had a significantly worse
QOL of life compared to the married patients. The single
patients may have had a worse QOL because of
embarrassment from having vitiligo with consequent
social inhibition and embarrassment. Also, patients in the
age range 18-39 years made up more than half of the
study population; this is the age range for marriage and
starting relationships. It is difficult to explain why the
QOL impairment in married people was not as low as
that of the single patients. We hypothesize that, it may be
because they already had their spouses and did not need
to start new relationships.
Studies on QOL, marital status and vitiligo have different
results. A similar report of a worse QOL in single
patients has been reported following a study of the effect
of vitiligo on sexual relationships.[2] In Iran, they found
the married women to have a worse QOL compared to
the single females.[8] The authors of the Iranian study
gave a cultural reason for their study result. In Iran, the
single females are all covered up and nobody sees their
lesions unlike the married females who have to expose
their lesions to their husbands. Also, these women face
the threat of divorce from their husbands unlike the
married men.

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Level of education was not found to significantly affect
QOL of patients in this study. This study shows that
QOL impairment by vitiligo is independent of level of
education. This is probably due to the fact that, people‟s
emotions and feelings have nothing to do with their level
of education. These patients will still be starred at,
questioned about their lesions and embarrassed
irrespective of their level of education. In Iran and India,
a similar lack of influence of level of education on QOL
impairment was reported.[8,27] However, in Korea, a
higher level of education was associated with a worse
QOL.[2]
History of re-pigmentation following treatment was not
found to be significantly associated with QOL
impairment. The extent of the lesions, number of lesions
and degree of depigmentation (hypopigmentation or
complete depigmentation) may have been responsible for
this insignificant difference in QOL impairment. Also,
these were all new patients, majority of them not yet on
treatment. Those on treatment had only just started. A
study comparing patients whose lesions have completely
re-pigmented with newly diagnosed patients is needed, to
ascertain the true impact of re-pigmentation on QOL.
With increasing severity of lesions, there was an
increasing worsening of QOL although; this association
was not statistically significant. Increased severity of
lesion may have been associated with a worsening of
QOL because increased area of body involvement would
influence the clothes worn with attendant problems of
how to cover the lesions, affect social life and cause
more embarrassment of the patients. Also, patients with a
large body area involvement are more likely to be starred
at and stigmatized. A similar report a similar worsening
of QOL with increasing severity of lesions has been
documented in other studies.[2,6,10,11] However Narahari et
al in India and Hedayat et al in Iran in their studies
reported no influence of the severity of vitiligo on QOL
impairment in their cohort of patients.[4,27] They opined
that, the DLQI did not reflect the true QOL impairment
in their patients.[27]
Visibility of lesions meaning lesions on exposed parts of
the body, was significantly associated with QOL
impairment. Visible lesions are likely to attract
comments from people and also these lesions will not be
easy to cover up with clothes. The consequent
embarrassment and limitation in the type of clothes worn
would have led to more QOL impairment. A similar
impairment of QOL due to the visibility of lesions of
vitiligo especially in patients whose lesions were in
visible parts e.g the face, hands has been reported.[2,3] In
Iran however, visibility of lesions was not associated
with QOL impairment.[8] Iran is a country where the
mode of dressing involves complete coverage of body
parts especially in females. This may be the reason for
this lack of effect of visibility of lesions on QOL
impairment.
There was no significant association between type of
vitiligo and QOL impairment. However, looking at the
different classes of vitiligo, acral and segmental vitiligo
impaired QOL more than vulgaris or focal vitiligo. Acral
vitiligo occurs in only visible parts of the body unlike
vulgaris which can occur in body parts that a patient can
cover. This may be the reason for this difference in QOL
impairment between the different types of vitiligo. This
study shows that there can be intra class variation in
QOL impairment in vitiligo and that patients with acral
vitiligo are especially affected. There were no other
studies comparing QOL between different classes of
vitiligo. In Holland, however, patients with universal
vitiligo were found to have a worse QOL compared to
other severities of vitiligo.[32]
History of spread of lesions of vitiligo at presentation to
the clinic, was significantly associated with QOL
impairment. Spread of lesion results in increased body
surface involvement with consequent more
embarrassment and social inhibition. Also, choice of
clothes becomes limited as patients need to wear clothes
that do not reveal their lesions. Patients live in fear of
how extensive their lesions will be and this is usually not
predictable. There was no study specifically correlating a
history of spread of vitiligo with QOL impairment to
compare this study with.
Duration of vitiligo was not significantly associated with
impairment of QOL in both old and new patients.
Duration of lesions and the number of times patients
attended clinic was not a problem to the patients in this
study. The reason for this is not known but may have
been because patients felt that they were in a specialist
clinic where their lesions would be cured. This study
result is similar to that reported in Holland where a study
of 119 vitiligo patients revealed no relationship between
disease duration and QOL in vitiligo patients.[25] A study
in Korea of QOL of one hundred and thirty three vitiligo
patients came to a contrary conclusion.[7] They found that
long duration of disease and frequent visits to the clinic
negatively impacts on QOL.[7] The authors thought that it
was the chronicity of the disease which led to the poor
QOL.
There was no significant association between age at
onset and QOL impairment. It did not matter at what age
vitiligo started, rather what was important to these
patients was that they had vitiligo. There was no study to
compare the influence of age at onset of vitiligo on QOL
with.
CONCLUSION
Vitiligo significantly impairs QOL and this QOL
impairment is irrespective of whether patients are newly
diagnosed or not. Level of QOL impairment was mostly
mild to moderate. All items on the DLQI were affected
by vitiligo with differences in level of impairment
between newly diagnosed and old patients.

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Embarrassment or self-consciousness, choice of clothing,
social interactions, problems with work and friendship
were the main items that impaired QOL. Significant
association was not found between gender, level of
education, history of re-pigmentation, class of vitiligo,
age at onset, duration of disease, number of visits to
clinic and QOL impairment. Marital status, age at
presentation, severity of lesions, visibility of lesions, and
history of spread of lesion were significantly associated
with QOL impairment.
LIMITATIONS TO THE STUDY.
The number of patients to study were few.
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