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Sleep Quality and Depression in Vitiligo Patients
Vitiligo Hastalarında Uyku Kalitesi ve Depresyon
Aynure Öztekin, Coşkun Öztekin

Euras J Fam Med 2020;9(1):35-41. https://doi.org/10.33880/ejfm.2020090105

 

Original Research / Orijinal Araştırma


ABSTRACT

Aim: Vitiligo is a common disorder that has not only dermatological but also psychological consequences. The aim of this study was to compare depression and sleep quality of vitiligo patients with healthy control group. 

Methods: In this cross-sectional case-control study, patients admitted to the Dermatology Clinic of Skin and Venereal Diseases Department of Hitit University Erol Olçok Education and Research Hospital between August 2018 and August 2019 were compared with healthy control group. The study included 67 patients and 69 control group participants who were matched for age, sex, marriage status, and education level. The subjects were asked to complete a sociodemographic data form, the Beck Depression Inventory, and the Pittsburgh Sleep Quality Index. 

Results: The median total Pittsburgh Sleep Quality Index score was higher in the patient group compared with the control group. The median scores for subjective sleep quality, sleep latency, and sleep disturbance were also higher in the patient group compared with the control group. A family history of vitiligo was present in 18 (26.9%) patients. The most common type was acrofacial vitiligo, which was present in 29 (43.3%) patients.

Conclusions: Increased probability levels of depression and impaired sleep quality in vitiligo patients suggest that psychiatric evaluation and treatment should be provided for vitiligo patients as a part of a multidisciplinary approach in order to increase the success of the treatment.

Keywords: Vitiligo, depression, sleep quality

ÖZ

Amaç: Vitiligo, dermatolojik etkileri yanında psikolojik etkileri de olan sık görülen bir hastalıktır. Bu çalışmanın amacı vitiligo hastalarının depresyon ve uyku kalitesi düzeylerini sağlıklı kontrol grubuyla karşılaştırmaktır. 

Yöntem: Bu kesitsel vaka-kontrol çalışmasında Hitit Üniversitesi Erol Olçok Eğitim ve Araştırma Hastanesi Dermatoloji Kliniği’ne Ağustos 2018 ve Ağustos 2019 tarihleri arasında başvuran hastalar sağlıklı kontrol grubuyla karşılaştırıldı. Yaş, cinsiyet, evlilik durumu ve eğitim düzeyi bakımından eşleştirilmiş olan 67 hasta ve 69 kontrol grup katılımcısı dahil edildi. Katılımcılardan sosyodemografik veri formu, Beck Depresyon Envanteri ve Pittsburgh Uyku Kalitesi İndeksi doldurmaları istendi.  

Bulgular: Medyan toplam Pittsburgh Uyku Kalitesi İndeksi puanı hasta grubunda, kontrol grubundan yüksekti. Subjektif uyku kalitesi, uyku latansı ve uykuda bozulma için medyan puanlar da hasta grubunda kontrol grubundan anlamlı yüksekti. Vitiligo için aile öyküsü 18 (%26,9) hastada vardı. En sık vitiligo tipi olan akrofasyal vitiligo 29 (%43,3) hastada vardı. 

Sonuç: Vitiligo hastalarında depresyon olasılığı ve uyku kalitesinde bozulma artmış olduğundan tedavi başarısını artırmak için multidisipliner bir yaklaşımın parçası olarak psikiyatrik değerlendirme ve uygun hastalarda tedavi yapılmalıdır. 

Anahtar kelimeler: Vitiligo, depresyon, uyku kalitesi


Introduction

Vitiligo is a common disorder that has a prevalence of approximately 0.5-2%, worldwide (1). Its etiology is not exactly known, and its characteristic feature is a partial or complete absence of functioning melanocytes (2). The etiology probably includes a mixture of genetic, autoimmune, and environmental factors (3). Chronic disturbance in physical appearance may lead to low self-esteem, social introversion, and depression in vitiligo patients (4). Besides depression, anxiety disorders especially social phobia and obsessive-compulsive disorder, substance abuse and dysthymic disorder are also common in vitiligo patients (5).

Sleep disturbances frequently accompany dermatological disorders (6). Previous studies have found sleep disturbances in atopic dermatitis (7), and psoriasis (8). Sharma et al. (9) found sleep disturbance in 20% of their vitiligo patients, and it was the most common psychiatric problem reported by the patients. Karelson et al. (10) studied a sample of Estonian vitiligo patients and found sleep disturbances in 30% of the patients. Few studies have investigated sleep quality in vitiligo patients. 

The aim of the present study was to assess sleep quality and depression level in vitiligo patients and to investigate the relationship between several parameters such as vitiligo type, disease duration, depression and sleep quality.

Methods

This was a cross-sectional case-control study. The study group included vitiligo patients above 18 years of age, who attended to the dermatology outpatient clinic of Skin and Venereal Diseases Department of Hitit University Erol Olçok Education and Research Hospital between August 2018 and August 2019. Vitiligo diagnosis was made by the researcher after dermatological examination using Wood lamp. Patients who received treatment for vitiligo during last 6 months and who had any systemic, dermatological, or psychiatric disease were excluded. The control group included hospital staff and their relatives with similar age and sex. All of the patients and control group participants filled a sociodemographic data form prepared by the authors along with the Beck Depression Inventory (BDI), and the Pittsburgh Sleep Quality Index (PSQI) after written informed consent was obtained. In addition, several disease parameters of vitiligo patients such as clinical types and disease durations were also recorded. The study was conducted in accordance with the ethical principles of Helsinki Declaration. The Clinical Research Ethics Committee at Hitit University Faculty of Medicine has approved the study (approval number: 2018-128).

The Beck Depression Inventory was developed to measure the severity of depression (11). It consists of 21 items. Each item can be scored from 0 to 3. Higher scores indicate more severe depression. The validity and reliability study of the Turkish version of this scale was performed by Hisli (12). 

The Pittsburgh Sleep Quality Index was developed by Buysse et al (13). This scale includes 24 items. The subject replies 19 items himself/herself and the other 5 items are reported by the spouse or a room partner. Seven subscale scores are produced from these questions: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleep medications and daytime dysfunction. The validity and reliability study of the Turkish version of the scale was performed by Agargun et al (14). 

Descriptive statistics were given as mean ± standard deviation and median and interquartile range for continuous variables. Categorical variables were given as number and percentage. Normality of numerical variables were checked by the Kolmogorov-Smirnov test. For the comparison of two independent groups, Independent Samples t-test was used when the numerical variables were normally distributed and the Mann-Whitney U test was used when they did not show normal distribution. Pearson’s Chi-Square test was used for comparison of categorical variables in 2x2 tables and Fisher’s Exact test was used for RXC tables. Spearman’s Rho correlation coefficient was used to evaluate the relationship between total and subdimension scores. Jamovi software was used for statistical analyses and p

Results

The study group included 67 vitiligo patients with a mean age of 35.1±10.5 years, the control group included 69 participants with a mean age of 35.3±10.3 years and the mean ages were similar between the groups (p=0.872). Thirty-one subjects (46.3%) in the study group and 33 subjects (53.7%) in the control group were males which was also comparable between the groups (p=0.452). Marriage and education status were also similar between the two groups (Table 1). 

The median total PSQI score was higher in the patient group (6.0; 4.0-9.5) compared with the control group (3.0; 2.0-6.0) (p<0.001). The median scores for subjective sleep quality, sleep latency, and sleep disturbance were also higher in the patient group compared with the control group (p<0.001, each) (Table 1). The median BDI total score of the patient group (9.0; 4.0-14.0) was higher than the control group (3.0; 1.0-9.0) (p<0.001) (Table 1). 

Table 1. Comparison of sociodemographic and clinical features of the vitiligo patients and the control group.

 

 

Patients
(n=67)

Control group
(n=69)

p

Age

35.1 ± 10.5

35.3 ± 10.3

0.872****

Gender (%)

Male

31 (46.3)

33 (47.8)

0.856*

Female

36 (53.7)

36 (52.2)

Marital Status (%)

Married

44 (65.7)

41 (59.4)

0.452*

Single

23 (34.3)

28 (40.6)

Education Status (%)

Primary school

13 (19.4%)

12 (17.4%)

0.983**

Secondary school

8 (11.9%)

8 (11.6%)

High school

19 (28.4%)

19 (27.5%)

College

27 (40.3%)

30 (43.5%)

Pittsburgh Sleep Quality Index

6.0 [4.0 – 9.5]

3.0 [2.0 – 6.0]

 <0.001***

Subjective sleep quality

1.0 [0.0 – 1.8]

0.0 [0.0 – 0.0]

 <0.001***

Sleep latency 

1.0 [1.0 – 2.0]

1.0 [0.0 – 1.0]

 <0.001***

Sleep duration

1.0 [0.0 – 1.5]

0.0 [0.0 – 1.0]

0.225***

Sleep efficiency

0.0 [0.0 – 1.0]

0.0 [0.0 – 1.0]

0.154***

Sleep disturbance

1.0 [1.0 – 2.0]

1.0 [1.0 – 1.0]

 <0.001***

Use of sleep medications

0.0 [0.0 – 1.0]

0.0 [0.0 – 1.0]

0.606***

Daytime sleepiness

 

1.0 [0.0 – 1.0]

0.0 [0.0 – 1.0]

0.062***

Beck depression inventory

9.0 [4.0 – 14.0]

3.0 [1.0 – 9.0]

 <0.001***

*Pearson Chi-Square test was used. Descriptive statistics were given as number (%). **Fisher's Exact Test was used. Descriptive statistics were given as number (%). ***Mann-Whitney U test was used. Descriptive statistics were given as median [IQR]. ****Independent Samples T Test was used. Descriptive statistics were given as mean ± standard deviation. P values in bold were accepted to be statistically significant (p<0.05).

A family history of vitiligo was present in 18 (26.9%) patients. The most common type was acrofacial vitiligo which was present in 29 (43.3 %) patients. The mean age of vitiligo onset was 29.3±12.6) years. In 15 (22.4%) patients the onset of vitiligo was below 18 years of age (Table 2). 

We compared disease characteristics of male and female vitiligo patients. The rates of atopy, hair involvement, age of onset of vitiligo, the percentage of patients whose disease started before 18 years of age and positive family history for vitiligo were similar between the male, and female patients. Acrofacial vitiligo was more common in males while focal vitiligo was more common in females (Table 3). 

Table 2. Disease characteristics of vitiligo patients.

Family history of vitiligo, yes

18 (26.9%)

Family history of atopia, yes

7 (10.4%)

Vitiligo type

Focal

16 (23.9%)

Acrofacial

29 (43.3%)

Vulgaris

22 (32.8%)

Hair involvement

10 (14.9%)

Nail involvement

11 (16.4%)

Vitiligo age of onset

29.3 ± 12.6

Vitiligo, disease duration (month)

69.9 ± 105.3

Age of onset

Before 18 years of age

15 (22.4)

Between 18 and 64 years of age

52 (77.6)

Descriptive statistics were given as number (%) for categorical variables and as mean ± standard deviation for numerical variables.  

   

Table 3. Comparison of vitiligo patients according to gender.

 

Gender

 

Male (n=31)

Female (n=36)

Vitiligo family history, yes

7 (22.6%)

11 (30.6)

0.463*

Presence of atopy (%), yes

2 (6.5)

5 (13.9)

0.437**

Vitiligo type

Focal

1 (3.2)

15 (41.7)

 0.001*

Acrofacial

20 (64.5)

9 (25.0)

 0.003*

Vulgaris

10 (32.3)

12 (33.3)

0.999*

Hair involvement

5 (16.1)

5 (13.9)

0.999**

Nail involvement

6 (19.4)

5 (13.9)

0.547*

Vitiligo age of onset

32.3 ± 13

26.7 ± 11.7

0.070****

Vitiligo disease duration (ay)

36.0 [7.0 – 84.0]

24.0 [12.0 – 66.0]

0.795***

Age of onset (%)

Before 18 years of age

7 (22.6)

8 (22.2)

0.999*

Between 18 and 64 years of age

24 (77.4)

28 (77.8)

*Pearson Chi-Square test was used. Descriptive statistics were given as number (%). **Fisher's Exact Test was used. Descriptive statistics were given as number (%). ***Mann-Whitney U test was used. Descriptive statistics were given as median [IQR]. ****Independent Samples T Test was used. Descriptive statistics were given as mean ± standard deviation. P values in bold were accepted as statistically significant (p<0.05).

Duration of vitiligo was not found to be correlated with PSQI or BDI total scores. Patients with disease onset below 18 years of age had similar BDI and PSQI scores compared with disease onset at or above 18 years of age. The subtype of vitiligo also did not affect PSQI or BDI scores (p=0.546, p=0.744, p=0.849).

Discussion

We found a significantly higher depression level and worse sleep in quality in the vitiligo patients compared with the control group. Age, sex, marital status, and education level were similar between the groups, which suggests that the two groups were comparable.

High levels of depression have been found in multiple previous studies on vitiligo patients. These studies used several scales to assess depression, including General Health Questionnaire (GHQ), Montgomery-Asberg Depression Rating Scale (MADRS), Hamilton Depression Rating Scale (HDRS), Hospital Anxiety and Depression Scale (HADS), and also BDI (4). Noh et al. (15) compared depression levels of 60 vitiligo patients, 60 atopic dermatitis (AD) patients, and 60 healthy control group with BDI. They found the highest levels in AD patients. The mean BDI score of vitiligo patients (7.32) was higher than the control group participants (5.52), although this difference couldn’t reach statistical significance. The difference between the results of this study and our study may be explained by two factors. In the study of Noh et al. (15), the percentage of male patients (51.7%) was higher in the vitiligo group while the percentage of females (58.3%) was higher in the control group. As females at childbearing age are known to have higher depression scores than males at the same age group (16), this might have increased depression scores in the control group. Indeed, the mean depression score in Salk et al. (16) study (5.52) was higher than the median BDI score (3) in our control group. Yanik et al. (17) also assessed depression levels in 57 patients with first onset vitiligo and 58 age- and sex-matched healthy subjects, who were hospital personnel. They couldn’t find a difference between the mean BDI scores of the patients (11.21±7.32) and the control group (10.62±7.47) (p=0.71). The main problem with this study was the high level of depression in the control group. As BDI scores between 10-16 are suggested to reflect mild depression (18), the depression level of the control group in Yanik et al.’s study (17) can’t be considered normal. Previous research has found higher levels of depression, anxiety, and burn-out in healthcare personnel compared with the general population (19). So, the control group in Yanik et al.’s study (17) may be biased, which may have prevented finding a significant relationship between vitiligo patients and control group participants in that study. 

We found impaired sleep quality in vitiligo patients. A previous study from Turkey also found worse sleep quality in vitiligo patients compared with healthy control group (20). They also found significant correlations between PSQI score and vitiligo severity (VASI), Hospital Anxiety and Depression Scale Depression and Anxiety Subscale Scores, Visual Analog Scale pain score, and Fibromyalgia Impact Questionnaire score. The median PSQI score of their control group participants was exactly the same as ours and the median PSQI score of their vitiligo patients was slightly higher than ours (3,6,7). These results suggest reproducibility of PSQI scores in vitiligo patients. The findings are in agreement with findings of the studies by Sharma et al. (9) and Karelson et al (10), which reported 20% and 30% sleep disturbance in vitiligo patients, respectively. Sleep disturbances commonly accompany psychiatric diseases such as depression and anxiety disorders. Increased levels of depression that have frequently been demonstrated in vitiligo patients, might be the cause of impaired sleep in these patients. Other factors, including itching, might also be responsible for impaired sleep. Itching was found in 20.2% of the vitiligo patients in a previous study, and it had a moderate severity (21). Vachiramon et al. (21) found more common itching in patients with focal vitiligo, which was present in 23.9% of our patients. Using objective scales for itching, together with sleep quality and psychogenic assessments in future studies will be helpful to discriminate the effects of psychogenic and biological factors. 

We found a family history of vitiligo in 18 patients (26.9%). This rate was very close to the family history of vitiligo of 24.8%, which was reported by Gonul et al. (22) in Turkish patients previously. Lower rates were reported in studies reported from Western countries (23). A high rate of consanguineous marriages in Turkey might have resulted in higher rates of family history. 

We did not find a relationship between vitiligo type and depression or PSQI scores. Sangma et al. (24) reported higher depression scores in vitiligo patients with vitiligo universalis subtype. They concluded that higher disease activity and more widespread skin involvement increased the level of depression in these patients. None of our patients had segmental vitiligo. Maleki et al. (25) found no relationship between vitiligo type and depression level, similar to our study. We couldn’t find any previous study that examined the relationship between vitiligo type and sleep quality. 

The number of males and females were similar in our study. Previous studies also usually found similar rates for males and females (22,26). Focal vitiligo was more common in females in our study. This may reflect an actual difference or may be due to a higher threshold for male patients to seek medical attention so that male patients with such types don’t come to medical attention while female patients with any vitiligo type take the condition more seriously.

Neither age of onset nor disease duration of vitiligo was a significant factor for depression or sleep quality in our study. This was also true for depression in Saleki et al.’s study (27). Vallerand et al. (28) found a higher depression score in patients diagnosed before the age of 30. They suggested that the sensitivity of young adults for their appearance was higher, and that affected the depression level. Cultural differences may be the result of the difference between the studies.

Conclusion

The findings of this study showed impaired sleep quality in vitiligo patients in addition to increased depression levels. Psychiatric evaluation and sleep quality assessment should be provided for vitiligo patients as a part of a multidisciplinary approach in order to increase the success of the treatment.

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How to cite / Atıf için: Oztekin A, Oztekin C. Sleep quality and depression in vitiligo patients. Euras J Fam Med 2020;9(1):35-41. doi:10.33880/ejfm.2020090105


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