gender differences in depression, coping, stigma, and...

Research ArticleGender Differences in Depression Coping Stigmaand Quality of Life in Patients of Vitiligo

Neena S Sawant 1 Nakul A Vanjari2 and Uday Khopkar3

1Department of Psychiatry Seth GS Medical College amp KEM Hospital Acharya Dhonde Marg Parel Mumbai 400012 India2Department of Psychiatry SMBT IMS amp RC Igatpuri Nashik India3Department of Dermatology Seth GS Medical College amp KEM Hospital Acharya Dhonde Marg Parel Mumbai 400012 India

Correspondence should be addressed to Neena S Sawant drneenasyahoocom

Received 23 August 2018 Revised 10 February 2019 Accepted 24 February 2019 Published 2 April 2019

Academic Editor Markus Stucker

Copyright copy 2019 Neena S Sawant et alThis is an open access article distributed under theCreative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Though vitiligo is one of the psychodermatological disorders which do not cause direct physical impairment it is cosmeticallydisfiguring leading to serious psychological problems in daily life We undertook this research to study patients of vitiligo theprevalence of depression coping stigma and quality of life and comparison of the same in both genders Patients diagnosedclinically as having vitiligo by consultant dermatologist were enrolled after informed consent and ethics approval 156 patientswere screened of which 100 satisfying criteria were taken up for the study A semistructured proforma was designed to collect thenecessary information with administration of Beckrsquos depression inventory participation scale dermatology life quality index andadjustment to chronic skin diseases questionnaire Depression prevalence was 6364 in females and 4286 in males (plt00457)the total mean BDI scores were significant with females having higher scores thanmales (plt00083) No significant differences wereseen on participation scale though 52 females felt stigmatized as compared to 45 males (p lt05779) While almost 97 of ourpatients had impaired quality of life there was no significant difference in both genders on the total score (plt03547) Females hadsignificantly higher faulty coping style than males with significant differences on all domains and total scores (plt 00094) Therewas a strong association of depression with faulty coping and stigma (plt 00001) in both genders Also association of stigma withquality of life showed highly significant findings in both genders (plt 00001) on all the domains of DLQI This study helps in earlyidentification of psychological problems in vitiligo patients and planning their future course of management hence improving theprognosis and quality of life

1 Introduction

Vitiligo is an acquired depigmentation disorder affecting1-4 of the world population with equal distribution inboth genders and all ethnic groups [1ndash3] In Mexico theprevalence has been reported to be around 4 [4 5] whereasin India around 88 [6] which is the highest incidenceof this condition [7] The depigmentation is caused byfunctional melanocytes disappearing from the lesional areaof the epidermis Till date no curative treatment is available

Vitiligo is disfiguring in all races but particularly more soin dark-skinned people because of strong contrast In Indiavitiligo commonly known as leucoderma is unfortunatelyassociated with some religious myths like being a curse ofGod or a sin for which patients seek help from faith healers

and do religious rituals than seekingmedical help thus result-ing in social ostracism [8 9] Given the visibility of chronicdermatoses stigmatization becomes a part of daily life invitiligo patients which can lead to psychosocial stress andultimately depression [10ndash14] The chronicity visibility andrelapsing nature of vitiligo impair quality of life and ability tocope [14ndash20] Severe depression has been known to lead tosuicidal ideations The reluctance of patients to report theirpsychological distress is often observed with consequence ofa greater focus on physical symptoms than on psychologicalaspects like depression stress or stigmatization

Research in vitiligo shows that at least 25 [11] ofdermatology patients suffered from significant psychiatriccomorbidity and 63 had positive findings on self-reportingquestionnaire-24 which was the psychiatric screener [10]

HindawiDermatology Research and PracticeVolume 2019 Article ID 6879412 10 pageshttpsdoiorg10115520196879412

2 Dermatology Research and Practice

Picardi et al suggested that untreated comorbid psychiatricdisorders may adversely affect the response of the derma-tological disorder to prescribed therapies [21] Treatmentof vitiligo patients should address their emotional effectsand include tools for psychological intervention which mayultimately lead to better adaptation to the disease and higherquality of life Treatment should be aimed at improving theoverall quality of life and reducing the stigmatization feelingcaused by this chronic diseaseThe importance of consideringthe stigmatization experience and coping in vitiligo patientshas to be emphasized in both future research and patienttreatment

Though there are Indian studies on several aspects ofvitiligo we undertook this research to know about genderdifferences in the prevalence of depression stigma copingand quality of life in vitiligo patients and to also find theassociation of depression with coping and stigma as well asthe association of stigma with quality of life

2 Methodology

Thestudy was initiated in the dermatology outpatient depart-ment of Seth GS Medical College and KEM Hospital atertiary general hospital in central Mumbai catering tolower socioeconomic strata of several ethnic groups likeHindus Muslims Christians Jews Parsis and Sikhs Theinstitutional ethics committee of Seth GS Medical Collegeand KEMHospital gave permission to conduct the study Allpatients were diagnosed as having vitiligo by the consultantdermatologist after clinical evaluation based on the presenceof a recent depigmented patch in the absence of any contactwith substance producing suchdepigmentationWoodrsquos lampaccentuation was used as a criterion [22] Site of lesion wasnoted as being on areas that were exposed unexposed orboth exposed and unexposed

All the patients were explained about the nature of studyand its applications and informed consent was obtained frompatients who were willing to participate in the study Patientswere initially screened and only those above 18 years of agewere enrolled in the study Data collection was done overa period of 12 months Those having medical comorbiditylike infections other immunological disorders or existingpsychopathologywith ongoing treatmentwere excluded fromthe study 156 patients were screened of which 100 wereenrolled in the study A proforma was designed to enquireinto the sociodemographic details like age sex maritalstatus religion education occupation and income Thesocioeconomic strata were assessed using the Kuppuswamyscale [23] It also included details about vitiligo lesions likeage of onset location and duration family history of vitiligoany previous medical or psychiatry illness and medicationhistory The clinical variables were compared between maleand female patients Both groups were studied for prevalenceof depression coping stigma and quality of life using thefollowing scales

21 Dermatology Life Quality Index (DLQI) The dermatol-ogy life quality index questionnaire is designed for use inadults ie patients over the age of 16 It is self-explanatory

and can be simply handed to the patient who is asked to fillit in without the need for detailed explanation The DLQI iscalculated by summing the score of each question resulting ina maximum of 30 and minimum of 0 The DLQI can also beexpressed as a percentage of the maximum possible score of30 Persons who scored ge10were considered as DLQI positivecases

Meaning of DLQI Scores

0-1 = no effect at all on patientrsquos life

2-5 = small effect on patientrsquos life6-10 = moderate effect on patientrsquos life11-20 = very large effect on patientrsquos life21-30 = extremely large effect on patientrsquos life

The higher the score is the more quality of life is impaired Itis usually completed in one to two minutes [24]

22 Participation Scale (PS) This tool has been validated inIndia Nepal and Brazil It measures the extent to whichpeople participate in common social events [25] The keyissue of stigma is that it excludes people from participatingin such events The P-scale is an 18-item instrument whichcovers eight out of the nine participation domains of theInternational Classification of Functioning Disability andHealth (ICF) to measure social participation in such stigma-tizing diseases The use of the word participation is based onthe ICF terminology and participation restriction is definedas problems an individual may experience with involvementin life situations [26] A five point rating scale was used tomeasure the level of participation for each item For eachsubject the scores obtained for the 18 items were added upIf the score was 12 or less people were considered not tohave restriction in their domestic and social situation Scoresof 13 to 90 represented restriction at different intensities 13to 32 as moderate 33 to 52 as severe and 53-90 as extremerestrictions

23 Beckrsquos Depression Inventory (BDI) This scale was devisedby Beck in 1961 It contains 21 sentence groups aimed atassessing the level of depression Observed depression signsare evaluated objectively The 21 signs of depression includedin the scale are sensibility pessimism sense of failure senseof guilt self-dissatisfaction self-accusation desire to commitsuicide hysterical weeping seizures nervous breakdownsocial retreat indecisiveness conflicting self-image sleepdisturbances tiredness loss of appetite loss of weight psy-chological complaints and lack of sexual desire All thequestions were developed based on signs normally seenin depressed individuals Each category receives a scoreof 0ndash3 points If a subject scores 0ndash16 points there is nodepression 17ndash20 points indicate mild depression 21-30points indicate moderate depression and gt 31 points revealsevere depression Studies using the scale indicate that theBDI is an appropriate method for assessing the signs andlevels of depression in a given subject [27]

Dermatology Research and Practice 3

24 Adjustment toChronic SkinDiseasesQuestionnaire (ASC)The ASC is a 51-item fully standardized self-rating instru-ment used to evaluate coping strategies the scoring systemwas also a Likert scale The ASC consists of six scales highscores on the ldquosocial anxietyavoidancerdquo scale indicate a fre-quent avoidance of certain situations due to a fear of rejectionhigh scores on the ldquoitch-scratch circlerdquo scale a deficient self-control resulting in frequent scratching High values on theldquohelplessnessrdquo scale correspond to the perception of an almostcomplete loss of control over the course of the disease highvalues on the ldquoanxious-depressive moodrdquo to a problematicadjustment to the skin disorder High scores on the ldquoimpacton quality of liferdquo scale are related to far-reaching objectiveconsequences that influence daily life high values on theldquodeficit in active copingrdquo scale to repetitive failing attempts ofpatients to find an active solution to problems for exampleby researching background information on their skin disease[28]

All analyses were done with SPSS statistical version 17 at5 significance

3 Results

There were 56 males and 44 females in our study with themale to female ratio being 121 We found the mean age ofmale patients of vitiligo to be 3578 plusmn 1423 years and thatof females to be 3688 plusmn 1422 years The age range of all thevitiligo was from 18 to 68 years with majority being in the18 to 34 years age group for both genders Majority of thepatients in both groups (males 66 and females 64) weremarried 44(78) males and 37(84) females were Hindu byreligion Among the minority religion groups there were 9(16) Muslims 2 (35) Sikhs and 1 Christian in the malegroup whereas there were 2Muslims 1 Sikh and 4 Christiansin the female group All males were literate while 34 (77)females were illiterate 46 (82) males were employed whileunemployment was seen in 34 (77) females About 32 (57)males and 29 (66) females had income less than 12000rupees per month whereas 14 (25) males and 13 (30)females earned between 12000 and 16000 rupees per month(Table 1(a))

The mean age of onset of vitiligo for males was 2889plusmn 1354 years and 2913 plusmn 1373 years for females In bothgenders we found predominance of vitiligo in the 20 to 40years of ageThe duration of the disease varied from less thanone year to several years Majority of our patients (47 (84)males and 40 (91) females) had illness duration of morethan 1 year indicating the chronic nature of the illness Familyhistory of vitiligo was found in 13 (23) males and 11 (25)females Most of our patients (52male and 68 female) hadlesions on both exposed and nonexposed parts of the body(Table 1(b))

When all the patients were assessed for prevalence ofdepression using BDI 52 of the total 100 patients werefound to be depressed The gender differences for depressionrevealed a higher prevalence of 28(6364) in females ascompared to 24 (4286) in males which was statisticallysignificant When BDI total scores were compared for genderdifferences a highly statistical difference was seen with the

female patients having a mean BDI total score of 2804plusmn 205 as compared to males who had a mean score 173plusmn 171 On assessing for severity of depression as per BDIin both groups about 23 (82) of females had severe toextreme depression as compared to 14 (58) males 10 (42)males were having predominantly borderline to moderatedepression as compared to 5 (18) females indicating againthat the severity of the depression was more in females thanmales (Table 2)

When we assessed our patients for prevalence of stigma48 of the total 100 patients were experiencing it in theform of participation restriction On assessing for genderdifferences 23 (52) of females as compared to 25 (45)males reported restriction in activities as per PS due to thestigma faced (Table 3)

When both groups were compared for differences incoping then a highly significant difference (U score-857 and pvalue-00094) was seen between the genders with the femaleshaving a higher score indicating faulty coping as per theASC Further assessing gender differences on the varioussubdomains of ASC revealed significant differences with afemale preponderance on social anxiety (U score-8795 and pvalue-00145) helplessness (U score-892 and p value-00183)anxious-depressive mood (U score-909 and p value-00247)and impact on quality of life (U score-8575 and p value-0066) except for itch-scratch which was not statisticallysignificant (Table 4)

We found almost all our patients (males 9643 andfemales 9773) to be having impaired quality of life whenassessed using dermatology life quality index When bothgroups were assessed for differences in the domain scores ofthe DLQI then no significant differences were seen on thevarious domains namely feeling and symptoms (U score-1076 and p value-02708) daily activities (U score-10095 andp value-01144) leisure ( U score-1191 and p value-07710)work and school (U score-1213 and p value-08889) personalrelationship ( U score-1229 and p value-09885) treatment( U score-1029 and p value-01304) and also the total score(U score-1098 and p value-03547)The total DLQI scores didnot show any statistically significant differences among malesand females indicating that the score was not influenced bygender

Among patients with impaired quality of life no statis-tically significant differences were noted between the twogenders Majority were having very large to extremely largeimpairment in their quality of life with 48 males and 53females falling under these two categories indicating the largeimpact of vitiligo on quality of life The highest individualmean score was obtained on the treatment question whilethe lowest was on sport activity question indicating most andleast impairment in the above respective areas (Table 5)

When both groups were assessed for association ofdepression with coping then highly significant findings wereseen in both genders on all the domains of ASC (Table 6)

Likewise association of depression with stigma showedhighly significant findings for both genders (Table 7)

Also assessment for association of stigma with quality oflife showed highly significant findings in both genders on allthe domains of DLQI (Table 8)


Table 1

(a) Demographic variables

Variables Male Female(n=56) (n=44 )

Sex 56 44

Age Mean 35786 36886SD 14238 14226

Age range18-34 years 31 (5536) 20 (4546)35-51 years 15 (2678) 16 (3636)52-68 years 10 (1786) 8 (1818)

Marital status Married 37 (6608 ) 28 (6364 )Unmarried 19 (3392 ) 16 (3636 )

Religion Hindu 44 (7857 ) 37 (8409 )Others 12 (2143) 7 (1591)

Education Literate 56 (100) 10 (2272)Illiterate 0 (0) 34 (7728)

Occupation Employed 46 (8214) 10 (2272)Unemployed 10 (1786) 34 (7728)

Income in rupees per monthlt 12000 Rs 32 (5714) 29 (6591)

12000-16000 Rs 14 (25) 13 (2954)gt16000 Rs 10 (1786) 2 (455)

(b) Illness variables

Variable Males Females(n= 56) (n= 44)

Age of onset of vitiligo Mean 2889 2913SD 1354 1373

Age range of onset of vitiligo0-20 years 20 (3571) 14 (3182)21-40 years 24 (4286) 20 (4545)41-60 years 12 (2143) 10 (2273)

Duration of vitiligo lt 1 year 9 (1607) 4 (909)gt 1 year 47 (8393) 40 (9091)

Family history of vitiligo Present 13 (2321 ) 11 (25 )Absent 43 (7679 ) 33 (75 )

Site of lesion of vitiligoExposed 21 (375) 8 (1818)

Unexposed 6 (1071) 6 (1364)Exposed + Unexposed 29 (5179) 30 (6818)

Table 2 Prevalence and severity of depression as per BDI

Depression as per BDIMales [n= 56 ()] Females [n= 44 ()] p value

Present Absent Present Absent 00457lowast( Fisherrsquos test)24 (4286) 32 (5714) 28 (6364) 16 (3636)

Severity of Depression Males [n= 24 ()] Females [n= 28()]

01375(Chi square for independence)

Borderline depression 2 (833) 2 (715)Moderate depression 8 (3333) 3 (1071)Severe depression 7 (2917) 7 (25)Extreme depression 7 (2917) 16 (5714)

BDI Total scores Mean plusmn SD Mean plusmn SD MannWhitneyU- 8520000083lowast17375plusmn 17168 28045plusmn20505


Table 3 Prevalence and severity of stigma as per participation scale

Stigma as per PSMales[ n= 56 ()] Females [n= 44 ()] p value

Present Absent Present Absent 05779 ( Fisherrsquos test)25 (4464) 31 (5536) 23 (5227) 21 (4773)

Restriction severity Males [n= 25 ()] Females [n= 23 ()]Mild Restriction 7 (28) 2 (869)Moderate Restriction 10 (40) 12 (5217)Severe Restriction 8 (32) 8 (3478)Extreme Restriction 0 (0) (434)

PS Total scores Mean plusmn SD Mean plusmn SD MannWhitneyU-100800 0118314054 plusmn 14444 18182 plusmn 15358

Table 4 Gender differences for coping as per ASC

DomainMales Females

Mann-Whitney U scorep valuen=56 n=44

Mean plusmn SD Meanplusmn SD

Social anxiety avoidance 33518plusmn 14025 40591plusmn 15083 8795000145lowast

Itch-Scratch 11875plusmn 5663 13773plusmn 6626 10245001045

Helplessness 22464plusmn 9796 27432plusmn 10643 8920000183lowast

Anxious-Depressive mood 16036plusmn 7913 20205plusmn 8938 9090000247lowast

Impact on Quality of life 11232plusmn 4191 13841plusmn 4861 842000066lowast

Total Score 95125plusmn 38902 11584plusmn 43253 8575000094lowast

4 Discussion

Researchers have found mean age of patients with vitiligoto be ranging from 2972 plusmn 701 years [14] and 438plusmn1248years [10] which are in keeping with our findings Howeverno gender studies showing an earlier onset in males orfemales are available Several researchers have reported maleto female ratio similar to our findings Pichaimuthu et al inhis sample of 55 males and 45 females also had a maleto female ratio of 121 [29] Sangma et al [14] reported amale to female ratio of 141 though female predominancehas been reported in some studies which could be due tothe womenrsquos tendency to give greater attention to cosmeticdefects as compared to men [13]

Marriage rate was seen to be 69 [30] in vitiligo patientsin previous studies which is in keeping with our findingswhereas Mishra et al [20] reported 48 to be married Thehigh marriage percentage could be explained by the culturalbackground as in India marriages occur in the early agesfrom 18 to 25 years Our religion percentage was in keepingwith cultural diversity of India which showed almost 81Hindus followed by minority groups namely Muslims Sikhand Christians Majority of our patients were from the upperlower and lower middle socioeconomic strata having income

mostly less than Rs 12000 or up to Rs16000 per monthreflecting the population attending a tertiary care generalhospital where medical services and medicines are suppliedfree of cost to the general public Also in our study moremale patients were educated and employed than femalesOther studies have found vitiligo predominantly in lower andmiddle classes (72 ) with a higher prevalence in the upperclasses (28) as compared to our study [31]

Pichaimuthu et al [29] found 35 of patients havingillness duration less than 1 year whereas we found the same inonly 13 of the patients Vitiligo has a polygenic or autosomaldominant inheritance pattern with incomplete penetrationand variable expression Our finding about family history isin keeping with those reported by Kruger and Schallreuter[11] Studies have also shown a relatively early onset of vitiligosymptoms in patients having family history of vitiligo [32]however it was not reflected in our study Positive familyhistory is considered to be poor prognostic factor for vitiligo

The site of lesion largely varies in different studies Ourfindings are different from other researchers who found 57patients to be having lesions on exposed parts like faceneck nape of the neck forearms hands fingers tips foottoes and 39 patients having lesions on both exposed andnonexposed body parts [29] Kruger and Schallreuter in their


Table 5 Prevalence and severity of impairment in quality of life (QOL) as per DLQI

Impairment in QoLMales [n= 56 ()] Females [ n= 44 ()] p value

Present Absent Present Absent100 ( Fisherrsquos test)

54 (9643) 2 (357) 43 (9773) 1 (227)DLQI Domain scores Mean plusmn SD Mean plusmn SD

Feelings amp symptoms 2339plusmn 1431 2682plusmn1475 MannWhitney U-1076002708

Daily activities 2304plusmn2288 3091plusmn2341 MannWhitney U1009501144

Leisure 1643plusmn1752 1614plusmn1385 MannWhitney U-1191007710

Work amp School 08036plusmn09802 07955plusmn09042 MannWhitney U- 1213008889

Personal relationships 1607plusmn1670 1591plusmn1661 MannWhitney U- 1229509885

Treatment 2036plusmn08304 2295plusmn07015 MannWhitney U- 1029001304

Total DLQI Score 10714plusmn7827 11977plusmn7605 Mann Whitney U- 1098503547

Severity of Impairment Males [n= 56 ()] Females [n= 44 ()]08257

(Chi square test forindependence)

Small impairment 19 (3518) 15 (3488)Moderate impairment 9 (1667) 5 (1163)Very Large impairment 20 (3704) 16 (3721)Extremely Large impairment 6 (1111) 7(1628)

Table 6 Association of depression with coping in both genders

Variable Males n= 56 Females n= 44

MeanplusmnSDSpearman

rp value


rp value

BDI total 17375 plusmn 17168 28045plusmn 20505

ASC domains

Social anxiety 33518plusmn14025 09318lt 00001lowast

40591plusmn15083 09123lt 00001lowast

Itch- scratch 11875plusmn5663 05727lt 00001lowast

13773plusmn6626 06818lt 00001lowast

Helplessness 22464plusmn9796 08880lt 00001lowast

27432plusmn10643 09510lt 00001lowast

Anxious-depressivemood

16036plusmn7913 08923lt 00001lowast 20205plusmn8938 09448

lt 00001lowast

Impact onquality of life



ASC total 95125plusmn38902 09187lt 00001lowast

11584plusmn43253 09460lt 00001lowast

Table 7 Association of depression with stigma in both genders

VariableMales n= 56 Females n= 44

Meanplusmn SD Spearman r pvalue Meanplusmn SD Spearman r p value

BDI total 17375 plusmn 17168 08542lt 00001lowast

28045plusmn20505 08961lt 00001lowastPS total 14054 plusmn 14444 18182plusmn15358


Table 8 Association of stigma with quality of life in both genders



rp value


rp value

PS total 14054 plusmn14444 18182plusmn 15358

DLQI Domains

Feelings amp symptoms 2339plusmn1431 07312lt00001

2682plusmn1475 07936lt00001

Daily activities 2304plusmn2288 08181lt00001

3091plusmn2341 08941lt00001

Leisure 1643plusmn1752 08084lt00001

1614plusmn1385 08934lt00001

Work amp School 08036 plusmn09802 06930lt00001

07955plusmn09042 06795lt00001

Personal relationships 1607plusmn1670 07199lt00001

1591plusmn1661 08247lt00001

Treatment 2036plusmn08304 06528lt00001 2295plusmn07015 04765

lt00011

Total score 10714plusmn7827 08111lt00001 11977plusmn7605 08705

lt00001

study reported most common sites as head (885) hands(833) arms (760) legs (750) trunk (708) and neck(573) [11] The probable reason for our findings of higherprevalence in both exposed andnonexposed body parts couldbe the chronic nature of illness with progression

Though vitiligo is one of the psychodermatological dis-orders which do not cause direct physical impairment itis cosmetically disfiguring leading to serious psychologicalproblems in daily life [3 10 11] Various psychological effectsof vitiligo include low self-esteem social anxiety isolationdepression impaired quality of life etc The prevalence ofpsychiatric morbidity associated with vitiligo ranged from56 to 79 in India [12] Several meta-analyses have shownthat prevalence of clinical depression as per standard criteriawas 8 which increased to 33 on using scales [22 33]on diagnostic codes the pooled prevalence of depressionamong patients with vitiligo was 0sdot253 [95 confidenceinterval (CI) 0sdot16ndash0sdot34 P lt 0sdot001)] while with self-reportedquestionnaires the pooled prevalence of depressive symp-toms was 0sdot336 (95 CI 0sdot25ndash0sdot42 P lt 0sdot001) [34 35]Similarly Osinubi et al reported the pooled prevalenceusing depression-specific and anxiety-specific questionnairesas 0sdot29 [95 confidence interval (CI) 0sdot21-0sdot38] and 0sdot33(95CI 0sdot18-0sdot49) respectively [36] Several researchers havereported depression in vitiligo patients ranging from 18-37 [37] 622 [11] to 79 [14] which is similar to ourfindings Depression could have a cause or effect with vitiligoas studied by many researchers [2 12 13 25] BDI totalscores indicated that females were affected more significantlyand severely than males Generally females experience moreintense depressive features because of the more stress expe-rienced and have a greater reactivity to it with a higher rateof body dissatisfaction and low self-esteem [11 33] Of thetotal patients who were depressed about 71 had severe toextreme depression 21 had moderate depression and 8

had borderline depression However we did not analyze theassociation between severity of vitiligo and depression

Vitiligo is known to be associated with stigma Otherresearchers from India have reported a lower stigma preva-lence of 17 as compared to our findings in the vitiligopatients [29]However Kent had found ahigher prevalence ofstigma in 63 of his patients [38] In our study participationrestriction was experienced in areas like social interactionwork opportunities religious activity going out in publicplaces meeting new people etc by all the patients Krugerand Schallreuter reported that 90 of patients experiencedbeing asked questions by strangers for their white spotsand 50-60 experienced rudeness and staring looks dueto which they had avoidance and concealing behaviours[11] This could be one of the reasons why majority of ourpatients experienced stigma though we did not get anystatistically significant difference in both genders We didnot study for the association between severity of vitiligo andstigmatization

On ASC scale females experienced significant socialanxiety and avoidance as compared to males probably due togreater cosmetic awareness with avoidance due to feeling oflooking unattractive or being stared by othersThis resulted inmaking them avoid meeting new people withdrawing fromfamily being sexually inhibited etc As compared to otherskin disorders there was no irresistible itching or scratchingseen in vitiligo patients and hence it was not a significantfinding in our study However in a study by Leibovici et alon comparing for coping differences in psoriasis and atopicdermatitis a significant difference was seen with psoriaticpatients having more social avoidance and greater impacton quality of life on the domains of ASC than the atopicdermatitis patients [39] Rahman et al also found itchingin only 16 of patients with vitiligo [31] On the domain ofhelplessness patients experienced ruminations felt desperate


worried about illness and future with a lot of attentionand time spent on inspecting their skin Females outscoredmales significantly in helplessness scores indicating higherseverity of symptoms in them with an almost complete lossof control over the course of the disease again Our findingis in keeping with Schmid-Ott et al who also felt that thefemalersquos retreat and low composure due to the stigmatizationexperience lead tomore perceived helplessness in copingwiththe disease [40] Anxious-depressive mood domain of ASCscale showed that patients who experienced nervousnesstiredness and lack of concentration got irritated and upseteasily Femaleswere significantlymore depressed and anxiousthan males Higher scores among females were also reportedon anxious-depressive mood domain suggesting negativeself-evaluation and problematic adjustment to the skin dis-order [40] On the domain of impact on the quality of life ofASC scale patients felt that chronic illnesses were expensivethey could not do certain jobs and had personal and workrelated difficulties We found females having significantlyhigher scores than males on the impact on quality of lifedomain

The chronic unpredictable nature of the disease and thelack of a universally effective treatment are disempoweringfor patients with vitiligo and leads to impaired quality of life[30] Our finding is in keeping with that of Talsania et al whofound impaired quality of life in 96 of their vitiligo patients[41] Our findings about gender differences in domains ofDLQI are similar to that of Parsad D et al [17] and Karelson etal [32] Parsad et al in their study on Indian vitiligo patientsfound higher mean total DLQI scores (1067 plusmn 456) whichwas associated with darker skin as compared to fairer skin[17] They postulated that the dark-skinned people attractedmore unwanted attention which was emotionally disturbingand upsetting Mishra et al [20] reported a lowermean DLQIscore of 68 in their patients

On the domain of symptoms and feelings of DLQIpatients felt self-conscious and embarrassed about the dis-ease and some had itching and pain over the lesions Thefemales scored more than the males probably due to cosmeticand aesthetic orientation as expected Similar findings werereported by Hedayat et al [42] On the domain of dailyactivities of DLQI patients had difficulties at looking afterhomework going out for shopping and their clothing stylewas also affected by lesions as many of them tried to hidethe lesions by wearing full clothes Leisure domain of DLQIindicated that the patients had many times difficulties intheir social and leisure activities and some of them werenot able to play or participate in sport activities becauseof the vitiligo Work and school domain of DLQI showedthat some of the patients experienced problems at work andschool as they were not able to concentrate enough and haddifficulties in completing their task Males had higher meanscores than females On the domain of personal relationshipmany faced problems in keeping touch with close friendsor relatives Also some claimed to have difficulties in sexualrelationship as they felt embarrassed and less enthusiasticdue to the lesions On this domain the males in our studygroup scored more than females and this was also reportedby Porter et al who observed more frequent embarrassment

in sexual relationships amongmenwith vitiligo [43] Vernwalreported that vitiligo affected marital sex life and intimacyand disrupted the social relationship and created a viciousstress-vitiligo cycle [37]Majority of the patients had to spendlot of time and money for the treatment as long follow-upswere needed due to chronic nature of illness Also their dailyroutine and work were disturbed due to repeated hospitalvisits Females in our groups scored more than males as theyexpressed difficulty in leaving household chores for follow upvisits

Our results indicate that depressed patients were havingsignificantly faulty coping styles or vice versa Picardi et alfound increased psychiatric morbidity in female outpatientswith skin lesions and reported that alexithymia insecureattachment and poor social support appeared to increasesusceptibility to vitiligo due to reduced ability to copeeffectively with stress [44 45] Gieler et al suggested that anearly improvement in coping strategies by using psychother-apeuticpsychosomatic measures could help in reducinghigher scores in anxious and depressed vitiligo patients [18]Higher scores on the lsquoanxious-depressive moodrsquo scale andthe lsquohelplessnessrsquo scale of the ASC imply a strongly negativeself-evaluation of affected persons resulting in retreat andavoidance and reduced quality of life which was significantlyseen in both our groups and reported by other researchers[40 45]

All those who were depressed experienced more stigmaand showed restrictions in job or work opportunities visitingmarkets or bazaar schools shops offices new people par-ticipating in festive and rituals chatting or meeting friendsor neighbours Also many claimed that they had less respectin community as compared to others and had difficulty inmaintaining long-term relationship with their partners Allstigmatized patients in our study were having significantlyimpaired quality of life or vice versa in both genders Stud-ies have shown that stigmatized and embarrassed patientsexperience low self-esteem and poor quality of life whichlead to significantly higher depression rates among them[46]

Overall womenrsquos greater reactivity compared to menhas been attributed to gender differences in biological andemotional responses self-concepts and coping styles whichcould be one of the reasons why the females in our sampleexperiencedmore depression poor coping and quality of lifewith a chronic illness like vitiligo probably exacerbating it[47 48]

5 Conclusions

This study helps to understand the impact of vitiligo andgender based differences in quality of life coping psychi-atric comorbidities like depression and stigma faced Theresults of study clearly support the notion that treatmentof vitiligo patients should address the emotional effectsand include tools for psychological intervention which mayultimately lead to better adaptation to the disease and copingthus improving the patients overall quality of life Liaisonwith the psychiatrist is important for early assessment of


depressive symptoms and considering both psychothera-peutic and psychopharmacological treatment options Long-term prospective studies in different chronic skin conditionswould help in the better understanding of the gender baseddifferences

Data Availability

The data used to support the findings of this study areincluded within the article

Additional Points

Limitations (1) The sample size was small and the casesbelonged to a tertiary care centre which did not reflect theprevalence in the general population (2) The aims of thestudy were not analyzed with respect to activity (ie activeor stable) severity and type (segmental or nonsegmental)of vitiligo which would improve our understanding of theimpact of vitiligo (3) Study population included only adultsand hence could not establish findings in children andadolescent population

Conflicts of Interest

The authors declare that they have no conflicts of interest

References

[1] P E Grimes Vitiligo Pathogenesis clinical features and diagnosis2016 httpwwwuptodatecomcontentsvitiligopathogenesisclinical-features-and-diagnosissource=searchresultampampsearch=grimes+vitiligoampampselectedTitle=47E88

[2] P E Grimes and M M Miller ldquoVitiligo Patient stories self-esteem and the psychological burden of diseaserdquo InternationalJournal of Womenrsquos Dermatology vol 4 no 1 pp 32ndash37 2018

[3] K Ezzedine P E Grimes J-M Meurant et al ldquoLiving withvitiligo Results from a national survey indicate differencesbetween skin phototypesrdquo British Journal of Dermatology vol173 no 2 pp 607ndash609 2015

[4] O Canizares ldquoGeographic dermatology Mexico and centralamerica The influence of geographic factors on skin diseasesrdquoJAMA Dermatology vol 82 no 6 pp 870ndash893 1960

[5] M Salinas-Santander C Sanchez-Domınguez C Cantu-Salinas et al ldquoVitıligo factores asociados con su aparicionen pacientes del noreste de Mexicordquo Dermatologıa RevistaMexicana vol 58 pp 232ndash238 2014

[6] E M Shajil S ChatterjeeD Agrawal T Bagchi and R BegumldquoVitiligo pathomechanisms and genetic polymorphism of sus-ceptible genesrdquo Indian Journal of Experimental Biology (IJEB)vol 44 no 7 pp 526ndash539 2006

[7] S Dhar P Dutta and R Malakar ldquoPigmentary disordersrdquo in inIADVL Textbook of Dermatology R G Valia and A R ValiaEds pp 736ndash798 Bhalani Publishing House Mumbai India3rd edition 2008

[8] S Abraham and P Raghavan ldquoMyths and facts about vitiligoAn epidemiological studyrdquo Indian Journal of PharmaceuticalSciences vol 77 no 1 pp 8ndash13 2015

[9] U Eram ldquoReview Article on Beliefs and Myths of VitiligordquoInternational Journal of Engineering Technology Science andResearch vol 4 no 7 pp 215ndash218 2017

[10] S Sarkar T Sarkar A Sarkar and S Das ldquoVitiligo andpsychiatric morbidity A profile from a vitiligo clinic of a rural-based tertiary care center of eastern Indiardquo Indian Journal ofDermatology vol 63 no 4 pp 281ndash284 2018

[11] C Kruger and K Schallreuter ldquoStigmatisation avoidancebehaviour and difficulties in coping are common among adultpatients with vitiligordquo Acta Dermato-Venereologica vol 95 no5 pp 553ndash558 2015

[12] S K Mattoo S Handa I Kaur N Gupta and R MalhotraldquoPsychiatric morbidity in vitiligo Prevalence and correlates inIndiardquo Journal of the European Academy of Dermatology andVenereology vol 16 no 6 pp 573ndash578 2002

[13] K M Tripathi S Arya and V Singh ldquoFrequency of occurrenceof different types of leucoderma and vitiligo rishi dasnaghaziabadrdquo International Journal of Current Microbiology andApplied Sciences vol 7 no 09 pp 1267ndash1276 2018

[14] L N Sangma J Nath and D Bhagabati ldquoQuality of life andpsychological morbidity in vitiligo patients A study in ateaching hospital from north-east Indiardquo Indian Journal ofDermatology vol 60 no 2 pp 142ndash146 2015

[15] A RThompson S A Clarke R J Newell andD JGawkrodgerldquoVitiligo linked to stigmatization in British SouthAsianwomenA qualitative study of the experiences of living with vitiligordquoBritish Journal of Dermatology vol 163 no 3 pp 481ndash486 2010

[16] J M Bae S C Lee T H Kim S D Yeom J H Shin and W JLee ldquoFactors affecting the quality of life in patients with vitiligoa nationwide studyrdquo British Journalof Dermatology vol 178 no1 pp 238ndash244 2018

[17] D Parsad R Pandhi S Dogra A J Kanwar and B KumarldquoDermatology life quality index score in vitiligo and its impacton the treatment outcomerdquo British Journal of Dermatology vol148 no 2 pp 373-374 2003

[18] U Gieler B Brosig U Schneider et al ldquoVitiligo-coping behav-iorrdquo Dermatology and Psychosomatics vol 1 no 1 pp 6ndash102000

[19] K Ongenae N Van Geel S De Schepper and J-M NaeyaertldquoEffect of vitiligo on self-reported health-related quality of liferdquoBritish Journal of Dermatology vol 152 no 6 pp 1165ndash11722005

[20] NMishraM K Rastogi P Gahalaut and S Agrawal ldquoDerma-tology specific quality of life in vitiligo patients and its relationwith various variables A hospital based crosssectional studyrdquoJournal of Clinical and Diagnostic Research vol 8 no 6 ppYC01ndashYC03 2014

[21] A Picardi D Abeni C Renzi M Braga C F Melchi and PPasquini ldquoTreatment outcome and incidence of psychiatric dis-orders in dermatological out-patientsrdquo Journal of the EuropeanAcademy of Dermatology and Venereology vol 17 no 2 pp 155ndash159 2003

[22] D J Gawkrodger A D Ormerod L Shaw et al ldquoGuidelinefor the diagnosis and management of vitiligordquo British Journalof Dermatology vol 159 no 5 pp 1051ndash1076 2008

[23] S Dudala ldquoUpdated Kuppuswamy1015840s socioeconomic scalemdashArevision of economic parameter for 2012rdquo Journal of Dr NTRUniversity of Health Sciences vol 2 no 3 p 201 2013

[24] A Y Finlay and G K Khan ldquoDermatology Life Quality Index(DLQI)mdasha simple practical measure for routine clinical userdquoClinical and Experimental Dermatology vol 19 no 3 pp 210ndash216 1994


[25] W H Van Brakel A M Anderson R K Mutatkar et al ldquoTheparticipation scale Measuring a key concept in public healthrdquoDisability and Rehabilitation vol 28 no 4 pp 193ndash203 2006

[26] World Health Organisation ldquoInternational classification offunctioning disability and health - short versionrdquo Tech RepWHO Publications Geneva Switzerland 2001

[27] A T Beck R A Steer andG K BrownBDIndashII BeckDepressionInventory Manual Harcourt Brace Boston Mass USA 2ndedition 1996

[28] U Stangier A Ehlers and U Gieler ldquoMeasuring adjustmentto chronic skin disorders validation of a self-report measurerdquoPsychological Assessment vol 15 no 4 pp 532ndash549 2003

[29] R Pichaimuthu P Ramaswamy K Bikash and R JosephldquoA measurement of the stigma among vitiligo and psoriasispatients in Indiardquo Indian Journal of Dermatology Venereologyand Leprology vol 77 no 3 pp 300ndash306 2011

[30] O D Balaban M I Atagun H D Ozguven and H H OzsanldquoPsychiatric morbidity in patients with vitiligo Vitiligoluhastalarda psikiyatrik morbiditerdquo Dusunen Adam The Journalof Psychiatry and Neurological Sciences pp 306ndash313 2011

[31] M Rahman M Amin M Rahman and M Satter ldquoA demo-graphic study on vitiligo sheti in Bangladeshrdquo InternationalJournal of Research in Medical Sciences vol 1 no 2 p 123 2013

[32] M Karelson H Silm T Salum S Koks and K Kingo ldquoDiffer-ences between familial and sporadic cases of vitiligordquo Journal ofthe European Academy of Dermatology and Venereology vol 26no 7 pp 915ndash918 2012

[33] GWangDQiuH Yang andW Liu ldquoTheprevalence and oddsof depression in patients with vitiligo a meta-analysisrdquo Journalof the European Academy of Dermatology and Venereology vol32 no 8 pp 1343ndash1351 2018

[34] Y C Lai Y W Yew C Kennedy and R A Schwartz ldquoVitiligoand depression a systematic review and meta-analysis ofobservational studiesrdquo British Journal of Dermatology vol 177no 3 pp 708ndash718 2017

[35] V K Sharma and R Bhatia ldquoVitiligo and the psycherdquo BritishJournal of Dermatology vol 177 no 3 pp 612-613 2017

[36] O Osinubi M J Grainge L Hong et al ldquoThe prevalence ofpsychological comorbidity in people with vitiligo a systematicreview and meta-analysisrdquo British Journal of Dermatology vol178 no 4 pp 863ndash878 2018

[37] D Vernwal ldquoA study of anxiety and depression in Vitiligopatients New challenges to treatrdquo European Psychiatry vol 41p S321 2017

[38] G Kent ldquoCorrelates of perceived stigma in vitiligordquo Psychologyamp Health vol 14 no 2 pp 241ndash251 1999

[39] V Leibovici L Canetti S Yahalomi et al ldquoWell being psy-chopathology and coping strategies in psoriasis compared withatopic dermatitis A controlled studyrdquo Journal of the EuropeanAcademy of Dermatology and Venereology vol 24 no 8 pp897ndash903 2010

[40] G Schmid-Ott HW Kunsebeck E Jecht et al ldquoStigmatizationexperience coping and sense of coherence in vitiligo patientsrdquoJournal of the EuropeanAcademyof DermatologyampVenereologyvol 21 no 4 pp 456ndash461 2007 (Chinese)

[41] N Talsania B Lamb and A Bewley ldquoVitiligo is more than skindeep A survey of members of the Vitiligo Societyrdquo Clinical andExperimental Dermatology vol 35 no 7 pp 736ndash739 2010

[42] K Hedayat M Karbakhsh M Ghiasi et al ldquoQuality of life inpatients with vitiligo A cross-sectional study based on VitiligoQuality of Life index (VitiQoL)rdquo Health and Quality of LifeOutcomes vol 14 no 1 2016

[43] J R Porter A H Beuf A B Lerner and J J Nordlund ldquoTheeffect of vitiligo on sexual relationshipsrdquo Journal of the AmericanAcademy of Dermatology vol 22 no 2 pp 221-222 1990

[44] A Picardi D Abeni C Renzi M Braga P Puddu and PPasquini ldquoIncreased psychiatric morbidity in female outpa-tients with skin lesions on visible parts of the bodyrdquo ActaDermato-Venereologica vol 81 no 6 pp 410ndash414 2001

[45] A Picardi P Pasquini M S Cattaruzza et al ldquoStressful lifeevents social support attachment security and alexithymia invitiligo A case-control studyrdquo Psychotherapy and Psychosomat-ics vol 72 no 3 pp 150ndash158 2003

[46] D Y Kim J W Lee S H Whang Y K Park S Hann andY J Shin ldquoQuality of life for Korean patients with vitiligoSkindex-29 and its correlationwith clinical profilesrdquoThe Journalof Dermatology vol 36 no 6 pp 317ndash322 2009

[47] Y Deng L Chang M Yang M Huo R Zhou and A BEder ldquoGender differences in emotional response inconsistencybetween experience and expressivityrdquo PLoS ONE vol 11 no 6Article ID e0158666 2016

[48] M Bianchin and A Angrilli ldquoGender differences in emotionalresponses Apsychophysiological studyrdquo Physiology ampampBehavior vol 105 no 4 pp 925ndash932 2011

Stem Cells International

Hindawiwwwhindawicom Volume 2018


MEDIATORSINFLAMMATION

of

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

Hindawi Publishing Corporation httpwwwhindawicom Volume 2013Hindawiwwwhindawicom

The Scientific World Journal

Volume 2018

Immunology ResearchHindawiwwwhindawicom Volume 2018

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine


Behavioural Neurology

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary andAlternative Medicine

Volume 2018Hindawiwwwhindawicom

Submit your manuscripts atwwwhindawicom


Picardi et al suggested that untreated comorbid psychiatricdisorders may adversely affect the response of the derma-tological disorder to prescribed therapies [21] Treatmentof vitiligo patients should address their emotional effectsand include tools for psychological intervention which mayultimately lead to better adaptation to the disease and higherquality of life Treatment should be aimed at improving theoverall quality of life and reducing the stigmatization feelingcaused by this chronic diseaseThe importance of consideringthe stigmatization experience and coping in vitiligo patientshas to be emphasized in both future research and patienttreatment

Though there are Indian studies on several aspects ofvitiligo we undertook this research to know about genderdifferences in the prevalence of depression stigma copingand quality of life in vitiligo patients and to also find theassociation of depression with coping and stigma as well asthe association of stigma with quality of life

2 Methodology

Thestudy was initiated in the dermatology outpatient depart-ment of Seth GS Medical College and KEM Hospital atertiary general hospital in central Mumbai catering tolower socioeconomic strata of several ethnic groups likeHindus Muslims Christians Jews Parsis and Sikhs Theinstitutional ethics committee of Seth GS Medical Collegeand KEMHospital gave permission to conduct the study Allpatients were diagnosed as having vitiligo by the consultantdermatologist after clinical evaluation based on the presenceof a recent depigmented patch in the absence of any contactwith substance producing suchdepigmentationWoodrsquos lampaccentuation was used as a criterion [22] Site of lesion wasnoted as being on areas that were exposed unexposed orboth exposed and unexposed

All the patients were explained about the nature of studyand its applications and informed consent was obtained frompatients who were willing to participate in the study Patientswere initially screened and only those above 18 years of agewere enrolled in the study Data collection was done overa period of 12 months Those having medical comorbiditylike infections other immunological disorders or existingpsychopathologywith ongoing treatmentwere excluded fromthe study 156 patients were screened of which 100 wereenrolled in the study A proforma was designed to enquireinto the sociodemographic details like age sex maritalstatus religion education occupation and income Thesocioeconomic strata were assessed using the Kuppuswamyscale [23] It also included details about vitiligo lesions likeage of onset location and duration family history of vitiligoany previous medical or psychiatry illness and medicationhistory The clinical variables were compared between maleand female patients Both groups were studied for prevalenceof depression coping stigma and quality of life using thefollowing scales

21 Dermatology Life Quality Index (DLQI) The dermatol-ogy life quality index questionnaire is designed for use inadults ie patients over the age of 16 It is self-explanatory

and can be simply handed to the patient who is asked to fillit in without the need for detailed explanation The DLQI iscalculated by summing the score of each question resulting ina maximum of 30 and minimum of 0 The DLQI can also beexpressed as a percentage of the maximum possible score of30 Persons who scored ge10were considered as DLQI positivecases

Meaning of DLQI Scores

0-1 = no effect at all on patientrsquos life

2-5 = small effect on patientrsquos life6-10 = moderate effect on patientrsquos life11-20 = very large effect on patientrsquos life21-30 = extremely large effect on patientrsquos life

The higher the score is the more quality of life is impaired Itis usually completed in one to two minutes [24]

22 Participation Scale (PS) This tool has been validated inIndia Nepal and Brazil It measures the extent to whichpeople participate in common social events [25] The keyissue of stigma is that it excludes people from participatingin such events The P-scale is an 18-item instrument whichcovers eight out of the nine participation domains of theInternational Classification of Functioning Disability andHealth (ICF) to measure social participation in such stigma-tizing diseases The use of the word participation is based onthe ICF terminology and participation restriction is definedas problems an individual may experience with involvementin life situations [26] A five point rating scale was used tomeasure the level of participation for each item For eachsubject the scores obtained for the 18 items were added upIf the score was 12 or less people were considered not tohave restriction in their domestic and social situation Scoresof 13 to 90 represented restriction at different intensities 13to 32 as moderate 33 to 52 as severe and 53-90 as extremerestrictions

23 Beckrsquos Depression Inventory (BDI) This scale was devisedby Beck in 1961 It contains 21 sentence groups aimed atassessing the level of depression Observed depression signsare evaluated objectively The 21 signs of depression includedin the scale are sensibility pessimism sense of failure senseof guilt self-dissatisfaction self-accusation desire to commitsuicide hysterical weeping seizures nervous breakdownsocial retreat indecisiveness conflicting self-image sleepdisturbances tiredness loss of appetite loss of weight psy-chological complaints and lack of sexual desire All thequestions were developed based on signs normally seenin depressed individuals Each category receives a scoreof 0ndash3 points If a subject scores 0ndash16 points there is nodepression 17ndash20 points indicate mild depression 21-30points indicate moderate depression and gt 31 points revealsevere depression Studies using the scale indicate that theBDI is an appropriate method for assessing the signs andlevels of depression in a given subject [27]




3 Results













Table 1



Sex 56 44

Age Mean 35786 36886SD 14238 14226







12000-16000 Rs 14 (25) 13 (2954)gt16000 Rs 10 (1786) 2 (455)























DomainMales Females









4 Discussion
























rp value


rp value


ASC domains


40591plusmn15083 09123lt 00001lowast




27432plusmn10643 09510lt 00001lowast



lt 00001lowast





11584plusmn43253 09460lt 00001lowast










rp value


rp value


DLQI Domains


2682plusmn1475 07936lt00001


3091plusmn2341 08941lt00001


1614plusmn1385 08934lt00001


07955plusmn09042 06795lt00001


1591plusmn1661 08247lt00001


lt00011


lt00001














5 Conclusions




Data Availability


Additional Points




References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of






















3 Results













Table 1



Sex 56 44

Age Mean 35786 36886SD 14238 14226







12000-16000 Rs 14 (25) 13 (2954)gt16000 Rs 10 (1786) 2 (455)























DomainMales Females









4 Discussion
























rp value


rp value


ASC domains


40591plusmn15083 09123lt 00001lowast




27432plusmn10643 09510lt 00001lowast



lt 00001lowast





11584plusmn43253 09460lt 00001lowast










rp value


rp value


DLQI Domains


2682plusmn1475 07936lt00001


3091plusmn2341 08941lt00001


1614plusmn1385 08934lt00001


07955plusmn09042 06795lt00001


1591plusmn1661 08247lt00001


lt00011


lt00001














5 Conclusions




Data Availability


Additional Points




References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of




















Table 1



Sex 56 44

Age Mean 35786 36886SD 14238 14226







12000-16000 Rs 14 (25) 13 (2954)gt16000 Rs 10 (1786) 2 (455)























DomainMales Females









4 Discussion
























rp value


rp value


ASC domains


40591plusmn15083 09123lt 00001lowast




27432plusmn10643 09510lt 00001lowast



lt 00001lowast





11584plusmn43253 09460lt 00001lowast










rp value


rp value


DLQI Domains


2682plusmn1475 07936lt00001


3091plusmn2341 08941lt00001


1614plusmn1385 08934lt00001


07955plusmn09042 06795lt00001


1591plusmn1661 08247lt00001


lt00011


lt00001














5 Conclusions




Data Availability


Additional Points




References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of


























DomainMales Females









4 Discussion
























rp value


rp value


ASC domains


40591plusmn15083 09123lt 00001lowast




27432plusmn10643 09510lt 00001lowast



lt 00001lowast





11584plusmn43253 09460lt 00001lowast










rp value


rp value


DLQI Domains


2682plusmn1475 07936lt00001


3091plusmn2341 08941lt00001


1614plusmn1385 08934lt00001


07955plusmn09042 06795lt00001


1591plusmn1661 08247lt00001


lt00011


lt00001














5 Conclusions




Data Availability


Additional Points




References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of





































rp value


rp value


ASC domains


40591plusmn15083 09123lt 00001lowast




27432plusmn10643 09510lt 00001lowast



lt 00001lowast





11584plusmn43253 09460lt 00001lowast










rp value


rp value


DLQI Domains


2682plusmn1475 07936lt00001


3091plusmn2341 08941lt00001


1614plusmn1385 08934lt00001


07955plusmn09042 06795lt00001


1591plusmn1661 08247lt00001


lt00011


lt00001














5 Conclusions




Data Availability


Additional Points




References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of























rp value


rp value


DLQI Domains


2682plusmn1475 07936lt00001


3091plusmn2341 08941lt00001


1614plusmn1385 08934lt00001


07955plusmn09042 06795lt00001


1591plusmn1661 08247lt00001


lt00011


lt00001














5 Conclusions




Data Availability


Additional Points




References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of



























5 Conclusions




Data Availability


Additional Points




References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of





















Data Availability


Additional Points




References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of
















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of



















gender differences in depression, coping, stigma, and...

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