Does the Diagnosis of Vitiligo Have a Psychological Impact on Adult Suffers in UK - Essay Example

Introduction A healthy normal skin plays indispensable role in individual’s life and offers physical, and emotional well being. The visible skin defects or blemish on the skin creates negative impact in terms of gender attractiveness, healthy personality, and self confidence. The skin disfigurement leads to mental abuses. Vitiligo is a polygenic dermatological condition distinguished by pale, white patches on the skin due to hypopigmentation. Pigmentation disorder is not contemplated as a serious health problem. The advancement and the route taken by this disorder vary depending on the individual. As the disease becomes chronic, it was observed that these patches may or may not grow in number and size, and may get eventually widely distributed all over the body surface. In some individuals it was observed that the growth of white lesions is static, and rarely even uneven repigmentation can be observed in vitiligo individuals (Patient UK EMIS and PiP, 2008). The specialised skin cells named melanocytes are responsible for the production of skin pigments called melanin, which are activated on sunlight exposure to form more melanin. They play an important role in skin protection from the suns rays, besides delivering colour to the outer layer of body. The people suffering from vitiligo have less or devoid of melanin content in affected areas. Therefore, such people due to lack of natural protection, are easily prone to skin burn by sun rays (Patient UK EMIS and PiP, 2008). It is conspicuous in darker skinned persons than faired skin people, where contrast with the surrounding area is prominent. It is estimated that 0.1-2% of worldwide population are vitiligo patients. UK has reported that almost 1% population suffers from vitiligo. People of all racial or ethnic backgrounds, and both the genders are equally vulnerable to vitiligo. Though, particular age limit is not there for catching this disease, the most susceptible age group is young age upto 20 years; where almost 50% of vitiligo cases are spotted (NHS choices, 2008). Vitiligo is not categorized as infectious disorder, since this is not transmitted from one person to other. In the UK, approximately 500000 suffer from this typical skin problem accompanied with cosmetic and psychological issues. Every physician has around 10 vitiligo clients. When survey was done to study the effects and extent of vitiligo, it was found that the average age of onset was 13 years, 50% vitiligo onset was linked with the onset stressful events such as marital and financial problems, 20% of the patients were depressed and 14% patients showed marked improvement after treatment. It was also observed that the patients with highly spread depigmentation patches are difficult to treat for vitiligo and depression. It was also noted that the application of skin camouflage creams were high (41% of men and 70% of women), and use of sunscreen was suboptimal (Agarwal, 1998). Various internal factors like autoimmune response, genetic makeup; and various external stimuli or environmental factors are responsible for this acquired skin disorder. Around 33% of reported vitiligo people have invariably affected family member (Patient UK EMIS and PiP, 2008). Vitiligo associated complications are most uncommon, however, it can lead to other immuno compromised conditions in individuals such as thyroid problems, diabetes and pernicious anaemia (Patient UK EMIS and PiP, 2008). Causes The causative factors for vitiligo are not yet clearly understood. Various factors such as autoimmune response, genetic makeup, and environmental factors alone or in combination can be the causative agents for vitiligo. It is assumed that autoimmune condition can be responsible for self destruction of melanocytes. There are reports of extensive familial aggregation. A genetic model for this disorder was earlier proposed by us. This model postulates that recessive alleles at multiple unlinked autosomal loci interact epistatically in the pathogenesis of vitiligo. While explaining genetic basis of the disorder, it has been reported that vitiligo individuals have extensive familial aggregation. It has been studied that epistatical interaction between recessive alleles at multiple unlinked autosomal loci results in the vitiligo disorder (Nath, Majumder, & Nordlund, November 1994). The cause and effect relationship between psychological stress and the development of vitiligo is being evaluated. It is reported that the stress factor is directly proportional to level of neuroendocrine hormones, and affects person’s defense system. This altered immune system response augments concentration of neuropeptides, and might commence pathogenesis of vitiligo (Parsad, Dogra, & Kanwar, 2003). Vitiligo can be the result of occupational hazard due to exposure of harmful chemicals to the skin. This leads to discoloration of the skin in contact, and is referred as occupational or e vitiligo (NHS choices, 2008). Diagnosis Pale/White patches on the skin without inflammation, soreness or itchiness are the main physical manifestations of vitiligo individuals. These well defined asymptomatic white maculae, on the skin most probably expand centrifugally (Moretti, 2003, p.1). Though these individuals are physically fit, they are very much prone to psychological illness. The most commonly observed discolouration sites are the areas on face, nake, and scalp. Other targeted sites include the backs of hands, front of knees, and elbows; and are symmetrical in nature. Even the hair on the scalp turn grey or white due to vitiligo in this region (Patient UK EMIS and PiP, 2008). Most of the time, hyperpigmentation is observed at the border of the patches. Sometimes, hypopigmented patches with marked depigmented lesions and normal skin can be found together (trichrome vitiligo) (Moretti, October 2003). The simple clinical photography and/or computerized morphometry can be used as preliminary tool to guage extent of vitiligo (The National Guideline Clearinghouse™ (NGC), 2008). Nordlund has classified vitiligo into three types on the basis of distribution and extension of lesions.: localized, generalized and universal vitiligo. Localised vitiligo can be of segmental nature where maculae are in dermatomal distribution; while focalis nature indicates nonsegmental pattern of one or more patches in the same region. Generalized vitiligo is further divided into acrofacial (targeting face and distal extremities), vulgaris (symmetrical distribution of lesions in typical pattern) and mixed types. Universal vitiligo is spread over 80% of the body (Moretti, October 2003). Vitiligo are classified into two groups according to Koga into vitiligo non segmentalis (type A) and vitiligo segmentalis (type B). The most prevalent type A, is linked with Koebner phenomenon, and new maculae may form throughout the life span of a patient. It is also accompanied with other auto immune disorders such as Sutton nevus, thyroid disorders, juvenile diabetes mellitus, pernicious anemia and Addison’s disease. Dermatomal distributed type B, has infrequent occurrence, and follows stable path after rapid initiation. The disease path cannot be chalked out clearly, and 10-20% of patients may exhibit spontaneous repigmentation in a perifollicular pattern (Moretti, October 2003). The differences between segmental versus nonsegmental vitiligo are tabulated in table 1 (Huggins, Schwartz, & Janniger, 2005). The magnitude of vitiligo disorder can be measured by The vitiligo area-scoring index (VASI) and Vitiligo European Task Force (VETF) tools (The National Guideline Clearinghouse™ (NGC), 2008). VETF also aids in evaluating distribution, severity and propagation of this skin disorder. The effect of the treatment can be routinely observed by taking serial photographs. Psychological effects The psychological and emotional impairment is inevitable in the persons suffering from this highly visible disease. Specially, if white patches are present on face, and/or hands people undergo more embarrassment. In addition to this, the psychological health of the person is influenced by affected individual’s attitudes towards vitiligo, age, family structure, and family socio-economic status. The early age onset of disease is the major reason of negative psychological impact, since teenagers are more conscious about their appearance. Such individuals are never easily accepted by society, though various supports and services are available to them. The hurting and humiliating remarks from the social circle make the person disillusioned and stigmatized. Poor impulse control, and inability to control anger are considered crucial behavioral issues since they affect all life domains. Family is one of the domains where relationship to this adult is considered. Vitiligo impacts on interpersonal relationships in and outside family, due to public perception of the disease, as well as inculcated depression and frustration (Parsad, Dogra, & Kanwar, 2003). The fear of disapproval and denouncement from their collegemates, and adults from their office colleagues, and social sphere; make such individuals socially imbalanced. Such discouraged patient might feel that God has given punishment to him/her. The patient generally focuses on worst events, negative feelings, beliefs, and thoughts those arise from the emotional disturbances. Multiple life skills deficit might arise due to dysfunctions like functional psychoses and neuroses. In these circumstances, the persons are not able to develop life skills. The chronic nature of disease, long term treatment, lack of uniform effective therapy and unpredictable course of disease (Parsad, Dogra, & Kanwar, 2003) causes loss of confidence in the treatment and loses self-esteem. This also leads to guilt, anxiety, distress and sorrow to individual suffering from this disorder. The negative feeling about this disorder is reinforced as the life goes on within a social circle and self image gets shattered. The psychological impact can include underachievement, decreased work productivity, poor health, neuropsychological impairment, other autoimmune conditions, social dysfunction, violence, poverty, homelessness, poor treatment outcome, and poor quality of life. The frustration, isolation from colleagues, and low self esteem ultimately leads to behavioral issues such as drug or alcohol abuse. The severity of mental abuses may cause even suicidal attempts. Their anticipation for rejection make them more sensitive and irritable (Parsad, Dogra, & Kanwar, 2003). In a study conducted by Parsad et al. (2003) on 150 vitiligo patients, the nature and extent of the social and psychological problems related to the disease and their consequences on treatment efficiencies by using Dermatology Life Quality Index [DLQI]. The inverse relationship was established between DLQI score and desired response. It was found that the improvement efficiency in vitiligo patients was less with high DLQI scores; and such patients have to be dealt with additional psychotherapeutic approaches. In another study Ongenae et al.(2005) has quantified the burden on the quality of life of vitiligo affected individuals in terms of DLQ scores. He has reported that the most influenced life areas due to depigmentation include feelings, clothing, social and leisure activities, and daily routine. He has also observed that the factors such as sex, number of consultations and subjective disease severity additionally affect lifestyle of the vitiligo victims (Ongenae et al, 2005). Financial consequences Though, this dermatalogical disorder is not a dreaded disease, it can have bad repercussion on health-related quality of life (QoL) and emotional fitness. The people undergo diverse treatments to get rid of uncurable vitiligo. Lack of stable emotional and financial support exposes vitiligo victims to unforeseen negative consequences. The causal factors that account for the varied job prospects include fighting, running away, substance abuse, funding issues etc. Lack of proper training and working skills increases unemployment. Poor academics during their schooling period can affect target vitiligo population badly. This leads to excessive absenteeism, beginning into or rise of drug and alcohol abuse or drooping out of school, involvement with gang etc. Lack of proper educational skills and degree make them unemployable. For the target population, the developmental milestones are not achieved at the level required for the same age group who has secured family past. This population lags behind in terms of becoming biologically and psychologically independent and mature. These youth, depending upon the quality of past life they have gone through (physical, sexual abuse, emotional turmoil) do idealistic and magical thinking without giving a deep thought. Restricted information about community resources, welfare systems, poor budgeting skills and lack of ability to approach apt healthcare settings makes everything difficult for a young person who feels deserted. Cost factor for the vitiligo treatment and allied psychological disorders are major attributes when the economic background of any person is considered. Restricted financial resources limit the use of costlier treatment policies and procedures. For women, vitiligo poses lot of financial burden in terms of high willingness-to-pay (WTP) than the men (Radtke, Schäfer, Gajur, Langenbruch, & Augustin, 2009). Legislative as well as cultural factors should be considered to fund educational programs and improve living conditions of the most vulnerable population. Financial and nutritional back up, and vitiligo counseling, empowerment and cost effective treatments should also be considered as important issue to enhance QoL of affected persons with vitiligo. The educational programs should focus on teaching people, vulnerable groups and health care providers about the vitiligo disease and treatments. Treatments The possible treatment of vitiligo is attributed to several factors like clinical manifestations of the vitiligo, age & preferences of the patient, advantages and disadvantages of a particular treatment in a specific patient. The person suffering from vitiligo might also be suffering from other issues at the same time like , abusive relationship, panic disorder, depression, substance abuse, and feeling suicidal. Such multiple problems should be resolved concurrently with the proper treatment approach. Clinicians personal and professional view and competency regarding the diagnosis are also important in deciding a particular strategy for a specific patient. Physician’s interpersonal skills boosts self confidence of the patient, increases patients satisfaction and thereupon increases treatment compliance and final outcome (Parsad, Dogra, & Kanwar, 2003). Mental health education should be provided to them so that they will continue the treatment and avoid future mishaps. The factors which play important role in vitiligo management include right start for the initiation of therapy, best combination approach for the individual, monitoring the patient for the effectiveness of therapy. Vitiligo management programs should be designed to reduce mental illness, distress, emotional trauma, family disruption, even protection from stressful exposures, and social discrimination. Noncurative symptomatic treatments are available to manage vitiligo patients. The different treatment alternatives include psychotherapy and pharmacological intervention. The pharmacological treatment treats physiological symptoms of vitiligo victims, which help them to get treated; while in psychotherapy the treatments are based on emotional attributes. Also, family education, family therapy, vitiligo education groups, stress management, are also useful in combating vitiligo. Psychosocial team that consists of a social worker, a mental health professional, and a pastoral counselor can help her in reducing distress resulting from psychosocial and spiritual issues. These professionals can assist him/her by finding positive events in life and at the same time mentally prepared her for all possible treatment outcomes. To achieve favourable treatment results, it is necessary to deal with psychological components of the affected individual. The pastoral counselors should advise her for the spiritual concerns that are bothering her. It is reported that competent counselor can positively influence his clients by assisting him to improve body image, self esteem, quality of life; and can even change the course of the disease (Parsad, Dogra, & Kanwar, 2003). The strategies should be aimed to improve behavioral outcomes, enhance life satisfaction, and greater level of competence in activities of daily living. Community service providers should have potential to provide developmentally-enriching experiences to vitiligo victims. Community counseling framework works should work on the principle of nurturing natural competency. They also should cherish desirable personal characteristics, problem solving skills and social skills. Early symptomatic treatment in the individuals can help the vitiligo individuals to forestall the later progression of comorbid psychiatric and/or medical disorders. Current treatment strategies are broadly classified into four classes (Patient UK EMIS and PiP, 2008): 1. Skin camouflage – 2. Vitiligo reverse treatments: Affected skin is treated to reverse the changes in the skin. 3. Depigmentation: Treatment to completely de-pigment the skin. 4. Sunblocking agents: The sun-exposed part of the skin should be covered with sunscreens to give protection from the sun rays. 1. Skin camouflage: Skin camouflage can be creams or lotions are applied on the white patches of the vitiligo patient to give cosmetic effect. These formulations are not responsible for treating the disease , but only covers the affected part to make them less visible. Therefore, if these camouflage has exact colour, it will give good effect to the skin reducing skin contrast. A free Skin Camouflage Service by the British Red Cross, NHS special cover creams are very much useful for this temporary solution. Thus, the person’s self confidence is boosted due to improved skin. Self-tanning lotions are applied on large areas, and have positive effect for longer duration, and reduces the frequency of application. But major limitation is to get exact matching skin colour camouflage. The areas such as the back of the hands can be covered with fake tans, where other camouflage are failed to give desire effect (Patient UK EMIS and PiP, 2008). 2. Vitiligo reverse treatments: Reverse treatments are the treatments dealing with the root cause of the problem such as retardation of the course and pace of vitiligo, and regain melanin as well as colour in the affected region. The various treatment modes should be combined to achieve desire result depending upon the patient’s attribute, response, and physician’s best decision (Patient UK EMIS and PiP, 2008). Steroid cream Short term (3-6 months) usage of steroid creams such as Betamethasone, Clobetasol, Fluocinolone, Fluticasone or Mometasone (The National Guideline Clearinghouse™ (NGC), 2008) can be useful when first insignificant white lesion apperas. The mechanism behind this might be suppression of the immune system to prevent invasion on melanocytes. However, the cream should be used cautiously to avoid undesirable side effects of longer exposure such as thinning of the skin and appearance of stretch marks. Steroid cream restricts the progression of patch, and at the same time may help to regain original skin colour. Tacrolimus cream The mechanism and acition of Tacrolimus cream is same as that of steroid cream to repigment the affected part in some vitiligo affected individuals. Psoralen and Ultra Violet A light (PUVA) treatment Psoralen drug causes the skin to become sensitive to light, and then this sensitive skin is exposed to ultra violet A light (UVA). The treatment is time exhausting, and should be taken for twice a week for a year. However, the restored colour in the skin may not have longer lasting effect, and the treated skin is liable to sunburn type reactions or skin freckling. Narrowband UVB phototherapy Ultaviolet B light (UVB) is a preferred treatment over PUVA in individuals with darker skin types. Treatments should be taken for twice a week for a year, and each session is shorter as compared to PUVA. Since psoralen drug is avoided in this treatment, the skin is saved from damaging effect. The treatment response varies with the individual, and affected regions, such as the hands and feet, cannot be efficiently treated with this therapy (The National Guideline Clearinghouse™ (NGC), 2008). Laser treatments The results in clinical trials of laser treatment are not consistent and promising to come under NHS treatment guidelines. Skin grafting Time consuming and not easily accessible skin grafting treatment for small white maculae has also shown inconsistent results. 3. Depigmentation The skin all over the body is depigmented to make it white and evenly coloured. This permanent treatment takes a year to remove all the skin pigment melanin from the skin, but should be consulted with the patient with proper guidance from the doctor (Patient UK EMIS and PiP, 2008).The chemicals such as d-(benzyloxy)phenol (MBEH) or 4-methoxyphenol (4MP) are used for removal of pigments for profoundly affected vitiligo adults (e.g., individuals with more than 50% depigmentation or adults with extensive depigmentation on the face or hands). These adults should be told about repigmentation treatment, before adopting depigmentation strategy (The National Guideline Clearinghouse™ (NGC), 2008). 4. Sunblocking agents: Vitiligo invaded areas should be covered with a high protection sun-block (factor 20 or above) to avoid sunburns. In addition to this, the skin should be covered with long sleeved clothing and with a large cap to cover hair on the head. Natural remedy: The scientists at Kings College London have found that the main constituent of black pepper, ‘piperine’ might play pivotal role in the treatment of vitiligo, by enhancing skin pigmentation evenly; and delivering the desirable effect faster and for longer span. It was concluded that piperine might reduce the repigmentation skin pathway with decreased UV radiation exposure (BBC News, 2008). Conclusion Vitiligo is a polygenic dermatological condition distinguished by pale, white patches on the skin due to hypopigmentation. The visible skin defects or blemish on the skin creates negative impact in terms of gender attractiveness, healthy personality, and self confidence. The final goal of the treatment strategy offered in vitiligo is to improve cosmetic and emotional health of the patient to lead healthy functional life. The multimodal treatment strategies for vitiligo management adopted by health care professionals plays an important role in such patients. The issues to be addressed in vitiligo are from cellular basic science to clinical research. More clarity is required in the areas of genetics and biological mechanisms of vitiligo such as identification of dysregulated genes to unravel the exact cause-effect relationship of this dermatological disorder. The development of novel molecular markers might able to predict development and progression of the vitiligo in affected individuals. The development of potential biomarkers and novel therapeutic approaches together can result in curable form of vitiligo in near future. Vitiligo persons who are exposed to positive care environment are motivated and hard-working, can become participating citizens with positive attitude. References NHS choices, 2008. “Vitiligo”. Available at: http://www.nhs.uk/conditions/Vitiligo/Pages/Introduction.aspx Last reviewed: 01/12/2008 Moretti S., 2003. “Vitiligo”. Orphanet Encyclopedia, October 2003. Available at: http://www.orpha.net/data/patho/GB/uk-vitiligo.pdf Patient UK. EMIS & PiP., 2008. “What are the treatment options for vitiligo?" Reviewed: 16 Oct 2008 . Available at: http://www.patient.co.uk/health/Vitiligo.htm. BBC news. Pepper to treat pigment disease Thursday, 14 February 2008. Available at: http://news.bbc.co.uk/2/hi/health/7244474.stm Nath SK, Majumder PP, Nordlund JJ (November 1994). "Genetic epidemiology of vitiligo: multilocus recessivity cross-validated". American Journal of Human Genetics, November 1994, 55 (5): 981–90. Huggins RH, Schwartz RA, Janniger CK (December 2005). “Vitiligo”. Acta Dermatovenerologica Alpina, Panonica, et Adriatica December 2005,14 (4): 137–42, 144–5. Parsad, Davinder, Dogra, Sunil, and Kanwar, Amrinder Jit (October 23). “Quality of life in patients with vitiligo. Health Qual Life Outcomes.” 2003; 1: 58. Published online 2003 October 23. doi: 10.1186/1477-7525-1-58. http://ukpmc.ac.uk/articlerender.cgi?artid=21836 Agarwal, G., (April 1998). “Vitiligo: an under-estimated problem”. Fam Pract.1998,Apr15 Suppl 1:S19-23. Radtke MA, Schäfer I, Gajur A, Langenbruch A, Augustin M. “Willingness-to-pay and quality of life in patients with vitiligo”. Br J Dermatol. 2009 Jul;161(1):134-9. Epub 2009 Mar 9. The National Guideline Clearinghouse™ (NGC) (Nov 2008). “Guideline for the diagnosis and management of vitiligo”. Available at: http://www.guideline.gov/summary/summary.aspx?doc_id=13567 Ongenae, K., Van Geel, N., De Schepper, S. and Naeyaert, J.M. (2005). “Effect of vitiligo on self-reported health-related quality of life”. British Journal of Dermatology,2005, 152(6): 1165 - 1172 Read More