Psychological Impact of Vitiligo

Abstract

Vitiligo is a depigmentation disorder with a high psychological impact. It affects 0.5–2% of the population worldwide. Psychological comorbidities associated with vitiligo are feelings of stigmatization, adjustment disorders, sleep disturbance, relationship difficulties, including sexual dysfunction and avoidance or restriction behavior. Depression, anxiety, and alexithymia have been associated too and we have several studies in this way, they will be included in the chapter. Female sex, visible or genital lesions, age < 30 years, and greater body surface area involvement are risk factors to develop psychological comorbidities. Psychological test (HADS, TAS-20, DLQI, or BDI-II) could be useful to assess these patients and to decide the better therapeutical approach.

1. Introduction

Depression and anxiety are reported as the most frequent psychosocial comorbidities in vitiligo patients. The following psychological comorbidities have been reported in more than 50% of these subjects in any study: depression, major depression disorder, anxiety, social phobia, feelings of stigmatization, adjustment disorders, sleep disturbances, avoidance and restriction behavior, self-consciousness, emotional impaired, relationship difficulties, and cognitive impairment. Psychosocial comorbidities reported in more than 25% of patients include coexisting depression and anxiety, sexual dysfunction, alexithymia, anger, suicidal thoughts, and dysthymic disorders [1]. Therefore, it is important to know the aspects that could aggravate the course of the disease, so we are going to list all of them.

1.1 Race/ethnicity

People with darker skin present more stigmatization and greater discrimination, since the contrast between normal and depigmented skin is much more evident. For this reason, psychosocial issues in this type of patient are very common [2].

1.2 Extension and localization of vitiligo lesions

Vitiligo lesions can appear in any part of the body, taking more or less extension.

As expected, when vitiligo affects a greater part of the body, the impact on the patient’s life quality is much more severe.

Is important to highlight that vitiligo does not affect equally when lesions are more visible since the more visible the lesions are to society, the more repercussions it has in the life quality of the individuals. In this case, the areas with greater exposure and psychological affectation usually are the face (Figure 1) and hands (Figure 2), without forgetting sensitive areas, such as genitals. With regard to this last part, when vitiligo is present in genitals, most of the time it is not reported to specialists because of embarrassment or stigmatization that it could be related to a sexually transmitted disease [3].

Figure 1.

Vitiligo lesions on the face (perioral distribution) with wood light.

Figure 2.

Vitiligo lesions on the dorsum of the left hand with wood light.

We know that vitiligo is usually asymptomatic, so the negative impact in the life quality is related to several psychological issues, such as a decrease in self-confidence or failure in social relationships [4].

1.3 Gender

There are skin diseases that do not affect equally between sexes. The social stigma to which they are bound and the lack of information from society in general lead us to “a weaker sex.”

Like in other skin disorders, such as alopecia, women who suffer from vitiligo have higher stress level than men. In addition to this, women manifest more hopelessness feelings [5].

1.4 Physical appearance

Nowadays, many cultures and societies give great importance to appearance, esthetic, and pigmentation. Therefore, any condition that affects appearance can lead to loss of privileges and opportunities.

The visibility of vitiligo, like other skin disorders, can affect considerably in terms of self-confidence. Patients who suffer from any skin disease like acne or vitiligo have experienced the feeling of being ugly or unattractive [6].

2. Psychological impairment and vitiligo

2.1 Stigmatization and quality of life

Vitiligo is more than a biological disorder. Several psychological and social disturbances have been described in these patients, which could interfere with their interpersonal relationships. The location and visibility of the lesions, as well as their size, are reported as a cause of suffering, not only for esthetic reasons but because of the discriminatory and stigmatizing views received in different social areas [1]. Stigmatization and discrimination are “justified” as a sign of fear of getting the disease. A negative image of themselves is usually associated with these patients. Thus, several resources to hide or camouflage the signs of vitiligo have been used by them, such as the use of makeup or the adaptation of their clothing. In addition, these subjects develop avoidance behaviors. All of this can lead to social isolation and low self-esteem [7].

Many civilizations and global societies assign great importance to physical appearance, esthetics, and skin pigmentation. Any condition that involves the esthetic appearance may lead to a loss of privileges and opportunities, and could disturb the professional career as well as personal and social interactions. This effect on self-esteem and the perception of beauty transcends race, age, gender, and socioeconomic status [3].

The impact of vitiligo on patients’ quality of life has been estimated in global populations with variable results. However, most of the results corroborate the negative impact of the disease on the self-esteem and quality of life of these patients [3]. When the affected body surface is greater than 25%, studies suggest a significant deterioration in the quality of life [8]. On the other hand, multiple studies have reported that lesions that affect more visible areas, such as the face or hands, and more sensitive areas, such as the genitals, have a more severe impact on the quality of life of these patients. Patients with involvement in the genital areas often do not consult doctors due to embarrassment or even the stigmatization that it could be related to a sexually transmitted disease. In addition, these patients may present sexual dysfunction, with equal frequency in male and female patients. Therefore, genital involvement and generalized vitiligo are significant risk factors that affect the sexual life of patients [3].

By gender, studies have reported more difficulties to accept the disease in women, secondary to its esthetic dysfunction, showing more troubles in social adaptation. A relationship between culture and the psychological burden of vitiligo has been reported. In addition, in young single women who live in a country with arranged marriages, vitiligo decreases the chances of marriage and in married women who develop the disease, the chance of divorce is increased. On the other hand, it is often assumed that the psychological disturbance is greater in racial or ethnic groups with darker skin [1, 3, 9].

The 25–38% of vitiligo patients are children. As in adults, several studies suggest that children experience a substantial disturbance related to vitiligo with a worse quality of life. Children and parents consider the face and legs as the most stigmatized areas. A large extension (BSA >25%) was associated with self-consciousness, fear, and bullying [8]. Negative childhood experiences may develop more problems in social relationships in adult life [10]. Furthermore, the quality of life of relatives has also been evaluated, and the findings suggest that parents of children with vitiligo experience significant psychological trauma and altered quality of life [3].

2.2 Alexithymia and vitiligo

Alexithymia is not only related to psychosomatic illnesses. Nowadays, it is considered as a risk factor for many medical and psychiatric illnesses [11]. Historically, much of the attention regarding alexithymia has focused on its overlap with autism spectrum disorder (ASD). The prevalence of alexithymia in ASD has been reported to be up to 63%, compared with the general population [12]. It is defined as a difficulty in differentiating, describing, distinguishing, or expressing one’s own feelings and those of others. Therefore, alexithymic subjects have a lower capacity to cope with stress. Psychological stress is known to be an important trigger in the onset or exacerbation of many dermatological diseases, including vitiligo [11].

Alexithymia is defined by three main features:

• Difficulty in identifying feelings, and, further, difficulty distinguishing between feelings and the bodily sensations of emotional arousal.

• Difficulty in describing feelings to other people.

• Restricted imaginative processes and externally oriented cognitive style.

The highly sensitive to physical stimuli is the link between alexithymia, a psychological construct, and physical illness. This high sensitivity may increase their likelihood of experiencing somatic symptoms during long periods of time. Alexithymia is often accompanied by mind-body mismatch and poor quality of social relationships, which may result in psychological distress and negative emotions. Such negative emotions and the physical sensations that accompany them (e.g., increased heart rate, sweating) tend to be confused with symptoms of illness. If this situation is prolonged in time, an intensified nervous system response from the neuroendocrine system could be arisen, further contributing to somatic disease [12].

Beyond somatic illness, alexithymia is related to other mental diseases. In fact, up to 58%, 51%, and 49% of alexithymic patients appear to suffer anxiety, depression, and addictive behaviors, respectively. Even more, higher levels of alexithymia appear to be associated with more severe manifestations of psychiatric illness [12].

An important interaction between alexithymia and skin disease has been reported. A 2008 systematic review concluded that alexithymia, which is related to changes in sympathetic activity, immunity, and brain activity, is associated with a number of dermatological diseases. In the findings reported up to September 2008, it was concluded that patients with alopecia areata, vitiligo, and urticaria have a higher prevalence and severity of alexithymia compared with healthy controls. For patients with psoriasis and atopic dermatitis, the results were contradictory, so that some studies suggested a higher prevalence of alexithymia in patients with these diagnoses and others did not [13].

More recently, in another systematic review published in 2022, the evidence accumulated after September 1, 2008, up to March 12, 2021, is reviewed, to better understand the relationship between alexithymia and dermatological diseases. Due to the inability of these people to understand, describe and specify emotions, which can create a significant barrier to self-control (essential in dermatology given the chronicity of many conditions), the impact of alexithymia on the burden of the disease was also investigated, psychosocial comorbidities and quality of life, as well as treatment success. Data from September 2008 onwards corroborate significant associations between alexithymia and dermatological disease. Consistent with previous data, the prevalence of alexithymia in patients with skin disease (5–76.4%) is markedly higher than the prevalence of alexithymia in the general population (10%). In reference to vitiligo, a prevalence of clinically significant alexithymia of up to 65.4% in patients was reported [12]. A case-control study involving 52 patients found no significant difference in prevalence between patients and controls, but a cross-sectional study involving 30 patients did. In both studies, patients had significantly higher TAS-20 total scores than controls [14, 15]. Any study included in this review reported data on alexithymia after the treatment of diseases other than psoriasis and alopecia areata [12].

Regarding the physiological mechanisms linking alexithymia to dermatological disease, the “stress-alexithymia hypothesis” proposes that specific cognitive, behavioral, and physiological components of alexithymia may contribute to the pathogenesis of stress-related disorders, including dermatological diseases. According to this hypothesis, the combined effects of a lack of emotional awareness, as well as effective expression and verbalization (cognitive component), can lead to ineffective and/or maladaptive coping attempts (behavioral component). This, in turn, can lead to prolonged exposure to stress, which exacerbates the somatovisceral response (physiological component), thus increasing susceptibility to disease. In addition, it has been observed that the immune response of alexithymic subjects is similar to that of individuals exposed to chronic stress, with a higher production of glucocorticoids, a depressed cell-mediated immunity response, and an alteration of ratio Th1/Th2 (toward Th2 response). All of these findings are associated with cutaneous disease too [16, 17]. With regard to alexithymia and skin disease morbidity, perceived defects in physical appearance may develop significant emotional and social consequences, in particular, the experience of shame, stigmatization, social exclusion, and loneliness. Failure to discern psychological manifestations from physical symptoms can lead to additional inappropriate somatovisceral responses that further precipitate disease. Furthermore, this impaired emotional self-awareness and emotional regulation may also be related to impaired self-control, possibly worsening the duration and severity of the disease. So, beyond the high prevalence of alexithymia in dermatology patients, it may influence the development of psychosocial comorbidities and their treatment [12, 16, 17].

2.3 Anxiety and depression in vitiligo

Studies show that two-thirds of patients feel embarrassed and more than one-half report feeling socially anxious [18]. In one study of more than 600 patients, 59% of them reported an incident in the past three weeks in which their vitiligo had made them feel somehow bad [19]. More than a half of patients have been stared at, and 16% had overhead rude remarks, such as “Yuck, what´s wrong with him?” or “People like that should not go out in public” [20]. Moreover, when talking about the psychological aspects in vitiligo, Silvan M [21] reports that his patients described similar incidents, such as one man who told him how, when he holds the handrail on the subway, and the person next to him often moves his or her hand away. Many patients have also felt job discrimination [20].

Bearing all these experiences in mind, it is not difficult to understand the psychosocial impact of the disease and how it may impact mood and cause disorders, such as anxiety and depression.

A systematic search for observational studies that examined the prevalence of anxiety in vitiligo patients found 15 studies, including 1176 patients. The general prevalence of anxiety using random-effects models was 35.8%. A statistically significant difference in anxiety rates was found among female patients (47.32 vs. 42.4%) (P = 0.03). In addition, the pooled odds ratio among vitiligo and non-vitiligo patients did not indicate a statistical significance among patients coming from different continents, comparing African, European, Middle East, and South Asian countries [22].

On the other hand, a cross-sectional self-assessment questionnaire-based study conducted in Thailand, including 104 patients with vitiligo [23], showed the mean Dermatology Life Quality Index [24] score was 7.46, meaning a moderate impact on quality of life. Domains that had higher scores were those related to embarrassment, social activities, and clothing. Depression was evaluated using the Patient Health Questionnaire (PHQ-9) [25] and it showed scores equal to or above 9, which has been reported to be the optimal cutoff score for diagnosing major depression in the Thai population [26], in a 13.5% of patients. These patients showed higher scores for social activities, embarrassment, clothing, shopping, and homecare. Depression was considerably more frequent in patients with active vitiligo than in those with stable disease. Those patients with new appearing lesions were more likely to be depressed than those with no new macules [23]. Nevertheless, no differences were found when taking into account age, gender, educational level, skin phototype, or type of vitiligo [23]. Both questionnaire measures correlated well, meaning that higher levels of depression were found among patients with the worst quality of life and vice versa [23].

A recent study analyzes not only anxiety and depression but hopelessness [5] using the Beck´s Depression and Anxiety Inventory (BDI and BAI) [27, 28], the Beck´s Hopelessness Scale (BHS) [29], and the General Health Questionnaire (GHQ-28) [30] among 100 vitiligo patients and 100 healthy controls in an Iranian population. Anxiety and hopelessness levels were significantly higher in vitiligo patients than in control participants and this difference was more important among women with vitiligo.

All three variables had a positive and significant relationship with disease duration, but age had a negative relationship with all of them, so as younger they were, they felt worst.

It was also demonstrated that single patients were more anxious, hopeless, and depressive than those married. Patients living with their couples were only more anxious and hopeless than healthy controls.

Vitiligo patients, women in special, showed the worst general health in this study [5].

We can also consider the role of stress, along with anxiety and depression. A cross-sectional study includes 50 vitiligo patients and 50 matched healthy controls [4] in which all patients were assessed by the Depression Anxiety Stress Scale (DASS) [31] to determine the severity of these three aspects and, Dermatology Life Quality Index (DLQI) [24] only in vitiligo patients, to evaluate the impact of the disease on daily life [4]; disease activity was measured using Vitiligo Area and Severity Index [32], and showed that the prevalence of stress was 76%, anxiety 78%, and depression 80% among vitiligo patients, and the difference was statistically significant between patients and controls. They also found that stress, anxiety, and depression were higher among women (P < 0.05). The degree of the disease implies more anxiety and depression (p > 0.05). The familiar history of vitiligo had a positive relationship with depression. Nevertheless, this study failed to demonstrate any statistically significant correlation with age, marital status, type of work, type of vitiligo, site of the lesions, and type of therapy with stress, anxiety, or depression. It is also interesting that they found a positive correlation between stress and feelings of embarrassment from vitiligo and clothes choice [4]. They feel embarrassed, and try to hide the lesions with clothes and it means more stress.

Another recent study conducted in Egypt [33] collected 100 patients with vitiligo that were subjected to clinical examination and disease activity was measured with VASI; they were compared with 50 healthy controls and assessed for quality of life with the DLQI and for anxiety and depression with the Hamilton Anxiety Rating Scale (HARS) [34, 35]. This tool rates depression by probing mood, feelings of guilt, suicide ideation, insomnia, agitation or retardation, weight loss, and somatic symptoms. They found higher scores on DLQI, showing worst levels of quality of life among patients (P<0.001), and also significant differences in the Hamilton Anxiety and Depression Score than the control group. A significant positive correlation was found between VASI score and extension of the disease, in special those with exposed areas of skin affected, with DLQI and HARS. Patients with a progressive course of the disease showed the worst quality of life. Female patients also showed higher levels of impairment. Although not significant, patients with lower skin phototypes showed lower levels of depression and better quality of life [33].

As stated above, alexithymic people have a lower ability to deal with difficult life events. As anxiety and depression, alexithymia might be a triggering factor for diseases [36, 37]. Namdar ND and Kurtoglu Y [38] conducted a study, including 50 vitiligo patients and 70 healthy controls, matched in age and sex and investigated anxiety, depression, and alexithymia among them. They grouped patients as generalized and localized vitiligo according to their clinical involvement. Depression was assessed with the Beck Depression Inventory [35], anxiety with the Beck Anxiety Inventory [28], and alexithymia using the Toronto Alexithymia Scale with 20 items, TAS-20 [39, 40]. Anxiety and depression levels were higher in vitiligo patients than in healthy control individuals (P = 0.000, P = 0.009 respectively), but no differences between alexithymia scores (P = 0.103). No correlation could be found between psychiatric scale scores and disease duration, age or gender of patients, or educational levels. Nevertheless, alexithymia levels correlated positively with anxiety and depression levels in vitiligo patients [38]. So, when psychosocial impairment is evident, feelings might be more difficult to recognize and show to patients, and these facts do not help them at all.

In 2009 ESDAP Congress, we report a case-control study that included 100 patients with vitiligo who attended our outpatient clinics between January and August, and 100 control subjects without clinical history of vitiligo. The aim was to analyze the prevalence of depression and/or anxiety in patients with vitiligo. All the patients were older than 16 years old. Both groups were matched in age and sex. They were included consecutively, using the Spanish version of the Hospital Anxiety and Depression Scale (HADS) [41]. The statistical analysis was performed with the SPSS program version 17.0. For the depression subscale, 3 patients had a score of 11 or higher (3.6%), 12 between 8 and 10 (14.5%), and 68 of 7 or lower (81.9%). For anxiety, 15 had a score of 11 or higher (18.1%), 20 between 8 and 10 (24.1%), and 48 of 7 or lower (57.8%). Anxiety was more frequent in women (24% in women vs. 9.1% in men) (Figure 3). Women also showed more cases (4% vs. 3%) and probable cases (20% vs. 6.1%) of depression (Figure 4). However, no significant differences were found between the sexes for anxiety or depression (p=0.224 and p=0.196). The prevalence of anxiety between age groups showed significant differences (p=0.022, p<0.05). In the analysis, differences were observed between patients aged 37–46 years and those over 66, who presented the highest and lowest frequency of cases, respectively. Higher levels of anxiety correlate with higher levels of depression (Rho=0.609, p<0.0001) [42].

Figure 3.

Anxiety and probably anxiety cases distributed by gender.

Figure 4.

Depression and probably depression cases distributed by gender.

3. Psychological approach

Patients with vitiligo usually feel socially isolated and with limitations in their daily life and that’s why they usually present depressive and anxious symptomatology. Therefore, it is very important that vitiligo treatment includes a complete psychological intervention. Moreover, data show that a multidisciplinary treatment in this type of patient can slow down the progression of vitiligo and even reduce the size of affected areas. It is usually patients with psychological deficits and strong emotional vulnerability and this is why it’s hard to find the right treatment. Taking this into account, it is crucial to take medical and psychological treatment simultaneously [21].

In view of the above, it would be accurate to give some surveys to the patients in order to have a qualitative and quantitative description of their psychological state. The surveys that we can use are Toronto Alexithymia Scale (TAS-20), Dermatology Life Quality Index (DLQI), and Beck Depression Inventory (BDI-II).

3.1 Toronto Alexithymia Scale (TAS-20)

This scale (Figure 5) was developed by Bagby, Parker and Taylor in 1994 [40] from former versions with 26 and 23 questions.

Figure 5.

Toronto Alexithymia Scale.

The TAS-20 is based on three factors:

• Evaluation of difficulty in identification of feelings and distinguishing them from physiological sensations that go with emotional activity (factor 1).

• Difficulty in describing feelings (factor 2).

• Thought focused on the external (factor 3).

It is a self-report with 20 questions, with a Likert-type scale of 5 points that show from “total agree” to “total disagree” with each of the statements [39].

3.2 Dermatology Life Quality Index (DLQI)

The DLQI survey (Figure 6) was developed in the U. K by AY Finlay and GK Khan in 1994 [24]. This instrument is simple, sensitive, and compact. It is made of 10 questions referred to in the last seven days. It presents a Likert-type scale with four possible answers: «not at all», «a little», «a lot» o «very much», with respective 0, 1, 2, and 3 punctuation, also having the possibility «not relevant». The health domains included in DLQI are as follows:

• Symptoms and perceptions (questions 1, 2).

• Daily activities (3, 4).

• Leisure (5, 6).

• Work/study (7).

• Interpersonal relationships, including sexuality (8, 9).

• Treatment (10).

Figure 6.

Dermatology Life Quality Index.

The total punctuation will give us a global value from 0–30. Such punctuation could be presented as the percentage of the impact of skin affection on the patient’s life quality. The more punctuation, the more impact on life quality related to patient’s health (HRQOL) [43].

3.3 Beck Depression Inventory (BDI-II)

The original version of the Beck Depression Inventory was published in 1961 by Beck, Ward, Mendelson, and Erbaugh [9] and updated in 1996 by Aaron T. Beck, Robert A. Steer and Gregory K. Brown (BDI-II). It is a self-report made up of 21 Likert-type items. Its items do not arise from any specific theory about depression but describe the most frequent clinical symptoms of patients with depression, such as sadness, crying, loss of pleasure, failure and guilt feelings, suicide thoughts or desire, and pessimism [44].

As previously mentioned, the BDI-II versión (Figure 7) was published in 1996, while in 2011, Jesús Sanz and Carmelo Vázquez, published the Spanish adaptation of this test [45].

Figure 7.

Beck Depression Inventory.

This inventory is of great relevance and that is why it is considered the fifth most used test by Spanish psychologists [46].

4. Psychological treatment

4.1 Depression

The cognitive therapy (CT) developed by Aaron T Beck in the late 50s is the most accurate procedure to treat depression since it’s specifically designed to work on this construct.

The CT gives us a complete concept of depression because it presents:

• A theory.

• A diagnostic evaluation.

• A therapeutic procedure.

With this theory, depression is explained by the existence of negative thoughts about oneself, about the world, and/or the future. This is due to depressive factors and failure in processing information.

This type of psychological treatment is very organized and consists of 15–25 sessions, including continuation and termination sessions. The CT is conceived from a psychoeducational point of view, since it tries to modify cognitions and behaviors. That is why it is also named as cognitive-behavioral therapy (CBT) [47].

The main features of this theory are the following:

• It emphasizes the relationship between cognitions, behavior, and emotions.

• It must be formulated individually in order to establish the therapeutic goals and the treatment to be followed.

• A good therapeutic relationship is key to achieve change.

• The patients will obtain a new way to understand their problems.

• It is focused on the current factors that sustain the problem.

• It needs active collaboration between therapist and patient.

• The patients will get the resources and skills required to manage their problems autonomously.

• It’s short (usually less than 30 sessions).

• The activities between sessions are very important for the treatment.

• It uses many cognitive and behavioral techniques and other approaches, such as full consciousness or mindfulness [48]

4.2 Anxiety

It is very important to know the existing differences between the different anxiety disorders and to know the diagnostic criteria of each one of them in order to take the right treatment in vitiligo patients. Otherwise, in many cases, in primary care medicine, anxiety disorders are not diagnosed. And this is why it is very important to detect and work on them.

In order to make an appropriate treatment, we must know the three components of anxiety, which are subjective fear, physiological activation, and avoiding behavior. These three components do not always change in the same way. So, the treatment will be aimed at that anxiety component that is affecting the patient. The effective physiological intervention trains an individual to reduce physiological activation through biofeedback and with several relaxing skills. Each method leads to self-calm of the body and reduction in physiology of stress and alert, so the patient will manage subjective fear. Cognitive therapy teaches the patients to modify fearful thoughts and redirect their attention far from fears, and self-training to overcome fearful experiences. With all the above, a full recovery needs a change in the cognitive-affective area, physiology activation, and behavioral avoidance [49].

4.3 Alexthymia

Over the years, changes have been proposed in order to conceptualize and measure alexithymia. This psychological feature has been related to several disorders. In general, psychotherapy seems to be useful to patients with alexithymia. There are several aspects that will help the patient to build a consistent narrative and explore the emotional dimensions. These aspects are the development of vocabulary in emotions, the learning of reading the emotions of others, and the relation between alexithymia and early life experiences. With this, we develop social and emotional skills. Interventions could be made individually or in groups. Another important aspect of the therapeutic process in patients with alexithymia is the empathy of the therapist. This allows the understanding of others, their goals, intentions and feelings, makes exploration easier, promotes the opening to new experiences and a curious behavior toward emotional experiences, and at the same time allows the deconstruction of assumptions and values [50].

Several neurobiological studies performed so far suggest that people who present alexithymia usually have a deficit in emotion recognition. Therefore, effective treatments for alexithymia include the training of skills in the domain of emotion recognition. It has been proven that the interventions based on smartphones (SBI), which offer training in skills, are great complements of psychological treatments. In 2019, a pilot study with 29 subjects with high levels of alexithymia were randomly assigned to an intervention group (SBI group) or a control group. Participants assigned to SBI group received a psychoeducation session and 14 days of training with the app alexitimia mindtastic (MT-ALEX) and the control group only received the psychoeducation session. MT-ALEX includes 14 emotion-specific workouts for training inter- and intraindividual recognition of seven basic emotions: fear, anger, disgust, sadness, joy, pride, and surprise. The results showed higher rates of emotion recognition skills by the SBI group. By this way, the SBI could improve emotion recognition skills in patients with alexithymia [51].

5. Conclusions

Vitiligo is one of the most psychologically devastating diseases in dermatology. Although the contrast of vitiligo lesions is more visible in racial/ethnic groups with darker skin, all vitiligo patients experience some degree of emotional disturbance caused by the disease. Therefore, health professionals should be aware that patients suffer from a significant psychosocial burden, which suggests that vitiligo treatment will always be necessary, not only for esthetic purposes. It is very important to recognize and assess the psychological and social problems of this disease to improve quality of life and treatment results.

In addition, an added factor is the high prevalence of alexithymia in these patients, as this may influence the development of other psychosocial comorbidities and their treatment. It is likely that early recognition and management of the alexithymia may improve dermatological care, mitigate psychological comorbidities, improve quality of life, improve self-management, get stronger patient-physician relationships, and reduce inappropriate use of drugs and health resources. More randomized clinical trials should be conducted to investigate the usefulness of therapeutic approaches targeting alexithymia to improve disease outcomes and quality of life for patients.

In conclusion, psychodermatology is a necessary subspecialty in our daily dermatological practice, especially in patients with vitiligo.

Acknowledgments

Acknowledgments go to CHUC dermatology department, especially Dr. Noda Cabrera, Dra. Marina Rodríguez y Dra. Patricia Contreras.

Acknowledgments go to Luis Trujillo Brito, Dermamedicin’s Director, and Manager.

Conflict of interest

The authors declare no conflict of interest.