DLQI and CDLQI scores should not be combined

Validation of the Urticaria Control Test (UCT) in Children With Chronic Urticaria

BACKGROUND

Few validated tools exist to evaluate chronic urticaria (CU) control in children. Although the Urticaria Control Test (UCT) exhibits favorable clinometric properties in adult CU, it is not yet validated in children.

OBJECTIVE

To evaluate the validity of the UCT for the assessment of pediatric CU.

METHODS

Children presenting with CU were consecutively recruited and completed both the UCT and the Children's Dermatology Life Quality Index (CDLQI) at study entry. Using the CDLQI as an anchor, we assessed the internal consistency, convergent and known-groups validity, and screening accuracy of the UCT at study entry and at follow-up.

RESULTS

A total of 52 children with CU were recruited. The UCT exhibited respectable internal consistency in the evaluation of CU (Cronbach's α, 0.73; 95% CI, 0.62-0.85). UCT and CDLQI scores strongly correlated (r = -0.74; P < .01). The UCT distinguished between different strata of disease severities established by the CDLQI (P < .01). Screening accuracy of the UCT was excellent in the discrimination of poorly controlled CU (area under the curve, 0.82). An optimal cutoff of less than or equal to 10 was determined for defining poorly controlled CU (sensitivity, 95.5%; specificity, 63.3%). Data at follow-up were consistent with data at study entry. Subgroup analyses of patients with chronic spontaneous urticaria were consistent with overall estimates of validity.

CONCLUSIONS

The UCT is a valid tool for the assessment of pediatric CU and chronic spontaneous urticaria, as evidenced by the acceptable internal consistency, convergent and known-groups validity, and screening accuracy at multiple time points.

Treatment persistence in paediatric and adolescent patients with psoriasis followed into young adulthood. From topical to systemic treatment: a prospective, longitudinal, observational cohort study of 448 patients

Background

Although solely topical treatment often suffices, patients with psoriasis may require more intensive treatment (phototherapy and/or systemic treatments) to control their disease. However, in paediatric, adolescent and young adult patients, little is known about persistence of topical treatment and time until switch to systemic treatment.

Objectives

To determine the median time from psoriasis onset until (i) discontinuation of solely topical agents and (ii) switch to systemic treatment, and to identify patient characteristics associated with switching to systemic treatments.

Methods

Data were extracted from the Child‐CAPTURE registry, a prospective, observational cohort of patients with paediatric‐onset psoriasis followed into young adulthood from 2008 to 2018. Data prior to inclusion in the registry were collected retrospectively. Median times were determined through Kaplan–Meier survival analyses. Cox regression analysis was used to identify patient characteristics associated with switch to systemic treatment.

Results

Of 448 patients, 62·3% stayed on solely topical treatment until data lock; 14·3% switched from topicals to phototherapy, but not to systemic treatment; and 23·4% switched to systemic treatment. The median time from psoriasis onset until discontinuation of solely topical treatment was 7·3 years, and until switch to systemics was 10·8 years. Higher Psoriasis Area and Severity Index and (Children’s) Dermatology Life Quality Index > 5 were independently associated with switching to systemic treatment.

Conclusions

In a population of paediatric and adolescent patients with mild‐to‐severe psoriasis, one‐third needed more intensive treatment than solely topical therapy to control their disease. We consider the median time until switching to systemics to be long.

What is already known about this topic?

Psoriasis in the majority of paediatric and adolescent patients can be adequately managed with solely topical treatment. However, some patients require a switch to more intensive treatment in order to control their disease.

Little is known about persistence of topical treatment and time until switch to systemic treatment.

What does this study add?

In 448 paediatric patients with mild‐to‐severe psoriasis, 62·3% persisted on solely topical treatment, 14·3% switched to phototherapy, but not to systemics, and 23·4% switched to systemic treatment at data lock (total median follow‐up 4·2 years, interquartile range 1·8–7·5).

The median time from psoriasis onset until discontinuation of solely topical treatment was 7·3 years, and until switch to systemic treatment 10·8 years.

Higher Psoriasis Area and Severity Index and (Children’s) Dermatology Life Quality Index > 5 at switch were independent characteristics associated with switching to systemic treatment.

Linked Comment: Salman. Br J Dermatol 2021; 184:387–388.

Plain language summary available online

Quality of life and psychological impact in the photodermatoses: a systematic review

BACKGROUND

The photodermatoses affect large proportions of the population but their impact on quality of life (QoL) and psychological health has not been reviewed. Several tools are available to evaluate QoL and psychological impacts.

OBJECTIVES

To systematically review current literature to identify tools used to assess QoL and psychological impacts in patients with photodermatoses, and to summarize the reported findings.

METHODS

A systematic search of PubMed, OVID Medline, PsycInfo and CINAHL was performed for articles investigating QoL and/or psychological impact in patients with photodermatoses, published between 1960 and September 2018.

RESULTS

Twenty studies were included: 19 incorporated QoL assessment while three evaluated psychological morbidity. Six QoL tools were found to be used: Dermatology Life Quality Index (DLQI), Children's DLQI, Family DLQI, Skindex (16- and 29-item versions), Erythropoietic Protoporphyria Quality of Life (EPP-QoL) and EuroQol. Between 31% and 39% of photosensitive patients reported a very large impact on QoL (DLQI > 10). Employment and education, social and leisure activities, and clothing choices were particularly affected. Only one tool was specifically designed for a photodermatosis (EPP-QoL). Four tools were used to evaluate psychological impact: the Hospital Anxiety and Depression Scale, Fear of Negative Evaluation, brief COPE and Illness Perception Questionnaire-Revised. Levels of anxiety and depression were approximately double British population data. Patients with facial involvement, female gender and younger age at onset showed more psychological morbidity.

CONCLUSIONS

Several tools have been used to assess QoL in the photodermatoses, and confirm substantial impact on QoL. Development of specific, validated QoL measures would address their unique impacts. Research delineating their psychological comorbidity is sparse and requires further exploration. What's already known about this topic? The photodermatoses negatively impact quality of life (QoL) and cause psychological distress, but no reviews of this area appear in the literature. What does this study add? Few studies have explored the psychological and social impacts of the photodermatoses. There are no fully validated QoL tools specific to the photodermatoses. Around one-third of adult and child patients with photosensitivity experience very or extremely large impact on QoL, with particular effect on clothing choices, employment and social and leisure activities. Studies suggest anxiety and depression levels in these patients are around double those in the U.K. general population. More attention is required on these 'hidden' conditions.

Quality-of-Life Research in Acne Vulgaris: Current Status and Future Directions

Acne patients may have significant quality-of-life (QoL) impairment, therefore assessment of health-related QoL (HRQoL) in acne patients is recommended by several national and international guidelines as an integral part of acne management. The inclusion of QoL assessment in core outcome sets is now a popular idea. Several acne-specific QoL questionnaires are available but none cover all topics presented in other instruments. The impact of acne on different aspects of QoL may vary between patients from different age groups. The European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes has initiated a study on the relevance of the different QoL topics in acne patients. Detailed recommendations on treatment goals and changes of treatment approaches based on a validated banding system and a minimal clinically important difference in HRQoL questionnaires (such as the Dermatology Life Quality Index) may be an important and promising approach.

Quality of life impact of childhood skin conditions measured using the Children's Dermatology Life Quality Index (CDLQI): a meta-analysis

BACKGROUND

The Children's Dermatology Life Quality Index (CDLQI) is the most widely used instrument for measuring the impact of skin disease on quality of life (QoL) in children.

OBJECTIVES

To provide a meta-analysis of all published QoL scores for a range of childhood skin conditions.

METHODS

Studies using the CDLQI questionnaire to measure QoL in skin conditions were identified by searching Medline and Embase from January 1995 (CDLQI creation) to December 2014. Studies were grouped according to condition and baseline scores were combined using meta-analysis.

RESULTS

Sixty-seven studies using the CDLQI met the inclusion criteria. The overall estimated CDLQI scores for conditions reported more than once were [point estimate (95% confidence interval, CI), number of studies (n), score range]: atopic eczema [8·5 (7·1-9·8), n = 38, 0-29], acne [5·3 (1·9-8·5), n = 5, 0-30], alopecia [3·1 (0-7·7), n = 2, 0-6], molluscum contagiosum [3·5 (0·6-6·7), n = 5, 0-27], psoriasis [8·0 (3·9-12·1), n = 6, 0-29], scabies [9·2 (0·0-20·3), n = 2, 1-26], urticaria [7·1 (0-15·4), n = 2, 0-22], vitiligo [6·5 (0·7-12·2), n = 2, 0-20] and warts [2·9 (0-5·8), n = 4, 0-16]. Overall, the mean effect on QoL [weighted average CDLQI score 4·6 (95% CI 3·9-5·4)] for children with these conditions was small. However, many children were found to experience a very large impact on QoL (34% of children with atopic eczema, 10% with molluscum contagiosum and 1-5% with acne) in studies where the distributions of scores were provided.

CONCLUSIONS

Most skin conditions in children have a 'small' mean effect on QoL. However, the range is large and a significant proportion of children with many common skin conditions will experience a very large effect on quality of life.

Clinical experience and psychometric properties of the Children's Dermatology Life Quality Index (CDLQI), 1995-2012

The Children's Dermatology Life Quality Index (CDLQI) is a widely used questionnaire to measure the quality of life of children aged from 4 to 16 years. The purpose of this review is to summarize all published data regarding the clinical experience of the CDLQI and its psychometric properties as a single reference source for potential users. A literature search was carried out to identify all articles describing the use of the CDLQI from 1995 to November 2012. One hundred and six articles were identified, with four excluded. The CDLQI has been used in 28 countries in 102 clinical studies and is available in 44 languages, including six cultural adaptations; a cartoon version is available in 10 languages. It has been used in 14 skin conditions and used in the assessment of 11 topical drugs, nine systemic drugs, 13 therapeutic interventions and two epidemiological and other studies. There is evidence of high internal consistency, test-retest reliability, responsiveness to change, and significant correlation with other subjective and objective measures. Rasch analysis has not been carried out and more information is needed concerning minimal clinically important difference; these are areas requiring further study.

Quality of life impairment in children and adolescents with vitiligo

Vitiligo significantly affects quality of life (QOL) in adults, but little is known about the effect on QOL of pediatric vitiligo and whether the extent, distribution, and duration of vitiligo are associated with QOL. We performed an online parental questionnaire-based study (N = 350) regarding children ages 0 to 17 years with vitiligo, including validated questions about body surface area (BSA), distribution, and age of onset of vitiligo, associated symptoms, and QOL using the Children's Dermatology Life Quality Index (CDLQI). Vitiligo negatively affected numerous aspects of and total CDLQI score (median 3.0, interquartile range 5.0). Their vitiligo lesions did not bother only 4.1% of teenagers ages 15 to 17 years, versus 45.6% of children ages 0 to 6 years and 50.0% of those ages 7 to 14 years (p < 0.001). There was no association between the child's age and whether the child's vitiligo bothered the parents (p = 0.27). The most bothersome sites of vitiligo lesions for children and parents were the face (25.6% and 37.4%, respectively) and legs (26.2% and 26.2%, respectively). Eighty-two patients (30.1%) reported itching and painful skin within the past week. Using multivariate ordinal logistic regression models, it was found that an affected BSA of more than 25% was associated with self-consciousness, difficulty with friendships and schoolwork, and teasing and bullying. Lesions on the face and arms were associated with teasing and bullying. The extent of vitiligo is associated with QOL impairment in children and adolescents, especially self-consciousness, but also bullying and teasing. Different distributions of vitiligo lesions are associated with different aspects of QOL impairment. Teenagers ages 15 to 17 years seem to experience the most self-consciousness of all pediatric age groups.