Quality of Life of People with Vitiligo: A Brazilian Exploratory Study

264 REVISTA DE PSICOLOGIA DA IMED Quality of Life of People with Vitiligo: A Brazilian Exploratory Study Qualidade de Vida de Pessoas com Vitiligo: Um Estudo Exploratório Brasileiro Calidad de Vida de Personas con Vitíligo: Un Estudio Exploratorio Brasileño Emerson Araújo Do Bú(1); Maria Edna Silva Alexandre(2); Vitória Medeiros Santos(3) 1 Instituto de Ciências Sociais da Universidade de Lisboa (ICS-UL), Lisboa, Portugal. Faculdade de Psicologia da Universidade de Lisboa (FP-UL), Lisboa, Portugal. E-mail: [email protected] | ORCID: http://orcid.org/0000-0003-3864-3872 2 Universidade Federal da Paraíba (UFPB), João Pessoa - Paraíba, Brasil. E-mail: [email protected] | ORCID: https://orcid.org/0000-0003-3610-7208 3 Universidade Federal de Campina Grande (UFCG), Campina Grande - Paraíba, Brasil. E-mail: [email protected] | ORCID: https://orcid.org/0000-0002-4319-2597 Endereço correspondente / Correspondence address Emerson Araújo Do Bú Av. Prof. Aníbal Bettencourt 9, 1600-189, Lisboa, Portugal. Sistema de Avaliação: Double Blind Review Editores: Jean Von Hohendorff e Ludgleydson Fernandes de Araújo Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 [Submetido: julho 29, 2020; Revisão: agosto 10, 2020 Aceito: agosto 26, 2020; Publicado: agosto 18, 2021] DOI: https://doi.org/10.18256/2175-5027.2021.v13i1.4236 Como citar este artigo / To cite this article: clique aqui!/click here! 265 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 Abstract Vitiligo is a dermatological disease characterized by the presence of hypopigmented macules on the skin. Considering that its effects are not limited to the biological dimension of the subject, it is assumed negative impacts on the quality of life of their bearers. Yet, little attention has been giving to this phenomenon in Brazilian studies. This research sought to overcome this gap by verifying the relationship between sociodemographic variables of people with Vitiligo, as well as their perceptions of discrimination and severity of the disease in their qualities of life. It is a quantitative study with a descriptive and exploratory nature, in which 200 Brazilians with Vitiligo participated, most of them female (73%), with white skin colour (50.5%) and predominantly residents of Southeast Brazil (31.02%). For data collection, a sociodemographic questionnaire and the Vitiligo-specific health-related quality of life instrument (VitiQoL) scale were used. Results revealed that female participants, with black skin colour, low income and white patches in areas of easy social perception showed worse rates of quality of life. The findings are discussed with pertinent literature, and it is expected that they contribute to the development of public policies aiming to improve the quality of life of Brazilians with Vitiligo. Keywords: Quality of Life, Prejudice, Vitiligo Resumo O Vitiligo é uma doença dermatológica caracterizada pela presença de máculas hipopigmentadas na pele. Considerando-se que seus efeitos não se limitam a dimensão biológica do sujeito, se supõem impactos negativos na qualidade de vida de seus portadores. Nesse contexto, sabendo-se da incipiência de pesquisas brasileiras que busquem entender aspectos alusivos da qualidade de vida deste público, buscou-se no presente estudo verificar a relação entre variáveis sociodemográficas de pessoas com Vitiligo, assim como suas percepções de discriminação e gravidade da afecção em suas qualidades de vida. Trata-se de um estudo quantitativo de cunho descritivo e exploratório, em que participaram 200 brasileiros com Vitiligo, a maioria do sexo feminino (73%), de cor de pele branca (50,5%) e prevalentemente residentes do Sudeste do Brasil (31,02%). Para a coleta de dados, utilizouse um questionário sociodemográfico e a escala Vitiligo-specific health-related quality of life instrument (VitiQoL). Os resultados apontaram que participantes do sexo feminino, de cor de pele negra, de baixa renda e com acromias em áreas de fácil percepção social demonstraram piores índices de qualidade de vida. Discute-se os achados com a literatura pertinente e esperase que os mesmos contribuam para o desenvolvimento de políticas públicas de intervenção junto a brasileiros com Vitiligo. Palavras-chave: Qualidade de Vida, Preconceito, Vitiligo Resumen El Vitíligo es una enfermedad dermatológica caracterizada por la presencia de máculas hipopigmentadas en la piel. Considerando que sus efectos no se limitan a la dimensión biológica del sujeto, se suponen impactos negativos en la calidad de vida de sus pacientes. No obstante, conociendo la incipiente investigación brasileña que busca entender aspectos alusivos a la calidad de vida de este público, este estudio buscó verificar la relación entre las variables sociodemográficas de las personas con vitíligo, sus percepciones de discriminación y la gravedad de la condición en su calidad de vida. Consiste en un estudio cuantitativo de carácter descriptivo y exploratorio, en el que participaron 200 brasileños con vitíligo, la mayoría mujeres (73%), de color blanco (50,5%) y predominantemente residentes del sureste brasileño 266 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 (31,02%). Los datos se recopilaron mediante un cuestionario sociodemográfico y la escala de calidad de vida relacionada con la salud específica para el Vitíligo (VitiQoL). Resultados mostraron que las participantes del sexo femenino, de piel negra, de bajos ingresos y con manchas en áreas de fácil percepción social demostraron peores índices de calidad de vida. Los hallazgos se discuten con la literatura relevante y se espera que contribuyan al desarrollo de políticas de intervención con brasileños con Vitíligo. Palabras clave: Calidad de vida, Preconcepción, Vitíligo Introduction Vitiligo is a chronic dermatological disease, characterized by the presence of hypopigmented and asymptomatic macules caused by the destruction and/or function loss of the melanocytes in the skin. It is estimated, worldwide, that this skin condition may display prevalence of occurrence in approximately 1% of the population. Moreover, different countries as India, Brazil, and United States verify some discrepancy from this percentage (.5% to 4%) (Boniface et al., 2018; Bonotis et al., 2016; Iannella et al., 2016; Sociedade Brasileira de Dermatologia [SBD], 2017). In Brazil, specifically, a study carried out by the Brazilian Society of Dermatology showed that there is some variance in the prevalence of Vitiligo among the regions in the country, having in the MiddleWest (.69%), the Southeast (.66%), and the North (.65%) its highest indices; whereas in the Northeast (.39%), and the South (.40%) the lowest numbers being registered (Sociedade Brasileira de Dermatologia [SBD], 2017). This affection may present itself in any age group and occur, on average, around the age of 20, having no significant difference in prevalence between sexes. Its progression tends to happen in a centrifugal way, as a local or generalized depigmentation (Boza, 2016; Silva et al., 2011). When local, Vitiligo may be focal (presence of one or more acromic macules that envelop a unilateral segment of the body, frequently following the distribution of a dermatome). When it is generalized, the affection may be acrofacial (presence of typical lesions in the distal part of the extremities and face), vulgar (acromic macules randomly distributed) and mixed (acrofacial and vulgar, segmental and acrofacial and/or vulgar) (Do Bú & Coutinho, 2019). Although the etiology of this illness is still not a consensus in the literature, some studies correlate its origin to psychosocial factors from the life of the bearer. Stress, in this regard, has been indicated as one of the main components of these factors as it is also linked to the development of other dermatological afflictions, such as acne, psoriasis, and alopecia areata (Dias et al., 2007; Sant’Anna et al., 2003). Furthermore, starting from the premise that the skin represents a key component of self-confidence, sexual attraction, and the sense of personal satisfaction, being extremely significant for the physical and mental well-being of an individual, it must be highlighted that the pathophysiological alterations in this organ might lead to 267 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 psychological consequences, such as, for instance, stress; which compromises, among other things, the quality of life of people who bear Vitiligo (Parsad et al., 2003). Also, Do Bú et al. (2018) point out that people with Vitiligo assimilate discriminatory and prejudiced situations lived by them (due to the affection) as stress and anxiety amplifier; which, consequently, may incite the Vitiligo progression in return. Consonantly, research on the quality of life and psychological effects of skin diseases in patients points to damages that are linked to self-esteem, body image, and interpersonal relationships (Andrade et al., 2016; Jorge et al., 2004; Neto et al., 2015; Sant’Anna et al., 2003). Damages from self-care behaviour (getting dressed, showering and looking in the mirror) also stand out (Jorge et al., 2004). When it comes, specifically, to studies regarding Vitiligo, reports evince that approximately 75% of the patients with the affliction possess a psychological disorder (Sarkar et al., 2018). In this regard, aspects such as the unpredictability of the course that the affection progresses, its chronicity and the lack of a uniform treatment to everyone with the disease appear as crucial variables for the low indices of quality of life, as well as to hinder the way to deal with the skin condition. Such effects are especially maximised when it comes to black people with Vitiligo and/or when the acromic patches are localized in areas of the body that are readily perceived by the social surroundings of the subject (Bonotis et al., 2016; Rodrigues et al., 2017). Therefore, it is valid to emphasize that, beyond the psychological factors; there are also social and cultural aspects to be taken into consideration in the life experience of people with Vitiligo, such as skin colour, gender, religion and nationality (Simons et al., 2020). This is made important once research shows that such factors may aggravate the psychological impacts of the disease, and, consequently, compromise even further the quality of life of the person who bears it (Bonotis et al., 2016; Parsad et al., 2003; Sangma et al., 2015). Based on what was shown; it becomes evident the potential Vitiligo has to negatively impact the quality of life of its carriers. Given that quality of life is understood as the perception of insertion of a being in its cultural ambience and in the system of values in which they live, its compromise is regarded as worrisome. This is true due to the fact that the former is fundamental to all spheres of life, be it physical, psychological, and social, as well as to personal beliefs and level of independence a person has (Fleck, 2000; The WHOQOL Group, 1995). Even though the pathophysiology of Vitiligo is widely investigated, studies on psychological effects on the afflicted people are still incipient in the international scope and, especially, in the Brazilian scope (Parsad et al., 2003; Sarkar et al., 2018). Consequently, there is a lack of studies on the incidence and the degree quality of life is compromised to the people with Vitiligo in Brazil, prompting an urgent and further development of new studies. Such studies may, besides guiding the practices 268 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 for professionals who deal with patients who bear this skin condition, stimulate the development of health public policies, aiming, among other things, to promote quality of life for this population. On the same topic, considering the aforementioned impacts of the affection, the importance of sociocultural factors to understand the daily experiences of people with Vitiligo, as well as the lack of studies that focus on this; the aim of this study is to verify the relation between socio-demographic variables of people with Vitiligo, their perceptions on social discrimination and the severity of the affliction on their respective qualities of life. Method Type of study and participants This is a quantitative study, with a descriptive and exploratory type; which had a convenience and non-probabilistic sample of 200 Brazilians with Vitiligo. The majority of them were female (73%), white (50.5%), aged between 18 and 28 years (36.5%), had a monthly income from 1 to 2 minimum wages (33.5%), and were residing in the Southeast of Brazil (31.02%). It must be highlighted that the inclusion criteria for the present sample were the following: being over the age of 18; possessing the diagnosis for Vitiligo issued by a dermatologist; and showing availability to participate in the research voluntarily. Instruments for data collection For data collection, initially, with the aid of the Google Forms tool, an online form was created with the following instruments (1) Vitiligo-specific health-related quality of life instrument (VitiQoL); (2) socio-demographic questionnaire. Later, the link to the form was made available in groups that deal with the theme of Vitiligo on a social network (Facebook), over a period of approximately 30 days, in the year of 2018. Attention must be drawn to the fact that these groups are closed to participants who have Vitiligo and that the participation of the researchers was made possible with the authorization of the moderators, but only after the clarification that the aim was to administrate a questionnaire to this specific public. VitiQoL, originally developed by Lilly et al. (2013), was adapted and validated to Brazil by Boza et al. (2015). This instrument possesses 15 items that aim to apprehend 3 factors that connect to the quality of life of the person with Vitiligo, i.e.: Limited Social Participation – LSP (which refers to the participation limitations of the subject in activities of their social environment, for instance, their daily activities); Stigma – STI (which corresponds to the stigma lived by the person in their social environment, for 269 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 instance, the shame); and, finally, Behaviour – BEH (which is linked to the caretaking attitudes the subject has towards its Vitiligo patches, for instance, solar protection of the achromias); answered on a scale that varies from 0 (nothing) to 6 (all the time). It must be highlighted that the internal consistency for each of the scale factors in this current study was .71 (LSP); .78 (STI); .73 (BEHA). It is also imperative to mention that, aside from the items that compose the aforementioned factors, there was, at the end of the questionnaire, a question that inquired the participant over their own perception on the severity of the affection on a scale from 0 (nothing) to 6 (all the time). Regarding the socio-demographic questionnaire, it had the aim to characterize the sample, to do so; it utilized questions to access age, sex, income, education, time since Vitiligo diagnosis, and exposure area of the affection. In order to complement the comprehension of the discriminatory processes that relate to Vitiligo, the following question was added to the end of the socio-demographic questionnaire: how much have you felt discriminated for possessing Vitiligo? The answer scale of this item varied from 0 (nothing) to 6 (profusely). Procedure for data analysis To process the collected data, descriptive analyses were done (average and standard deviation), percentages and confidence interval were set to 95% to characterize the sample. Moreover, inferential statistics were carried out, such as the analysis of variance (ANOVA), analysis of covariance (ANCOVA), and linear correlations (Pearson and Spearman coefficients). All these analyses were carried out using the Statistical Package for Social Science for Windows – IBM SPSS (version 26) software. Ethical aspects The procedures for data collection followed all ethical recommendations laid down for research with human beings (number of the ruling: 2.190.296), in accordance with Resolution n. 510/2016 of the National Council of Brazilian Health (Ministério da Saúde [MS], 2016), in such a way that the participants were informed about the aim of the study and that the participation was voluntary, also that they could give up at any time in case they manifested any discomfort to answer the instruments. When this was done, it was requested that the participants sign the Termo de Consentimento Livre e Esclarecido (Free and Clarified Consent Term) (TCLE), and a copy was sent to their respective emails. 270 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 Results Descriptive analyses Initially, descriptive analyses will be presented generated from the sociodemographic questionnaire that was administered, in order to get to know the profile of the participants, in accordance with the frequency shown in Table 1. In general terms, the investigated sample was majorly composed of women with white skin (53.4%), with income up to 1 minimum wage (31.5%), time with Vitiligo up to 10 years (42.6%), and type of exposition considered readily perceivable in a social ambience (55.6%). Table 1. Sociodemographic characteristics of participants with Vitiligo (N=200). Variable Female (%) Male (%) Skin colour White 53.4 42.6 Black 11.0 11.1 Brown 32.9 42.6 Indigenous 2.7 3.7 Income Until 1 wage 31.5 22.6 From 1 to 2 wages 27.8 35.6 From 2 to 3 wages 20.4 20.5 Higher than 3 wages 20.4 21.2 Time with Vitiligo Until 10 years 42.6 47.9 From 11 to 20 years 33.3 21.9 From 21 to 30 years 13.0 17.1 Higher than 30 years 11.1 13.0 Exposure area Easy perception to the social environment 55.6 43.8 Imperceptible to the social environment 11.1 10.3 Both perception areas (easy and unnoticeable to the social environment) 33.3 45.9 Note: % = Percentage. When it comes to the male sex, it is verified a higher percentage of white-skin (42.6%) and brown-skin (42.6%) males, with income ranging from 1 to 2 minimum wages (35.6%), prevalent time with Vitiligo up to 10 years (47.9%), as well as exposition area of the whitened macules readily perceivable in a social ambience (45.9%). Moving onto the descriptive statistics of each one of the items of VitiQoL, displayed in Table 2, it was obtained, respectively, higher averages regarding Vitiligo progression (item 15, M=4.93; SD=1.99), discomfort (item 1, M=4.65; SD=1.93), frustration (item 2, M=4.59; SD=2.04), and shame (item 7, M=4.19; SD=2.27) for having the illness. All these elements displayed an average above 4.00. 271 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 Table 2. Descriptive Statistics for VitiQoL Items (n = 200). Items MSD CI (95%) 1. Inconvenience 4.65 1.93 4.36 4.92 2. Frustration 4.59 2.04 4.29 4.87 3. Affective Difficulty 2.60 2.55 2.24 2.95 4. Daily Activities 2.17 2.27 1.89 2.51 5. Concern with the thoughts of others 3.68 2.45 3.35 4.02 6. Fear of criticism 3.67 2.43 3.34 4.01 7. Shame 4.19 2.27 3.89 4.50 8. How to dress 2.74 2.60 2.41 3.12 9. Social and leisure activities 2.84 2.43 2.53 3.20 10. Physical well-being 2.91 2.37 2.59 3.25 11. General physical health 2.31 2.24 2.02 2.63 12. Cares with the appearance 2.77 2.53 2.42 3.15 13. Sun protection 3.93 2.31 3.60 4.24 14. New friends 1.56 2.18 1.26 1.86 15. Disease progression 4.93 1.99 4.65 5.22 Note: Scores between 0 and 6; M - average; SD - Standard Deviation; CI (95%) - 95% Confidence Interval. Association among categorical variables (nominal) Aiming to verify if there was any association among the categorical sociodemographic variables of the current study, Pearson’s chi-squared tests were carried out. Among the expected correlations from the pertinent literature, it could be observed that the exposition area of Vitiligo and the perception of severity to having the affection were associated [X² (10) = 19.98; p = .02]. Thus, it was observed that among people who possess Vitiligo that is exposed, the majority (35.5%) pointed to the highest severity degree (6), whereas, in relation to the people that possess both types of exposition (readily spotted and imperceptible in a social ambience), the majority (40%) indicated severity levels of 5 and 6. This all reveals that if the participant has exposed patches or from both categories (readily spotted and imperceptible in a social ambience), they have a superior perception of the severity of having Vitiligo. It is worth mentioning that there was no significant p-value for the following associations: exposition area of Vitiligo and participants’ sex; sex and severity perception of the affliction; as well as exposition area of Vitiligo and time having the affection. 272 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 Figure 1. Association between the Vitiligo exposure and the perception of gravity for having the disorder. Analysis of Variance and Analysis of Covariance Aiming to compare the averages for quality of life from VitiQoL in accordance with the socio-demographic variables from the participants of the current study, the analysis of variance (ANOVA) and analyses of covariance (ANCOVA) were carried out. These results may be visualized in Table 3. From ANCOVA, the factors for quality of life that relate to the socio-demographic variables were compared, keeping the effect of the other related variables under control. As a result, it was verified the statistically meaningful difference in the LSP factor when it comes to the income of the participants [F (3.195) = 2.67; p = .048]; when the effect of education level was controlled. Tukey’s post hoc test evinced that people who have a lower income feel more socially limited when compared to people with a greater one, i.e., between 3 and 4 minimum wages (p = .03) and above 4 salaries (p = .012). 279 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 Vitiligo towards people with Vitiligo; to verify aspects connected to self-esteem, selfconcept and the quality of life of people with Vitiligo; to explore a possible relation between the variables of being the carrier of Vitiligo and stress; to identify if there are variations in the perception of discrimination of people with Vitiligo according to the type of social environment; as well as to know confrontational strategies utilized by people with Vitiligo against the perceived discrimination. 280 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 References AlGhamdi, M. K., Moussa, N. A., AlKofidi, A. M., Madani, A., AlDaham, N., & AlKamel, A. A. (2012). Public Perceptions and Attitudes Toward Vitiligo. Journal of Cutaneous Medicine and Surgery, 16(5), 334-340. doi: https://doi.org/10.1177/120347541201600510 Andrade R. R., Coelho, A.B., Pinto, J. M. D. (2016). Avaliação do paciente com vitiligo frente às representações sociais acerca da doença. Revista UNILUS Ensino e Pesquisa - RUEP, 13(13), 58–62. Retrieved from http://revista.unilus.edu.br/index.php/ruep/article/ view/735 Boniface, K., Seneschal, J., Picardo, M., & Taïeb, A. (2018). Vitiligo: Focus on Clinical Aspects, Immunopathogenesis, and Therapy. Clinical Reviews in Allergy and Immunology, 54(1), 52–67. doi: https://doi.org/10.1007/s12016-017-8622-7 Bonotis, K., Pantelis, K., Karaoulanis, S. Katsimaglis, C., Papaliaga, M., Zafirious E., & Tsogas, P. (2016). Investigations of factors associated with health-related quality of life and psychological distress in vitiligo. Journal der Deutschen Dermatologischen Gesellschaft, 14(1), 45-9. doi: https://doi.org/10.1111/ddg.12729 Boza, J. C., Kundu, R. V., Fabbrin, A., Horn, R., Giongo, N., & Cestari, T. F. (2015). Translation, cross-cultural adaptation and validation of the vitiligo-specific health-related quality of life instrument (VitiQoL) into Brazilian Portuguese. Anais Brasileiros de Dermatologia, 90(3), 358-362. doi: https://doi.org/10.1590/abd1806-4841.20153684 Boza, J. C. (2016). Qualidade de vida em pacientes adultos e pediátricos com vitiligo:estudo baseado em questionários de qualidade de vida genéricos e específicos. Tese. Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brasil. Retrieved from https://lume.ufrgs.br/handle/10183/143643 Dias, H. Z. J., Rubin, R., Dias, A. V., & Gauer, G. J. C. (2007). Relações visíveis entre pele e psiquísmo: um entendimento psicanalítico. Psicologia Clínica, 19(2), 23-34. doi: https:// doi.org/10.1590/S0103-56652007000200002 Do Bú, E. A., Alexandre, M. E. S, Scardua, A., & Araújo, C. R. F. (2018). Vitiligo as a psychosocial disease: apprehensions of patients imprinted by the white. Interface - Comunicação, Saúde, Educação, 22(65), 481-491. doi: https://doi.org/10.1590/180757622016.0925 Do Bú, E. A., & Coutinho, M. P. L. (2019). Representational structure of Vitiligo: nonRestrictive Skin Marks. Trends in Psychology, 27(3), 615-629. doi: https://doi.org/10.9788/ TP2019.3-02 Fleck, M. P. A. (2000). O instrumento de avaliação de qualidade de vida da Organização Mundial da Saúde (WHOQOL-100): características e perspectivas. Ciência & Saúde Coletiva, 5(1), 33-38. doi: https://doi.org/10.1590/S141381232000000100004 Gupta, M. A., & Voorhees, J. J. (1990). Psychosomatic dermatology: is it relevant? Arch Dermatol, 126(1), 90-93. doi: https://doi.org/10.1001/archderm.1990.01670250096016 281 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 Iannella, G., Greco, A., Didona, D., Didona, B., Granata, G., Manno, A., …& Magliulo, G. (2016). Vitiligo: Pathogenesis, clinical variants and treatment approaches. Autoimmunity Reviews, 15(4), 335–343. doi: https://doi.org/10.1016/j.autrev.2015.12.006 Jorge, H. Z., Müller, M. C., Ferreira, V. R. T., & Cassal, C. (2004). Pacientes portadores de dermatoses: relações iniciais e auto-agressividade. PSIC, 5(2), 22-25. Retrieved from http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1676-73142004000200004 Karelson, M., Silm, H., & Kingo, K. (2013). Quality of Life and Emotional State in Vitiligo in an Estonian Sample: Comparison with Psoriasis and Healthy Controls. Acta Dermo Venereol, 93(4), 446-450. doi: https://doi.org/10.2340/00015555-1520 Lilly, E., Lu, P. D., Borovicka, J. H., Victorson, D., Kwasny, M. J., West, D. P., & Kundu, R. V. (2013). Development and validation of a vitiligo-specific quality-of-life instrument (VitiQoL). Journal of the American Academy of Dermatology, 69(1), e11-e18. doi: https:// doi.org/10.1016/j.jaad.2012.01.038 Ministério da Saúde. (Brasil). (2017). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Diário Oficial da União. Brasília: MS. Retrieved from https://bvsms.saude.gov.br/bvs/ publicacoes/vigitel_brasil_2017_vigilancia_fatores_riscos.pdf Ministério da Saúde. (Brasil). (2016). Resolução nº 510, de 7 de abril de 2016. Estabelece as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União. Brasília: MS. Retrieved from http://www.in.gov.br/materia/-/asset_ publisher/Kujrw0TZC2Mb/content/id/22917581 Morales-Sánchez, M. A., Vargas-Salinas, M., Peralta-Pedrero, M. L., Olguín-García, M. G., & Jurado-Santana, F. C. (2017). Impact of Vitiligo on Quality of Life. Actas Dermosifiliorg, 108(7), 637-642. doi: https://doi.org/10.1016/j.ad.2017.03.007 Neto, A. T. M., Silva, V. S., Rodrigues, M. D., & Pinto, F. O. (2015). Vitiligo: O Problema Que Não Está Apenas Na Pele. Reinpec, 1(2), 250–288. doi: https://doi.org/10.20951/24466778/v1n2a18 Parsad, D., Dogra, S., & Kanwar, A. J. (2003). Quality of life in pacients with vitiligo. Health and Quality of Life Outcomes, 1(1), 58. doi: https://doi.org/10.1186/1477-7525-1-58 Porter, R. J., & Beuf, A. H. (1988). Response of older people impaired appearance: the effect of age on disturbance by Vitiligo. Journal of Aging Studies, 2(2), 167-181. doi: https://doi. org/10.1016/0890-4065(88)90031-X Rodrigues, M., Ezzedine, K., Hamzavi, I., Pandya, A. G., & Harris, J. E. (2017). New discoveries in the pathogenesis and classification of vitiligo. Journal of the American Academy of Dermatology, 77(1), 1–13. doi: https://doi.org/10.1016/j.jaad.2016.10.048 Sangma, L. N., Nath, J., & Bhagabati, D. (2015). Quality of life and psychological morbidity in vitiligo pacients: a study in a teaching hospital from North-East India. Indian Journal of Dermatology, 60(2), 142-6. doi: https://doi.org/10.4103/0019 5154.152508 282 Revista de Psicologia da IMED, Passo Fundo, vol. 13, n. 1, p. 264-282, janeiro-junho, 2021 - ISSN 2175-5027 Sant’Anna, P. A., Giovanetti, R. M., Castanho, A. G., Bazhuni, N. F. N., & La Selva, V. A. (2003). A expressão de conflitos psíquicos em afecções dermatológicas: um estudo de caso de uma paciente com vitiligo atendida com o jogo de areia. Psicologia: Teoria e Prática, 5(1), 81-96. Retrieved from http://editorarevistas.mackenzie.br/index.php/ptp/ article/view/1183 Sarkar, S., Sarkar, T., Sarkar, A., & Das, S. (2018). Vitiligo and psychiatric morbidity: a profile from a vitiligo clinic of a rural-based tertiary care center of eastern India. Indian Journal of Dermatology, 63(4), 281-284. doi: https://doi.org/10.4103/ijd.IJD_142_18 Shah, M., & Coates, M. (2006). An assessment of the quality of life in older patients with skin disease. British Association of Dermatologists, 154, 150-3. doi: https://doi.org/10.1111/ j.1365-2133.2005.06959.x Silva, A., Castoldi, L., & Kijner, L. C. (2011). A pele expressando o afeto: Uma intervenção grupal com pacientes portadores de psicodermatoses. Contextos Clínicos, 4(1), 53-63. doi: https://doi.org/10.4013/ctc.2011.41.06 Silverberg, N. B. (2015). The Epidemiology of Vitiligo. Current Dermatology Reports, 4(1), 3643. doi: https://doi.org/10.1007/s13671-014-0098-6 Simons, R. E., Zevy, L. D., & Jafferany, M. (2020). Psychodermatology of Vitiligo: Psychological impact and consequences. Dermatologic Therapy, 33(3). doi: https://doi.org/10.1111/ dth.13418 Sociedade Brasileira de Dermatologia. (2017). Sociedade Brasileira De Dermatologia Alerta A População A Procurar Um Dermatologista Sempre Que Perceber Alguma Mancha Branca Na Pele. Rio de Janeiro: SBD. Retrieved from http://www.sbd.org.br/noticias/25-dejunho-dia-mundial-do-vitiligo The WHOQOL Group. (1995). The World Health Organization of life assessment (WHOQOL): position paper from the World Health Organization. Social Science and Medicine, 41(10), 1403-1409. doi: https://doi.org/10.1016/0277-9536(95)00112-K Wong, S., & Baba, R. (2012). Quality of life among Malaysian patients with vitiligo. Journal International of Dermatology, 51, 158–161. doi: https://doi.org/10.1111/j.13654632.2011.04932.x