New Patient Assessment on Stigmatization of Visible Skin Conditions is Validated

Khaled Ezzedine, EpidermE, Université Paris-Est Créteil (UPEC), Department of Dermatology, Henri Mondor University Hospital, AP-HP, and investigators conducted a study to find an effective way to evaluate stigmatization in individuals with visible skin conditions. Because the skin is a primary aspect of one’s physical appearance, it plays an important role in the establishment of interpersonal relationships.

Skin conditions are commonly dismissed as cosmetic issues, even though they affect a quarter of the global population and are a major cause of disability, according to investigators. Visible skin disorders can have profound impacts on an individual even if the condition is mild.

Changes in skin color or appearance not only have a long-lasting history of misconception, but the reactions and behavior changes from others can cause social exclusion and isolation—and additional burden beyond the physical. To be able to measure the impact of these characterizations of stigma, the team developed a dermatologic-specific questionnaire.

Understanding the Stigma of Skin Conditions

After investigators initiated a literature search on PubMed, a verbatim report collected the items to be included on the questionnaire based on qualitative interviews with patients who live with various dermatologic conditions. A study was then implemented for psychometric analysis of the Patient Unique Stigmatization Holistic tool in Dermatology (PUSH-D).

Refinement of the dermatology-specific stigmatization questionnaire consisted of item reduction according to inter-question correlations, consensus among experts and exploratory factor analysis. The PUSH-D questionnaire started with a primary list of 22 items and reduced to 17.

For validation, investigators calculated Cronbach’s alpha for internal consistency, and then the correlation between PUSH-D and the Dermatology Life Quality Index (DLQI) and the Rosenberg Self-Esteem Scale (RSES) for concurrent validity.

New Dermatology-Specific Stimatization Questionnaire is Validated

According to the study analyses, the PUSH-D questionnaire provides a comprehensive perspective on the stigmatization of visible skin disorders.Additionally, the questionnaire demonstrated the ability to compare degrees of stigmatization across various dermatologic conditions.

The study population during the development and validation phase included a total of 2620 patients (57% women) with a mean age of 45.14 years. The self-reported disease severity was mostly low (42.9%) and moderate (44.9%), with 9.7% reporting high severity. The skin conditions included were atopic dermatitis/eczema, psoriasis, acne, rosacea, hair loss, skin aging, visible facial scar, and vitiligo.

Based on the exploratory factor analysis, the 17-item questionnaire covers 2 relevant dimensions related to “felt stigma” and “enacted stigma”. The results displayed construct validity and PUSH-D revealed reliable internal consistency. The correlation between PUSH-D and the DLQI was strong and the relationship with the RSES was moderate.

“Dermatology specific instrument such as PUSH-D is necessary to compare the stigmatization level across various skin conditions,” investigators wrote. “It can, of course, be further supplemented with a disease-specific instrument for more in-depth analysis of QOL and stigmatization. It is worth mentioning that PUSH-D is a dermatology specific instrument which is not limited to visible dermatologic diseases only, but also includes visible skin conditions such as facial scars and skin aging which are both highly stigmatized.”

According to the team, there were previously no adequately validated instruments available to assess stigmatization in this specific population.

“This report provides support for PUSH-D's feasibility, reliability and validity as a specific instrument designed to assess stigmatization in visible skin conditions. With its 17 items and six possible answers for each, this questionnaire is relatively short, understandable, and easy-to-use by patients,” investigators stated.

The study, “Patient Unique Stigmatization Holistic tool in dermatology (PUSH-D): Development and validation of a dermatology-specific stigmatization assessment tool” was published in Eur Acad Dermatol Venereol.