Author’s Reply

Cultural adaptation and contextual validity of FDLQI in Indian setting

The concern regarding the cultural adaptation of the Family Dermatology Life Quality Index (FDLQI) in India² is valid. While formal cultural validation was not performed, using translated and validated Hindi and English versions ensured linguistic relevance. The tool captures broad domains such as emotional burden, time spent on care, and family functioning—constructs that are globally relevant. Furthermore, similar domain-level findings across studies from Turkey and Australia suggest cross-cultural applicability. Nonetheless, we recognise this as a limitation.^3,4

Cross-Sectional design and causal interpretations

We acknowledge that our cross-sectional design limits causal inference. Associations, such as between joint involvement and self-consciousness (χ²=11.07, p=0.01) and between Psoriasis Area and Severity Index (PASI), Children’s Dermatology Life Quality Index (CDLQI), and FDLQI (rs=0.549 and 0.609, p=0.001), highlight a meaningful pattern. The strong correlation between CDLQI and FDLQI (rs=0.790, p<0.001) reflects shared burden in children and caregivers. Though longitudinal or comparator-group studies would better establish causality, our design provides valuable initial insights into paediatric psoriasis in India.

Disconnect between disease severity and QoL impact

The disconnect between mild-to-moderate disease severity (median PASI-3.4) and high caregiver burden (FDLQI: 96.1% affected; 25.4% with extremely large effect) reflects the stronger influence of psychosocial and socioeconomic factors over clinical severity alone. Significant associations with catastrophic health expenditure (Catastrophic Health Expenditure (CHE); 40.1%, p=0.014), treatment expense (rs=0.483, p=0.000), and exposed site involvement (p=0.003) underscore the impact of financial strain and stigma.^4,5

Although caregiver income and literacy were not included in the regression, caregiver education and occupation were reported [Table 1], and treatment expense—a direct proxy for financial strain—was a significant predictor (p=0.031). Income was self-reported, a standard practice in low-resource settings, and the study provides essential context with median income (₹2,40,000) and treatment costs (₹18,500), illustrating financial vulnerability.

Arbitrary categorisation of treatment response

Treatment response was categorised as “minimal,” “moderate,” or “good” based on patient report. While this lacks standardisation, it captures patient-perceived improvement, highly relevant to quality of life. Although it may introduce misclassification bias, patient-reported outcomes are increasingly recognised for reflecting the lived experience, especially in real-world settings.⁶

Lack of formal mental health screening for caregivers

Given the high emotional burden FDLQI score (mean 1.75±0.88, median-2), incorporating a separate mental health screening tool would be ideal, but we explicitly state this as a limitation of our study. However, the FDLQI is a validated tool designed to assess emotional and psychosocial impacts, and its emotional domain effectively captures caregiver distress, as evidenced by 95% of caregivers reporting impairment.⁷ The significant correlation between FDLQI and CDLQI (rs=0.790, p=0.001) reinforces its utility in identifying caregiver burden. We agree that future studies should incorporate formal tools like Patient Health Questionnaire (PHQ-9) or General Anxiety Disorder questionnaire (GAD-7) to more comprehensively assess psychological distress.

We thank the authors for their keen interest in our work and for highlighting areas that deserve further attention. We hope our study will further stimulate researchers to explore psychosocial aspects of childhood psoriasis and its impact on their care-givers.