Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Brief Report
87 (
3
); 375-378
doi:
10.4103/ijdvl.IJDVL_276_18
pmid:
31464197

Family dermatology life quality index in patients with pemphigus vulgaris: A cross-sectional study

Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
Department of Dermatology, Shahid Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran

Corresponding author: Dr. Farhad Handjani, Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Zip code: 71348-46114, Shiraz, Iran. hanjanif@yahoo.com

Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Sajedianfard S, Handjani F, Saki N, Heiran A. Family dermatology life quality index in patients with pemphigus vulgaris: A cross-sectional study. Indian J Dermatol Venereol Leprol 2021;87:375-8.

Abstract

Background and Aims:

Pemphigus vulgaris is a rare autoimmune intraepidermal vesiculobullous disease involving the skin and mucosa. It impacts the quality of life of both patients and their families.

Methods:

A total of 70 patients with pemphigus vulgaris (either outpatient or hospitalized) were enrolled using the simple sampling method between 2016 and 2017 from the dermatology clinic at Faghihi Hospital, Shiraz, Iran. A validated Persian version of the Family Dermatology Life Quality Index (FLDQI) questionnaire was filled by a family caregiver. The questionnaire contained 10 items assessing the quality of life of the family. Demographic variables were recorded in a separate form.

Results:

The mean age of the patients was 51 ± 11.3 years and that of the family caregivers was 32 ± 8.8 years. The FLDQI score was higher (poorer quality of life) if the patient was male, older, had shorter disease duration or had fewer disease recurrences (P = 0.046, 0.01, 0.001 and >0.001, respectively). Higher scores were also obtained in the less-educated caregivers (P = 0.026) but there was no association with either gender or age (P = 0.399, 0.1).

Conclusion:

Pemphigus vulgaris significantly affects the Family Dermatology Life Quality Index. Education and counseling of family caregivers by various support groups such as Pemphigus Family Associations could be effective in improving the quality of life of the caregivers.

Limitations:

This study did not assess the effect of comprising domain analysis, severity of disease, patients’ Dermatology Life Quality Index (DLQI), mucosal involvement, response to treatment, outpatient or admitted status, socioeconomic status, or the quality of life among the various family members.

Keywords

Caregivers
family dermatology life quality index
pemphigus vulgaris

Introduction

Pemphigus vulgaris is a rare autoimmune intraepidermal vesiculobullous disease affecting the skin and mucosa most often in the sixth decade of life.1,2 Immunoglobulin G autoantibodies targeting desmoglein 1 and 3 cell adhesion molecules are linked to its pathogenesis.3-8 The disease is rare, with an estimated global incidence of 0.076:100,000 and a male–female ratio of 1:1.1–2.25.7,9,10

Owing both to the nature of the disease and the prolonged treatment that it entails, pemphigus vulgaris gravely impacts the quality of life (QOL) of the patient.11 It also affects the QOL of the caregivers and family and this further negatively impacts patient care. Most studies have assessed the QOL of the patients but not of the caregivers or the families. A number of tools have been developed for assessing the QOL of caregivers of patients with chronic dermatologic diseases.12,13 In view of the importance of the QOL of caregivers and the family and its influence on patient management,14-19 we studied the impact of pemphigus on the Family Dermatology Life Quality Index (FDLQI).

Methods

This cross-sectional study was conducted among patients referred to the dermatology clinic in Faghihi Hospital, Shiraz, Iran between 2016 and 2017. The study was approved by the Ethics Committee of Shiraz University of Medical Sciences (code: 94-01-01-9758). All the patients and their caregivers gave written informed consent.

Seventy patients (outpatient or hospitalized, significant difference = 1.5; standard deviation = 6.4; α = 0.05; 1−β = 0.9) with pemphigus vulgaris were selected by the simple sampling method and their caregivers were enlisted for the study. All patients were diagnosed clinically by a dermatologist, and the diagnosis was confirmed by skin biopsy. A physician confirmed that the selected patients did not suffer from any other health conditions that could affect the quality of life, by history and face-to-face interview.

Family caregivers enrolled for the study were usually first-degrees relative aged 18 years or more. Most patients had a single caregiver; however in the event of multiple caregivers, one of them was randomly selected for the study. The study objectives were carefully explained to each caregiver.

A validated Persian version of the FDLQI questionnaire was filled by the family caregiver. The questionnaire contained 10 items assessing the QOL of the family.20,21 The scores for each question ranged from 0 to 3 and the total score was the sum of the scores for the 10 questions. Demographic variables were recorded in a separate form.

The Statistical Package for the Social Sciences software (IBM Corp., released in 2013; IBM SPSS Statistics for Windows, version 22.0, Armonk, NY; IBM Corp.) was used for statistical analysis. After checking the normality by Kolmogorov–Smirnov’s test, the mean ± standard deviation or median (interquartile range) was reported. Independent t-test (or Wilcoxon rank-sum test), one-way analysis of variance (or Kruskal–Wallis test) and Pearson’s correlation r were used. P ≤ 0.05 was considered as statistically significant.

Results

The questionnaire was completed by all 70 caregivers. Their ages ranged from 18 to 53 years (mean 32 ± 8.8 years). No correlation was observed between the age of the caregivers and the total scores (P = 0.1, Pearson’s correlation r = 0.198). Demographic and clinical features of the patients and caregivers are shown in Tables 1 and 2. Pemphigus had a moderate to severe impact on the QOL of the caregivers with 39 (55.7%) caregivers scoring 10–20 and 18 (25.7%) caregivers scoring >20. Caregivers often suffered from emotional distress and depression, but other domains of QOL were also affected including time spent on looking after the patient, physical wellbeing such as sleep and rest, recreation and leisure activities, and extra house-work. Caregivers were less affected by issues such as staying away from job or study, reduction in work hours, peoples’ reactions to the patient, social life problems, household expenditures and disruption of family relationships.

Table 1: Demographic and clinical features of the pemphigus patients in the study
Variable n (%) Mean score obtained by family caregiver±SD P
Sex
Male 30 (42.9) 18±8.6 0.046a
Female 40 (57.1) 14.4±6.5
Age 51±11.3 16.7±7 0.01 (0.305)b
Disease duration
<1 month 25 (35.7) 20.56±7 0.001c
1-12 months 20 (28.6) 14.7±25.2
1-5 years 14 (20) 13.5±7.2
>5 years 11 (15.7) 11.55±5.3
Recurrence episodes
1 28 (40) 19.5±7.4 <0.001 (−0.494)b
2 21 (30) 16.2±7.6
3 13 (18.6) 12.1±4.5
4 2 (2.8) 15.5±3.5
5 6 (8.6) 6.7±4.9
Medications
Prednisolone 70 (100) - -
Azathioprine 58 (82.9) 15.7±8 vs. 16.9±5.8e 0.554d
Cyclosporine 6 (8.6) 18.8±9 vs. 15.7±7.6 0.436d
Rituximab 0 - -
Wilcoxon rank-sum test, bPearson’s correlation r, cKruskal-Wallis, dIndependent t-test, eMedication positive vs. medication negative. SD: Standard deviation
Table 2: Demographic features of the family caregivers
Features n (%) Mean score±SD P
Gender
Male 23 (32.9) 17±8.6 0.399a
Female 47 (67.1) 15.7±4.2
Age (years) 32±8.8 16±7.7 0.1 (0.198)b
Relationship
Spouse 14 (20) 20±8.2 0.0005c
Child 38 (54.3) 17.1±7.3
Sibling 18 (25.7) 10.4±4.8
Educational level
Below high school diploma 20 (28.6) 19.9±7 0.026c
High school diploma 34 (48.5) 13.8±6.8
Bachelor `s degree 13 (18.6) 14.6±8.7
Master`s degree and higher 3 (4.3) 19±9.6
Independent t-test, bPearson’s correlation r, cKruskal-Wallis. SD: Standard deviation

Spouses had higher scores (poorer QOL) as compared to other relatives (P = 0.0005). Twenty of the family caregivers were poorly educated (illiterate and under high school diploma) and 50 were well educated (high school diploma and above) - a poorer QOL was seen in the the less educated caregivers (19.9 ± 7 vs. 14.3 ± 7.3;P = 0.005). There was no significant difference between the genders (17 ± 8.6 vs. 15.7 ± 4.2;P = 0.399) [Table 2], but a poorer quality of life was noted in caregivers of male patients (18 ± 8.6 vs. 14.4 ± 6.5;P = 0.046) and older patients (P = 0.01, Pearson’s r = 0.305).

All patients were treated with prednisolone and none of them had received rituximab. The FDLQI was not influenced by the type of adjuvant used: azathioprine (15.7 ± 8 vs. 16.9 ± 5.8;P = 0.554) or cyclosporine (18.8 ± 9 vs. 15.7 ± 7.6;P = 0.436). The duration of the disease (2 ± 2.7 years) was negatively correlated with scores (P = 0.001) i.e. a lower impact on the FDLQI was seen in caregivers of patients with a shorter disease duration. The impact on quality of life was less in caregivers of patients with more frequent recurrences (P < 0.001, Pearson’s r = −0.494) [Table 1].

Discussion

Chronic diseases can affect many aspects of the quality of life of both patients and their families including their social, mental and physical health, living expenses, time spent with the patient and issues related to job or studies.16,21-26

In the present study, the most affected aspects of the quality of life of caregivers were emotional distress and depression, time spent on looking after the patient, physical wellbeing such as sleep and rest, recreation and leisure activities, and extra house-work. The least affected domains were staying away from job or study, working-hour reduction, peoples’ reactions to the patient, social life problems, household expenditures and disruption of family relationships. However, in atopic dermatitis and epidermolysis bullosa household expenditure and leisure time were most affected,26-28 while in caregivers of psoriatic patients major concerns were the impact on job and reduced working hours.24 Higher divorce rates were also seen in the families of children with atopic dermatitis, but the family quality of life was better in daughters.29 Caregivers of patients with multiple sclerosis believed that the disease had a negative impact on intra-family relationships including tension and decreasing mutual understanding.30

We found that caregivers of male patients were more dissatisfied which may be due to the nature of the disease, patients’ responsibilities to the family (especially household expenditure) and local culture.29,31 Spouses were more impacted as compared to other relatives, possibly due to a higher burden on the spouse to manage the responsibilities which the patients could no longer handle. Higher levels of education were directly linked to a better quality of life - the more educated caregiver may be able to understand the disease better and thus cope better; the higher income of these caregivers may also translate into improved care and facilities.

Decreased caregivers scores were observed with longer disease duration and more recurrences. The shock of being diagnosed with a dreaded chronic disease, initial denial, and subsequent acceptance and adjustment to the illness may also explain this observation. It is likely that with time both patient and caregiver learn to cope with the chronicity of the disease and return to a near normal life.

Limitations of our study include the fact that we did not assess such factors as the quality of life in different family members or the effects of socioeconomic status. These will be addressed in future studies by interviewing more than one caregiver. Several variables comprising domain analysis, severity of disease, patients’ DLQI, mucosal involvement, response to treatment and outpatient or admitted status could be evaluated to define the family caregiver score, in more detail.

Conclusion

We studied the FDLQI among patients with pemphigus vulgaris and found significant impact on the QOL of the caregivers. Pemphigus family associations and support groups may be encouraged to step up support and educate family caregivers regarding the disease in order to improve the quality of life of both caregivers and patients.

Acknowledgment

The present article was extracted from the medical thesis written by Dr. Sarvin Sajedianfard, which was financially supported by Shiraz University of Medical Sciences (grant no. 9758).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was financially supported by Shiraz University of Medical Sciences (grant No. 9758).

Conflicts of interest

There are no conflicts of interest.

References

  1. , , , , . Molecular diagnosis in autoimmune skin blistering conditions. Curr Mol Med. 2014;14:69-95.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , , , , et al. Prediction of survival for patients with pemphigus vulgaris and pemphigus foliaceus: A retrospective cohort study. Orphanet J Rare Dis. 2015;10:48.
    [CrossRef] [PubMed] [Google Scholar]
  3. . Bullous skin diseases: Classical types of autoimmune diseases. Scientifica (Cairo). 2013;2013:457982.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , , , , et al. Autoimmune bullous diseases the spectrum of infectious agent antibodies and review of the literature. Autoimmun Rev. 2011;10:527-35.
    [CrossRef] [PubMed] [Google Scholar]
  5. , . Modern diagnosis of autoimmune blistering skin diseases. Autoimmun Rev. 2010;10:84-9.
    [CrossRef] [PubMed] [Google Scholar]
  6. , . Autoimmune blistering diseases of the skin. Autoimmun Rev. 2012;11:226-30.
    [CrossRef] [PubMed] [Google Scholar]
  7. , , . Pemphigus. Dent Clin North Am. 2013;57:597-610.
    [CrossRef] [PubMed] [Google Scholar]
  8. , , . Autoantibodies against a novel epithelial cadherin in pemphigus vulgaris, a disease of cell adhesion. Cell. 1991;67:869-77.
    [CrossRef] [Google Scholar]
  9. , , , , , , et al. A globally available internet-based patient survey of pemphigus vulgaris: Epidemiology and disease characteristics. Dermatol Clin. 2011;29:393-404, vii-iii
    [CrossRef] [PubMed] [Google Scholar]
  10. , , , , , , et al. Population-specific association between a polymorphic variant in ST18, encoding a pro-apoptotic molecule, and pemphigus vulgaris. J Invest Dermatol. 2012;132:1798-805.
    [CrossRef] [PubMed] [Google Scholar]
  11. , , , , . Quality of life and psychological status of patients with pemphigus vulgaris using dermatology life quality index and general health questionnaires. J Dermatol. 2012;39:141-4.
    [CrossRef] [PubMed] [Google Scholar]
  12. , , . Kaplan and Sadock's Comprehensive Textbook of Psychiatry. . 2017;2
    [Google Scholar]
  13. , , . Psychiatry: An Oxford Core Text (Oxford Core Texts) (3rd ed). Oxford: Oxford University Press; .
    [Google Scholar]
  14. , , , . Measurement of family impact of skin disease: Further validation of the family dermatology life quality index (FDLQI) J Eur Acad Dermatol Venereol. 2008;22:813-21.
    [CrossRef] [PubMed] [Google Scholar]
  15. , , . The family dermatology life quality index: Measuring the secondary impact of skin disease. Br J Dermatol. 2007;156:528-38.
    [CrossRef] [PubMed] [Google Scholar]
  16. , , . Quality of life: Impact of chronic illness on the partner. J R Soc Med. 2001;94:563-6.
    [CrossRef] [PubMed] [Google Scholar]
  17. , , , . The impact of disease on family members: A critical aspect of medical care. J R Soc Med. 2013;106:399-407.
    [CrossRef] [PubMed] [Google Scholar]
  18. , . The effect of chronic illness on the psychological health of family members. J Ment Health Policy Econ. 2003;6:13-22.
    [Google Scholar]
  19. , , , . The impact of patients' chronic disease on family quality of life: An experience from 26 specialties. Int J Gen Med. 2013;6:787-98.
    [CrossRef] [PubMed] [Google Scholar]
  20. , , , , . Preliminary reliability and validity of Persian version of the family dermatology life quality index (FDLQI) Qual Life Res. 2014;23:869-75.
    [CrossRef] [PubMed] [Google Scholar]
  21. , . Impact of dermatological diseases on family members of the patients using family dermatology life quality index: A preliminary study in Iran. Iran J Dermatol. 2013;16:128-31.
    [Google Scholar]
  22. . Results of quality of life research in chronic psychiatric patients. Psychiatr Pra×1993;. ;20:88-90.
    [Google Scholar]
  23. , . The family impact of skin diseases: The greater patient concept. Br J Dermatol. 2007;156:929-37.
    [CrossRef] [PubMed] [Google Scholar]
  24. , , . Psoriasis has a major secondary impact on the lives of family members and partners. Br J Dermatol. 2007;156:1245-50.
    [CrossRef] [PubMed] [Google Scholar]
  25. , , , , , . Family quality of life: A qualitative inquiry. Ment Retard. 2003;41:313-28.
    [CrossRef] [Google Scholar]
  26. , , , , , . The evaluation of family impact of recessive dystrophic epidermolysis bullosa using the Italian version of the family dermatology life quality index. J Eur Acad Dermatol Venereol. 2013;27:1151-5.
    [CrossRef] [PubMed] [Google Scholar]
  27. , . Impairment quality of life in families of children with atopic dermatitis. Acta Dermatovenerol Croat. 2010;18:243-7.
    [Google Scholar]
  28. . The impact of childhood atopic dermatitis on the patients' family. Pediatr Dermatol. 2010;27:618-23.
    [CrossRef] [PubMed] [Google Scholar]
  29. , , , , , , et al. The relationship between child and adolescent atopic dermatitis, attachment and the quality of parental life. Korean J Dermatol. 2008;46:1457-62.
    [Google Scholar]
  30. , , . Advanced multiple sclerosis and the psychosocial impact on families. Psychol Health. 2011;26:113-27.
    [CrossRef] [PubMed] [Google Scholar]
  31. , , , , , . Family quality of life among families of children with atopic dermatitis. Asia Pac Allergy. 2016;6:213-9.
    [CrossRef] [PubMed] [Google Scholar]
Show Sections