Response to assessing the impact of childhood and adolescent chronic plaque psoriasis on parents/caregivers using the family dermatology life quality index (FDLQI)

Dear Editor,

We read with great interest the recent article by Bhandari et al., exploring the impact of childhood psoriasis on caregivers using the Family Dermatology Life Quality Index (FDLQI).¹ The authors deserve commendation for addressing a topic of clinical and public health importance that has received limited attention in low- and middle-income country settings. That said, we would like to offer a few observations and concerns regarding certain methodological and interpretive aspects of the study.

First, while the authors employ the FDLQI as a primary outcome measure, the cultural adaptation and contextual validity of this instrument in Indian settings remain unclear.² The FDLQI, developed in the UK, reflects family structures and emotional frameworks that may not directly align with caregiving norms in India. In the absence of formal cultural validation, linguistic translation alone may not adequately capture the nuances of caregiver burden in India. Other studies have highlighted the importance of adapting dermatology-specific quality-of-life instruments for local sociocultural environments before deploying them at scale.²

Second, we noted that the study’s cross-sectional design was sometimes interpreted in causal terms. For example, the authors assert that childhood psoriasis negatively impacts caregivers and that joint involvement makes children more self-conscious. These are plausible but unproven statements. Without a comparator, it is difficult to establish whether the observed FDLQI scores are psoriasis-specific or reflect a broader phenomenon of caregiving stress in chronic paediatric illness. Moreover, the absence of formal psychological assessments in children or caregivers limits the depth of these conclusions.

Another area requiring careful interpretation is the apparent disconnect between disease severity and quality-of-life impact. The median Psoriasis Area and Severity Index (PASI) score of 3.4 indicates mild-moderate disease, yet over 96% of caregivers reported impaired FDLQI scores, with 25% experiencing extremely large effects. While this may reflect heightened caregiving strain, it also suggests that psychosocial or socioeconomic factors may be playing a larger role than the clinical burden alone. It is therefore surprising that variables such as caregiver income, education, or healthcare literacy were not included in the multivariable model. The authors report that 40% of families experienced catastrophic health expenditure (CHE), defined as treatment costs exceeding 10% of annual income. This is a striking statistic, particularly in a setting where most healthcare expenses are out-of-pocket. The manuscript does not clarify whether income was self-reported or verified, nor does it explore which treatments (e.g., biologics vs. conventional systemic therapy) contributed most to this burden. Prior studies from India suggest that CHE in dermatology is highly sensitive to insurance coverage, polypharmacy, and referral pathways.³ A more detailed financial analysis would therefore have added valuable insight to this observation.

We also noted that treatment response was categorised into “minimal,” “moderate,” and “good” levels based on patient reports, without use of standardised outcome scales such as the Physician Global Assessment or validated satisfaction scores. This arbitrary stratification may have introduced misclassification bias, particularly in regression analyses examining QoL correlates.

Finally, the highest scoring domain of the FDLQI was “emotional burden,” which may reflect underlying caregiver distress, anxiety, or depression. However, the study did not include any formal mental health screening of caregivers. This is a missed opportunity, as several studies have shown that FDLQI scores are often influenced as much by caregiver psychopathology as by the child’s dermatological condition.^4-6

In summary, the authors have raised a critical issue with potential implications for patient care, caregiver support and health policy. Future studies should consider mixed-method designs, include psychological screening tools and better control for socioeconomic confounding. We hope our comments are received in the constructive spirit intended and serve to support ongoing research in this important area.