Psychological distress statistically mediates the association between vitiligo severity and health-related quality of life: a cross-sectional study from Kandahar, Afghanistan

Introduction
Vitiligo substantially impairs health-related quality of life (HRQoL). However, mechanisms linking disease severity to HRQoL in low-resource and conflict-affected settings remain insufficiently understood.

Aim
To assess whether psychological distress mediates the association between vitiligo severity and HRQoL among patients in Kandahar, Afghanistan.

Material and methods
In this cross-sectional study, 402 adult patients with vitiligo were recruited from eight dermatology clinics between September 2024 and July 2025. Disease severity was measured using the Vitiligo Area Severity Index (VASI); psychological distress using the General Health Questionnaire-12 (GHQ-12); anxiety using the Hamilton Anxiety Rating Scale (HAM-A); depression using the 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR16); and HRQoL using the Dermatology Life Quality Index (DLQI). Mediation analysis was performed using a regression-based framework, with indirect effects assessed by the Sobel test.

Results
Mean age of the patients was 30.4 ±10.5 years; 59.5% of them screened positive for psychological distress. Vitiligo severity showed a weak correlation with DLQI (r = 0.135, p = 0.007) and a moderate correlation with psychological distress (r = 0.496, p < 0.001). In multivariable models, psychological distress, anxiety severity, and depressive symptom severity were independently associated with poorer HRQoL. After adjustment for psychological distress, the association between vitiligo severity and HRQoL was no longer significant. The indirect effect was significant (Sobel Z = 7.94, p < 0.001).

Conclusions
Psychological distress substantially mediates the relationship between vitiligo severity and HRQoL. Integrating routine psychological assessment into dermatologic care may improve patient outcomes in low-resource settings.