Introduction
Vitiligo is a condition characterised by the loss of pigment in skin cells [1]. It affects between 0.5% and 2% of the global population [2]. This condition can have a significant impact on both psychological and social wellbeing, which often leads to symptoms such as anxiety, depression, and social stigmatisation [3, 4]. The condition significantly impairs health-related quality of life (HRQoL) [5], and the severity of this effect often correlates to a modest degree with patient-reported outcomes [6].
In conservative societies like Afghanistan, visible differences in skin colour are frequently misinterpreted as contagious conditions or divine retribution. This amplifies the psychological impact [4, 7]. The same stigma patterns have been documented in other collectivist cultures as well. To illustrate, a study conducted in India reported that patients who suffer from vitiligo had notably higher rates of anxiety and depression [8]. Additionally, Iranian patients suffering from vitiligo have been shown to experience a significant reduction in their health-related quality of life, particularly in domains related to social interaction and self-esteem. These effects are not consistently related to the clinical severity of the condition [9]. Moreover, similar findings have recently been reported in a multinational European cohort, in which vitiligo was consistently associated with significant HRQoL impairment, regardless of the disease duration or treatment status [10]. These findings are consistent with broader regional evidence. A study of dermatology outpatients in India found that over half screened positive for psychiatric disorders were those with vitiligo and they particularly had high rates of anxiety and depression [10]. More recently, it has been reported that a substantial proportion of Indian patients with vitiligo experience clinically significant psychological symptoms such as anxiety and social avoidance. This shows the transregional burden of distress in pigmentation disorders [8].
There is a modest correlation between the severity of vitiligo and health-related quality of life impairment. However, this relationship is inconsistent across different populations [6]. The hypothesis that psychological distress may mediate this relationship is supported by evidence from studies [11, 12]. However, the applicability of this hypothesis is constrained by the limited availability of data from conflict-affected and low-resource settings [13]. The fragmentation of Afghanistan’s healthcare system and the paucity of mental health services give rise to a critical knowledge gap. This concern is consistent with reports highlighting limited mental health infrastructure in Afghanistan [13].
Aim
This study aimed to test whether psychological distress statistically mediates the association between vitiligo severity and health-related quality of life (HRQoL) among adult patients attending selected public and private hospitals in Kandahar Province, Afghanistan.
Material and methods
Study design and setting
This was a cross-sectional study conducted between April 2025 and November 2025 among vitiligo patients attending eight dermatology outpatient departments in Kandahar City, Afghanistan (three public and five private hospitals). These health facilities manage approximately 2,000 weekly dermatology consultations.
Participants and sampling
Adults aged ≥ 18 years with clinically confirmed vitiligo for ≥ 1 month were eligible. Exclusions included: systemic therapy (e.g., steroids, cyclosporine, or psychotropic drugs) within 3 months, chronic comorbidities, pregnancy/lactation and pre-existing psychiatric diagnoses.
Sample size calculation was based on power analysis for mediation using the normal theory framework underlying the Sobel test [12, 14]. With expected medium effect size (κ2 = 0.09) from pilot data (n = 30), α = 0.05, and power (1 – β) = 0.80, the minimum required sample was 395 participants. After accounting for 10% non-response rate, we targeted 435 participants.
The stratified systematic sampling was employed with proportional allocation across hospitals. Within each hospital, systematic random sampling was conducted by selecting every second eligible patient (k = 2) after a randomly determined starting point. The response rate was 92.4% (402/435 eligible patients approached). Non-participants (n = 33) were similar to participants in age and gender distribution.
Study measurements
Disease severity: Vitiligo Area Severity Index (VASI) was used, which is a validated tool for assessing affected body surface area [15], but also as a sensitive outcome measure in therapeutic trials of phototherapy [16], with demonstrated reliability in diverse populations. Categories included: very mild (0–1), mild (> 1–5), moderate (> 5–10), severe (> 10–25), very severe (> 25–90).
Psychological distress: General Health Questionnaire-12 (GHQ-12) [17]. Score ≥ 4 indicated distress.
Anxiety: Hamilton Anxiety Rating Scale (HAM-A) [18].
Depression: Quick Inventory of Depressive Symptomatology (QIDS-SR16) [19].
GHQ-12 was conceptualized as global distress, while HAM-A and QIDS captured domain-specific symptom dimensions.
HRQoL: Dermatology Life Quality Index (DLQI) [20, 21]. Higher scores indicate greater impairment.
The DLQI has been validated in populations with vitiligo and shows that it can detect changes in quality of life that are particular to the condition, which supports its use in everyday clinical practice [21].
In the present sample, internal consistency was good to excellent across instruments (Cronbach’s α: GHQ-12 = 0.87; HAM-A = 0.91; QIDS-SR16 = 0.89; DLQI = 0.93).
All study instruments were translated into Pashto using validated forward–backward translation procedures in accordance with WHO recommendations and established cross-cultural adaptation frameworks [22, 23]. Translations were reviewed by bilingual dermatologists and psychologists. Pilot testing in 30 patients confirmed adequate comprehension, with good inter-rater reliability (κ = 0.84).
Statistical analysis
Data were analysed with the use of IBM SPSS Statistics (version 24). To summarise participant characteristics and study variables, we used descriptive statistics which included means with standard deviations (SD) for continuous variables and frequencies with percentages for categorical variables. To examine bivariate relationships between key continuous variables, we calculated the Pearson correlation coefficients. The multiple linear regression analyses were conducted for identifying the independent predictors of health-related quality of life (DLQI).
Mediation analysis was conducted using the regression-based mediation framework as described by Baron and Kenny [24]. First, the total effect of vitiligo severity (VASI) on health-related quality of life (DLQI) was examined. Second, the association between vitiligo severity and psychological distress (GHQ-12) was assessed. Third, DLQI was regressed simultaneously on VASI and GHQ-12 to evaluate the direct effect of vitiligo severity and the effect of the mediator. Evidence of mediation was inferred when the association between VASI and DLQI was attenuated after the inclusion of psychological distress in the model. The statistical significance of the indirect effect was assessed using the Sobel test [12, 14]. Statistical significance was set at p < 0.05.
Results
Participant characteristics
The cohort included 402 patients (50.5% male) with mean age of 30.4 ±10.5 years. Most were married (58.5%), illiterate (62.7%), and unemployed (61.9%). Mean VASI was 6.74 ±5.89. Non-segmental vulgaris was the most common clinical presentation (60.7%) (Table 1).
Table 1
Sociodemographic and clinical characteristics of the study participants (n = 402)
Psychological status and HRQoL
Psychological distress affected 59.5% (GHQ ≥ 4). Anxiety was prevalent (59.0%, mean HAM-A 17.4 ±4.8), whereas depression symptoms were less severe (9.6% moderate-severe, mean QIDS 8.0 ±3.3). Mean DLQI was 5.1 ±3.0. Normality tests indicated DLQI scores were approximately normally distributed (Shapiro-Wilk p = 0.087) (Table 2).
Table 2
Psychological status and health-related quality of life of vitiligo patients (n = 402)
Association between vitiligo characteristics and HRQoL
Pearson correlation revealed a small but significant positive association between VASI and DLQI (r = 0.135, 95% CI: 0.037–0.229, p = 0.007, Cohen’s d = 0.27). One-way ANOVA showed significant differences in HRQoL across disease severity groups, F (4, 397) = 3.03, p = 0.018, η2p = 0.030. Post-hoc Bonferroni comparisons indicated that patients with very severe vitiligo had significantly higher DLQI scores compared to those with very mild (p = 0.012), mild (p = 0.006), moderate (p = 0.006), and severe disease (p = 0.007) (Table 3).
Table 3
Association between vitiligo severity and health-related quality of life (n = 402)
Psychological predictors of HRQoL
Multiple linear regression analysis revealed that psychological distress (B = 0.406, 95% CI: 0.151–0.660, p = 0.002, β = 0.137), anxiety (B = 0.401, 95% CI: 0.337–0.465, p < 0.001, β = 0.589), and depression (B = 0.211, 95% CI: 0.118–0.304, p < 0.001, β = 0.209) were significant independent predictors of DLQI scores after controlling for age, gender, and vitiligo severity. The model explained 41.2% of variance in HRQoL (R2 = 0.412, F (5, 396) = 55.6, p < 0.001) (Table 4).
Mediation analysis
Mediation analysis based on regression was conducted to examine whether psychological distress mediated the association between vitiligo severity and health-related quality of life.
In the first step, vitiligo severity (VASI) was significantly associated with HRQoL (DLQI) (B = 0.070, 95% CI: 0.019–0.121, p = 0.007), which indicated a significant total effect.
In the second step, vitiligo severity was a strong predictor of psychological distress (GHQ) (B = 0.982, 95% CI: 0.813–1.151, p < 0.001).
In the third step, when DLQI was regressed simultaneously on VASI and GHQ, psychological distress remained a significant predictor of HRQoL (B = 0.570, 95% CI: 0.143–0.997, p = 0.009), whereas the direct association between vitiligo severity and HRQoL was attenuated and no longer statistically significant (B = 0.119, 95% CI: −0.097–0.335, p = 0.280).
The indirect effect of vitiligo severity on HRQoL through psychological distress was formally tested using the Sobel test and found to be statistically significant (Z = 7.94, p < 0.001), which supported the presence of a significant mediation effect. Collectively, these findings suggest that psychological distress statistically accounts for a substantial portion of the association between vitiligo severity and quality of life (Table 5).
Table 5
Regression-based mediation analysis of the association between vitiligo severity and health-related quality of life through psychological distress
Discussion
This study provides initial evidence that psychological distress statistically mediates the vitiligo severity-HRQoL relationship in Afghanistan. While initial severity exhibited a modest direct association with impairment (β = 0.135, p = 0.007), this association was attenuated and became statistically non-significant after adjustment for distress. This finding suggests that emotional response to disease visibility may contribute more strongly to quality-of-life impairment than the lesion extent alone. Although the direct association was modest, the statistical significance of the indirect pathway has potential implications for psychodermatological care models.
The statistically significant indirect effect (Sobel Z = 7.94, p < 0.001) is consistent with psychosocial models suggesting that psychological distress may statistically account for a substantial portion of the association between vitiligo severity and HRQoL [11, 12]. The present findings extend evidence from high-income country studies [2, 18] to a distinct sociocultural context, where conservative norms and limited health literacy may intensify stigma-related experiences [4, 7].
It is noteworthy that anxiety emerged as the predominant predictor (β = 0.589, p < 0.001), although depressive symptoms were also independently associated with HRQoL impairment. This pattern aligns with findings from skin of colour populations, where social evaluation anxiety has been emphasised [13]. In contrast, several Western studies have reported a predominance of depressive symptomatology [10], whereas more recent South Asian data suggest an anxiety-dominant psychological profile among patients with vitiligo [8]. While 59.0% of the subjects exhibited anxiety symptoms, only 9.6% displayed moderate-severe depression, suggesting that anticipatory anxiety regarding social judgement, marital discrimination, and occupational exclusion may be more debilitating than mood symptoms in this context [8, 13]. Although depression was less prevalent in our cohort, previous studies have demonstrated a significant association between depressive symptoms and reduced quality of life among patients with vitiligo [25]. This “anxiety-driven” pattern is distinct from the predominant depression-driven pattern observed in Western studies [10], underscoring the necessity for culturally sensitive assessment methodologies.
A number of statistical mechanisms have been identified as mediating factors in the observed outcomes. Afghan cultural norms place considerable emphasis on physical appearance in the context of marriage and social standing. These sociocultural dynamics may be particularly relevant in Kandahar, where previous clinical data have demonstrated distinct patterns of vitiligo presentation and patient characteristics within the local population [26]. Limited public understanding of the aetiology of vitiligo may contribute to stigma [4, 7], while the absence of adequate psychological services may further amplify the impact on HRQoL [1]. The strong association of severity and distress (β = 0.496) shows that patients may interpret lesion extent as predictive of social rejection, and this creates a cycle of hypervigilance and avoidance.
These results indicate a requirement for integrated psychodermatological care. Current practice prioritises repigmentation without addressing psychosocial comorbidities [27]. The findings of this study indicate that the GHQ-12 can be administered in a time period of less than 5 min with a high degree of efficacy in identifying patients who are at high risk and who would benefit from counselling. This supports the integration of brief psychological screening tools into dermatological practice, as recommended in the guidelines [27]. In instances where mental health professionals are not available, a pragmatic approach involves the training of dermatology staff in fundamental psychosocial counselling and cognitive-behavioural techniques [28]. Furthermore, non-pharmacological interventions, including cosmetic camouflage, which has been demonstrated to enhance HRQoL and alleviate distress when employed in conjunction with medical therapy [29], may provide a cost-effective psychological intervention in settings such as Afghanistan, where treatment options are constrained.
The study’s strengths include a large, systematically sampled cohort, validated instruments that have been culturally adapted, a robust mediation methodology, and novel evidence from an underrepresented region. The following limitations should be noted: although the mediation analysis is statistically robust, the cross-sectional design precludes causal inference, and the findings should be interpreted as evidence of statistical mediation rather than temporal or causal pathways [30]. Secondly, the treatment seeking sample may underestimate the population burden, which is a common challenge in clinic-based studies [10]. Thirdly, potential confounders (social support, income) were not assessed, despite the recognised influence of these factors on dermatological quality of life [10, 28]. Finally, self-reported measures are subject to bias.
It is recommended that future research employ longitudinal designs in order to confirm temporal ordering and to test the hypothesis that psychological interventions disrupt the mediation pathway in low-resource settings. The execution of qualitative studies exploring stigma experiences would facilitate the development of culturally adapted interventions [31].
Conclusions
Psychological distress was statistically associated and substantially explained the observed relationship between vitiligo severity and HRQoL among Afghan patients. These findings are consistent with the interpretation that psychological processes may contribute meaningfully to quality-of-life impairment in this population. Anxiety emerged as the most important independent predictor of HRQoL impairment, but depressive symptoms were also independently associated with worse quality of life. These findings highlight the imperative for comprehensive psychodermatological care, including routine structured screening for psychological distress, particularly in sociocultural contexts where stigma intensifies the burden of disease.
