==== Front Dermatol Res Pract Dermatol Res Pract DRP Dermatology Research and Practice 1687-6105 1687-6113 Hindawi 10.1155/2020/6694191 Research Article Chronic Urticaria and Its Impact on the Quality of Life of Nepalese Patients https://orcid.org/0000-0001-8665-5355Paudel Sushil paudelsushil@gmail.com 1 https://orcid.org/0000-0001-6869-4959Parajuli Niraj 2 https://orcid.org/0000-0001-9202-869XSharma Rabindra Prasad 1 https://orcid.org/0000-0001-6888-0153Dahal Sudip 3 https://orcid.org/0000-0001-6112-1867Paudel Sudarshan 4 1Department of Dermatology, Civil Service Hospital, Kathmandu 44600, Nepal 2Department of Dermatology, National Academy of Medical Sciences, Kathmandu 44600, Nepal 3Department of Statistics, Civil Service Hospital, Kathmandu 44600, Nepal 4School of Public Health, Patan Academy of Health Sciences, Lalitpur 44600, Nepal Academic Editor: E. Helen Kemp 2020 28 11 2020 2020 669419114 10 2020 16 11 2020 17 11 2020 Copyright © 2020 Sushil Paudel et al.2020This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Chronic urticaria (CU) is a skin condition characterized by sudden and recurrent episodes of wheals, angioedema, or both and commonly associated with itching for a duration of more than six weeks. The available data indicate that urticaria markedly affects both objective functioning and subjective well-being of patients. A review of patients' records with chronic urticaria attending Civil Service Hospital from January 2018 to December 2019 was done. A detailed demographic data of all patients with chronic urticaria was also retrieved. Dermatology Life Quality Index questionnaire (DLQI) Nepalese version was used for the assessment of the impact of disease on life quality. Mann–Whitney U-test was applied to compare means, and principle component analysis for factor analysis was used. A total of 149 patients were included, with a male-to-female ratio of 1 : 1.9. The mean age of the study population was 32.86 ± 12.837 years. The mean DLQI score was 8.30 ± 6.73 with men having a significantly greater score than women (p < 0.02). DLQI scores negatively correlated with age (p < 0.01). There was a high internal consistency among items (Cronbach's alpha 0.89), and all items had satisfactory correlation with each other as well. Principle component extraction revealed that there were two underlying factors in the DLQI questionnaire on measuring quality of life in chronic urticaria. Males had a greater impairment in quality of life than females due to chronic urticaria. Most severe impairment was seen in symptoms/feelings subdomain. It also revealed that there were two different underlying factors in DLQI questionnaire. ==== Body 1. Background Chronic urticaria (CU) is a skin condition characterized by pruritus with sudden and recurrent episodes of wheals, angioedema, or both for more than six weeks [1]. The worldwide prevalence of chronic urticaria is estimated to be at 1% and that of acute urticaria is in a range of 10–20% [2]. A single study conducted in rural Nepal estimated the prevalence of urticaria to be at 2.4% [3]. The available data till now have indicated that urticaria markedly affects both objective functioning and subjective well-being of patients [4–6]. Health status scores in CU patients were comparable with that of patients with coronary artery disease [7], but lower than those with respiratory allergy, which showed a significant impact on the patient's life quality [8]. The Dermatology Life Quality Index (DLQI) was the first dermatology specific instrument developed to assess the impact of skin diseases in an individual's life based on the experiences of the previous seven days [9]. It is a validated tool to measure the quality of life and has been widely used in more than 30 different skin conditions and translated in more than 50 languages including Nepali [10, 11]. It has also been used in evaluating the treatment efficacy or intervention in patients with chronic urticaria [12–17]. However, there is a paucity of data regarding its impact in the lives of Nepalese population. This study endeavored to evaluate the impairment of different aspects of life in patients with chronic urticaria. 2. Materials and Methods This was a retrospective review of records of patients visiting outpatient department of dermatology in Civil Service Hospital, Kathmandu, from January 2018 to December 2019 with chronic urticaria. All the demographic details and details from the DLQI-Nepali version filled up by consenting patients as part of the initial assessment for the treatment of CU were reviewed and included in this study. All patients, more than 16 years of age, with the diagnosis of chronic spontaneous urticaria were included in this study. Exclusion criteria included patient less than 16 years old, incomplete DLQI forms, patients presenting with only angioedema or only chronic inducible urticaria, and patients with other chronic diseases that could impact the quality of life. The DLQI-Nepali questionnaire was translated by Dr. Sudha Agrawal and was downloaded from https://www.cardiff.ac.uk/medicine/resources/quality-of-life-questionnaires/dermatology-life-quality-index for the purpose of this study. There are 10 questions or items in the DLQI questionnaire, which are further subdivided into six subdomains of life. Items 1 and 2 pertain to symptoms and feelings; items 3 and 4, to daily activities; items 5 and 6, to leisure; item 7, to work and school; items 8 and 9, to personal relationships, and item 10 pertains to treatment. There are four choices to choose from in response to each of the items: “not at all,” “a little,” “a lot,” and “very much” which are scored as 0, 1, 2, and 3, respectively. Some of the items contain a fifth option, “not relevant” which is scored as 0. The maximum score of DLQI reaches up to 30. A higher score indicates greater impairment of quality of life. For ease of interpretation, the scores are banded in six categories each representing different severities of the disease. In summary, a total score of 0-1 signifies no impairment; 2–6, mild impairment; 6–10, moderate impairment; 11–20, severe impairment; and 21–30, very severe impairment in QoL. Based on the distribution of the variables mean ± standard error (SE) and median values were calculated. Student's t-test or Mann–Whitney U-test were used to find significant differences in the means, and correlations between continuous variables were tested. Normality of the distribution of variables was tested by Shapiro–Wilk test (p < 0.05 rejecting the hypothesis of normality). The internal consistency (reliability) of the Nepali version of DLQI in chronic urticaria was tested using Cronbach's alpha, and the value of alpha greater than .70 was considered satisfactory. Exploratory factor analysis was performed by the principle component analysis method to find the underlying factor(s) structure in DLQI. In all tests, α was set at 5%. Statistical tests were performed using the Statistical Package for the Social Sciences (SPSS) version 25. 3. Results In total, 149 patients with CU fulfilled the inclusion criteria and were included in the final evaluation. Females outnumbered males, with a male-to-female ratio of 1 : 1.9. The mean age (±SE) of the study population was 32.86 ± 1.05 years. Age of the females (34.66 ±  1.29) was significantly higher than that of the males (29.39 ± 1.71), (p=0.017). The mean duration (±SE) of disease in males was 15.37 ± 3.07 months and that in females was 13.28 ± 1.94 months. However, the difference was not statistically significant (p=0.91). The median duration of the disease, in the study population, was 6 months, and the range was from 1.5 months to 120 months. 3.1. Dermatology Life Quality Index Scoring The mean DLQI score was 8.30 ± 0.55, which indicated that the impact of chronic urticaria was moderate in the study population. According to the sex, mean DLQI score was 10.51 ± 1.1 (range: 1–28) in males and 7.15 ± 0.58 (range: 1–21) in females (p=0.026). The mean score was significantly higher in males than in females for questions/items 6 to 10 (Table 1). Among the six subdomains of life quality measured by the questionnaire, four of them showed that males were more severely affected in comparison with females by CU (p < 0.05) (Table 2). On correlating DLQI score with the age and duration of disease, there was a decreasing DLQI score with an increase in age (rs = −0.459; p < 0.01). Younger patients had significantly more impaired QoL as compared to adults (Figure 1(a)). But, no correlation was found between the duration of disease and the DLQI score (rs = 0.038; p=0.64) (Figure 1(b)). 3.2. Test for Internal Consistency The internal consistency among the questions (items) was found to be high. Cronbach's alpha was 0.88, which became 0.89 after standardization, and it did not change with the deletion of any of the items which is higher than the traditionally accepted level of 0.70. The interitem correlation matrix revealed that the correlation coefficients (r) ranged from 0.097 to 0.730 (Table 3). All items had a satisfactory correlation with each other. Thus, all the items were included for the further factor analysis. 3.3. Factor Analysis Principle component analysis method was used for factor analysis. Bartlett's test of sphericity showed χ2 = 781.19 (p < 0.001); the Kaiser–Meyer–Olkin measure of sampling adequacy had a value of 0.89, which indicated that this dataset could be analyzed for factor analysis. Principle component extraction method revealed that there are two factors with the initial eigenvalues of more than 1 and a cumulative contribution of 65.91% (Table 4). These results mean that the DLQI has two factors (underlying dimensions) while measuring chronic urticaria. The cutoff value for the item loading (α coefficient) was set at 0.4. The Varimax rotation with Kaiser normalization resulted component matrices of the items as shown in Table 4. Items 1 to 3 had large loading on factor (component) 1, and items 4 to 10 loaded on factor 2. Items 4 and 5 had higher load on factor 2, though their load on factor 1 was more than 0.5 and suggested to have a shared loading on both factors. 4. Discussion CU was more common in females (male : female = 1 : 1.9), which is similar to the findings from other similar studies conducted in India [16], China [17], Italy [18], Germany [19], and Korea [20]. The mean age of patients suffering from CU was 32.86 ± 12.83 years, similar to that from China. However, the mean age was lower in Japan [15], where it was 45.2 ± 11.3 years, and in Germany [19], where it was 42.17 ± 9.24 years. The mean age of males was significantly lower than females in this study, which has not been reported by other studies. In our study, the mean total DLQI score was 8.30, indicating a moderate impairment in the QoL. This score is close to studies done by Basra et al. [11], where he analyzed studies conducted in 12 different countries with a mean DLQI of 9.80 with a range of 7.16–13.40. Similar scores were also noted in a study conducted in China (mean DLQI score = 9.93) [17]. In contrast, the mean DLQI score was lower in India (mean = 6.63) [16] and Japan (mean score = 4.8) [15]. Males were affected significantly more by CU than females (p < 0.05) in our study, which was different from other studies [16, 17, 19, 21]. However, Poon et al. [22] found that there was no difference in total DLQI score between the genders. The two biggest impacts were in the subdomains related to symptoms and feelings (57.66%) and work/school (30.33%). Personal relationship (9.5%) and treatment (16%) subdomains were the two least affected. These findings were similar to findings from study in China [17]. Males were significantly more affected in four out of six subdomains, namely, leisure (p=0.005), work/school (p=0.001), personal relations (p=0.004), and treatment (p=0.033) in our study. Similar results were also derived in a study by Poon et al., where leisure was more impaired in men [22]. However, a study from China [17] showed that school/work subdomain was significantly more impaired in females. Our study found that the QoL was more impaired in younger age. This finding was consistent with some studies [17, 19], but opposite to others [22]. DLQI being a generic skin HRQoL measurement can take various dimensionalities, and its reliability could differ from the disease under study and the population under study [11]. The reliability for the Nepalese version of DLQI was found to be high. When examined for dimensionality, it was found to have two dimensions while measuring the CU in Nepalese population. Items 1 to 3 had a large load on factor 1 and items 6 to 10 had loads on factor 2. Items 4 and 5 had a shared loading on both factors. Item 4, named clothing in the original version of DLQI, more aptly fits with the other items of factor 1. When internal consistency was tested with item 4 in factor 1, Cronbach's alpha was satisfactory for both factor items (Table 5). These findings suggest that the impact of CU as measured by DLQI in Nepalese population has at least two dimensions. Factor 1 comprises the items representing symptoms and embarrassing situations that itching and wheals can produce and be labelled as “itching/embarrassing,” and factor 2 comprises the items related to different social and personal functions, so it can be labelled as “functioning”. Similar two-dimensionality of DLQI in CU was found in Chinese version [17] also, but due to the low correlation coefficient between the items, they eliminated item 1 from factorization and found items 2 to 6 loaded on factor 1 and items 7 to 10 on factor 2. However, the study by Lennox et al. [14] had found that the DLQI is a one-dimensional measure of QoL. 5. Conclusion The males were more severely affected by CU in comparison with females in our study. The impact of CU in Nepalese population as measured by DLQI had two dimensions of affliction. These findings need to be reevaluated in a larger population. There is a need for further studies in other skin conditions apart from CU and a larger set of populations for a proper validation of the Nepali version of DLQI in our population. Data Availability The data used to support the findings of this study are available from the corresponding author upon request. Conflicts of Interest The authors declare that they have no conflicts of interest. Figure 1 Bivariate correlation between the DLQI score and (a) the age of the patient showing a significant negative correlation between the two and (b) the duration of the disease showing no correlation between the two. Table 1 The mean DLQI scores for each item (questions) and their comparison with the gender Mann–Whitney U-test (p value). DLQI questions Mean score p value Shortened names Male Female All (1) Symptoms 2.14 2.33 2.26 0.187 (2) Feeling 1.31 1.15 1.21 0.478 (3) Daily activities 1.12 0.94 1.00 0.347 (4) Choice of clothing 0.82 0.53 0.63 0.083 (5) Social/leisure 0.80 0.52 0.62 0.160 (6) Sports 0.94 0.40 0.58 0.001 (7) Work/study 1.69 0.51 0.91 0.001 (8) Relationships 0.65 0.23 0.38 0.003 (9) Sexual difficulties 0.35 0.12 0.20 0.019 (10) Treatment 0.67 0.40 0.49 0.033 Total 10.51 7.15 8.30 0.026 The mean scores of items 6 to 10 were significantly higher in males compared to females (p < 0.05), indicating males were more severely affected by CU in those areas. Table 2 The mean score ± standard error by the subdomains of the DLQI in patients with chronic urticaria. Subdomains (full marks) Male (%) Female (%) All patients (%) p value Symptoms and feelings (6) 3.45 ± 0.24 (57.5) 3.47 ± 0.15 (57.83) 3.46 ± 0.13 (57.66) 0.859 Daily activities (6) 1.94 ± 0.27 (32.33) 1.64 ± 0.17 (27.33) 1.63 ± 0.13 (27.17) 0.204 Leisure (6) 1.74 ± 0.25 (29.00) 0.91 ± 0.13 (15.16) 1.20 ± 0.12 (20.00) 0.005 Work and school (3) 1.68 ± 0.19 (56.00) 0.51 ± 0.10 (17.00) 0.91 ± 0.10 (30.33) <0.001 Personal relationships (6) 1.00 ± 0.22 (16.66) 0.35 ± 0.10 (5.83) 0.57 ± 0.10 (9.50) 0.004 Treatment (3) 0.66 ± 0.13 (22.00) 0.39 ± 0.08 (13.00) 0.48 ± 0.07 (16.00) 0.033 Total score (30) 10.51 ± 1.10 (35.03) 7.15 ± 0.58 (23.83) 8.3 ± 0.55 (27.67) 0.026 Mann–Whitney U-test (p value). Out of six sub-domains of the DLQI questionnaire, four, namely. leisure, work and school, personal relationships and treatment were significantly more impaired in males compared to females. Table 3 Interitem correlation matrix of the DLQI items.   Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q1 0.466 0.437 0.215 0.336 0.168 0.127 0.097 0.133 0.158 Q2   0.639 0.548 0.562 0.516 0.424 0.390 0.338 0.445 Q3     0.581 0.514 0.480 0.511 0.303 0.292 0.377 Q4       0.482 0.623 0.550 0.417 0.439 0.518 Q5         0.549 0.470 0.524 0.514 0.573 Q6           0.599 0.506 0.455 0.573 Q7             0.559 0.435 0.551 Q8               0.730 0.701 Q9                 0.623 Q: question/item. Table 4 Principal component analysis with Varimax rotation: loading of the items on the two factors. Items Factor 1 Factor 2 Q1   0.780 Q2   0.767 Q3   0.792 Q4 0.566 0.517 Q5 0.595 0.501 Q6 0.674   Q7 0.687   Q8 0.874   Q9 0.816   Q10 0.827   % of variance 39.444 26.474 Cumulative (%) 39.444 65.918 Table 5 Internal consistency for 2 factors of Nepali version. Factor Items Cronbach's alpha 1 1, 2, 3, 4 0.79 2 5, 6, 7, 8, 9, 10 0.86 ==== Refs 1 Zuberbier T. Aberer W. Asero R. The EAACI/GA2 LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria Allergy 2018 73 7 1393 1414 10.1111/all.13397 2-s2.0-85048001207 29336054 2 Zuberbier T. Maurer M. Urticaria: current opinions about etiology, diagnosis and therapy Acta Dermato-Venereologica 2007 87 3 196 205 10.2340/00015555-0240 2-s2.0-34447521676 17533484 3 Shrestha D. P. Gurung D. Rosdahl I. Prevalence of skin diseases and impact on quality of life in hilly region of Nepal Journal of Institute of Medicine 2012 34 3 http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-101086www.jiom.com.np 10.3126/jiom.v34i3.8917 4 Maurer M. Staubach P. Raap U. Richter-Huhn G. Baier-Ebert M. Chapman-Rothe N. ATTENTUS, a German online survey of patients with chronic urticaria highlighting the burden of disease, unmet needs and real-life clinical practice British Journal of Dermatology 2016 174 4 892 894 10.1111/bjd.14203 2-s2.0-84953288695 26406483 5 Maurer M. Staubach P. Raap U. H1-antihistamine-refractory chronic spontaneous urticaria: it’s worse than we thought—first results of the multicenter real-life AWARE study Clinical & Experimental Allergy 2017 47 5 684 692 10.1111/cea.12900 2-s2.0-85014064835 28160338 6 Maurer M. Abuzakouk M. Bérard F. The burden of chronic spontaneous urticaria is substantial: real-world evidence from ASSURE-CSU Allergy 2017 72 12 2005 2016 10.1111/all.13209 2-s2.0-85022200688 28543019 7 O’Donnell B. F. Lawlor F. Simpson J. Morgan M. Greaves M. W. The impact of chronic urticaria on the quality of life The British Journal of Dermatology 1997 136 2 197 201 9068731 8 Baiardini I. Giardini A. Pasquali M. Quality of life and patients’ satisfaction in chronic urticaria and respiratory allergy Allergy 2003 58 7 621 623 10.1034/j.1398-9995.2003.00091.x 2-s2.0-0037899093 12823121 9 Finlay A. Y. Khan G. K. Dermatology Life Quality Index (DLQI)-a simple practical measure for routine clinical use Clinical and Experimental Dermatology 1994 19 3 210 216 10.1111/j.1365-2230.1994.tb01167.x 2-s2.0-0028332995 8033378 10 Lewis V. Finlay A. Y. 10 years experience of the dermatology life quality index (DLQI) Journal of Investigative Dermatology Symposium Proceedings 2004 9 2 169 180 10.1111/j.1087-0024.2004.09113.x 2-s2.0-1842450793 11 Basra M. K. A. Fenech R. Gatt R. M. Salek M. S. Finlay A. Y. The dermatology life quality index 1994−2007: a comprehensive review of validation data and clinical results British Journal of Dermatology 2008 159 997 1035 10.1111/j.1365-2133.2008.08832.x 2-s2.0-54249168036 18795920 12 Kapp A. Pichler W. J. Levocetirizine is an effective treatment in patients suffering from chronic idiopathic urticaria: a randomized, double-blind, placebo-controlled, parallel, multicenter study International Journal of Dermatology 2006 45 4 469 474 10.1111/j.1365-4632.2005.02609.x 2-s2.0-33645549364 16650180 13 Lachapelle J. Decroix J. Henrijean A. Desloratadine 5 mg once daily improves the quality of life of patients with chronic idiopathic urticaria Journal of the European Academy of Dermatology and Venereology 2006 20 3 288 292 10.1111/j.1468-3083.2006.01429.x 2-s2.0-33645981589 16503889 14 Lennox R. D. Leahy M. J. Validation of the dermatology life quality index as an outcome measure for urticaria-related quality of life Annals of Allergy, Asthma & Immunology 2004 93 2 142 146 10.1016/s1081-1206(10)61466-4 2-s2.0-4344597726 15 Itakura A. Tani Y. Kaneko N. Hide M. Impact of chronic urticaria on quality of life and work in Japan: results of a real-world study The Journal of Dermatology 2018 45 8 963 970 10.1111/1346-8138.14502 2-s2.0-85051078833 29897137 16 Lakshmikanth M. Sukumar D. The impact of chronic spontaneous urticaria on quality of life : a study from south India Journal of Dental and Medical Sciences 2016 15 12 110 114 10.9790/0853-151202110114 17 Liu J.-B. Yao M.-Z. Si A.-L. Xiong L.-K. Zhou H. Life quality of Chinese patients with chronic urticaria as assessed by the dermatology life quality index Journal of the European Academy of Dermatology and Venereology 2012 26 10 1252 1257 10.1111/j.1468-3083.2011.04277.x 2-s2.0-84866243971 21958389 18 Lapi F. Cassano N. Pegoraro V. Epidemiology of chronic spontaneous urticaria: results from a nationwide, population-based study in Italy British Journal of Dermatology 2016 174 5 996 1004 10.1111/bjd.14470 2-s2.0-84960983733 26872037 19 Młynek A. Magerl M. Hanna M. The German version of the chronic urticaria quality-of-life questionnaire: factor analysis, validation, and initial clinical findings Acta Allergologica European Journal of Allergy and Clinical Immunology 2009 64 6 927 936 10.1111/j.1398-9995.2008.01920.x 2-s2.0-65549130606 19453340 20 Kim B. R. Yang S. Choi J. W. Choi C. W. Youn S. W. Epidemiology and comorbidities of patients with chronic urticaria in Korea: a nationwide population-based study The Journal of Dermatology 2018 45 1 10 16 10.1111/1346-8138.14075 2-s2.0-85040041443 28983950 21 Maurer M. Ortonne J.-P. Zuberbier T. Chronic urticaria: a patient survey on quality-of-life, treatment usage and doctor-patient relation Allergy 2009 64 4 581 588 10.1111/j.1398-9995.2008.01853.x 2-s2.0-62449242090 19175591 22 Poon E. Seed P. T. Greaves M. W. Kobza-Black A. The extent and nature of disability in different urticarial conditions British Journal of Dermatology 1999 140 4 667 671 10.1046/j.1365-2133.1999.02767.x 2-s2.0-0032956384 10233318