10.5826/dpc.1304S2a315S
Introduction: Vitiligo is an acquired disorder of pigmentation, characterized by the development of white patches on the skin, often with a typical symmetrical distribution and progressive extension [1,2]. Although vitiligo does not cause direct physical impairment, it can produce a relevant psychosocial burden. Despite this burden, effective treatments are lacking, emphasizing the need for new therapeutic options.
Objectives: The aim of this study was to systematically scan the scientific literature for studies dealing with vitiligo epidemiology. Additionally, the study aimed to assess the social costs of vitiligo, ultimately raising awareness about the societal impact of the condition. The focus was on Italian data.
Methods: Our research employed a comprehensive methodology. For the epidemiology, we systematically searched PubMed database up to October 2023 and complemented the analysis with Real World Evidence. For social costs, we conducted an in-depth literature review, administered a web-survey to 20 Italian dermatologists and conducted an equivalent number of interviews during the same period in March 2022.
Results: The data suggest that in Italy the prevalence of vitiligo increases with age, and it varies from 0.19% (age 18-21) to 0.6% (age &gt;45) [3,4]. We estimated 152,000 patients diagnosed with Non-Segmental Vitiligo (NSV) in Italy; based on Body Surface Area (BSA), 33% are Not Severe, 31% Mild, 27% Moderate/Severe, 9% Very Severe. The yearly social costs of vitiligo amount to €0.5Bln.
Conclusions: There is a remarkable association of vitiligo with anxiety and depression [5,6,7,8,9], and Mental Health is associated with 30% of social costs. Moreover, vitiligo social costs distribution highlights inequity, with patients bearing 55% of them.
text/xml
2160-9381
4075
en
Chiara Alduini
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
social cost
Vitiligo: Epidemiology and Economic Impact 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2023-12-19
2023-11-28
2023-12-19
2024-01-25
e2023315S
Dermatol Pract Concept
Introduction: Vitiligo is an acquired disorder of pigmentation, characterized by the development of white patches on the skin, often with a typical symmetrical distribution and progressive extension [1,2]. Although vitiligo does not cause direct physical impairment, it can produce a relevant psychosocial burden. Despite this burden, effective treatments are lacking, emphasizing the need for new therapeutic options.
Objectives: The aim of this study was to systematically scan the scientific literature for studies dealing with vitiligo epidemiology. Additionally, the study aimed to assess the social costs of vitiligo, ultimately raising awareness about the societal impact of the condition. The focus was on Italian data.
Methods: Our research employed a comprehensive methodology. For the epidemiology, we systematically searched PubMed database up to October 2023 and complemented the analysis with Real World Evidence. For social costs, we conducted an in-depth literature review, administered a web-survey to 20 Italian dermatologists and conducted an equivalent number of interviews during the same period in March 2022.
Results: The data suggest that in Italy the prevalence of vitiligo increases with age, and it varies from 0.19% (age 18-21) to 0.6% (age &gt;45) [3,4]. We estimated 152,000 patients diagnosed with Non-Segmental Vitiligo (NSV) in Italy; based on Body Surface Area (BSA), 33% are Not Severe, 31% Mild, 27% Moderate/Severe, 9% Very Severe. The yearly social costs of vitiligo amount to €0.5Bln.
Conclusions: There is a remarkable association of vitiligo with anxiety and depression [5,6,7,8,9], and Mental Health is associated with 30% of social costs. Moreover, vitiligo social costs distribution highlights inequity, with patients bearing 55% of them.
Chiara Alduini
2023/12/19
10.5826/dpc.1304S2a315S
e2023315S
Kearney, Milan
2160-9381
social cost
en
e2023315S
Verbooy K, Hoefman R, van Exel J, Brouwer W. Time Is Money: Investigating the Value of Leisure Time and Unpaid Work. Value Health. 2018 Dec; Epub 2018 Jul 14. PMID: 30502787.
Vitiligo: Epidemiology and Economic Impact 
https://dpcj.org/index.php/dpc/article/download/4075/2438
          Vitiligo: Epidemiology and Economic Impact
                                   Luigi Naldi1, Adriano Pagani2, Chiara Alduini2


1 UOC Dermatologia, Ospedale San Bortolo, Vicenza, Centro Studi GISED, Bergamo
2 Kearney, Milan



Key words: vitiligo, epidemiology, mental health, social cost
Citation: Naldi L, Pagani A, Alduini C. Vitiligo: Epidemiology and Economic Impact. Dermatol Pract Concept.2023;13(4)S2:e2023315S.
DOI: https://doi.org/10.5826/dpc.1304S2a315S
Accepted: December 11, 2023; Published: December 2023
Copyright: ©2023 Naldi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Chiara Alduini, Kearney, Milan, Italy. Email: chiara.alduini@kearney.com




  ABSTRACT              Introduction: Vitiligo is an acquired disorder of pigmentation, characterized by the development of
                        white patches on the skin, often with a typical symmetrical distribution and progressive extension
                        [1,2]. Although vitiligo does not cause direct physical impairment, it can produce a relevant psycho-
                        social burden. Despite this burden, effective treatments are lacking, emphasizing the need for new
                        therapeutic options.
                        Objectives: The aim of this study was to systematically scan the scientific literature for studies dealing
                        with vitiligo epidemiology. Additionally, the study aimed to assess the social costs of vitiligo, ultimately
                        raising awareness about the societal impact of the condition. The focus was on Italian data.
                        Methods: Our research employed a comprehensive methodology. For the epidemiology, we systemati-
                        cally searched PubMed database up to October 2023 and complemented the analysis with Real World
                        Evidence. For social costs, we conducted an in-depth literature review, administered a web-survey to
                        20 Italian dermatologists and conducted an equivalent number of interviews during the same period
                        in March 2022.
                        Results: The data suggest that in Italy the prevalence of vitiligo increases with age, and it varies from
                        0.19% (age 18-21) to 0.6% (age >45) [3,4]. We estimated 152,000 patients diagnosed with Non-­
                        Segmental Vitiligo (NSV) in Italy; based on Body Surface Area (BSA), 33% are Not Severe, 31% Mild,
                        27% Moderate/Severe, 9% Very Severe. The yearly social costs of vitiligo amount to €0.5Bln.
                        Conclusions: There is a remarkable association of vitiligo with anxiety and depression [5,6,7,8,9],
                        and Mental Health is associated with 30% of social costs. Moreover, vitiligo social costs distribution
                        highlights inequity, with patients bearing 55% of them.




Review | Dermatol Pract Concept. 2023;13(4)S2:e2023315S                                                                                1
Introduction                                                         Evidence, scientific publications, public entities’ websites
                                                                     (e.g., INPS, GU (Gazzetta Ufficiale)), scientific guidelines,
Vitiligo is a chronic autoimmune depigmenting skin disease           national and regional NHS tariffs, statistics institutes
that results in patchy loss of skin color due to the progressive     (e.g., ISTAT, EUROSTAT), surveys, interviews, as well as in-
destruction of melanocytes [1,10]; it is now widely accepted         formation from company websites and the medical press.
that vitiligo has an autoimmune nature. This condition is
characterized by extended periods of stability interspersed          Epidemiology
with shorter periods of accelerated depigmentation [11].             We systematically searched PubMed database up to October
Treatment remains a challenge in dermatology, as available           4, 2023, with the following key words: epidemiology, prev-
options produce limited results [12,13].                             alence, incidence, co-morbidities, risk factors. A total of 761
    Vitiligo is a prevalent global skin condition which affects      papers were retrieved and, after an eligibility assessment,
equally both genders, though slightly more prevalent in fe-          only 82 were maintained. Out of these papers, 12 were sys-
males, and more than 60% of patients experienced disease             tematic reviews summarising various aspects of the vitiligo
onset before the age of 30 [14,15].                                  epidemiology [5-9,25-28], and another 8 studies presented
    There are two main clinical phenotypes [16]: Non-­               data on the epidemiology of vitiligo in Italy [3,4,29-35]. To
Segmental vitiligo (NSV) and Segmental vitiligo (SV). NSV is         avoid repetition and redundancy, we decided to focus on the
the most common form, characterized by symmetrical lesions           above-mentioned studies only, i.e., systematic reviews and
on both sides of the body, progressing slowly and unpredictably.     Italian data.
    Vitiligo is frequently associated with various autoim-              We then complemented the analysis through a bottom-up
mune comorbidities such as hypothyroidism and rheumatoid             approach, using Real-World Evidence [36]. Lastly, we es-
arthritis [17].                                                      tablished patient classes for Non-Segmental vitiligo (NSV)
    The psychological impact is substantial, negatively af-          based on clinical and demographic characteristics and vali-
fecting patients’ quality of life (QoL) and Mental Health            dated these classifications through expert interviews.
[5,6,7,8,9,18,19]. Indeed, the stigma associated with vitil-
igo impacts personal lives and productivity, leading to poor         Social Cost
self-acceptance and psychological distress [20]. Everyday ac-        We assessed both healthcare and non-healthcare costs asso-
tivities are disrupted, causing considerable time and energy         ciated with vitiligo. Among healthcare costs, we examined
waste for patients and their caregivers. Patients commonly           three components:
experience depression, anxiety, stigmatization, hopelessness,
and loss of self-esteem [20,21].                                     • Vitiligo Treatment: through the Medical Survey, we investi-
    Despite the substantial burden it places on individuals,           gated the treatment behavior within distinct patient classes,
there is still a notable unmet need for effective treatments,          specifically focusing on topical treatments, phototherapy,
leaving patients frustrated and hopeful for the development            depigmentation, and surgery. We further quantified the
of efficacious options.                                                costs associated with each treatment, using publicly avail-
                                                                       able sources. Both NHS and patient costs were considered.
Objectives                                                           • Autoimmune Comorbidities: our study delved into the
                                                                       prevalence of autoimmune comorbidities among vitiligo
The goals of the study were to determine the prevalence of             patients, including conditions such as hypothyroidism,
vitiligo in Italy, segment patients to understand treatment            rheumatoid arthritis, and inflammatory bowel disease.
adoption and behavior, and assess the social costs associated          For each of these comorbidities, we examined literature
with the condition. Moreover, the aim was to shed light on             on both direct and indirect associated costs.
the economic and societal burdens of vitiligo in Italy.              • Mental Health Conditions Assessment: we explored the
                                                                       prevalence of Mental Health comorbidities, such as de-

Methods                                                                pression and anxiety, in vitiligo patients and their caregiv-
                                                                       ers, as reported in the literature.
Our research utilized a comprehensive methodology, en-
compassing web-surveys involving 20 Italian dermatologists              On the non-healthcare cost front, we assessed two
(i.e., “Medical Survey”) in March 2022, interviews with an           components:
additional 20 dermatologists during the same period, and an
extensive desk research that scrutinized over 100 publica-           • Non-Drug Products: through Medical Survey, we ex-
tions, articles, and industry reports. In particular, data collec-     amined the usage of non-drug products (e.g., make-up/
tion included a broad range of sources, including Real-World           concealer, self-tanners, sunscreen) within different patient



2                                                                            Review | Dermatol Pract Concept. 2023;13(4)S2:e2023315S
  classes. Other direct costs were also considered (e.g.,            In addition, an Italian ReS Real-World Evidence study [36]
  transportation expenses).                                       was considered. This study examined the number of patients
• Indirect Social Costs: our study included an estimation of      undergoing phototherapy treatment for vitiligo from 2013 to
  the time allocated for treating vitiligo and Mental Health      2018 and revealed that 0.06% of the patient population received
  comorbidities within each patient class. We also evaluated      such treatment during that period. Employing a bottom-up
  the influence of Mental Health comorbidities on employ-         methodology, we expanded the study’s scope to incorporate pa-
  ment status.                                                    tients who underwent phototherapy prior to 2013 or received
                                                                  alternative treatments, to ensure a complete understanding of
Results                                                           the vitiligo-diagnosed population. We then added undiagnosed
                                                                  cases (41%) [35] to derive a lifetime vitiligo prevalence rate of
Epidemiology                                                      0.55%, which is in line with that reported by literature.
Here we present eight Italian studies with a clear epidemio-         Considering that only 15% of vitiligo cases are
logic design [3,4,29-35].                                         Non-Segmental vitiligo (NSV) [37-40], we estimated a to-
   In the Praktis study, conducted between March 1, 2003,         tal of 279,000 NSV patients in Italy in 2022. Among these,
and April 30, 2004, a random sample of 12,483 Italian             152,000 received a diagnosis, with 33% classified as having
subjects aged 45 or older was collected and interviewed,          BSA <0.5% (Not Severe at all), 31% with BSA 0.5%-3.5%
showing a 0.6% lifetime prevalence of physician-diagnosed         (Mild), 27% with BSA 3.5%-10% (Moderate/Severe), and
vitiligo, with no difference according to gender and an in-       9% with BSA >10% (Very Severe) [41].
creasing prevalence with age [29].
   The Epienlist project, carried out by the Department of        Vitiligo Treatment Cost
Dermatology at the Italian Navy Hospital in Taranto, exam-        The costs of vitiligo treatment include all direct medical ex-
ined 23,468 potential conscripts in southern Italy, aged 18-21.   penses, including therapies, examinations, laboratory tests,
Those with skin lesions were referred to the hospital for diag-   and supplements. NSV treatment rate varies among patient
nosis. The point prevalence of vitiligo was 0.19% [3]. Qual-      segments. Treatment rate tends to be higher in more Severe
ity of life was assessed for 40 vitiligo patients, with a mean    forms of NSV: only 35% of Not Severe NSV patients receive
Dermatology Life Quality Index (DLQI) score of 1.82 [33].         treatment compared to 84% of Very Severe NSV patients.
Analysis revealed that only lesions on the hands (OR:6.32)        Within the same Moderate-Severe segment, adolescents and
and face (OR:5.03) significantly influenced the mean DLQI.        females exhibit a relatively higher treatment rate (81% and
   A survey of quality of life was conducted on 181 consec-       80% respectively) compared adult males (70%).
utive vitiligo patients at a single institution in Rome, using       For each patient class, treatment preferences were exam-
the Skindex-29 tool [30]. The problems more frequently ex-        ined through the Medical Survey: preferred options for cases
perienced were worry of the disease getting worse (60%),          of lower severity included topical corticosteroids and calci-
anger (37%), embarrassment (34%), depression (31%).               neurin inhibitors, while in Moderate-Severe cases, photother-
   Another survey of quality of life using DLQI was con-          apy and systemic corticosteroids were preferred (Figure 1).
ducted on a sample of 161 vitiligo patients referred to 9            To compute costs, we identified the most used molecules
dermatological departments in Italian hospitals [34]. The         and their average therapeutic regimens, and we distinguished
mean total DLQI score was 4.3 (SD±4.9; range: 0-22). In           between costs in private and public settings (Table 2). Ac-
multivariate analysis, DLQI >5 was associated with female         cording to the Medical Survey, 49.5% of patients are treated
gender, stability of the disease and involvement of the face at   in public, and 50.5% in private settings. Then, considering
disease onset.                                                    the specific needs of each class of NSV patients, we added
   In a survey conducted during spring 1997, a total of           costs for dermatologist and nutritionist examinations, blood/
3,179 schoolchildren attending secondary schools in Italy         urine tests, and supplements.
were assessed through a questionnaire filled in by their par-        Total medical costs for NSV patients amount to €80Mln
ents [31]. The reported prevalence of vitiligo was 0.06%.         and the large majority (95%) is covered by the patient. Costs
   The EDEN Fragrance study enrolled 2,035 randomly               consist of treatments (35%) and supplements (38%), fol-
sampled individuals aged 18 or older in Italy. Clinical ex-       lowed by medical examinations (23%) and lab tests (4%).
aminations and patch tests were conducted. The lifetime           The annual treatment cost per patient ranges from €208 for
prevalence of vitiligo was 0.4%, with no significant gender       Not Severe cases to €906 for Moderate/Severe adolescents.
difference [35].
   The prevalence of vitiligo in Italy, as determined by the      Autoimmune Comorbidities
studies, falls within the range of 0.19%-0.6%, increasing         In a retrospective study, 15.3% of patients with vitiligo had
with age.                                                         one or more significant comorbid autoimmune condition,



Review | Dermatol Pract Concept. 2023;13(4)S2:e2023315S                                                                          3
                          Table 1. Summarization of data from relevant Italian studies.
    First Author    Publication            Focus                   Study size                            Results
 Naldi [29]        2004             Lifetime              Random sample of 12,483         Lifetime prevalence 0.06% with no
                                    prevalence            Italian citizens aged >45       difference based on age and sex
 Ingordo [3]       2007             Point Prevalence      23,468 conscripts in            Point prevalence 0.19%
                                                          southern Italy, aged 18-21
 Sampogna [30] 2008                 Quality of life       181 consecutive vitiligo        Problems frequently experienced:
                                                          patients at a Roman             worry of getting worse (60%), anger
                                                          institution, using Skindex-29   (37%), embarrassment (34%),
                                                          tool, 12-item General           depression (31%). The prevalence of
                                                          Health Questionnaire            patients with probable depression or
                                                                                          anxiety was 39%
 Naldi [31]        2009             Risk factors          3,179 schoolchildren aged       Lifetime prevalence of vitiligo 0.6%
                                    and diseases          12-17 years
                                    associated with
                                    atopic dermatitis
 Ingordo [32]      2011             Autoimmunity in       40 conscripts with vitiligo     Circulating autoantibodies detected
                                    vitiligo              systematically assessed for     in 42.5% of subjects
                                                          autoantibodies and history
                                                          of immune-related disease
 Ingordo [33]      2012             Quality of life       40 conscripts with vitiligo     Mean total DLQI score 1.82
                                                          assessed through DLQI           (SD± 2.95; min/max: 0-13). The
                                                                                          localization on the hands (OR:6.32)
                                                                                          and on the face (OR:5.03) influenced
                                                                                          significantly the mean DLQI
 Ingordo [34]      2014             Quality of life       161 vitiligo patients           DLQI score 4.3 (SD ±4.9; range:
                                                          referred to dermatological      0-22). In multivariate analysis,
                                                          departments in Italy assessed   DLQI >5 was associated with female
                                                          by DLQI                         gender, stability of the disease over
                                                                                          time and involvement of the face at
                                                                                          disease onset
 Svensson [35]     2018             Lifetime              Random sample of 2,035          Lifetime prevalence of vitiligo
                                    Prevalence of         people aged >18 in Bergamo      0.4% with no significant difference
                                    vitiligo in a                                         according to gender
                                    survey on contact
                                    dermatitis




Figure 1. NSV Treatment Preference by Patient Class (%)



4                                                                          Review | Dermatol Pract Concept. 2023;13(4)S2:e2023315S
                                  Table 2. NSV treatment options costs (€, yearly).
                                                            Overall cost        Of which on patient            Of which on NHS
 Induction therapy CS systemic (± TCS)                             351                    192                            159
 Induction therapy TCS                                             291                    192                             99
 Induction therapy TCI                                             461                    236                            225
 Maintenance therapy TCS (lower dose)                               84                      55                            29
 Maintenance therapy TCI (lower dose)                              200                    102                             97
 UVB phototherapy (e.g., NB-UVB, excimer laser)                4,077                     3,947                           130
 UVB phototherapy + TCS or TCI                                 4,198                     4,014                           184
 PUVA                                                          4,373                     4,247                           125
 Candidate for surgery (scheduled/operated)                    2,488                        33                       2,454
 Depigmentation                                                    800                    800                              -



                      Table 3. Disease costs for selected autoimmune diseases (€, yearly).
                                                      Overall cost            Of which direct cost         Of which indirect cost
 Hypothyroidism                                             953                          250                           702
 Rheumatoid arthritis                                     12,341                        5,891                        6,450
 Inflammatory bowel disease                                3,032                        2,817                          215
 Lymphoma                                                 52,992                       47,004                        5,988
 Systemic lupus erythematosus                             18,574                        2,637                      15,937
 Seronegative arthritis                                   12,341                        5,891                        6,450
 Idiopathic thrombocytopenic purpura                       8,417                        7,294                        1,123
 Multiple sclerosis                                       38,000                       17,351                      20,649
 Pernicious anemia                                          393                          103                           289
 Myasthenia gravis                                        14,950                       12,160                        2,790



                                 Table 4. Direct costs associated to Mental Health.
                                           Overall cost                  Of which on patient               Of which on NHS
 Depression treatment                         2,879                              374                              2,504
                                           Overall cost                  Of which on patient               Of which on NHS
 Anxiety treatment                            2,431                              615                              1,816
                                           Overall cost                  Of which on patient               Of which on NHS
 Psychotherapy session                          76                                76                                ~0



with hypothyroidism and rheumatoid arthritis being the               Major Depressive Disorder (MDD) and anxiety (referred
most common [17]. Vitiligo patients incur direct and indirect        to as Generalized Anxiety Disorder, Social Phobia, Specific
costs due to autoimmune comorbidities [42-53]. Direct costs          Phobia, Post-Traumatic Stress Disorder, Agoraphobia, Ago-
include healthcare and non-healthcare costs (e.g., inpatient         raphobia with Panic Disorder and Panic Disorder) were the
care, drug costs, tests, transportation). Indirect costs include     most reported. Moreover, patients with vitiligo recur to psy-
productivity losses due to morbidity/mortality, borne by the         chotherapy more often than the general population.
individual, family, society, or the employer (e.g., sick leave,          We argue that the cost of mental health issues can be
early retirement). Indirect costs were assessed by the human         part of the overall cost of vitiligo. This is because the in-
capital approach (HCA) and the friction cost approach (FCA).         creased psychological distress in this group mostly arises
                                                                     from the difficulties caused by the disease itself. Therefore,
Mental Health Costs                                                  we collected literature evidence for direct costs of depression
According to a systematic review on psychosocial effects of          (i.e., costs for residential structures, psychiatry-related tests,
vitiligo [3,15,23,54,55], disorders including or related to          hospitalizations, antidepressants [55, 56]), costs for anxiety



Review | Dermatol Pract Concept. 2023;13(4)S2:e2023315S                                                                              5
                                             Table 5. NSV non-drug costs (€).
                                                       Cost of products                             Cost of products
                                                   (€ monthly per patient)                       (€ yearly per patient)
 Concealers/Make-up                                            13                                           150
 Self-tanners                                                  12                                           140
 Sunscreen                                                     46                                           285
                                                      Cost of transport                            Cost of transport
                                                       (€ for occasion)                          (€ yearly per patient)
 Transport for testing/examinations                             8                                           18-38
 Transport for phototherapy                                     6                                           824
 Transport for surgery                                         12                                            12



(drugs, hospitalizations, outpatient care, medical devices          value of the HC is approximated by the value of an individ-
[57,58]) and costs for public and private psychotherapy.            ual’s earning, so that the period of absence from work due to
    Factors associated with a higher burden of psychosocial         illness/treatment is considered and valued by the achievable
comorbidities include female sex, greater body surface area         gross income [59]. The HC method does not address the is-
involvement (i.e., severity), and younger age. Our analysis         sue of the categories not receiving any income (typically stay-
shows that Moderate-Severe NSV females are the group with           at-home spouses, unemployed and students) [60] and their
the highest spend in Mental Health (1,171€/year), followed          inclusion in indirect costs computation is at the researcher’s
by Very Severe NSV (1,157€/year) and Moderate-Severe                discretion. To address the limits of HC method, in this study
older males (1,145€/year). Interestingly, another group af-         we valued the “unemployed lost time” at the value of gov-
fected by vitiligo-induced Mental Health issues are the care-       ernmental unemployed benefit (NASpI [61]); “Inactive care-
givers of children and adolescents, spending approximately          givers’ time” at the value of minimum domestic labor wage;
1,062€/year. The group spending less on Mental Health is            “Time lost out of working time for vitiligo treatment”
children (642€/year), who are mostly unaware of their phys-         (e.g., ointment application, make-up) at the value of willing-
ical appearance. ￼                                                  ness to pay for an additional hour of leisure time vs. unpaid
                                                                    work [62], assuming that the burden of treatment is compa-
Non-Drug Costs                                                      rable to unpaid work. The data for this section comes from
Non-drug costs consist in purchases of skin products for vit-       scientific publications, public entities’ websites (e.g., INPS),
iligo (e.g., professional concealers, sunscreen) exceeding the      statistics institutes (e.g., INSTAT).
usual expenses associated with standard skincare, and trans-           Our analysis shows that the indirect costs associated to
port costs specifically related to vitiligo disease (e.g., trans-   vitiligo amount to €91Mln/year: 30% of this cost (€31Mln)
port to reach phototherapy center). Research shows that             is associated to Mental Health (for either productivity loss
make-up and concealers are mostly used by Moderate/Severe           related to treatment time or unemployment). The annual in-
NSV females (65%), followed my Mild NSV cases (55%)                 direct social cost per diagnosed patient ranges from €288 for
and Moderate/Severe NSV adolescents (55%); sunscreen is             Not Severe cases to €1,182 for Moderate-Severe older males.
widely used across patient classes, up to 95% among Very
Severe cases.
                                                                    Conclusions
    The non-drug annual cost for diagnosed patient ranges
from 117€/year for Not Severe cases to 789€/year for                In summary, data indicate that vitiligo prevalence increases
­Moderate/Severe women.                                             with age in Italy, ranging from 0.19% at 18-21 years to
                                                                    0.6% after age 45. Real World Evidence-based prevalence
Indirect Costs                                                      was estimated at 0.55%. These figures align with the find-
NSV patients lose time managing their condition, giving up          ings reported in systematic reviews and recent studies.
both work and leisure time. Additionally, NSV patients lose            Analyzing five cost components, the annual social cost of
time due to mental health comorbidities, either for treat-          vitiligo in Italy is €500 million, with costs per patient rang-
ment (e.g., psychotherapy) or due to disabling symptoms             ing from €2,200 to €4,600/year. Patients bear 55% of the
(e.g., hospitalizations, lost workdays).                            cost, the NHS covers 18%, and 27% is borne by society. This
    To assess indirect cost due to productivity loss, we opted      distribution results in significant inequity, with over half of
for the human capital (HC) approach, which states that the          the social cost being paid directly by patients or caregivers.



6                                                                           Review | Dermatol Pract Concept. 2023;13(4)S2:e2023315S
References                                                                   20. Ezzedine K, Eleftheriadou V, Jones H, Bibeau K, Kuo F, Sturm D,
                                                                                 Pandya A EADV 2020. Poster P1239 (Paris, France) Prevalence
 1. Ezzedine K, Eleftheriadou V, Whitton M, van Geel N. Vitiligo.                of Psychosocial Comorbidities in Vitiligo: A Systematic Litera-
    Lancet. 2015; 386:74-84.                                                     ture Review
 2. Bergqvist C, Ezzedine K. Vitiligo: A focus on pathogenesis and its       21. Firooz A, Bouzari N, Fallah N, Ghazisaidi B, Firoozabadi MR,
    therapeutic implications. J Dermatol. 2021; 48:252-270.                      Dowlati Y. What patients with vitiligo believe about their con-
 3. Ingordo V, Gentile C, Iannazzone SS, Cusano F, Naldi L. The                  dition. International journal of dermatology. 2004; 43(11),
    ­‘EpiEnlist’ project: a dermo-epidemiologic study on a representa-           811-814.
     tive sample of young Italian males. Prevalence of selected pigmen-      22. Zhang Y, Cai Y, Shi M, et al. The Prevalence of Vitiligo: A Meta-
     tary lesions. J Eur Acad Dermatol Venereol. 2007 Sep;21(8):1091-6.          Analysis. 2016; PLoS ONE 11(9): e0163806. doi:10.1371/
 4. Naldi L, Parazzini F, Gallus S; GISED Study Centres. Prevalence              journal.pone.0163806.
     of atopic dermatitis in Italian schoolchildren: factors affecting its   23. Osinubi O, Grainge MJ, Hong L, Ahmed A, Batchelor JM,
     variation. Acta Derm Venereol. 2009; 89:122-5.                              ­Grindlay D, Thompson AR, Ratib S. The prevalence of psycho-
 5. Lai YC, Yew YW, Kennedy C, Schwartz RA. Vitiligo and depres-                  logical comorbidity in people with vitiligo: a systematic review
     sion: a systematic review and meta-analysis of observational                 and meta-analysis. Br J Dermatol. 2018; 178:863-878.
     studies. Br J Dermatol. 2017; 177:708-718.                              24. Liu CW, Huang YC. Vitiligo and autoantibodies: a system-
 6. Wang G, Qiu D, Yang H, Liu W. The prevalence and odds of                      atic review and meta-analysis. J Dtsch Dermatol Ges. 2018;
     depression in patients with vitiligo: a meta-analysis. J Eur Acad            16:845-851.
     Dermatol Venereol. 2018; 32:1343-1351.                                  25. Saikarthik P, Reddy VH, Rafi SM, Basha VW, Padmakar S. A
 7. Kussainova A, Kassym L, Akhmetova A, et al. Vitiligo and                      Systematic Review on Prevalence and Assessment of Sexual Dys-
     anxiety: A systematic review and meta-analysis. 2020; PLoS
     ­                                                                            function in Vitiligo. J Assoc Physicians India. 2022; 70:11-12.
     ONE 15(11): e0241445.                                                   26. Xia J, Melian C, Guo W, Usmani H, Clark R, Lozeau D. ­Vitiligo
 8. Ezzedine K, Eleftheriadou V, Jones H, et al. Psychosocial Effects             and Metabolic Syndrome: Systematic Review and Meta-­Analysis.
     of Vitiligo: A Systematic Literature Review. Am J Clin Dermatol.            JMIR Dermatol. 2022 Mar 16; 5(1):e34772.
     2021; 22:757-774.                                                       27. Kang P, Zhang WG, Ji ZH, Shao ZJ, Li CY. Association between
 9. Picardo M, Huggins RH, Jones H, Marino R, Ogunsola M,                        vitiligo and relevant components of metabolic syndrome: a sys-
     ­Seneschal J. The humanistic burden of vitiligo: a systematic lit-          tematic review and meta-analysis. J Dtsch Dermatol Ges. 2022;
      erature review of quality-of-life outcomes. J Eur Acad Dermatol            20:629-641.
      Venereol. 2022; 36:1507-1523.                                          28. Rooker A, Ouwerkerk W, Bekkenk MW, Luiten RM, Bakker
10. Rodrigues M. Skin cancer risk (nonmelanoma skin cancers/­                    WJ. The Risk of Keratinocyte Cancer in Vitiligo and the Po-
      melanoma) in vitiligo patients. Dermatologic clinics, 2017, 35.2:          tential Mechanisms Involved. J Invest Dermatol. 2023 Oct 2;
      129-134.Silverberg N.B. et al. 2010                                        S0022-202X(23)02566-6.
11. Gawkrodger DJ, Ormerod AD, Shaw L, et al. Guideline for the              29. Naldi L, Colombo P, Placchesi EB, et al. Study design and pre-
      diagnosis and management of vitiligo. British Journal of Derma-            liminary results from the pilot phase of the PraKtis study: self-­
      tology. 2008; 159(5), 1051-1076.                                           reported diagnoses of selected skin diseases in a representative
12. Bergqvist C, and Ezzedine K Vitiligo: a review. Dermatology                  sample of the Italian population. Dermatology. 2004; 208:38-42.
      236.6. 2020; 571-592.                                                  30. Sampogna F, Raskovic D, Guerra L, Pedicelli C, Tabolli S, Leoni
13. A Taieb, A Alomar, M Böhm, et al. Guidelines for the manage-                 L, Alessandroni L, Abeni D. Identification of categories at risk
      ment of vitiligo: the European Dermatology Forum consensus,                for high quality of life impairment in patients with vitiligo. Br J
      Br J Dermatol 2013 Jan;168(1):5-19                                         Dermatol. 2008; 159:351-9.
14. Krüger C, Schallreuter KU. A review of the worldwide prevalence          31. Naldi L, Parazzini F, Gallus S; GISED Study Centres. Prevalence
      of vitiligo in children/adolescents and adults. International jour-        of atopic dermatitis in Italian schoolchildren: factors affecting its
      nal of dermatology 51.10. 2012; 1206-1212.                                 variation. Acta Derm Venereol. 2009; 89:122-5.
15. Ezzedine K, Seneschal J, Da Silva A, et al. Vitiligo patient popu-       32. Ingordo V, Gentile C, Iannazzone SS, Cusano F, Naldi L. Vitiligo
    lation and disease burden in France: VIOLIN study results from               and autoimmunity: an epidemiological study in a representative
    the CONSTANCES cohort. J Eur Acad Dermatol Venereol. 2023                    sample of young Italian males. J Eur Acad Dermatol Venereol.
    Aug 21; Epub ahead of print                                                  2011; 25:105-9.
16. Picardo M, Dell’Anna ML, Ezzedine K., et al. Vitiligo Nature             33. Ingordo V, Cazzaniga S, Gentile C, Iannazzone SS, Cusano F,
    Reviews Disease Primers, 15011 (2015)                                        Naldi L. Dermatology Life Quality Index score in vitiligo pa-
17. Hadi A, Wang JF, Uppal P, Penn LA, Elbuluk N. Comorbid dis-                  tients: a pilot study among young Italian males. G Ital Dermatol
    eases of vitiligo: a 10-year cross-sectional retrospective study of          Venereol. 2012; 147:83-90.
    an urban US population. Journal of the American Academy of               34. Ingordo V, Cazzaniga S, Medri M, et al. To what extent is quality
    Dermatology. 2020; 82(3), 628-633.                                           of life impaired in vitiligo? A multicenter study on Italian pa-
18. Teasdale E, Muller I, Sani AA, Thomas KS, Stuart B, Santer M.                tients using the dermatology life quality index. Dermatology.
    Views and experiences of seeking information and help for                    2014; 229:240-7
    ­vitiligo: a qualitative study of written accounts. BMJ open. 2018;      35. Svensson A, Ofenloch RF, Bruze M, et al. Prevalence of skin dis-
     8(1), e018652.                                                              ease in a population-based sample of adults from five European
19. Radtke MA, Schäfer I, Gajur A, Langenbruch A, & Augustin M.                  countries. Br J Dermatol. 2018; 178:1111-1118.
     Willingness‐to‐pay and quality of life in patients with vitiligo.       36. Martini N., et al. Real World Evidence (RWE) analysis of vitiligo
     British Journal of Dermatology. 2009; 161(1), 134-139.                      patients. 2022




Review | Dermatol Pract Concept. 2023;13(4)S2:e2023315S                                                                                            7
37. Hann SK, Lee HJ. Segmental vitiligo: clinical findings in             50. Vidal-Alaball J, Butler CC, Potter CC. Comparing costs of intra-
    208 ­patients. Journal of the American Academy of Dermatology.            muscular and oral vitamin B12 administration in primary care: a
    1996; 35(5), 671-674.                                                     cost-minimization analysis. Eur J Gen Pract. 2006; 12(4):169-73.
38. Silverberg JI, Silverberg AI, Malka E, Silverberg NB. A pilot study   51. Khellaf M, Le Moine JG, Poitrinal P, et al. Costs of managing
    assessing the role of 25 hydroxy vitamin D levels in patients with        severe immune thrombocytopenia in adults: a retrospective anal-
    vitiligo vulgaris. Journal of the American Academy of Dermatol-           ysis. Ann Hematol. 2011 Apr; 90(4):441-6. PMID: 20922528.
    ogy. 2010; 62(6), 937-941.                                            52. Mounié M, Costa N, Conte C, et al. Real-world costs of illness
39. Lin Z, Tian Y, Bai B, et al.. Comprehensive survey of vitiligo pa-        of Hodgkin and the main B-Cell Non-Hodgkin lymphomas in
    tients in the northeast of China using a predesigned question-            France. J Med Econ. 2020 Mar; 23(3):235-242. Epub 2019 Dec
    naire. The Journal of Dermatology. 2018; 45(1), 39-45.                    26. PMID: 31876205.
40. Lotti T, et al. Linee guida e raccomandazioni SIDeMaST: Vitilig-      53. Principi M, Labarile N, Bianchi FP, et al. The Cost of Inflamma-
    ine. 2022.                                                                tory Bowel Disease Management Matches with Clinical Course:
41. Van Geel N, Uitentuis SE, Zuidgeest M, et al. Validation of a Pa-         A Single Outpatient Centre Analysis. Int J Environ Res Public
    tient Global Assessment for extent, severity and impact to define         Health. 2020 Jun 24; PMCID: PMC7344991.
    the severity strata for the Self Assessment Vitiligo Extent Score     54. De Girolamo G, Polidori G, Morosini P, et al. Prevalence of com-
    (SA‐VES). Journal of the European Academy of Dermatology                  mon mental disorders in Italy: results from the European Study
    and Venereology. 2021; 35(1), 216-221.                                    of the Epidemiology of Mental Disorders (ESEMeD). Soc Psychi-
42. Sobocki P, Pugliatti M, Lauer K, Kobelt G. Estimation of the cost         atry Psychiatr Epidemiol. 2006 Nov; Epub 2006 Aug 16. PMID:
    of MS in Europe: extrapolations from a multinational cost study.          16915360.
    2007                                                                  55. Perrone V, Sangiorgi D, Andretta M, et al. Healthcare Resource
43. Doria A, Amoura Z, Cervera R, et al. Annual direct medical cost           Consumption and Related Costs of Patients Estimated with
    of active systemic lupus erythematosus in five European coun-             Treatment-Resistant Depression in Italy. Clinicoecon Outcomes
    tries. Annals of the rheumatic diseases. 2014; 73(1), 154-160.            Res. 2021 Jul 5; PMCID: PMC8275098.
44. Jönsen A. et al. Direct and indirect costs for systemic lupus er-     56. Ruggeri M, Drago C, Mandolini D, Francesa Morel P, Mencacci
    ythematosus in Sweden. A nationwide health economic study                 C, Starace F. The costs of treatment resistant depression: evidence
    based on five defined cohorts. 2015                                       from a survey among Italian patients. Expert Review of Pharma-
45. Møllehave LT, Linneberg A, Skaaby T, et al. Trends in Costs               coeconomics & Outcomes Research. 2022; 437-444.
    of Thyroid Disease Treatment in Denmark during 1995-2015.             57. Pugliatti M, Sobocki P, Beghi E, et al. Cost of Disorders of the
    ­European Thyroid Journal. 2018; 7(2), 75-83.                             Brain in Europe” Study Group. Cost of disorders of the brain
46. Vadziuk I, Klishch I, Markiv I. 12-month cost of illness analysis         in Italy. Neurol Sci. 2008 Apr; Epub 2008 May 16; PMID:
     of the thyroid disease in Ukraine. PubMed 2013                           18483707.
47. Benucci M, Rogai V, Atzeni F, Hammen V, Sarzti-Puttini P,             58. Adnkronos Sanità, 2019
     ­Migliore A. Costs associated with rheumatoid arthritis in Italy:    59. Kirch, W Encyclopedia of Public Health: Volume 1: A-H Volume
      past, present, and future. ClinicoEconomics and Outcomes Re-            2: I-Z. Springer Science & Business Media. 2008
      search. 2016; 33-41.                                                60. Garattini L, Ghislandi S, Tediosi F. L’inclusione dei costi indi-
48. Landfeldt E, Pogoryelova O, Sejersen T, Zethraeus N, Breiner A,           retti nelle valutazioni economiche: la situazione italiana. CESAV.
      Lochmüller H. Economic costs of myasthenia gravis: a system-            2000.
      atic review. Pharmacoeconomics. 2020; 38, 715-728.                  61. Nuova Assicurazione Sociale per l’Impiego (NASpI), ISTAT
49. Schepelmann K, Winter Y, Spottke AE, et al. Socioeconomic                 website
      burden of amyotrophic lateral sclerosis, myasthenia gravis and      62. Verbooy K, Hoefman R, van Exel J, Brouwer W. Time Is Money:
      facioscapulohumeral muscular dystrophy. Journal of neurology.           Investigating the Value of Leisure Time and Unpaid Work. Value
      2010; 257, 15-23.                                                       Health. 2018 Dec; Epub 2018 Jul 14. PMID: 30502787.




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