The Quality of Life in Patients with Chronic Urticaria

Background: Chronic skin urticaria (CU) is a type of skin illness that is characterized by pruritus, angioedema, or wheals for longer than six weeks. It has a major impact on patients quality of life. Study aim: To identify the impact of chronic skin urticaria on the patients quality of life. Study setting: Erbil Dermatology Teaching Center. Study sample: One hundred and three patients, above 16 years of both sexes who were having chronic urticaria were included in the study sample. Study design: A case series research was used in this study. Study period: The study was conducted from the first of March 2021 to the end of January 2022. Data collection: All patients were interviewed by the researcher using a specially designed questionnaire sheet and the needed information was filled by the researcher. These information include age, gender, education, occupations, residence, marital status, and skin types in addition to the DLQI questionnaire which was downloaded from Cardiff University website. There are 10 questions or items in the DLQI questionnaire, which are further subdivided into six subdomains of life. Result: The score mean of DLQI was (9.3±4.37); 24 (23.3%) CU patients have a low effect, 39 (37.9%) with moderate effect and 40 (38.8%) patients have high effects. The mean DLQI score was higher among self employed patients and lower among retired patients and higher among CU patients were visiting more than two doctors and among patients who receiving treatment. Conclusion: Chronic skin urticaria has commonly moderate effect on the patients’ quality of life and affected by occupation, severity of disease, and treatment. Recommendations: This study recommended that the physician should adopt an integral plan in management of CU taking in consideration mental and social wellbeing of patients. Additionally, more national researches on the QoL of CU patients must be maintained.


INTRODUCTION
ruritus with abrupt and recurrent bouts of angioedema, wheals, or may be both which extended beyond the six weeks duration is referred to as chronic urticaria (CU) 1 . Chronic urticaria is supposed to affect 1% of the people worldwide 2 .
Chronic urticaria is predicted to affect 2.4 percent of people in rural Nepal, according to a research 3 .
According to the current research, urticaria has a significant influence on both objective and subjective well-being in sufferers [4][5][6] . Chronic urticaria patients' health status scores were comparable to those of patients with coronary artery disease 7 , indicating that the disease had a significant consequence on the quality of life of patients 8 .
When compared to other dermatological illnesses, persistent urticaria can have similar effects on LQ as acne and psoriasis 9 . Acute urticaria (less than 6 weeks in duration and generally resolves within hours to days) and CU (more than 6 weeks in duration, with daily wheals or episodic) are the two types of urticaria 10 . CU can be spontaneous in origin or inducible, depending on whether the skin lesions arise on their own or are triggered by a specific trigger; both forms can coexist 1,11 . Chronic spontaneous urticaria (CSU) is distinguished by the presence of wheals with or without angioedema for a period of six weeks or more 12 .
The prevalence of CSU in the United States and internationally, is estimated to be between 0.23 percent and 1.8 percent of the population 13 . There is a pronounced feminine bias, with women being affected twice as often as males 14 . Children and adults are both afflicted; with the prevalence among individuals between the ages of 40 and 60 of the highest rate. The CSU is diagnosed mostly through blood tests for complete blood count and C-reactive protein and/or erythrocyte sedimentation rate, which are used to exclude further disorders 15 .
The CSU can have a chief consequence on a patient's QoL 6,15 . The consequences of CSU on patients' QoL should not be overlooked, and counseling and psychotherapy can sometimes have a significant impact on these patients' overall health outcomes 16 .
The Dermatology Life Quality Index (DLQI) was the primary dermatology-specific tool established to assess the consequences of skin diseases in a person's life based on the preceding seven days' experiences 7 . It is a validated instrument of measuring the QoL and has been used to over 30 different skin diseases 17,18 . It also evaluates the efficiency of treatments or interventions in CU patients 7 . There are limited studies conducted about the QoL in patients with CU in Kurdistan Region and in Iraq. The aim of this study is to measure the DLQI score to assess the effect of CU on the QoL of patients attending Erbil Dermatology Teaching Center.

PATIENTS AND METHODS
A case series research design was used in this study. The study carried out from the 1st of March 2021 to the 1st of February 2022. One hundred and three patients, above 16 years of both sexes who were having chronic urticaria were included in the study sample. The sample was taken from patients attending Erbil Dermatology Teaching Center. The participants in study were interviewed by the investigator about the aim and purposes of the study and were agreed to participate.
All patients who were 16 years or more and clinically diagnosed with CSU were included in this study. Exclusion criteria were patients less than 16 years old, patients complaining from only chronic inducible urticaria or angioedema and patients with other chronic diseases that may affect the QoL. The assessment of the patients done through a questionnaire sheet prepared and filled by the researcher. The designed questionnaire of this study is based on Dermatology Life Quality Index (DLQI) questionnaire along with socio-demographic questions and other specific questions about the topic. The DLQI questionnaire was downloaded from Cardiff University website 19 . There are 10 P questions or items in the DLQI questionnaire, which are further subdivided into six subdomains of life. Symptoms and feelings are addressed in items 1 and 2, everyday activities are addressed in items 3 and 4, leisure is addressed in items 5 and 6, job and school is addressed in item 7, personal affiliations are addressed in items 8 and 9, and management is addressed in item 10. 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 include a fifth option, "not relevant" which is scored as 0. The DLQI can have a maximum value of 30. A higher score suggests a higher level of quality of life impairment. The scores are alienated into five categories for simplicity of understanding, each signifying a distinct level of disease severity. In summary, a total score of 0-1 indicates no influence on the patient's quality of life; 2-5, a minor effect; 6-10, a moderate effect; 11-20, a very big effect; and 21-30, an extremely huge effect. The Hawler Medical University's ethics committee/ College of Medicine approved the trial, and the Erbil Directorate of Health provided a letter of facilitation. Each participant was given a comprehensive explanation of the study's purpose before giving their informed verbal consent during the direct interview with the researcher. This data will be kept confidential. The CU patients' information were recorded and analyzed statistically by statistical package of social sciences (SPSS) software version 26. Suitable statistical tests (unpaired t-test for independent sample and one way ANOVA analysis) were used for analysis of means of DLQI score accordingly with p value of ≤0.05 as significant.

RESULTS
In this study, one hundred and three patients with chronic urticaria (CU) were enrolled with mean age of (37.9±12.2 years) and range of (16-68 years); 8.7% of them were in age of less than 20 years, 14.6% of them were in age group 20-29 years, 24.2% of them were in age group of 30-39 years, 37.9% of them were in age group of 40-49 years, 9.7% of them were in age group of 50-59 years and 4.9% of them were in age of 60 years and more. Female patients with CU were more than males (64.1% vs. 35.9%). The educational level of CU patients was distributed as followings; illiterate (29.1%), primary level (29.1%), secondary level (25.3%) and college/institute (16.5%).
About half of CU patients were housewives, 19.4% of them were self employed, 16.5% of them were public employees, 10.7% of them were students and 2.9% of them were retired. The residence of CU patients was urban for 62.1% of them and rural for 37.9% of them. The marital status was single in 19.4% of CU patients, married in 78.7% of them and widow in 1.9% of them. The skin types of CU patients were normal in 59.2% of them, dry in 20.4% of them and oily in 20.4% of them (Table 1). The answers for DLQI score questions were mostly higher (very much) for question 1 (49.5%), while high prevalence of a lot answer in questions 7 (50%), 1 (39.8%) and 2 (31.1%) and high prevalence of a little answer in question 3 (25.3%).  Figure 1).    *One way ANOVA was used, **t-test for independent two means was used As shown in table (5); the mean DLQI score was significantly higher among CU patients were visiting more than two dermatologists (p=0.01). The mean DLQI score was significantly higher among CU patients were receiving treatment, while lower among patients not receiving treatment (p=0.01). 0.01** Present 9.6 (4.6) *One way ANOVA, **t-test for independent two means

DISCUSSION
The CU is an allergic dermatological disease with uncertain etiology and complex treatment. The QoL for CU patients is important to evaluate the general health status of patients and assessing the effect of treatment 20 . The current work showed that means score of DLQI was (9.3±4.37). This finding is close to results of Paudel et al 7 retrospective study of 7 in Nepal on 149 patients with CU which found that the mean score of DLQI for CU patients was (8.3±0.55). However, the mean score of DLQI for the current work is better than the results of Silvares et al 21 31 in Italy found a profound socioeconomic burden by chronic urticaria and treatment of chronic urticaria lead to better work productivity. Many authors reported the social strain facing CU patients in their life and work which expressed in different psychological problems like anxiety and stress that lead to declination of health related QoL and sometimes to treatment non-compliance and refractory urticaria cases [32][33][34] .
The current study showed that mean score of DLQI was significantly higher among CU patients were visiting more than two doctors (p=0.01). This finding is matching with results of Maurer et al 35 study in Germany which found a significant impact of CU quality of life and the satisfaction of CU patients and their relationship with the physicians. Additionally, a multicenter study conducted in Italy by Rimoldi et al 36 stated that a defect either in implementing guidelines or in quality of life of CU patients lead to low satisfaction and defective patients-physicians relationship. However, increased DLQI score with increased doctors visits might be attributed to severe and refractory cases of chronic urticaria. The mean DLQI score in current study was higher among CU patients receiving treatment in a statistically significant way, while lower among patients not receiving treatment (p=0.01). This finding is inconsistent with results of Weller et al 37 research in Germany which found that mean DLQI score was significantly decreased after treatment. This discrepancy could be related to fact that patients who received treatment were severe cases of CU. Similarly, Dias et al 38 cross sectional research in Brazil on 112 patients with chronic urticaria revealed a direct relationship between large effect on QoL and severe cases of chronic urticaria. Costa et al 39 study in Portugal exposed that CU had a great impact on quality of life in patients' refractory to anti-histamine treatment.

CONCLUSION
The chronic urticaria has commonly moderate to very large consequence on QoL for patients. The QoL for CU patients is affected by occupation of patients, severity of disease and treatment.

RECOMMENDATIONS
This study recommended: 1. The physician should adopt an integral plan in management of CU taking in consideration mental and social wellbeing of patients. 2. More national researches on the QoL of CU patients must be maintained.