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Dermatology Life Quality Index

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The Dermatology life Quality Index (DLQI) is a ten-question questionnaire used to measure the impact of skin disease on the quality of life of an affected person. It is designed for people aged 16 years and above.

History

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The DLQI was created by Andrew Y Finlay and Gul Karim Khan from 1990 to 1994 at the Department of Dermatology, University of Wales College of Medicine (now Cardiff University), Cardiff, UK.[1] 120 patients with a variety of skin diseases completed a questionnaire that asked them to write down all of the ways that their skin disease affected their lives. 49 different ways were identified, and these were used as the basis of the questions of the DLQI.[2]

The DLQI was first presented at the British Association of Dermatologists annual meeting in July 1993[3] and described in an article published in 1994 in Clinical and Experimental Dermatology.[4] This article has become one of the most frequently cited articles in clinical dermatology.[5] The DLQI is the most frequently used method for evaluating quality of life for patients with different skin conditions.[6]

Questionnaire description

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There are 10 questions, covering the following topics: symptoms, embarrassment, shopping and home care, clothes, social and leisure, sport, work or study, close relationships, sex, treatment. Each question refers to the impact of the skin disease on the patient’s life over the previous week.[7]

Language availability

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The DLQI has been translated into over 140 languages. The full translations are available at the Cardiff University Department of Dermatology website.[8]

Scoring

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Each question is scored from 0 to 3, giving a possible score range from 0 (meaning no impact of skin disease on quality of life) to 30 (meaning maximum impact on quality of life).

Meaning of DLQI scores

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A series of validated “band descriptors” were described in 2005 to give meaning to the scores of the DLQI.[9]

These bands are as follows: 0-1 = No effect on patient’s life, 2-5 = Small effect, 6-10 = Moderate effect, 11-20 = Very large effect, 21-30 = Extremely large effect.

The Minimal Clinically Important Difference (MCID) is the score difference that is the minimum meaningful difference for a patient. Although previously considered to be 5,[10] the DLQI MCID for inflammatory skin diseases should be considered to be a score difference of 4.[11]

Conversion to EQ-5D scores

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DLQI scores can be converted to EQ-5D utility values.[12]

Uses of DLQI

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Clinical practice

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The DLQI can provide clinicians with more accurate insight into the impairment of quality of life experienced by individual patients. This may lead to more appropriate clinical decisions.[13] The DLQI can also be used when required by national guidelines, for example in the management of psoriasis[14] or hand eczema.[15]

Guidelines

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The DLQI is recommended for use in national treatment guidelines, and to assist management decisions,[16] in many countries, including: Australia,[17] Canada,[18] Bulgaria,[19] Croatia,[19] Czech Republic,[19] England and Wales,[20] Europe,[21] Germany,[22] Hungary,[19] Italy,[23] Japan, [24] Norway,[25] Poland,[19] Romania,[19] Saudi Arabia,[26] Scotland,[27] Singapore,[28] South Africa,[29] Spain,[30] Sweden,[31] Switzerland,[32] Taiwan,[33] Turkey[34] and Venezuela.[35]

Research

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The DLQI has been used as a patient reported outcome measure in many published clinical research studies.[36] For example, it has been used to assess novel drugs,[37] models of clinical care, in audit of clinical services and in assessment of teledermatology.[36] The DLQI is the most widely used quality of life outcome measure in randomised controlled trials of therapies for psoriasis.[38]

Rule of Tens

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The Rule of Tens is a concept to aid clinicians in making the diagnosis of “severe psoriasis”.[39] It states that a patient is considered to have “severe psoriasis” if their body surface area affected is >10%, or if their Psoriasis Area and Severity Index (PASI) score is >10, or if the DLQI score is >10.[39] The Rule of Tens has influenced national guidelines concerning the criteria to be fulfilled before starting a patient on biological therapy.[14]

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The DLQI is copyrighted but the originators allow it to be used for routine clinical purposes without seeking permission and without charge.[8]

E-delivery

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The DLQI has been validated for use on tablets such as the iPad.[40]

Systematic reviews of DLQI usage

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Several systematic reviews have been carried out documenting the use of the DLQI.

The DLQI has been used as an outcome measure in 454 randomised controlled trials, involving 69 diseases and 43 countries.[41] In 24 randomised control trials the DLQI was used as a primary outcome measure.[42] The DLQI has been used as a benchmark in the validation of 101 quality of life instruments.[43]

A systematic review of 207 studies has described aspects of the validation of the DLQI.[44] The 207 articles included 58,828 patients from >49 different countries and 41 diseases met the inclusion criteria. The DLQI demonstrated strong test–retest reliability; 43 studies confirmed good internal consistency, Twelve studies used anchors to assess change responsiveness with effect sizes from small to large, giving confidence that the DLQI responds appropriately to change. Forty-two studies tested known-groups validity, providing confidence in construct and use of the DLQI over many parameters, including disease severity, anxiety, depression, stigma, scarring, well-being, sexual function, disease location and duration.

References

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  1. ^ Finlay AY, Khan GK. "The Dermatology Life Quality Index: A simple practical measure for routine clinical use". British Association of Dermatologists Annual Meeting, Oxford, July 1993. British Journal of Dermatology, 1993; 129 (Suppl 42): 27.
  2. ^ Finlay AY, Khan GK. "Dermatology Life Quality Index (DLQI) - a simple practical measure for routine clinical use". Clinical and Experimental Dermatology, 1994; 19: 210-216.
  3. ^ Finlay AY, Khan GK. "The Dermatology Life Quality Index: A simple practical measure for routine clinical use". British Association of Dermatologists Annual Meeting, Oxford, July 1993. British Journal of Dermatology, 1993; 129 (Suppl 42): 27.
  4. ^ Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) - a simple practical measure for routine clinical use. Clinical and Experimental Dermatology, 1994; 19: 210-216.
  5. ^ Anstey A, Reynolds NJ. "What does the BJD now stand for? A position statement". British Journal of Dermatology 2015; 172: 1463-1465.
  6. ^ World Health Organisation. Global report on psoriasis. ISBN 978 92 4 156518 9. WHO Press, Geneva, 2016, p16.
  7. ^ "Quality of life questionnaires".
  8. ^ a b Cardiff University Department of Dermatology website www.cardiff.ac.uk/medicine/resources/quality-of-life-questionnaires/dermatology-life-quality-index
  9. ^ Hongbo Y, Thomas CL, Harrison MA. Salek MS, Finlay AY. Translating the science of quality of life into practice: what do Dermatology Life Quality Index scores mean? Journal of Investigative Dermatology 2005; 125: 659-664.
  10. ^ Khilji FA, Gonzalez M, Finlay AY. Clinical meaning of change in Dermatology Life Quality Index scores. British Journal of Dermatology 2002; 147 (Suppl 62): 50.
  11. ^ Basra MK, Salek MS, Camilleri I, Sturkey R, Finlay AY. "Determining the minimal clinically important difference and responsiveness of the Dermatology Life Quality Index (DLQI): further data". Dermatology 2015: 230 (1): 27-33.
  12. ^ Ali FM, Kay R, Finlay AY, Piguet V, Kupfer J, Dalgard F, Salek MS. Mapping of the DLQI TO EQ-5D Utility Values using ordinal logistic regression. Quality of Life Research 2017 (in press)
  13. ^ Salek S, Roberts A, Finlay AY. "The practical reality of using a patient-reported outcome measure in a routine dermatology clinic". Dermatology 2007; 215: 315-319.
  14. ^ a b Smith CH, Anstey AV, Barker JNWN, Burden AD, Chalmers RJG, Chandler DA, Finlay AY, Griffiths CEM, Jackson K, McHugh NJ, McKenna KE, Reynolds NJ, Ormerod AD. "British Association of Dermatologists’ guidelines for biologic interventions for psoriasis" 2009. British Journal of Dermatology 2009; 161: 987-1019.
  15. ^ Basra MK, Chowdhury MM, Smith EV, Freemantle N, Piguet V. "A review of the use of the dermatology life quality index as a criterion in guidelines and health technology assessments in psoriasis and hand eczema". Dermatol Clin 2012; 30: 237-44.
  16. ^ Mrowietz U, Kragballe K, Reich K et al. Definition of treatment goals for moderate to severe psoriasis: a European consensus. Arch Derm Res 2011; 303; 1-10.
  17. ^ Baker C, Mack A, Cooper A, Fischer G, Shumack S, Sidhu S, Soyer P, Wu J, Chan J, Nash P, Rawlin M, Radulski B, Foley P. Treatment goals for moderate to severe psoriasis: An Australian consensus. Australas J Dermatol. 2013; 54: 148-154.
  18. ^ Adams SP, Albrecht L, Barankin B et al. Canadian guidelines for the management of plaque psoriasis: overview. J Cutan Med Surg 2011:15; 210-219.
  19. ^ a b c d e f Rencz F, Kemény L, Gajdácsi JZ, Owczarek W, Arenberger P, Tiplica GS, Stanimirović A, Niewada M, Petrova G, Marinov LT, Péntek M, Brodszky V, Gulácsi L. Use of biologics for psoriasis in Central and Eastern European countries. J Eur Acad Dermatol Venereol. 2015;29(11):2222-30.
  20. ^ NICE guidelines: Psoriasis: Infliximab TA134 (2008), pages 4,6,8-13,15-16, available at http://www.nice.org.uk/nicemedia/live/11910/38954/38954.pdf Archived 2012-05-12 at the Wayback Machine.
  21. ^ Pathirana D, Ormerod AD, Saiag P et al. European S-3 guidelines on the systemic treatment of psoriasis vulgaris. J Eur Acad Dermatol Venereol 2009; 23 (Suppl 2): 1-70.
  22. ^ Nast A, Kopp IB, Augustin M, et al. Evidence-based (S3) guidelines for the treatment of psoriasis vulgaris. J Dtsch Dermatol Ges 2007;5 Suppl 3:1-119.
  23. ^ Marchesoni A, Altomare G, Matucci-Cerinic M et al. An Italian shared dermatological and rheumatological proposal for the use of biological agents in psoriatic disease. J Eur Acad Dermatol Venereol 2010; 24: 578-586.
  24. ^ Ohtsuki M, Terui T, Ozawa A et al. Japanese guidance for use of biologics for psoriasis (the 2013 version). J Dermatol 2013; 40: 683-95.
  25. ^ Kragballe K, Gniadecki R, Mork N-J et al. Implementing best practice in psoriasis: a Nordic expert group consensus. Acta Dermato-Venereolica 2014; 94: 547-552.
  26. ^ Hamadah IR, Al Raddadi AA, Bahamdan KA et al. Saudi practical guidelines on biologic treatment of psoriasis. J Dermatolog Treat 2015; 26: 223-9.
  27. ^ Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and psoriatic arthritis in adults. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2010 Oct. 65 p. (SIGN publication; no. 121).
  28. ^ Su-Ni W, Theng C. Dermatological Society of Singapore Psoriasis Management Guidelines, 2016.
  29. ^ Raboobee N, Boobaker J, Jordaan HF et al. Guideline on the management of psoriasis in South Africa. South African Medical Journal 2010; 100: 259-282.
  30. ^ L. Puig, J.M. Carrascosa, E. Daudén, J.L. Sánchez-Carazo, C. Ferrándiz, M. Sánchez-Regaña, M. García-Bustinduy, X. Bordas, J.C. Moreno, J.M. Hernanz. Spanish Evidence-Based Guidelines on the Treatment of Moderate to Severe Psoriasis with Biologic Agents. Actas Dermo-Sifiliográficas 2009; 100: 386-413.
  31. ^ M Schmitt-Egenolf. PsoReg – The Swedish registry for systemic psoriasis treatment. The registry’s design and objectives. Dermatology 2007; 214: 112-7.
  32. ^ Kolios AGA, Yawalker N, Anliker M et al. Swiss S1 guidelines on the systemic treatment of psoriasis vulgaris. Dermatology 2016; 232: 385-406.
  33. ^ Tsai TF, Lee C-H, Huang Y-H. Taiwanese dermatological consensus statement on management of psoriasis. Dermatologica Sinica 2017; 35: 66-77.
  34. ^ Alper S et al. Updated guidelines for the management of psoriasis with biologic agents. Turkderm 2010; 44: 105-112.
  35. ^ Otero FG, Paez E. I consenso nacional de psoriasis, 2009. Dermatol Venez 2009; 47: 37-56.
  36. ^ a b Basra MKA, Fenech R, Gatt RM, Salek MS, Finlay AY. The Dermatology Life Quality Index 1994-2007: A comprehensive review of validation data and clinical results. British Journal of Dermatology 2008; 159: 997-1035.
  37. ^ Katugampola RP, Lewis VJ, Finlay AY. The Dermatology Life Quality Index: assessing the efficacy of biological therapies for psoriasis. British Journal of Dermatology 2007; 156: 945-950.
  38. ^ Ali FM, Cueva AC, Vyas J, Atwan AA, Salek MS, Finlay AY, Piguet V. A systematic review of the use of quality of life instruments in randomized controlled trials of psoriasis. Br J Dermatol 2017; 176(3): 577-593.
  39. ^ a b Finlay AY. "Current severe psoriasis and the Rule of Tens". British Journal of Dermatology 2005; 152: 861-867.
  40. ^ Ali FM, Johns N, Finlay A, Salek MS, Piguet V. Comparison of the paper-based and electronic versions of the Dermatology Life Quality Index (DLQI): evidence of equivalence. Br J Dermatol. 2017 Jan 23. doi: 10.1111/bjd.15314.
  41. ^ Vyas J, Johns JR, Ali FM, Singh RK, Ingram JR, Salek S, Finlay AY. A systematic review of 454 randomised controlled trials using the Dermatology Life Quality Index: experience in 69 diseases and 43 countries. British Journal of Dermatology 2024; 190: 315-339. doi: 10.1093/bjd/ljad079.
  42. ^ Johns JR, Vyas J, Ali FM, Ingram JR, Salek S,, Finlay AY. The Dermatology Life Quality Index (DLQI) as the Primary Outcome in Randomised Clinical Trials: A systematic review. British Journal of Dermatology 2024; 191: 497-507. doi: 10.1093/bjd/ljae228.
  43. ^ Johns JR, Vyas J, Ali FM, Ingram JR, Salek S,, Finlay AY. The Dermatology Life Quality Index (DLQI) used as the benchmark in validation of 101 quality of life instruments: A systematic review. Journal of the European Academy of Dermatology and Venereology 2024 Sep 13. doi: 10.1111/jdv.20321.
  44. ^ Vyas J, Johns JR, Ali FM, Singh RK, Ingram JR, Salek S, Finlay AY. A systematic review of 207 studies describing validation aspects of the Dermatology Life Quality Index (DLQI). Acta Dermato-Venereologica 2024 (in press)
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