When a patient has a skin problem, one could make a judgment about the severity by assessing the amount of skin involved, but does that really tell you much about how it is affecting the patient? So often we see patients with problems we may regard as minor, for example, but the patient might see it as a significant issue. In dermatology, the idea of taking the patient's perspective as part of the assessment was not realised and developed until the early 1990s.
In the early nineties, dermatologist Professor Andrew Findlay and Gul Karim Kham developed a new tool in dermatology that assessed the impact of the skin problem on the patient by measuring their quality of life. It was called the Dermatology Quality of Life Index (DLQI) [1] and consisted of 10 questions that covered symptoms, feelings, daily and leisure activities, work or school, personal relationships and treatment. Each question referred to the impact of the skin disease on the patient’s life over the previous week. Each area of questioning was simply answered with one of four responses - not relevant [scores 0], not at all [scores 0], a little [scores 1], a lot [scores 2], or very much [scores 3].
From these responses, a DLQI score is obtained by adding together the score from each question. For any given patient the score can range from 0 – 30, the higher the score, the higher the impact of the condition on the patient’s quality of life as shown below:
Score Meaning
0 – 1 No effect at all on patient's life
2 – 5 Small effect on patient's life
6 – 10 Moderate effect on patient's life
11 – 20 Very large effect on patient's life
21 – 30 Extremely large effect on patient's life
Since its introduction, the instrument has been used widely in dermatology in research and clinical practice [2], being translated into many languages. Being able to measure and quantify the patient's perspective has many uses. For example, when assessing the effectiveness of a treatment scoring using the DLQI before and after allows the impact to be assessed from the patient's perspective by seeing how it changes their daily lives. It has also been used widely in research and as a means of demonstrating the utility of dermatology services when for example, competing for funding.
A new DLQI smartphone APP
Previously the DLQI has been administered as a paper-based questionnaire but now it is available as a free smartphone app that can be downloaded from App stores and can be used without charge for clinical use. So, what’s its utility in the podiatry clinic? The value of the DLQI is that it is easy to use in a clinical setting and gives an additional dimension to practice. Below, are two case examples from my own practice where the DLQI has been helpful.
Case 1
A 60-year-old woman with stable psoriasis, who I had been treating for a year or two, came in and I immediately noted a deterioration in her psoriasis. Her feet and ankles showing extensive psoriatic plaques. When I spoke to her, she said that she had had a sudden deterioration in her psoriasis generally, with new areas of skin being involved. There had been no change in her medication and there seemed to be no obvious reason for it. She had spoken to her general practitioner via a telephone consultation, due to COVID-19 restrictions, but felt she could not convey easily to her doctor, the extent of the problem or how it was affecting her. I had previously took a DLQI score from the patient but decided to administer it again. Her score had jumped from 5 (small effect on the patient's quality of life) to 20 (very large effect on the patient’s quality of life). Consequently, I wrote to the patient's GP with a letter explaining her concerns and the deterioration but also included references to the change in DLQI score, expressing the significant effect on her daily life. She was consequently referred to her local dermatology department for assessment and treatment.
Case 2
A 46-year-old woman attended my clinic with discoloured toenails which she felt were deteriorating and wanted treatment to improve their appearance. A dermatophyte test strip revealed the presence of a dermatophyte in 8 out of ten of her nails. The patient was keen to express how the look of her nails was affecting her daily life. A DLQI measurement was undertaken, and she scored 8 indicating a moderate effect of the problem on her quality of life. She was subsequently prescribed oral terbinafine (250mgs daily for three months) and this was supplemented with nail fenestration using Clearanail and topical terbinafine spray, once weekly to the nails. Clear nail growth was observed ten weeks later at which point the oral terbinafine was stopped. At a 9-month review from the start of treatment, the patient expressed her satisfaction at the significant improvement in her nails. The DLQI was repeated at this point and the patient scored 1. The case here demonstrates the sensitivity of the DLQI which when incorporated into the treatment process adds an additional dimension. Thus demonstrating a positive effect of treatment on a patient’s daily life which is otherwise difficult to capture. The use of DLQI has been studied in patients with onychomycosis [3] and interestingly showed that the average DLQI were 6 [moderate effect on a patients life] women with onychomycosis scored more highly than men (scores of 5 [small effect] in men on average versus 6 [moderate effect] in women.
The app is easy to use and stores previous DLQI scores for comparison. It is designed for personal use but can easily be used in the clinic by the clinician. The smartphone app is available from Google Play and the Apple App Store.
References
1. Finlay A, Khan G: Dermatology Life Quality Index (DLQI) - a simple practical measure for routine clinical use. Clin Exp Dermatol 1994, 19(3):210-216.
2. 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. Br J Dermatol 2008, 159(5):997-1035.
3. Kayarkatte MN, Singal A, Pandhi D: Impact of Onychomycosis on the Quality of Life: Dermatology Life Quality Index-Based Cross-Sectional Study. Skin appendage disorders 2020, 6(2):115-119.