Of the 3541 patients with diagnosed vitiligo included in the analysis [4, 5], 40.8% (n = 1445) of patients had darker skin and 59.2% (n = 2096) had fairer skin (i.e., Fitzpatrick skin types I–III; Table 1). Median (range) affected body surface area (BSA), as estimated by the Self Assessment Vitiligo Extent Score (SA-VES) tool [8], was higher among patients with darker versus fairer skin (6.6% [0–73.9%] vs 2.5% [0–73.9%]; P < 0.0001). A greater percentage of patients with darker versus fairer skin also reported > 10% affected BSA (36.3% [525/1445] vs 24.0% [502/2096]; P < 0.0001), with even greater percentages among patients with skin types V (42.7% [224/525]) and VI (53.4% [55/103]) than those with skin type IV (30.1% [246/817]; P < 0.0001 for both). Of note, a greater percentage of patients with skin type I (30.0% [95/317]) reported > 10% affected BSA versus patients with skin types II (24.6% [261/1061]; P = 0.06) and III (20.3% [146/718]; P < 0.001).

The mean (SD) 12-item VIPs score was significantly higher among patients with darker versus fairer skin (31.2 [15.6] vs 24.5 [15.0]; P < 0.0001). Over half of patients with darker skin (range across questions, 50.4–56.7%) responded that each concern assessed by the VIPs was frequently burdensome (i.e., responses of often, very often, or all the time); burden was significantly greater among patients with darker versus fairer skin (P < 0.0001 for all questions; Fig. 1). Rates of burden per the VIPs were generally highest among patients with skin types V and VI versus all others; interestingly, patients with skin type I showed the highest rates of burden among those with fairer skin (Supplementary Fig. S1).

Patient QoL concerns per the VIPs. A summary of responses including often, very often, and all the time is shown. Questions from the two validated 12-item VIPs were completed by patients with some attributes only applying to fairer (Fitzpatrick skin types I–III) or darker (Fitzpatrick skin types IV–VI) skin. ****P < 0.0001 vs skin types I–III. DS included in the 12-item VIPs for patients with darker skin; FS included in the 12-item VIPs for patients with fairer skin; QoL quality of life; VIPs Vitiligo Impact Patient scale

Daily activities of patients were more frequently impacted (i.e., responses of often, very often, or all the time) among those with darker versus fairer skin (P < 0.0001 for all activities assessed; Fig. 2). The most stressful activities for patients with darker skin included determining what clothes to wear (62.1% [898/1445] vs 50.5% [1058/2096] for fairer skin) and going to the beach or pool (57.6% [833/1445] vs 46.6% [977/2096] for fairer skin). The highest rates of frequent impact were seen among patients with skin types V and VI versus all others (Supplementary Fig. S2); notably, among those with fairer skin, patients with skin type I reported higher rates of frequent impact on daily activities than those with skin types II and III, including determining what clothes to wear (59.0% [187/317]) and going to the beach or pool (58.0% [184/317]).

Impact of vitiligo on patient’s daily lives. A summary of responses including often, very often, and all the time is shown. Patients were asked how frequently vitiligo affected their decision to participate in daily activities (before the COVID-19 pandemic). ****P < 0.0001 vs skin types I–III

Emotional well-being, including self-esteem/stigma, relationships, and work/promotion, was impacted in more than 30% of patients globally; greater percentages of patients with darker versus fairer skin reported considerable impact (i.e., responses of agree or strongly agree) across domains (Supplementary Fig. S3), particularly among those with skin types IV–VI overall and those with skin type I versus others with fairer skin (Supplementary Table S1). Globally, 46.6% (1649/3541) of patients reported that “no one understands what it’s like to live with vitiligo,” with higher rates among patients with darker versus fairer skin (51.8% [749/1445] vs 42.9% [900/2096]; P < 0.0001). Over 40% of patients globally reported that having vitiligo made them feel less accepted (darker vs fairer skin, 48.7% [703/1445] vs 37.3% [782/2096]; P < 0.0001) and that people avoided shaking hands with them (darker vs fairer skin, 47.1% [681/1445] vs 36.1% [757/2096]; P < 0.0001).

In terms of impact on work/professional life, over 40% of patients globally reported that they would be further along in their careers (darker vs fairer skin, 46.4% [671/1445] vs 38.7% [812/2096]; P < 0.0001) or would have chosen a different line of work if they did not have vitiligo (darker vs fairer skin, 46.0% [665/1445] vs 36.6% [768/2096], P < 0.0001). Patients with skin types V and VI reported the highest rates of impact on work/promotion versus all other skin types, and patients with skin type I reported highest rates of impact versus others with fairer skin (Supplementary Table S1). Globally, 49.5% (1753/3541) of patients also reported missing personal obligations, which included days at work and childcare responsibilities, due to time needed for medical treatment for vitiligo (darker vs fairer skin, 60.1% [882/1445] vs 41.6% [871/2096]; P < 0.0001); rates were highest among patients with skin types V (73.0% [383/525]) and VI (76.7% [79/103]) versus all others (skin types: I, 53.0% [168/317]; II, 39.7% [421/1061]; III, 39.3% [282/718]; IV, 51.4% [420/817]; all P < 0.0001).

Significantly higher percentages of patients with darker skin reported having a previously diagnosed mental health condition (73.4% [1061/1445] vs 48.5% [1017/2096] for fairer skin; P < 0.0001), with significantly higher rates of diagnosed anxiety (34.7% [501/1445] vs 24.7% [518/2096] for fairer skin; P < 0.0001) and depression (29.1% [420/1445] vs 21.3% [446/2096] for fairer skin; P < 0.0001; Supplementary Fig. S4). Among individual skin types, at least one-quarter of patients with skin types I, IV, V, and VI reported formally diagnosed anxiety or depression, and those with skin types V and VI generally reported highest rates of other diagnosed mental health conditions, including eating disorder (Supplementary Table S2).

Although 24.5% (866/3541) of patients reported being diagnosed with depression, the PHQ-9 results indicated that 55.0% (1948/3541) had moderate-to-severe symptoms of depression, with significantly higher rates among patients with darker skin (68.3% [987/1445] vs fairer skin, 45.8% [961/2096]; P < 0.0001). Among individual skin types, rates of moderate-to-severe depressive symptoms were highest in patients with skin types V (77.1% [405/525]) and VI (77.7% [80/103]) versus all others (skin types: I, 58.0% [184/317]; II, 45.4% [482/1061]; III, 41.1% [295/718]; IV, 61.4% [502/817]; all P < 0.01).