Quality of Life and Psychiatric Comorbidities among Subjects Practicing Artificial Skin Depigmentation in 2020 in the City of Cotonou (Benin)

Introduction The purpose of this study was to study the quality of life and psychiatric comorbidities of subjects practicing voluntary skin depigmentation in the city of Cotonou. Methods A cross-sectional, prospective, and analytical study, based on a three-stage probabilistic sampling method, included from June to October 2020, consenting subjects over 15 years of age, practicing artificial skin depigmentation, and residing for at least one year in Cotonou. The Dermatology Life Quality Index, Rosenberg, and Hospital Anxiety and Depression scales allowed us to evaluate the quality of life and self-esteem, and identify anxiety and depression, respectively. A p value <0.05 indicated a significant result. Results We included 330 subjects. The mean age was 33.6 ± 11.6 years and the sex ratio was 0.4. Impaired quality of life was observed in 93.7% of subjects. Anxiety was diagnosed in 11.2% and depression in 5.8% of them. Self-esteem was low or very low in 24.2%. The degree of quality of life and the alteration of self-esteem, and the frequency of anxiety and depression were proportional to the number of skin lesions, the lightening products used, and the monthly cost of the products. Conclusion The use of several lightening products exposes patients to numerous skin lesions, which are a source of impaired quality of life and whose persistence leads to psychiatric comorbidities.


Introduction
Artifcial depigmentation is a very common practice in black-skinned populations, involving the lightening of the natural color of the skin, at the risk of sometimes dramatic complications [1][2][3][4][5][6].Tese complications are dermatological, systemic, and psychiatric [3,[7][8][9].Psychiatric complications are characterized by addiction, altered quality of life, low self-esteem, anxiety, depression, and suicidal ideation [4,[10][11][12][13].However, little is known in the literature about the quality of life and psychiatric comorbidities associated with dermatological complications in subjects practicing depigmentation.Tis led to the present study.Te aim of this study was to investigate the quality of life and psychiatric comorbidities in subjects practicing voluntary skin depigmentation in the city of Cotonou.

Methods
Tis study took place in each of the 13 districts of the city of Cotonou.It was a prospective cross-sectional study with analytical objectives, conducted from June to October 2020.Te sample size was calculated using the Schwartz formula.We used a probabilistic three-stage sampling method.
A district per arrondissement was selected at random.In each district, we selected a single neighborhood using simple random sampling.Once in the selected neighborhood, we employed the bottle method.Te subjects for the survey were chosen based on convenience, meaning we selected them according to the ease of access, while still adhering to the inclusion criteria until the desired sample size was achieved.Subjects aged 15 and over, practicing voluntary skin depigmentation, residing for at least one year in the neighborhood where the survey was carried out, and having given their free and informed consent were included in the study.A structured interview conducted in French and based on the pre-established questionnaire, was used to collect information on various variables.In cases of language barriers, the interviewers translated the questionnaire to the respondents without infuencing their answers.First, we collected sociodemographic data; second, we listed the cosmetic products used and the dermatological complications presented by the subjects surveyed; and third, we assessed the quality of life and identifed any psychiatric comorbidities using specifc scales.
Te Dermatology Life Quality Index (DLQI) is the standard tool for measuring the quality of life in dermatology.It consists of ten questions regarding the impact of skin problems on the subject's life over the past week.Te questions cover symptoms, feelings, daily activities, leisure, work or school, personal relationships, and treatment.Patients answer each question by ticking one of the following boxes: "not at all," "a little," "a lot," and "a great deal."Te score for each question is between 0 and 3, for a total score of 30 [14].
Te Hospital Anxiety and Depression Scale (HADS) [15,16] is a 14-item self-questionnaire that assesses anxiety and depression over the past week.Seven items, originally present in the Clinical Anxiety Scale, concern psychological anxiety.Te depression subscale items assess dysphoria (1 item), slowing down (1 item), and anhedonia (5 items).Each item is scored from 0 to 3. Te threshold score of 10 is proposed by many authors for each of the subscales.
Te Rosenberg scale is used to assess self-esteem.Te questionnaire consists of 10 items, 5 of which assess positive self-esteem and 5 negative self-esteem.Te response varies according to a four-point Likert-type scale ranging from "totally disagree" (1) to "totally agree" (4).Te score is obtained by adding the scores for questions 1, 2, 4, 6, and 7.For questions 3, 5, 8, 9, and 10, the scoring is reversed.Te score is between 10 and 40 [17].Data were entered using EPI Data version 3.1 and exported to SPSS and Excel 2013 for processing and analysis.Te chi-square test with p value was performed at a signifcance level below 0.05.Pearson's coefcient was used to determine the correlation between the dependent variables in terms of scores and the study's quantitative independent variables, as well as among the dependent variables themselves.
Te various skin complications observed in our study were dominated by dyschromia (75.8%), stretch marks (57%), superfcial mycoses (46.1%), and acne (41.5%).Of the 314 subjects with skin complications, more than half (54.5%) had more than 2 skin complications.Te mean quality of life score of the subjects surveyed was 9.3 ± 3.3, with extremes of 0 and 28.Te quality of life was altered in 93.7% of the subjects (Figure 1).
Skin lesions due to the consequences of voluntary skin depigmentation signifcantly impacted the quality of life of young and female subjects, who were mostly single and had a secondary or higher level of education (Table 1).Tere was an increasing trend between the impairment of quality of life and the number of lightening products used, the number of skin complications, and the monthly cost allocated to depigmenting products (Table 1).
Te mean anxiety score of the subjects surveyed was 8.3 ± 2.1, and 11.2% of them were anxious.Most of the anxiety subjects were over 50 years old, female, single or married, with secondary or higher education, and were employees or shopkeepers (Table 2).As the number of products used increased, so did the level of anxiety.Te same was true for the number of skin lesions and the monthly cost allocated to these products (Table 2).

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Te mean depression score was 7.4 ± 2.8 and 5.8% were depressed.Most of the subjects with depression were younger (20-40 years), single, married, or divorced, with secondary or higher education, and were wage earners or shopkeepers (Table 3).Subjects who used more than 3 products at a time, had more than two skin lesions, and spent more than 10,000 FCFA on the monthly purchase of these products were more depressed (Table 3).
Te mean self-esteem score for the subjects surveyed was 32.1 ± 3.1, and 24.2% of the subjects had low to very low selfesteem.Most subjects with low to very low self-esteem were single, shopkeepers, and had a high school education (Table 4).Te degree of self-esteem was inversely proportional to the number of skin lesions, the number of lightening products used, and the monthly cost allocated to these products (Table 4).

Discussion
Te 20-40 age group remains the most concerned in all sub-Saharan African studies.Te prevalence of voluntary depigmentation at this age can be explained by the more active search for a partner or the maintenance of a relationship for the purpose of seduction [1][2][3][4][5][6][7].Te trend of females observed in our study has also been reported in most previous studies.Regarding the marital status of our respondents, the desire to be more beautiful, the main goal sought by female practitioners, would be more present among these single women, still looking for a partner, or among married women where there is rivalry between the wives of the same husband in a polygamous context [1-4, 11, 18].As reported by some authors, women with a high level of education practice voluntary depigmentation more than artisans and housewives.Tis is because they are more easily infuenced by magazines, the media, and the Internet, thanks to their reading skills [2,[19][20][21].When comparing our results with the DLQI averages found in other studies, we note that the average score for quality of life impairment in our subjects was higher than that found in most other diseases [22][23][24][25][26][27][28].
In fact, there is a very close link between beauty and wellbeing.Artifcial depigmentation, regarded as the indispensable means of achieving the beauty sought after by practitioners, is more likely to lead to a deterioration in the quality of life than other dermatoses, when it leads to the opposite and disastrous results [4,[10][11][12][13].We note that subjects who used more cosmetic products had a greater deterioration in quality of life.In fact, skin lesions secondary to artifcial depigmentation are an addictive phenomenon in practitioners.Tey often hope to fnally obtain a positive or better result.However, the accumulation of depigmenting products leads to a worsening of preexisting lesions or the appearance of new ones, which contributes to a further deterioration in their quality of life.Only dyschromia, acne, and superfcial mycoses were signifcantly associated with poor quality of life.Tese complications were found in several other studies at varying frequencies [1][2][3][4][5][6][7][8][9][18][19][20][21].Dyschromia and acne are highly visible lesions, often located in exposed areas of the body and therefore more difcult to conceal.Tis leads to greater aesthetic prejudice in subjects in search of seduction and relational difculties, in short, an alteration in the quality of life, leading to avoidance or even isolation.
Anxiety afected the older subjects in our population, while depression afected the younger ones.Younger people encourage themselves to continue their practice in the hope of better results.Tis leads them to use products with a more "powerful" lightening efect.Tey end up feeling depressed about the skin disasters caused by these products.Older subjects, on the other hand, start to worry about their skin lesions, which are generally no longer recent.Instead, they fear a malignant transformation of the lesions or a systemic disease in which the skin lesions are just the tip of the iceberg.Tis situation leads to constant fear, hence the high prevalence of anxiety at this age.However, it should be noted that 10.5% of subjects with defnite symptoms of depression had no skin lesions whatsoever.In fact, some of the participants in our study used skin-lightening cosmetics but saw no efect on their skin.Teir complexion remained unchanged and there were no skin lesions.Tis represented a failure in their quest for a clear complexion, leading to feelings of disappointment, despair, and even depression.
Most of the subjects with low self-esteem were single, and the discomfort caused by the adverse cutaneous efects of depigmentation diminished their own perception of beauty and their seductive impulse, especially compared to models from the Western beauty canon.Tis leads to a feeling of failure, frustration, lack of self-confdence, an inferiority complex, and therefore a drop in self-esteem in these subjects, who are nonetheless in search of partners [10][11][12][13]29].
Dyschromia, stretch marks, and acne are unruly and conspicuous.Tey prevent victims from displaying their relational and seductive assets.Dyschromia, more specifcally hyperpigmentation of the interphalangeal and ankle regions, is a fagrant sign of depigmentation failure.People with these lesions are mocked and ridiculed by society.All of this would further impair self-image and therefore selfesteem.Tese results are in line with those found by Njimegne et al. in a similar study in Yaoundé in 2019 [30].Tis refects the close link between perception of one's own beauty, well-being, and self-esteem.

Conclusion
Artifcial skin depigmentation in the city of Cotonou generally afects young, female, single, civil union, or married subjects with secondary or higher education.Tey used several galenic forms of lightening products in combination and the majority had more than two skin lesions, essentially dyschromia, stretch marks, superfcial mycosis, and acne.Skin lesions afected the quality of life of 93.7% of the participants.11.2% had defnite symptoms of anxiety, and 5.8% had defnite symptoms of depression.24.2% of the subjects had below-average self-esteem.Subjects who used various lightening products had more skin lesions, leading to an altered quality of life, the persistence of which led to psychiatric comorbidities.

Figure 1 :
Figure 1: Distribution of 330 subjects undergoing artifcial skin depigmentation in the city of Cotonou in 2020 according to the quality of life score.

Table 1 :
Distribution of the quality of life score among 330 subjects undergoing artifcial skin depigmentation in the city of Cotonou in 2020, according to sociodemographic data, the number and monthly cost of lightening cosmetics used, and the number of skin complications.

Table 2 :
Distribution of the anxiety score among 330 subjects undergoing artifcial skin depigmentation in the city of Cotonou in 2020 according to sociodemographic data, the number and monthly cost of lightening cosmetics used, and the number of skin complications.
4e bold values represent the proportions of variables that are signifcantly associated with anxiety.4DermatologyResearch and Practice

Table 3 :
Distribution of the depression score among 330 subjects undergoing artifcial skin depigmentation in the city of Cotonou in 2020 according to sociodemographic data, the number and monthly cost of lightening cosmetics used, and the number of skin complications.
Te bold values represent the proportions of the variables that are signifcantly associated with depression.Dermatology Research and Practice

Table 4 :
Distribution of the self-esteem score among 330 subjects undergoing artifcial skin depigmentation in the city of Cotonou in 2020 according to sociodemographic data, the number and monthly cost of lightening cosmetics used, and the number of skin complications.
6e bold values represent the proportions of variables that are signifcantly associated with self esteem impairment.6DermatologyResearch and Practice