The impact of viral warts on the quality of life of patients

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Abstract. Background:Viral warts are a common skin infection caused by the human papillomavirus. Aim:To understand the impact of viral warts on the quality of ...
Clinical RESEARCH

The impact of viral warts on the quality of life of patients Mabel Qi He Leow, Hazel Hwee Boon Oon Abstract Background: Viral warts are a common skin infection caused by the human papillomavirus. Aim: To understand the impact of viral warts on the quality of life (QoL) of patients receiving liquid nitrogen treatment and the variables that affect QoL of patients. Method: A cross-sectional survey was conducted at the National Skin Centre (NSC), Singapore, between November 2014 and September 2015. Patients with viral warts on the face, hand and foot were included in the study. The Dermatology Life Quality Index for Viral Warts (DLQI-VW) was the main outcome measure. Results: 222 out of 259 patients (85.7%) participated in the study. Patients were most frustrated with the persistence of warts (1.85±1.51), recurrence of warts (1.50±1.58), and time spent on treatment (1.16±1.31). Using multiple regression, Chinese race (p=.032), patients who had sought over-the-counter treatments prior to coming for liquid nitrogen treatment (p=.024), higher education (p=.002), patients who sought over-thecounter treatment (t=2.27, p=0.02), and perceived ineffectiveness of treatment (t=-3.16, p=.002) predicted lower QoL. Factors such as age (r=-0.22, p=0.001), marital status (t=2.49, p=0.01), wart site (F=5.40, p=0.001), number of warts (r=0.16, p=0.02), and number of treatments (r=0.14, p0.04), were significant in the univariate analysis but not in the overall multiple regression. Conclusion: Patients were most frustrated with the persistence and recurrence of viral warts, and time spent on treatment. Protective factors included Malay race, patients who have not sought over-the-counter treatments, lower education, and perceived effectiveness of treatment. Factors such as age, marital status, wart site, number of warts and number of treatment sessions were significant in the univariate analysis but not in the overall multiple regression. Citation: Leow MQH, Oon HHB. The impact of viral warts on the quality of life of patients. Dermatological Nursing 2016, 15(4): 44-48

Introduction    

Mabel Qi He Leow was a Research Nurse at the National Skin Centre Singapore and is currently a Research Scientist at the Biomechanics Laboratory, Singapore General Hospital. Hazel Hwee Boon Oon is a Consultant Dermatologist at the National Skin Centre Singapore

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Viral warts are a common skin infection caused by the human papillomavirus (HPV), occurring typically on the hands and feet. Prevalence of viral warts has been reported to be between 0.84% in the US and 12.9% in Russia1. At the National Skin Centre (NSC), Singapore, viral warts are the fourth commonest skin disorder for which a consultation is sought. Hence it is important to understand the impact of viral warts on patients’ quality of life to provide better care and advice. Liquid nitrogen cryotherapy is the most common form of treatment, and approximately 1,200 patients receive cryotherapy annually at the NSC. Liquid nitrogen treatment is prescribed weekly or every two weeks at the NSC. Adjuvants are occasionally prescribed in between treatments, and salicylic acid is the most common adjuvant at the NSC.

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Clinical RESEARCH The presence of warts on hands and feet (Figures 1 and 2) can affect a person’s quality of life (QoL)2. From a survey of 85 patients, most patients reported they were moderately or extremely affected by the viral warts.The negative impacts of viral warts included embarrassment, fear of negative appraisal by others, frustration due to the persistence of the viral warts and recurrence, discomfort due to the warts, and impact on their social or leisure activities2. Pain and blistering after liquid nitrogen cryotherapy might contribute to their frustration with the treatment. Our study also hypothesised that the size of the wart could affect patients’ QoL, and patients with larger warts could have poorer QoL. No study has been conducted to understand the relationships between patients’ demographic, clinical factors such as viral wart site and number, and QoL.This study aimed to understand the impact of viral warts on the QoL of patients receiving liquid nitrogen treatment and determine the factors that affect QoL of patients with viral warts.

Method

Study design A cross-sectional survey was conducted between November 2014 and September 2015 at the NSC, Singapore. 259 patients were approached and 222 patients (85.7%) agreed to participate in the study. 220 (128 males, 92 females) patients were included in the data analysis, and two were excluded as it was later found that they did not meet the inclusion criteria. A convenience sample of patients aged 16 years old and above, who were receiving liquid nitrogen treatment for viral warts on either the face, hands or feet, and were able to read and speak English, were recruited. Patients with known mental illness or genital warts were excluded. Ethical approval was sought from the local Domain Specific Review Board (DSRB) prior to conducting the study. Sample size was calculated based on the central limit theorem; at least 30 patients were required for each study category3. Study categories that were included were patients’ wart site categorisation, treatment regime, and race. Variables of interest 1 Dermatology Life-Quality Index for viral warts (DLQI-VW)2 www.bdng.org.uk

Table 1.

Table 1.

Patient socio-demographic and clinical data.

Continued

Demographic

Mean (SD)

Treatment type

Age, years (mean±SD, range)

40.46±15.19, 16-83

Salicylic acid

61 (27.73)

Corn plaster

26 (11.82)

Cold freeze (Wartner ) ®

Sex

7 (3.18)

Male

128 (58.18)

Wart site

Female

92 (41.82)

Hand(s)

58 (26.36)

Foot/feet

71 (32.27)

Race Chinese

153 (69.55)

Hand(s) and foot/feet

45 (20.45)

Malay

30 (13.64)

Face

46 (20.91)

Indian

30 (13.64)

Others

7 (3.18)

Number of warts (mean±SD, range)

3.51±3.98, 1-28

Current treatment regime

Marital status Single

97 (44.09)

Weekly

46 (20.91)

Married

123 (55.91)

Every two weeks

140 (63.64)

Every two weeks + salicylic acid

34 (15.45)

Duration of treatment, weeks (mean±SD, range)

19.88±25.32, 0.5-192 12.30±20.53, 2-150 0.44±0.86, 0.01-7.32

Education level No formal education

9 (4.09)

Cambridge Ordinary Level

46 (20.91)

A level/diploma

88 (40.00)

Tertiary

77 (35.00)

Number of treatments received (mean±SD, range)

Working

147 (66.82)

Wart size, area (mean±SD, range)

Not working

73 (33.18)

Perceived effectiveness of treatment

Duration of current viral wart, months (mean±SD, range)

24.33±45.88, 1-372

Yes

186 (84.55)

No

34 (15.45)

Employment status

History of having viral warts

Sought over-counter treatment Yes

78 (35.45)

Yes

83 (37.73)

No

142 (64.55)

No

137 (62.27)

The DLQI-VW was developed specifically to measure the impact of viral warts on patients’ QoL. Using a global scale, the questionnaire measured the extent to which viral warts affected the patients’ physical, psychological, social and financial wellbeing. Fifteen items were rated on a 5-point Likert scale.The scores ranged from 0 to 60. Higher scores indicated poorer QOL.The questionnaire was a used in a previous study2 and permission to use the DLQI-VR was granted by the authors. Internal consistency of the questionnaire was done in this study, and the Cronbach’s α was 0.87, representing an acceptable reliability.

2 Socio-demographic data and clinical data Socio-demographic data included age, gender, race, marital status, education status and employment status. Clinical data included duration of current viral wart, whether patient sought prior treatment for viral warts and the type of treatment used, treatment regime (weekly, every two weeks, or every two weeks with salicylic acid), current duration of treatment, wart sites (face, hand(s), foot/feet, or hand(s) and foot/feet), number of warts, perceived effectiveness of treatment, wart size (tracing and dot-point method to calculate area), and previous history of viral warts on hand, foot or face.

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Clinical RESEARCH Data analysis Data were analysed using Stata 14. Descriptive statistics were used to describe the patients’ socio-demographic characteristics and clinical data. Univariate analysis (T-test, ANOVA and Pearson’s correlations) was conducted to identify factors that had a relationship with QoL. The statistical values for T-test, ANOVA and Pearson’s correlations were reported as t-values, F-values, and r-values respectively. Significant factors in univariate tests were included in the multivariate regression analysis. A p