Clinical and Experimental Dermatology 1994; 19: 210-216

Dermatology Life Quality Index (DLQI)—a simple

practical measure for routine clinical use
A.Y.FINLAY AND G.K.KHAN Department of Dermatology, University of Wales College of Medicine, Card
UK

Accepted for publication 23 September 1993

Summary disability experienced by patients with different skin

diseases and non-dermatological disease.'' The UKSIP is
A simple practical questionnaire technique for routine useful in a research environment but has the disadvantage
clinical use, the Dermatology Life Quality Index (DLQI) of being a lengthy questionnaire and impractical for
is described. One hundred and twenty patients with routine use in a busy dermatology clinic.
different skin diseases were asked about the impact of There is a need for a simple, compact uniform
their disease and its treatment on their lives; a question- measure, applicable to patients with any skin disease, for
naire, the DLQI, was developed based on their answers. use as an assessment tool in routine daily clinical practice.
The DLQI was then completed by 200 consecutive new This paper describes the development, preliminary use
patients attending a dermarology clinic. This study and reliability testing of a new disability index to meet
confirmed that atopic eczema, psoriasis and generalized this need, the 'Dermatology Life Quality Index' (DLQI).
pruritus have a greater impact on quality of life than acne,
basal cell carcinomas and viral warts. The DLQI was also
completed by 100 healthy volunteers; their mean score
was very low (16%, s.d. 3-5) compared wirh the mean Materials and Methods
score for the dermatology patients (24 2%, s.d. 20 9). The
reliability of the DLQT was examined in 53 patients using Ethical permission for this study was given by rhe Joint
a 1 week test-retest method and reliability was found to Medical Ethical Committee of the University Hospital of
be high (7^-0-99). Wales.

Skin disease has been recognized as having a detrimental Development of the DLQf
effect on the quality of life of patients.' ^ This psychoso-
cial aspect of skin disease has important implications for One hundred and twenty consecutive patients aged 15-70
optimal management of patients.^ Although dermatolo- years attending the Dermatology Out-Patient Depart-
gists and other clinicians have long recognized the impact ment, University Hospital of Wales, were given a sheet of
of skin disease on a patient's life, it is only recently that paper with the following question;
quality of life measures have been used as assessment We are trying to find out how much skin disease affects people. We
parameters in the management of chronic skin disease would he grateful if you could help us, though there is no obligation to
do so. Please could you write down all the ways that your skin
and in the evaluation of new rrcatmenrs." disease affects you. Please include any affects on your work life,
Disease-specific indices of disability have been devel- social life, personal relationships and leisure activities, or any other
oped to record the impact of atopic eczema, psoriasis and ways in which your skin disease aftects your life. Although we need a
acne,''"" but these cannot be used to compare different record of your diagnosis, sex and age for analysis, your reply is
skin diseases. In contrast, general health measures of otherwise anonymous.
quality of life, such as the United Kingdom Sickness No patient refused to answer.
Impact Profile (UKSIP), can be used to compare the Each answer was analysed by identifying different
aspects of life quality impairment. Tbe number of
Correspondence: Dr A.Y.Finlay, F.R.C.P., Senior Lecturer and different aspects identified in each answer ranged from 0
C-onsultant Dermatologist, Department of Dermatology, University
of Wales College of Medicine, Cardiff Cr4 4XN, Wales, UK, to 8. A total of 49 different aspects were identified, sorted
This paper was presented at the British Association of Dermatolo-
into different overall categories and then ranked accord-
gists and Canadian Dermatology Association Joint Annual Meeting, ing to their frequency of mention (Table 1). After the
Oxford, UK, 6-10 July 1993. analysis of the first 70 answers, no additional problems
210
 OKRMA'rOLOGY LIFE QUALITY INDEX 211
Table I. DifTerent aspects of life impairment identified from answers Table 2. Details ofthe diagnoses of the 120 patients who provided tbe
given h\ 120 new out-patients with a range of skin diseases. information on which the D1.(^I was based

UiHerent iispects of life affected No. of patients No. of

Diagnosis patients Sex Age range
Symptoms
Sore/painful/stinging 21 Acne 15 M9 I'6 IS 37
Itehinp 20 Psoriasis 14 MfiFS 19 71
Sleep disiurbanec 11 Other eczema 10 M4 1-6 23-65
Irritaiiiin 10 Mole 9 M5 14 19-62
Uncomfortahle 6 Atopic eczema 9 M4F5 20-45
Bleeding 5 Viral wart 8 M5F3 16-44
Sensitive in sun 5 BCC 7 M5F2 51-86
Sehorrhoeic wart 5 M4F1 50-78
I'eelings Solar keratosis 5 Ml F4 58-84
Sell'-eonseious 24 IJowen's disease 4 MO F4 45 -70
l''.niharrassmcnt 20 I'aeial rash/flushing 3 Ml F2
V\ (irr i ed,.' eon ccrncd 10 Alopecia areata 2 M0F2 17-36
I )epressed miserahlc 8 C.ysi 2 MI Fl 2(>-53
Irritahle 7 Discoid lupus erythcmatosus 2 MO 1-2 43-44
Loss of confidence 7 Derma tofihroma 2 M0F2 41-63
III at ease 4 Granuloma annulare 2 Ml FI 25-28
Nervous 4 On y c h om y cos i s 2 M2F0 40 46
I'eel degrading 3 Pityriasis rosea 2 M0F2 24-26
Want to .stay ai home 3 Rosacea rhinophyma 2 M2F0 31-38
C.hondrodermatilis 1 Ml FO 24
Diiily activities
Derniatomyositis 1 MO 1-1 46
AHet-ts choice of clothes U 1 MI FO
L'nahic to go tn shops 7 Dermatitis herpctiformis 54
I )rug reaction 1 MO Fl 53
Diftitulty in doing housework 6 MO Fl
Try to hide ihe lesions S I lair loss 73
I laemangioma MI FO 31
('.annoT work in garden 4 Ml FO
AH'ccts cooking 4 Lcntigo simplex 32
Localized blistering Ml FO 56
Have to wear hat 4 MOFl
Leg callosity 29
1 .eisure activities Pilar cyst MI FO 21
Leisure activities affected or limited 14 Piiyriasis versieolor Ml FO 43
Swimming affected Seabies MOFl 16
Stops/limits sport n Sweet's syndrome Ml 10
Limits social life 9 Other
llj\L' rn avoid sun 7
Stops going on holidays 3
1
Work or school
Difficulties M work 12 were recorded from the sitbsequetit 50 patient responses.
Career aflecied 10 This suggests that all important aspects of life quality
Loss of work time 9 impairment that are usually induced by skin disease were
.Aflucts studies 8 recorded. Details of the diajinoses of the 120 patients who
Employment difficult to get or refused 8
Avoids seeing customers 4 took part in this information gathering exercise are given
Colleagues make fun 3 in Table 2. It can be seen that patients with a very wide
Reduced income 3 range of conditions contributed information.
Personal relationships
The first draft of a uniform skin disability question-
DifTieulties in making new relationships 14 naire consisting of 10 questions was then developed,
Sexual difTieulties 7 based on the most commonly identified aspects of quality
People start at me 7 of life impairment. However, the questi()ns were phrased
Stop mixing with new people or avoid social so that they also encompassed the least frequently
gatherings 6 mentioned aspects of life quality impairment. In the
Cjnnoi answer the door 4
People comment 4 questionnaire, patients are a.sked to consider the impacr of
the disease on them over the previous week only, a short
Treatment enough time to allow clear recall.
Messy
Smelly ointments The questionnaire was initially piloted on 20 patients
Makes clothes greasy and minor modifications made based on their comments.
The modified version was redesigned and piloted again
212 A.Y.FINLAY AND G.K.KHAN

DERMATOLOGY LIFE QUALITY INDEX

DL9I
Hospital No: Date:
Name: Score:
Address: Diagnosis:

The aim of this questionnaire Is to measure how much your skin problem has
affected your life OVER THE LAST WEEK. Please tick • one box for each question.
1. Over the last week, how itchy, sore.
painful or stinging has your skin
Very much
A lot
been? A little
Not at all
2. Over the last week, how embarrassed Very much G
or self conscious have you been because A lot G
of your skin? A little G
Not at all G
3. Over the last week, how much has your Very much G
skin interfered with you going A lot G
shopping or looking after your home or A little G
garden? Not at all G Not relevant G
4. Over the last week, how much has your Very much G
skin influenced the clothes A lot G
you wear? A little G
Not at all G Not relevant G
5. Over the last week, how much has your Very much
A lot C
skin affected any social or
leisure activities? A Uttie C
Not at all C Not relevant G
6. Over the last week, how much has your Very much G
skin made It difficult for A lot G
you to do any sport? A little G
Not at all G Not relevant G
7. Over the last week, has your skin Yea G
Not relevant G
prevented you from working or No G
studying?
If "No", over the last week how much has A lot G
your skin been a problem at A little G
work or studying? Not at all G
8. Over the last week, how much has your Very much G
skin created problems with your A lot G
partner or any of your close friends A little G
or relatives? Not at all G Not relevant G

9. Over the last week, how much has your

skin caused any sexual
Very much
A lot
G
G
difficulties? A litUe G
Not at all G Not relevant G
10. Over the last week, how much of a Very much G
problem has the treatment for your A lot G
skin been, for example by making A little G
your home messy, or by taking tip time? Not at all Not relevant G
Please check you have answered EVERY question. Thank you.
® A Y r i n l i j y . G K K l u n i . A p r i l 1 9 9 2 . T h i s m i i s l i m r !"• i i . | i « - . i w u l m u t r h r j x - r i r r r ^ s m i i <.i r h i - . . u r h n r s

Figure I. The Dermatology Life Quality Index {DLQI) questionnaire.

 DERMATOLOGY LIFE QUALITY INDEX 213
on a further 20 patietits to confirm that it was clearly controls. The healthy volunteers were randomly selected
understood, unambiguous, practical and applicable. The from the relatives who accompanied patients attending
final version of the questionnaire was deliberately the dermatology out-patient department. The criteria for
designed so that it would fit clearly on one side of an 'A4' the selection of controls were that they should not have
size sheet for ease of use and filing (Fig. 1). The space at seen their general practitioner over the previous 3
the top left corner of the sheet is suitable for a standard months, they should have had no skin problem or other
'stick on' hospital label giving patient name, number, systemic medical disease over this time, and they should
address and date of birth. The 'date', 'diagnosis' and have had no apparent disability. Controls were not
'final score' are designed to be completed by the exactly individually matched to the age and sex of the
physician. patient population, but the control group was of a similar
age range and sex distribution.
Scaling and scoring ofthe DLQJ
Reliability ofthe DLQI
The questionnaire was structured with each question
having four alternative responses: 'not at all', 'a little', 'a To assess the reliability ofthe DLQI, 53 patients with a
lot' or 'very much' with corresponding scores of 0, 1, 2 variety of skin diseases were recruited from the dermato-
and 3, respectively. The answer 'not relevant', is scored as logy out-patient clinic at the University Hospital of
'0'. The DLQI is calculated by summing the score of each Wales. The 32 male and 21 female patients were aged 15-
question, resulting in a maximum of 30 and minimum of 66 years (median 39). After the nature ofthe study was
0. The higher the score, the greater the impairment of explained, the DLQI was given to the patients to
quality of life. The DLQI can also be expressed as a complete. Following an interval of 7-10 days, all the
percentage of the maximum possible score of 30. patients reattended the out-patient clinic to complete the
DLQI questionnaire again.
Preliminary use ofthe DLQJ The results were analysed using non-parametric statis-
tical techniques, the Mann-Whitney t/-test and the
Two hundred patients (84 male, 116 female), aged 15-75 Kruskal-Wallis one-way ANOVA test, as appropriate.
years (median 42 years) suffering from a range of skin
diseases were recruited sequentially from the dermato-
logy out-patient clinic at the University Hospital of
Wales, Cardiff. The nature ofthe study was described to Results
each patient and all patients agreed to take part. The The diagnosis, age and sex distribution of the patients
questionnaire was explained to each patient and then along with the healthy volunteers are shown in Table 3.
completed by the patient in a quiet corner of the out- One hundred and ninety-six (98%) patients correctly
patient department. completed all 10 questions. The remaining four (2%) did
One hundred healthy volunteers (40 male, 60 female), not complete questions 8 and 9, concerning personal
aged 15-75 years (median 34 5) were also selected as relationships and sex life.

Table 3. Measurement of quality of life (DLQI) in 200 patients with a variety of skin diseases and 100 eontrols

Kange
Mean age Mean (s.d.) Mean (s.d.) DLQI
Diagnosis No. of patients Sex (years) D L Q I score DLQI score (%) score

Psoriasis 52 27 M, 25 F 436 8-9 (6 3) 29-7 (21-0) 0-28

Pruritus 9 4M, 5F 51-9 10'5(5-8) 35-0 (19-3) 3-22
Atopie eezema 13 5 M, 8 F 309 12-5 (4'8) 41-7 (16-1) 6-23
Other eezema 17 3 M, 14 F 47-0 8-6(6'5) 28-6(21-6) 2-27
Aene 18 13 M, 5 F 23-4 4-3 (3-1) 14-4(10-5) 0-11
Solar keratosis 5 4M, 1 F 60-8 3-4(1'5) 11-3 (5-0) 2-6
Viral wart 12 5M, 7 F 27-0 6-7 (5-6) 22-2(18-8) 2-22
Seborrhoeie wart 5 2 M, 3 F 58-0 1-8 (0-8) 6-0 (2'8) 1-3
Hasal eell eareinoma 8 3M, 5 F 606 2-0 (2'2) 6-7 (7-3) 0-6
Moles 7 7F 346 1-0 (1-4) 3-3 (4-7) 0-4
Miseellaneous 54 18 M, 36 F 509 6-9 (6-9) 22-9 (23-0) 0-28
Overall 200 84M, 116F 43-7 7-3 (6-3) 24-2 (20-9) 0-2S
Controls 100 40 M, 60 F 36-9 0'5(M) 1-6(3-5) 0-6
214 A.Y.FTNLAY AND G.K.KHAN
Mean score tor each question (rrraximum 3) Correlation coetticient(rs)
1,4
I Patients Llffl Conlrol
1.2
0,99 0,96 0,98 0,98 0-98 0-98 096 0,98 0,97 0,95 0,9B

1 -

0,8-I

0,6 -

0-4 -

0,2

0
4 5 6 7 8
DLQI question numbei- 0,8

Figure 2. The mean scores of each DLQI question for patients OLQI question number
(n = 200) and eontrols («=100).
Figure 3. Reliahlity of DLQI test-retest scores. (Correlation in 53
patients with a range of skin diseases.

Results of questionnaire analysis

the greater the number and severity of perceived prob-
The mean score for each DLQI question for patients and lems.
controls is given in Fig. 2. Overall responses were positive The scores of the patients with atopic eczema
more frequently for questions 1, 2, 4, 5 and 10. [mean—12-5, s.d.=4-8 (41-7%)1, generalized pruritus
[mean—10-5, s.d. —5-8 (30-2%)], psoriasis [mean —8-9,
Consistency between question responses s.d. —6-3 (29-7%)], viral warts [mean —6-7 s.d. —5-6
(22-2%)] and acne [mcan = 4-3, s.d. = 3-1 (14-4%)] were
The degree of consistency of responses between ques- all strongly significantly higher (/*<0-0001) than for the
tions was tested using the Rank correlation test. The control population. The scores for patients with atopic
consistency between all questions when paired was found eczema, generalized pruritus and psoriasis were higher
to be statistically significant at the level of 0-002 and (P<000\) than for patients with acne, basal cell carci-
ranged from Rank correlations of 0-23-0-70 (see Table 4). noma and viral warts.
The higher the Rank correlation value, the higher the The overall mean DLQJ score for the patients was 7-3
consistency. s.d. —6-3 (24-2%) and for the controls was 0-5, s.d. —M
(1-6%). The scores ofthe patients with skin disease were
considerably higher than contrt)ls across all 10 DLQI
Quality of life assessment
questions. There was no significant difference (P—0-67)
The overall DI,QI scores for the different diagnostic in the D1.,QJ scores of patients with skin disease between
categories, and the DLQI scores from the healthy group men [K = 84, mean DLQI = 7-3, s.d.=6-3 (24-4%)] atid
of volunteers are shown in Table 3. The higher the scores, women [«= 116, m e a n - D L Q I = 7-2, s.d.-6-3 (24-0%)].

Table 4. The consistency hetween paired DLQI questions using the Reliability
rank correlation teehnique. The higher the rank correlation value, the
greater the consistency hetween the questions Test-retest reliability correlation coefficients were
obtained using the Spearman rank correlation technique
Question 1 (Fig. 3). The correlation between overall DLQJ scores
was very high (y, = 0-99, /'<0-0001). The test-retest
0-33 reliability of individual question scores was also examined
0-33 0-32 and the correlations were also high (7^ —0-95-0'98,
0-36 043 0-35
0-35 0-53 0-58 0-57
0-27 0-45 0-51 0-45 0-70
0-38 0-34 041 0-23 0-43 0-38
0-43 045 0-40 0-39 0-53 0-39 0-47 Discussion
0-25 0-30 0-25 0-31 0-36 0-34 0-41 0-57
10 0-41 0-39 0-25 0-53 0-43 0-39 0-27 0-32 0-24 Methods of measuring disability caused by skin disease
are needed for several reasons; first, to provide a
 DERMATOLOGY LIFE QUALITY INDEX 215
comparator with systemic diseases in discussions con- Tn general the DLQI was very reliable in its overall score
cerning resource allocation hetween medical specialities; as well as in individual questions.
second, to assess the effectiveness of new therapies; third, A 'leisure questionnaire' for use by dermatology
to use in audit ofthe effectiveness of dermatology clinical patients was proposed by Ryan'- to record impairment of
services; fourth, to provide an additional patient-oriented quality of life, though no overall scoring system was
measure of disease status for routine clinical monitoring, proposed nor was the origin or practical use of this
and fifth, to provide comparisons between the 'impor- questionnaire described. The 10 questions in the 'leisure
tance' of different skin diseases and the relative effective- questionnaire' are largely covered by questions 3, 5, 6 and
ness of therapy. 9 in the DLQI; the other six DLQI questions concern
Some of these needs can be met by previously areas not mentioned in the 'leisure questionnaire', but
described methods. The UKSIP provides a possible which were frequently mentioned by patients in the
comparator between different skin diseases and between survey on which the DLQI is based. When comparing
other systemic diseases. Novel therapies, used for specific the questions in the DLQI with those in thePDL and the
diseases, can be assessed using disease specific question- ADI^, it is clear that similar areas are covered; however, in
naires such as the Psoriasis Disability Index (PDI) or the the psoriasis and the acne measures there is a specific
Acne Disability Index (ADI).^'^ The need for measures in emphasis to the questions refiecting each disease, w hereas
the audit ofthe effectiveness of a dermatology service can the DLQI questions are more widely encompassing. It
only partly be met by the use of disease specific should be noted that the scoring system used for the
questionnaires as too many different instruments would DLQI, as for other similar questionnaires, is ultimately
need to be used, and the use of general health measures of arbitrary, and the scoring refiects the bias ofthe question
life quality may be impractical. These difficulties also selection. It is possible for example that patients from
apply in routine clinical use. C-omparison can be drawn other cultures might place a different emphasis on the
between different skin diseases by using the UKSIP but importance ofthe various aspects of handicap covered by
for extensive studies or ongoing monitoring a simpler the questionnaire.
technique is required. The DLQI has been designed to This questionnaire has been specifically designed to be
meet the need for a very simple but sensitive method of practical and to be of clinical value when used in a busy
measuring disability caused by skin diseases. It was clinical setting. The scoring system is therefore deliber-
completed rapidly and without difficulty by patients over ately simple and the information is most conveniently
a wide range of age and intellectual ability, usually in 1-3 summarized as an overall score. By definition, if the score
min. The DLQI, therefore, potentially fulfils the pre- of one question increases at the same time as the score of
viously unmet needs identified above. another question decreases, the overall score remains the
Time-scale is an important factor to be considered same: this is as intended as maintenance ofthe same score
when constructing questions in any measure of handicap. reflects an overall unchanged average level of quality of
We chose a 1-week time-scale as an appropriate time over life. It is possible of course, if required, to maintain and
which patients could easily remember events. This time- use the detailed information given in the replies by
scale is also short enough to allow the DLQI to be used analysing either each question or groups of questions
for comparative purposes in routine clinical use. separately. We have previously used this approach in
tn the first of a series of validation studies, we have grouping questions under five headings when analysing
established a construct validity for the questionnaire by data from the PDI.** A similar analysis ofthe DLQJ, using
initially measuring the quality of life of two different six headings, could group the 10 questions as follows:
groups, patients with skin disease and normal healthy
subjects. The questionnaire scores were able to discrimi- Symptoms, feelings 1,2
Daily activities 3,4
nate between these two groups.
The method of 'test-retest' reliability assessment Leisure 5,6
adopted in this study does not involve any observer or Work/school 7
Personal relationships 8,9
'rater','" and is therefore a preferred method of quantify-
ing the reproducibility of self-administered measures Treatment 10
such as the DLQI. The test-retest reliability of the
overall scores ofthe DLQI was consistent and high. The It is essential to demonstrate thar quality of life assess-
reliability correlations for the individual questions were ment methods can detect change in quality of life.
also consistent and high, but were slightly lower than that Measures of quality of life should not, for example, be
for the overall DLQI scores. This was expected, because used in clinical trials unless responsiveness has been
the reliability of assessment of one facet of dysfunction is demonstrated in the skin condition being examined. A
not likely to be as great as when all facets are included.^^ current study is using the DLQI to measure changes in
216 A.Y.FINLAY AND G.K.KHAN
quality of life before and after in-patient admission for Acknowledgments
skin disease (H.A.Kurwa and A.Y.Finlay, unpublished).
Preliminary analysis of the first 60 patients in this .study We wish to thank Dr M.S.Salek, Medicines Research
has demonstrated reduction in the mean DLQI from 14-3 Unit, University of Wales College of Cardiff and Dr
(before admission) to 8-4 (after admission), indicating R.G.Newcombe, Department of Medical Computing
that the DLQI is responsive to change. Clearly, however, and Statistics, University of Wales College of Medicine,
further responsiveness studies need to be carried out. for their helpful advice concerning this study.
External validity testing is also of importance, compar-
ing the results of the DLQI with other life quality
measures when used in parallel. Such an initial parallel References
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study designed to assess the effect of skin cancer on yVfe^inwe 1991; 46: 33-36.
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A.Y.Finlay, unpublished). We plan further external impact of skin conditions. Social Sciences and Medicine 1985; 20:
425-429.
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We have demonstrated previously that a very short psoriasis. Journal ofthe American Academy of Dermatology 1989;
disease-specific questionnaire^ can successfully be used in 20: 53-63.
routine clinical use to assess the impact of acne and its 4. Motley RJ, Finlay AY. Practical use of a disability index in the
treatment on patients' quality of life. We have now used a routine management of acne. Clinical and Experimental Dermato-
logy 1992; 17: 1-3.
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the handicap experienced by patients with a wide range of ment in cyclosporin treated atopic dermatitis patients—a double
different skin diseases. As expected, this study has blind cross over study. British Journal of Dermatology, 1991; 125
confirmed that patients with chronic skin diseases such as (Suppl, 38): 16.
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This may reflect the selected nature of dermatology Sickness Impact Profile and Psoriasis Disability Index in psoria-
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