In the present study, 38 (76%) patients experienced moderate to severe stress, 39 (78%) patients experienced moderate to severe anxiety, and 40 (80%) patients experienced moderate to severe depression. These findings are consistent with Henning et al.  whom reported that vitiligo patients experience a lot of stress. The incidence and development of vitiligo can be influenced by the stress in which the patients are subjected to. Also, these findings are consistent with Nikam et al.  who reported that vitiligo is strongly associated with psychiatric disorders. Depression and anxiety remain the foremost common. Also, according to Vernwal , a stress-vitiligo cycle occurs when vitiligo causes psychological discomfort and adversely affects social relations.
Within this study, vitiligo patients are slightly more likely than control group to have stress, anxiety, and depression. These findings corroborate those of Lai et al.  who found that patients suffering vitiligo are slightly more likely than those without vitiligo to have an affective disorder or experience depressive symptoms. Also, Öztekin and Öztekin  found a significantly higher depression level and worse sleep quality in the vitiligo patients than the control group. Also, Hamidizadeh et al.  found that the quantity of tension and hopelessness in patients with vitiligo was significantly higher than healthy controls.
Regarding the possible causes of vitiligo, the death of a family member was identified as a potential cause of vitiligo in 22% of patients; according to the current study, 6% had family member illness, and 16% had fear as other possible causes of their vitiligo. These results are in agreement with Cupertino et al.  who reported that stressful life events generate vitiligo. As they conducted a large study that assessed 1541 vitiligo patients to assess the stressors’ effect on these patients Among the attendees and before the onset of vitiligo within 2 years, 56.6% had a minimum of one stressor, including the death of a loved (16.6%) and financial/work issues (10.8), the loss of a long-term relationship (10.2%), and family problems (7.8% ) are among the most traumatic life events (51.0%).
In the present study, females experienced significant stress, anxiety, and depression as compared to males. Sawant et al.  looked at gender inequalities in depression and found a greater prevalence of 28 (63.64%) in females compared to 24 (42.86%) in males, which was statistically significant. Also, this could be to keep with according to Abdelmaguid et al. , vitiligo has a negative impact on patients’ psychological well-being in regards of anxiety and depression, especially in female patients. These findings are consistent with Hamidizadeh et al.’s  findings showing that women with vitiligo were more nervous and hopeless than healthy controls, although there was no substantial difference in the degree of tension and hopelessness between the two groups.
With this study, there was no relation between the area involved by vitiligo and psychological disturbances. In agreement with Kota et al. , they found that there was no significant correlation between skin area affected by vitiligo and depression. Regarding the effect of vitiligo on quality of life, the majority of cases 46% showed tremendous effect on their quality of life. Also, these results are within the road with Silpa-Archa et al.  who found that in the Thai population, vitiligo caused medium QoL impairment, and there was a moderate incidence of depression. Also, these results are in line with Cupertino et al.  who reported that vitiligo sufferers have a moderate DLQI score (range from 4.4 to 17.1), which is similar to psoriasis and atopic dermatitis.
Regarding sexual difficulties and problems with the partner, the present study showed that about 10% had many sexual difficulties. Also, within the current study, about 21% had many problems with their partners. These findings are consistent with those of Cupertino et al.  who discovered that roughly 25% of vitiligo patients reported that their condition has damaged their interpersonal relationships. Overall, 10–15% believe that vitiligo has hampered their ability to socialize with people of the opposite gender, as well as their ability to locate, amount, and frequency of possible or actual sexual interactions. Furthermore, about half of those who were impacted said it was because of their personal humiliation, 13% said it was because of their partner’s humiliation, and 37% said it was because of both.
In the present study, 20% have no embarrassment of vitiligo, 8% have little embarrassment, 24% have a lot of embarrassment, and 48% have very much embarrassment. These results are in line with the results of Sarkar et al.  who reported that the most common psychiatric morbidity in vitiligo patients was depression (62.29%) followed by embarrassment (55.73%). Regarding clothes choice and social activities, the present study showed that 18% were not plague by vitiligo in clothes choice, 8% vitiligo moderately affected, 18% vitiligo had many effects, and 56% has very much effect. Also, 18% of vitiligo did not affect their social activities, 12% of vitiligo has a little effect, 32% of vitiligo has a lot of effects, and 38% of vitiligo has abundantly affected.
These findings are consistent with Kota et al. ; they also found that vitiligo can even pose difficulty in primary daily activities like wearing clothes, having food of their choice, and going to social events. Within this study, there were two patients (4%) who developed vitiligo during pregnancy. This can be in line with Mason et al.  who reported that a precipitating factor was identified in nine of their vitiligo patients (22%), including pregnancy, sunburn, and skin trauma. In the present study, there is one patient (2%) who developed vitiligo after delivery, and this is against Delatorre et al.  who reported that almost all patients experienced stable vitiligo during pregnancy, still as within the 6-month period after delivery.
During this study, there have been 3 patients (6%) who developed vitiligo after leprosy. This is consistent with the findings of Boisseau-Garsaud et al.  who found eleven individuals with vitiligo between 101 patients with lepromatous (multibacillary) leprosy. The link between vitiligo and leprosy was not coincidental. The physiopathology leading to this high rate of vitiligo in leprosy is unclear.
There was no significant correlation between stress, anxiety, and depression and quality of life in patients with vitiligo. This was in line with Hedayat et al.  who concluded that psychiatric conditions such as depression and anxiety have no impact on the quality of life in people with vitiligo, while in contrast with Mechri et al.  who stated that the quality of life ratings had a positive association with depression and anxiety scores.
The limitation of this study is that the study was conducted in a single large university hospital which might not represent all individuals with vitiligo or might not be generalizable to other countries. Although DASS is the standard measurement for screening of depression, anxiety, and stress, its limitation is that it is a self-rated questionnaire. Additional clinical information, e.g., patient’s function, effects of medication, illness, and psychiatric evaluation, are recommended for definite diagnosis and comprehensive evaluation. Furthermore, we did not evaluate patients younger than 12 years old.