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
A simple practical questionnaire technique for routine
clinical use, the Dermatology Life Quality Index (DLQI)
is described. One hundred and twenty patients with
different skin diseases were asked about the impact of
their disease and its treatment on their lives; a question-
naire, the DLQI, was developed based on their answers.
The DLQI was then completed by 200 consecutive new
patients attending a dermarology clinic. This study
confirmed that atopic eczema, psoriasis and generalized
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
score for the dermatology patients (24 2%, s.d. 20 9). The
reliability of the DLQT was examined in 53 patients using
a 1 week test-retest method and reliability was found to
be high (7^-0-99).
Skin disease has been recognized as having a detrimental
effect on the quality of life of patients.' ^ This psychoso-
cial aspect of skin disease has important implications for
optimal management of patients.^ Although dermatolo-
gists and other clinicians have long recognized the impact
of skin disease on a patient's life, it is only recently that
quality of life measures have been used as assessment
parameters in the management of chronic skin disease
and in the evaluation of new rrcatmenrs."
Disease-specific indices of disability have been devel-
oped to record the impact of atopic eczema, psoriasis and
acne,''"" but these cannot be used to compare different
skin diseases. In contrast, general health measures of
quality of life, such as the United Kingdom Sickness
Impact Profile (UKSIP), can be used to compare the
Correspondence: Dr A.Y.Finlay, F.R.C.P., Senior Lecturer and
C-onsultant Dermatologist, Department of Dermatology, University
of Wales College of Medicine, Cardiff Cr4 4XN, Wales, UK,
This paper was presented at the British Association of Dermatolo-
gists and Canadian Dermatology Association Joint Annual Meeting,
Oxford, UK, 6-10 July 1993.
210
disability experienced by patients with different skin
diseases and non-dermatological disease.'' The UKSIP is
useful in a research environment but has the disadvantage
of being a lengthy questionnaire and impractical for
routine use in a busy dermatology clinic.
There is a need for a simple, compact uniform
measure, applicable to patients with any skin disease, for
use as an assessment tool in routine daily clinical practice.
This paper describes the development, preliminary use
and reliability testing of a new disability index to meet
this need, the 'Dermatology Life Quality Index' (DLQI).
Materials and Methods
Ethical permission for this study was given by rhe Joint
Medical Ethical Committee of the University Hospital of
Wales.
Development of the DLQf
One hundred and twenty consecutive patients aged 15-70
years attending the Dermatology Out-Patient Depart-
ment, University Hospital of Wales, were given a sheet of
paper with the following question;
We are trying to find out how much skin disease affects people. We
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
disease affects you. Please include any affects on your work life,
social life, personal relationships and leisure activities, or any other
ways in which your skin disease aftects your life. Although we need a
record of your diagnosis, sex and age for analysis, your reply is
otherwise anonymous.
No patient refused to answer.
Each answer was analysed by identifying different
aspects of life quality impairment. Tbe number of
different aspects identified in each answer ranged from 0
to 8. A total of 49 different aspects were identified, sorted
into different overall categories and then ranked accord-
ing to their frequency of mention (Table 1). After the
analysis of the first 70 answers, no additional problems
 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
on a further 20 patietits to confirm that it was clearly
understood, unambiguous, practical and applicable. The
final version of the questionnaire was deliberately
designed so that it would fit clearly on one side of an 'A4'
size sheet for ease of use and filing (Fig. 1). The space at
the top left corner of the sheet is suitable for a standard
'stick on' hospital label giving patient name, number,
address and date of birth. The 'date', 'diagnosis' and
'final score' are designed to be completed by the
physician.
Scaling and scoring ofthe DLQJ
The questionnaire was structured with each question
having four alternative responses: 'not at all', 'a little', 'a
lot' or 'very much' with corresponding scores of 0, 1, 2
and 3, respectively. The answer 'not relevant', is scored as
'0'. The DLQI is calculated by summing the score of each
question, resulting in a maximum of 30 and minimum of
0. The higher the score, the greater the impairment of
quality of life. The DLQI can also be expressed as a
percentage of the maximum possible score of 30.
Preliminary use ofthe DLQJ
Two hundred patients (84 male, 116 female), aged 15-75
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
each patient and all patients agreed to take part. The
questionnaire was explained to each patient and then
completed by the patient in a quiet corner of the out-
patient department.
One hundred healthy volunteers (40 male, 60 female),
aged 15-75 years (median 34 5) were also selected as
213
controls. The healthy volunteers were randomly selected
from the relatives who accompanied patients attending
the dermatology out-patient department. The criteria for
the selection of controls were that they should not have
seen their general practitioner over the previous 3
months, they should have had no skin problem or other
systemic medical disease over this time, and they should
have had no apparent disability. Controls were not
exactly individually matched to the age and sex of the
patient population, but the control group was of a similar
age range and sex distribution.
Reliability ofthe DLQI
To assess the reliability ofthe DLQI, 53 patients with a
variety of skin diseases were recruited from the dermato-
logy out-patient clinic at the University Hospital of
Wales. The 32 male and 21 female patients were aged 15-
66 years (median 39). After the nature ofthe study was
explained, the DLQI was given to the patients to
complete. Following an interval of 7-10 days, all the
patients reattended the out-patient clinic to complete the
DLQI questionnaire again.
The results were analysed using non-parametric statis-
tical techniques, the Mann-Whitney t/-test and the
Kruskal-Wallis one-way ANOVA test, as appropriate.
Results
The diagnosis, age and sex distribution of the patients
along with the healthy volunteers are shown in Table 3.
One hundred and ninety-six (98%) patients correctly
completed all 10 questions. The remaining four (2%) did
not complete questions 8 and 9, concerning personal
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 mean score for each DLQI question for patients and
controls is given in Fig. 2. Overall responses were positive
more frequently for questions 1, 2, 4, 5 and 10.
Consistency between question responses
The degree of consistency of responses between ques-
tions was tested using the Rank correlation test. The
consistency between all questions when paired was found
to be statistically significant at the level of 0-002 and
ranged from Rank correlations of 0-23-0-70 (see Table 4).
The higher the Rank correlation value, the higher the
consistency.
Quality of life assessment
The overall DI,QI scores for the different diagnostic
categories, and the DLQI scores from the healthy group
of volunteers are shown in Table 3. The higher the scores,
the greater the number and severity of perceived prob-
lems.
The scores of the patients with atopic eczema
[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,
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
all strongly significantly higher (/*<0-0001) than for the
control population. The scores for patients with atopic
eczema, generalized pruritus and psoriasis were higher
(P<000\) than for patients with acne, basal cell carci-
noma and viral warts.
The overall mean DLQJ score for the patients was 7-3
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
questions. There was no significant difference (P—0-67)
in the D1.,QJ scores of patients with skin disease between
men [K = 84, mean DLQI = 7-3, s.d.=6-3 (24-4%)] atid
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
comparator with systemic diseases in discussions con-
cerning resource allocation hetween medical specialities;
second, to assess the effectiveness of new therapies; third,
to use in audit ofthe effectiveness of dermatology clinical
services; fourth, to provide an additional patient-oriented
measure of disease status for routine clinical monitoring,
and fifth, to provide comparisons between the 'impor-
tance' of different skin diseases and the relative effective-
ness of therapy.
Some of these needs can be met by previously
described methods. The UKSIP provides a possible
comparator between different skin diseases and between
other systemic diseases. Novel therapies, used for specific
diseases, can be assessed using disease specific question-
naires such as the Psoriasis Disability Index (PDI) or the
Acne Disability Index (ADI).^'^ The need for measures in
the audit ofthe effectiveness of a dermatology service can
only partly be met by the use of disease specific
questionnaires as too many different instruments would
need to be used, and the use of general health measures of
life quality may be impractical. These difficulties also
apply in routine clinical use. C-omparison can be drawn
between different skin diseases by using the UKSIP but
for extensive studies or ongoing monitoring a simpler
technique is required. The DLQI has been designed to
meet the need for a very simple but sensitive method of
measuring disability caused by skin diseases. It was
completed rapidly and without difficulty by patients over
a wide range of age and intellectual ability, usually in 1-3
min. The DLQI, therefore, potentially fulfils the pre-
viously unmet needs identified above.
Time-scale is an important factor to be considered
when constructing questions in any measure of handicap.
We chose a 1-week time-scale as an appropriate time over
which patients could easily remember events. This time-
scale is also short enough to allow the DLQI to be used
for comparative purposes in routine clinical use.
tn the first of a series of validation studies, we have
established a construct validity for the questionnaire by
initially measuring the quality of life of two different
groups, patients with skin disease and normal healthy
subjects. The questionnaire scores were able to discrimi-
nate between these two groups.
The method of 'test-retest' reliability assessment
adopted in this study does not involve any observer or
'rater','" and is therefore a preferred method of quantify-
ing the reproducibility of self-administered measures
such as the DLQI. The test-retest reliability of the
overall scores ofthe DLQI was consistent and high. The
reliability correlations for the individual questions were
also consistent and high, but were slightly lower than that
for the overall DLQI scores. This was expected, because
the reliability of assessment of one facet of dysfunction is
not likely to be as great as when all facets are included.^^
215
Tn general the DLQI was very reliable in its overall score
as well as in individual questions.
A 'leisure questionnaire' for use by dermatology
patients was proposed by Ryan'- to record impairment of
quality of life, though no overall scoring system was
proposed nor was the origin or practical use of this
questionnaire described. The 10 questions in the 'leisure
questionnaire' are largely covered by questions 3, 5, 6 and
9 in the DLQI; the other six DLQI questions concern
areas not mentioned in the 'leisure questionnaire', but
which were frequently mentioned by patients in the
survey on which the DLQI is based. When comparing
the questions in the DLQI with those in thePDL and the
ADI^, it is clear that similar areas are covered; however, in
the psoriasis and the acne measures there is a specific
emphasis to the questions refiecting each disease, w hereas
the DLQI questions are more widely encompassing. It
should be noted that the scoring system used for the
DLQI, as for other similar questionnaires, is ultimately
arbitrary, and the scoring refiects the bias ofthe question
selection. It is possible for example that patients from
other cultures might place a different emphasis on the
importance ofthe various aspects of handicap covered by
the questionnaire.
This questionnaire has been specifically designed to be
practical and to be of clinical value when used in a busy
clinical setting. The scoring system is therefore deliber-
ately simple and the information is most conveniently
summarized as an overall score. By definition, if the score
of one question increases at the same time as the score of
another question decreases, the overall score remains the
same: this is as intended as maintenance ofthe same score
reflects an overall unchanged average level of quality of
life. It is possible of course, if required, to maintain and
use the detailed information given in the replies by
analysing either each question or groups of questions
separately. We have previously used this approach in
grouping questions under five headings when analysing
data from the PDI.** A similar analysis ofthe DLQJ, using
six headings, could group the 10 questions as follows:
Symptoms, feelings 1,2
Daily activities 3,4
Leisure 5,6
Work/school 7
Personal relationships 8,9
Treatment 10
It is essential to demonstrate thar quality of life assess-
ment methods can detect change in quality of life.
Measures of quality of life should not, for example, be
used in clinical trials unless responsiveness has been
demonstrated in the skin condition being examined. A
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
skin disease (H.A.Kurwa and A.Y.Finlay, unpublished).
Preliminary analysis of the first 60 patients in this .study
has demonstrated reduction in the mean DLQI from 14-3
(before admission) to 8-4 (after admission), indicating
that the DLQI is responsive to change. Clearly, however,
further responsiveness studies need to be carried out.
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
assessment with the UKSIP is being carried out in a
study designed to assess the effect of skin cancer on
quality of life (S.Blackford, D.L.Roberts, M.S.Salek and
A.Y.Finlay, unpublished). We plan further external
validity testing with the UKSIP and the PDI.
We have demonstrated previously that a very short
disease-specific questionnaire^ can successfully be used in
routine clinical use to assess the impact of acne and its
treatment on patients' quality of life. We have now used a
new simple short questionnaire to compare quantitatively
the handicap experienced by patients with a wide range of
different skin diseases. As expected, this study has
confirmed that patients with chronic skin diseases such as
atopic eczema, psoriasis and acne experience a greater
impairment of quality of life than patients with moles and
seborrhoeie warts, which have little impact on a patient's
day to day activities. On the other hand it was surprising
that in this study patients with acne recorded less
impaired quality of life than patients with viral warts.
This may reflect the selected nature of dermatology
referrals seen at this secondary referral centre.
We hope that the use of the DLQI in the routine
clinical assessment of patients with skin disease may make
the patient-physician interaction more patient-centred
by highlighting the psychosocial influences on the indi-
vidual patient's well-being, as well as providing a useful
practical measure for regular use.
Acknowledgments
We wish to thank Dr M.S.Salek, Medicines Research
Unit, University of Wales College of Cardiff and Dr
R.G.Newcombe, Department of Medical Computing
and Statistics, University of Wales College of Medicine,
for their helpful advice concerning this study.
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