Psychological Distress and Associated Factors in Patients with Autoimmune Bullous Dermatoses: A Cross-sectional Study Using the Distress Thermometer

Psychological Distress and Associated Factors in Patients with Autoimmune Bullous Dermatoses: A Cross-sectional Study Using the Distress Thermometer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychological Distress and Associated Factors in Patients with Autoimmune Bullous Dermatoses: A Cross-sectional Study Using the Distress Thermometer Chenchen Feng, Yanmin Zhao, Yu Ou, Lingxiao He, Dan Jia, Wei Li, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9173406/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Objective This study aimed to evaluate psychological distress and its associated factors in Autoimmune bullous dermatoses patients using the Distress Thermometer. Methods A cross-sectional study was conducted with 252 patients. Psychological distress was assessed using the Distress Thermometer. Univariable and multivariable binary logistic regression were performed to identify factors associated with psychological distress. Results The median distress score was 2.0 (IQR: 0.0–4.0), with 33.33% of patients exhibiting clinically significant psychological distress. Univariable analysis indicated age (P = 0.021), educational level(P = 0.002), current skin lesions number(P = 0.002), history of COVID-19 infection(P = 0.014), disease staging(P = 0.002), pain(P < 0.001), itch(P < 0.001), and sleep quality(P < 0.001) were significantly associated with psychological distress in Autoimmune bullous dermatoses patients. Multivariable analysis identified absence of prior COVID-19 infection (aOR = 2.311, 95% CI: 1.066–5.014; P = 0.034), pain(aOR = 1.198, 95% CI: 1.009–1.423; P = 0.039), itch(aOR = 1.418, 95% CI: 1.171–1.717; P < 0.001), and sleep quality (aOR = 1.202, 95% CI: 1.097–1.316; P < 0.001) showed statistically significant associations with psychological distress in Autoimmune bullous dermatoses patients. Conclusion This study highlights the high prevalence of psychological distress in Autoimmune bullous dermatoses patients and identifies key factors contributing to distress, including absence of prior COVID-19 infection, pain, itch, and sleep quality. These findings underscore the need for comprehensive psychological assessments and tailored interventions to address the multifaceted challenges faced by Autoimmune bullous dermatoses patients, ultimately improving their overall well-being through integrated care strategies. Autoimmune diseases Bullous dermatoses Cross-sectional Study Distress Thermometer Psychological distress Rare disease Introduction Autoimmune bullous dermatoses (AIBD) are a group of rare chronic skin disorders characterized by blistering and erosions on the skin and mucous membranes. These conditions, including pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, and other autoimmune bullous diseases (AIBDs), may present with significant physical symptoms to varying degrees across subtypes, such as pain, pruritus, and refractory oral erosions. 1 , 2 The chronic nature of AIBD, coupled with the need for long-term treatment and the potential for severe complications and side effects, places a substantial burden on patients' physical health and overall quality of life. 3 Beyond the physical manifestations, AIBD also exerts a profound impact on patients' mental health, leading to emotional distress, anxiety, depression, and diminished self-esteem. 4 , 5 Studies have shown that the prevalence of anxiety and depression among patients with bullous dermatoses ranges from 40% to 80%. 6,7 It was also reported that the prevalence of anxiety and depression in patients with pemphigus vulgaris and pemphigus foliaceus was between 28–77%, significantly higher than in the general population and patients with other chronic skin diseases. 5 This underscores the critical need to address the psychological well-being of AIBD patients as an integral part of their overall care. Researchers have further investigated the specific issues experienced by patients that contribute to psychological problems. White reported that AIBD patients experienced a high level of body image disturbance. 8 Wang discovered that approximately 14.8% of patients experienced stigmatization in the workplace due to their appearance, leading to varying degrees of impairment in work and activities, making them more susceptible to feelings of loneliness and social isolation. 9 Maione found that the quality of life, particularly in terms of sexual activity, was significantly affected in patients with pemphigus. 10 AIBD patients may also suffer from feeding, pain, itching, and sleep disturbances, yet current studies on AIBD patients' psychological problems and the exploration of specific causes and factors of these psychological problems is insufficient. Psychological distress is a broader psychological concept that refers to emotional experiences resulting from various causes, encompassing psychological (cognitive, behavioral, emotional) aspects, social and/or spiritual experiences. It manifests as emotional reactions such as vulnerability, sadness, and fear, or severe psychological problems such as depression, anxiety, fear, feelings of social isolation, and mental crises. 11 , 12 Existing research indicates that the Distress thermometer (DT) can serve as a rapid, effective, and reliable screening tool for identifying psychological distress in dermatology outpatients. 13 Furthermore, this tool can investigate specific distress issues experienced by patients, which may help improve healthcare professionals' understanding of the psychological problems. Existing evidence highlights that mental health in chronic dermatosis patients is significantly associated with disease-related factors (e.g., pain, itch, sleep problems, systemic comorbidities, disease staging) 4 , 5 , 7 , 14 , 15 and socioeconomic determinants like educational attainment, social support,etc. 16 – 18 Additionally, the COVID-19 pandemic has exerted long-term impacts on the mental health of individuals with chronic diseases. 19 , 20 Maybe due to the rarity of the disease, there is a lack of study on AIBD patients ’ psychological distress and its related problems. Based on the Biopsychosocial Model and Stress 21 and Coping Theory 22 , we hypothesize that psychological distress in AIBD patients is driven not by isolated factors but by the interplay of disease characteristics (e.g., number of skin lesions, pain), psychosocial factors (e.g., educational level, social support), and external events (e.g., COVID-19 infection history). Therefore, this study aimed to investigate the psychological distress and associated factors in AIBD patients, so as to provide theoretical support for the assessment, identification, and therapeutic intervention of psychological distress in AIBD patients. Methods Subjects This cross-sectional observational study included 257 AIBD patients from XX hospital between June and October 2023. Finally, 252 valid questionnaires were retained. We included patients who visited the AIBD Specialty Clinic and had AIBD diagnosis, age no less than 18 years. Patients with poor cognitive function (inability to understand and cooperate in completing the questionnaire), a history of psychiatric disorders, the presence of other major diseases such as heart failure or malignant tumors were excluded. Measurement tools Sociodemographic characteristics form This form was developed by researchers based on their own experiences and literature review. 23 – 25 It included demographic and disease-related information. Demographic information included items such as gender, age, educational level, marital status, employment status, etc. Disease-related information included disease diagnosis, duration of illness, current skin lesions number, history of COVID-19 infection, etc. Visual Analogue Scale (VAS) : Pain and itch were assessed using the 10-centimeter line scale with a starting point of "0" and an endpoint of "10". The severity was divided into four levels: 0 for none, 1–3 for mild, 4–6 for moderate, and 7–10 for severe. 26,27 Pittsburgh Sleep Quality Index (PSQI) : It consists of 19 self-rated items covering seven dimensions: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction. 28 Additionally, there are five other-rated items that do not contribute to the scoring. Each self-rated item is scored from 0 to 3, and the cumulative score is the PSQI total score, ranging from 0 to 21. Sleep quality is categorized into four levels: 0–5 for high quality, 6–10 for good, 11–15 for general, and 16–21 for poor. 29 The Distress Thermometer (DT) : It includes a VAS with a numerical scale from 0 to 10, where 0 represents no psychological distress and 10 indicates extreme distress. Scores of 1–3 indicate mild distress, 4–6 moderate distress, and 7–9 severe distress, with 10 being extremely severe. 30 DT scoring 4 or above is the threshold for clinically significant distress that requires intervention. 31 DT also includes a Problem List (PL) with five dimensions: practical problems (6 items), family problems (4 items), emotional problems (10 items), physical problems (19 items), and spiritual/religious concerns (1 item). Each of these items is answered with yes or no, scoring 1 or 0 respectively. The average score for each dimension is calculated by dividing the total score by the number of items in that dimension, with scores ranging from 0 to 1. 12 A higher score indicates more issues in that dimension. This screening tool has shown good reliability and validity in non-cancer patient, with a Cronbach's alpha of 0.87 to 0.93. 32 A cut-off score ≥ 4 on the DT provided the optimal ratio of sensitivity (90.7%) to specificity (56.1%) in chronic skin disease patients. 13 Sample Size Calculation The formula for calculating the sample size is n = (Z_(α/2)/δ)^2 * π(1-π), where Z_(α/2) represents the Z-value for the two-tailed probability α in the standard normal distribution, δ represents the allowable error, and π represents the incidence rate of psychological distress. For α = 0.05, Z_(α/2) = 1.96, δ = 0.05, and π = 0.15 (based on a pre-survey investigation rate of psychological distress of 15%), the calculated sample size is 245. Considering a 5% sample attrition rate, the planned survey sample size is 257 cases. Data collection Two trained nurses from the AIBD Specialty Clinic conducted the survey. The purpose of the survey was explained to the patients when they visited AIBD Specialty Clinic, who then provided informed consent to participate. Patients completed the questionnaire independently, and if they were unable to do so, the survey staff completed the questionnaire based on the patients' statements. Statistical Analysis Data entry was conducted using Excel software with double-check verification. Data processing was performed using SPSS 25.0 software. Measured data were described using median and interquartile range; count data were represented by frequency and percentage (%).Univariable and multivariable binary logistic regression were performed. Multivariable analysis included variables with P < 0.05 in univariable testing and clinically important covariates. Collinearity among variables was assessed using variance inflation factor (VIF), with VIF < 5 indicating no significant multicollinearity. Model goodness-of-fit was evaluated with the Hosmer-Lemeshow test. P < 0.05 indicates statistical significance. Results Psychological Distress and related problems in AIBD patients The median age of patients was 53.0 years (IQR: 43.0–60.0). Of these, there were 146 cases of pemphigus vulgaris, 39 cases of bullous pemphigoid, 30 cases of pemphigus foliaceus, as detailed in Table 1.The median DT score was 2.0 (IQR: 0.0–4.0).33.33% of AIBD patients (84 cases) scored 4 or above. The Emotional problems dimension scored the highest, followed by Practical and Family problems dimension, as detailed in Table 2. The top three reported problems were worry (51.19%), appearance/body image (41.27%), and sleep problems (40.08%), as presented in Table 3. Table 1 : Participants’ sociodemographic and clinical characteristics. Variable (N = 252) n (%) Age(years) , [median (IQR)] 53 (43-60) Gender Male 115 (45.63%) Female 137 (54.37%) Educatio n level Elementary school or below 58 (23.02%) Junior high school 88 (34.92%) High school/vocational 37 (14.68%) Associate’s degree or higher 69 (27.38%) Marital status Not-married 36 (14.29%) Married 216 (85.71%) Employment status Employed 134 (53.17%) Retired 65 (25.79%) Unemployed 53 (21.03%) Long-term residence Rural 98 (38.89%) Urban 154 (61.11%) Residential origin Same city 76 (30.16%) Same province, other city 131 (51.98%) Other province 45 (17.86%) Living a lon e Yes 25 (9.92%) No 227 (90.08%) Household monthly income per capita ≤ 3,000 CNY 138 (54.76%) 3,000–6,000 CNY 81 (32.14%) ≥ 6,000 CNY 33 (13.10%) Primary caregiver Self 30 (11.90%) Others 222 (88.10%) Payment method Uninsured out-of-pocket payment 59 (23.41%) Insured 193 (76.59%) Diagnosis PV 146 (57.94%) BP 39 (15.48%) PF 30 (11.90%) Others 37 (14.68%) Duration of illness ≤ 3 months 25 (9.92%) 3–6 months 30 (11.90%) 6–12 months 41 (16.27%) 1–3 years 82 (32.54%) ≥3 years 74 (29.37%) C urrent skin lesions number 0 42 (16.67%) 1 50 (19.84%) ≥ 2 160 (63.49%) History of COVID-19 infection Yes 153 (60.71%) No 99 (39.29%) Systemic comorbidities Yes 38 (15.08%) No 214 (84.92%) Current t herapeutic regimen Steroids only 144 (57.14%) Combined with steroids 63 (25%) Others 45 (17.86%) Disease staging Partial remission 161 (63.89%) Complete remission 61 (24.21%) Relapse/flare/failure 30 (11.90%) Pain score , [median (IQR)] 1 (0-3) Itch score ,[median (IQR)] 2 (0-4) PSQI score , [median (IQR)] 8 (4-12) DT score , [median (IQR)] 2 (0-4) < 4 168 (66.67%) ≥ 4 84 (33.33%) Abbreviations: CNY:Chinese Yuan; DT: Distress Thermometer; IQR:Interquartile range; PV:Pemphigus vulgaris; BP:Bullous pemphigoid; PF:Pemphigus foliaceus; PSQI: Pittsburgh Sleep Quality Index Table 2 : Dimension score of psychological distress problems in AIBD Patients (N = 252). Dimension Minimum Score Maximum Score Median IQR Emotional problems 0.00 1.00 0.20 (0.00, 0.40) Practical problems 0.00 1.00 0.17 (0.00, 0.33) Family problems 0.00 1.00 0.00 (0.00, 0.25) Physical problems 0.00 0.68 0.11 (0.05, 0.21) Spiritual/Religious concerns 0.00 1.00 0.00 (0.00, 0.00) Table 3 : Psychological distress problems in AIBD Patients (N = 252). Specific problems n (%) Emotional problems Worry 129 (51.19% ) Sleep problems 101 (40.08%) Nervousness 74 (29.37%) Memory decline 68 (26.98%) Depression 55 (21.83%) Loss of interest in usual activities 54 (21.43%) Difficulty concentrating 52 (20.63%) Fears 44 (17.46%) Sadness 34 (13.49%) Loneliness 24 (9.52%) Practical problems Insurance/Financial 81 (32.14%) Housing 46 (18.25%) Transportation 44 (17.46%) Work/School 43 (17.06%) Care for children/elderly 41 (16.27%) Surrounding environment 20 (7.94%) Family problems Interaction with children/elderly 52 (20.63%) Interaction with partner 43 (17.06%) Interaction with relatives and friends 39 (15.48%) Interaction with medical staff 8 (3.17%) Physical problems Appearance/body image 104 (41.27%) Mouth scores 72 (28.57%) Fatigue 69 (27.38%) Bathing/Dressing 62 (24.60%) Pain 50 (19.84%) Daily activities 41 (16.27%) Eating 38 (15.08%) Skin dry/itchy 34 (13.49%) Feeling swollen 29 (11.51%) Tingling in hand/feet 20 (7.94%) Indigestion 19 (7.54%) Changes in urination 16 (6.35%) Changes in defecation (constipation/diarrhea) 16 (6.35%) Dizziness 15 (5.95%) Nose dry/congested 12 (4.76%) Breathing 11 (4.37%) Nausea 7 (2.78%) Sexual 7 (2.78%) Fevers 3 (1.19%) Spiritual/Religious concerns 8 (3.17%) Univaria bl e and m ultivariable b inary logistic regression a nalysis of Psychological Distress in AIBD Patients The results of the univariable analysis indicated that age (P = 0.021), educational level(P = 0.002), current skin lesions number(P = 0.002), history of COVID-19 infection(P = 0.014), disease staging(P = 0.002), pain(P < 0.001), itch(P < 0.001), and sleep quality(P < 0.001) were associated with psychological distress in AIBD patients, as detailed in Table 4. After adjusting for potential confounders, COVID-19 infection history, pain, itch, and sleep quality showed statistically significant associations with psychological distress in AIBD patients. Patients with no prior COVID-19 infection exhibited 2.3-fold higher odds of psychological distress (aOR = 2.311, 95% CI: 1.066–5.014; P = 0.034). Each 1-point increase in pain score corresponded to 19.8% higher odds (aOR = 1.198, 95% CI: 1.009–1.423; P = 0.039).Each 1-point increase in itch score was associated with 41.8% higher odds of distress (aOR = 1.418, 95% CI: 1.171–1.717; P < 0.001).Each 1-point increase in PSQI score was linked to 20.2% higher odds (aOR = 1.202, 95% CI: 1.097–1.316; P < 0.001), as detailed in Table 5. Table 4 : Univariable Logistic Regression Analysis of Factors Associated With Psychological Distress in AIBD Patients (N = 252). Variable N OR (95%CI) P Age (years) 252 1.022 [1.003, 1.040] 0.021* Gender Male 115 1.00 (Ref.) - - Female 137 0.826 [0.488, 1.396] 0.475 Educatio n level 0.002* Elementary school or below 58 1.00 (Ref.) - - Junior high school 88 0.723 [0.370, 1.414] 0.343 High school/vocational 37 0.622 [0.266, 1.454] 0.273 Associate’s degree or higher 69 0.195 [0.084, 0.453] <0.001* Marital status Not-married 36 1.00 (Ref.) - - Married 216 0.753 [0.364, 1.561] 0.446 Employment status 0.366 Employed 134 1.00 (Ref.) - - Retired 65 0.974 [0.513, 1.848] 0.935 Unemployed 53 1.555 [0.806, 2.999] 0.188 Place of residence Rural 98 1.00 (Ref.) - - Urban 154 0.673 [0.395, 1.146] 0.145 Residential origin 0.920 Same city 76 1.00 (Ref.) - - Same province, other city 131 1.067 [0.586, 1.943] 0.831 Other province 45 0.921 [0.417, 2.034] 0.839 Living a lone Yes 25 1.00 (Ref.) - - No 227 0.503 [0.219, 1.157] 0.106 Household monthly income per capita 0.526 ≤ 3,000 CNY 138 1.00 (Ref.) - - 3,000–6,000 CNY 81 0.786 [0.438, 1.411] 0.419 ≥ 6,000 CNY 33 0.660 [0.285, 1.530] 0.333 Primary caregiver Self 30 1.00 (Ref.) - - Others 222 0.615 [0.283, 1.335] 0.219 Payment method Uninsured out-of-pocket payment 59 1.00 (Ref.) - - Insured 193 0.877 [0.476, 1.617] 0.674 Diagnosis 0.246 PV 146 1.00 (Ref.) - - BP 39 1.387 [0.658, 2.924] 0.390 PF 30 2.167 [0.972, 4.831] 0.059 Others 37 1.507 [0.709, 3.206] 0.287 Duration of illness 0.144 ≤ 3months 25 1.00 (Ref.) - - 3–6months 30 1.114 [0.383, 3.236] 0.843 6–12months 41 0.467 [0.163, 1.333] 0.155 1–3years 82 0.438 [0.172, 1.113] 0.083 ≥ 3years 74 0.731 [0.291, 1.836] 0.505 C urrent skin lesions number 0.002* 0 42 1.00 (Ref.) - - 1 50 1.895 [0.643, 5.584] 0.246 ≥ 2 160 4.213 [1.679, 10.569] 0.002* History of COVID-19 infection Yes 153 1.00 (Ref.) - - No 99 1.947 [1.142, 3.321] 0.014* Systemic comorbidities Yes 38 1.00 (Ref.) - - No 214 0.833 [0.406, 1.709] 0.619 Current therapeutic regimen 0.266 Steroids only 144 1.00 (Ref.) - - Combined with steroids 63 0.616 [0.321, 1.181] 0.144 Others 45 0.677 [0.327, 1.402] 0.293 Disease staging 0.002* Partial remission 161 1.00 (Ref.) - - Complete remission 61 0.348 [0.164, 0.737] 0.006 Relapse/flare/failure 30 2.030 [0.925, 4.455] 0.078 Pain score 252 1.375 [1.218, 1.553] <0.001* Itch score 252 1.546 [1.359, 1.758] <0.001* PSQI score 252 1.223 [1.141, 1.311] <0.001* Abbreviations: OR:Odds Ratio;CI :confidence interval; *Statistically significant ( P <0.05) Table 5: Multivariable Binary Logistic Regression Analysis of Factors Associated With Psychological Distress in AIBD Patients (N = 252). Variable Category aOR(95%CI) P Reference Group History of COVID-19 infection No(vs.Yes) 2.311(1.066-5.014) 0.034 * Yes Pain score Per 1-point increase 1.198(1.009-1.423) 0.039 * - Itch score Per 1-point increase 1.418(1.171-1.717) <0.001 * - PSQI score Per 1-point increase 1.202(1.097-1.316) <0.001 * - Abbreviations: CI :confidence interval; OR:Odds Ratio; aOR = adjusted odds ratio (adjusted for all variables in final model) Reference groups (Ref) indicated for categorical variables *Statistically significant ( P <0.05) Discussion Psychological Distress and related problems in AIBD Patients The research found that 33.33% of patients experienced psychological distress, consistent with Wang et al.’s report of 30.7% of pemphigus patients suffering from anxiety (25%) or depression (14.3%). 4 A systematic review noted that the prevalence of depressive symptoms among patients with bullous dermatoses ranged from 40% to 80%, and the prevalence of depression diagnosis among patients with bullous dermatoses ranged from 11.4% to 28%. 7 Variations in detection rates may result from differences in sample size, assessment tools, psychological definitions, disease classifications, and disease stage, highlighting the need for a comprehensive approach to assess psychological health in AIBD patients. The analysis of specific dimensions and items of psychological distress in AIBD patients revealed prominent issues in three key dimension: emotional, family and practical. The top three reported items were "worry" (51.19%), "appearance/body image (41.27%)" and "sleep problems" (40.08%). This finding is consistent with prior research that has identified emotional distress as a significant burden for AIBD patients. 4 Our study also revealed that "appearance/body image" and "sleep problems" were among the primary concerns affecting AIBD patients. These results provide a holistic view of psychological distress and related problems in AIBD patients. Healthcare professionals can better understand patients' challenges and develop tailored interventions. Factors Influencing Psychological Distress in AIBD Patients Patients without prior COVID-19 infection exhibited higher odds of psychological distress. This may be related to the changes in lifestyle and psychological state that people have experienced during the pandemic, challenging everyone's adaptability. 19 This phenomenon aligns with the concept of "post-traumatic growth," where individuals develop new coping strategies and psychological adaptation mechanisms after facing difficulties or trauma, which may help alleviate psychological distress and potentially improve cognitive function. 33 What’s more, patients who have recovered from COVID-19 may have undergone a positive psychological transformation, which may be associated with the reduced fear of the virus and the gradual establishment of herd immunity in the later stages of the pandemic. 20 Our study indicates that the history of COVID-19 infection may have long term influence on people’s health and requires further research. Increase in pain score was associated with higher odds of distress. This aligns with multiple studies, indicating pain is both a primary physical symptom and a mental health threat for AIBD patients. 18,34 In a study about the incidence of pain in BP patients and its association with disease activity, 53% of patients reported pain, with 26% experiencing moderate to severe pain. 35 Previous research has also confirmed the bidirectional relationship between pain and depression, with pain being both a predictor and a result of depression. 36 This suggests that pain management is not only necessary for treating physical symptoms but is also key to maintaining patients' mental health and improving their quality of life. Therefore, it is crucial to monitor AIBD patients' pain level associated with lesions and to develop long-term pain control strategies for them.Future research should explore pain-psychological distress mechanisms and develop interventions combining pharmacotherapy, psychological support, and lifestyle changes. Our study also found that the higher the level of itch in AIBD patients, the greater the odds of psychological distress. BP is characterized by severe itch accompanied by tense blisters on the trunk and limbs, significantly reducing patients' quality of life. 35 Itch not only leads to delayed sleep onset and frequent awakenings but also triggers a series of psychological issues such as restlessness, embarrassment, and social interaction difficulties. 37 BP patients often have scratching behaviors, which can result in scars, bleeding, and some patients may develop chronic pruritus over time. 38 Chronic pruritus not only poses a threat to patients' physical health but can also lead to severe psychological burdens, with patients suffering from moderate to severe itch being more likely to exhibit symptoms of depression. 39 The underlying mechanisms of AIBD-related itch are not fully understood, and the lack of effective treatment options for this problem has become a significant challenge. 40,41 This indicates that, in addition to focusing on pain, itch is also an issue worthy of attention from dermatologists. Our research has found that the poorer the quality of sleep, the more likely individuals are to experience psychological distress. In the field of chronic skin diseases, the close relationship between sleep quality and mental health has been confirmed by numerous studies. 42,43 A research summary indicated that psoriasis patients have lower sleep quality than the healthy population, with an increased risk of sleep disturbances and more frequent symptoms of depression. 44 Pedroni pointed out that there is a complex bidirectional relationship between pemphigus and sleep disturbances. The inflammatory response and chronic pain of pemphigus may impair sleep quality, while sleep disturbances can exacerbate pemphigus symptoms. Additionally, there is a strong mutual interaction between sleep problems and depressive moods. Sleep disturbances not only increase the risk of depression but the presence of depression can also lead to further deterioration in sleep quality. 45 Henderson's research further confirmed the key mediating role of sleep problems in increasing the risk of anxiety and depression in patients with chronic skin diseases, showing a significant correlation between the decline in sleep quality and negative changes in the psychological state of patients with eczema and psoriasis. 46 Therefore, it is recommended that clinical doctors inquire about AIBD patients' current sleep quality and that further consultations should be arranged for patients with sleep disturbances to develop a more comprehensive treatment plan. Limitations This single-center study may lack generalizability, but AIBD is a rare disease and the inclusion of AIBD patients from various provinces across China, where few hospitals can diagnose and treat this rare disease, may partially mitigate this limitation. Conclusion This study revealed a high prevalence of psychological distress among AIBD patients and numerous issues troubling patients such as "worry","appearance/body image" and "sleep problems" have been identified. Absence of prior COVID-19 infection , pain, itch and sleep quality were found to be significant predictors of psychological distress. By utilizing the DT, clinicians can promptly identify psychological distress in AIBD patients and develop personalized interventions based on the specific contributing factors and individual needs. Comprehensive intervention strategies should encompass disease symptom management, psychological support, health education, and other measures, aiming to holistically improve the physical and mental well-being of patients. Abbreviations AIBD: autoimmune bullous dermatoses; aOR: adjusted odds ratio; BP: bullous pemphigoid; CI: confidence interval; COVID-19: Coronavirus disease 2019; DT: Distress Thermometer; IQR: interquartile range; PL: Problem List; PSQI: Pittsburgh Sleep Quality Index; SPSS: Statistical Package for the Social Sciences; VAS: Visual Analogue Scale; VIF: variance inflation factor. Declarations Ethics approval and consent to participate All subjects provided informed consent and voluntarily participated in the research. The study was ratified by the Ethics Committee of West China Hospital (No. 2024/1617) and was carried out in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials Data are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors ’ contributions Chenchen Feng was responsible for study design and manuscript writing. Yanmin Zhao participated in data collection and analysis. Yu Ou participated in manuscript writing. Lingxiao He was in charge of questionnaire design and statistical guidance. Dan Jia, Wei Li, and Shuzhen Zhao provided guidance on study design, questionnaire revision, and manuscript revision. All authors read and approved the final manuscript. Acknowledgements We sincerely thank Dr. Lin Li and Dr. Lu Li for their expert guidance on the statistical methodology of this study. References Holtsche MM, Boch K, Schmidt E. Autoimmune bullous dermatoses. J Dtsch Dermatol Ges 2023;21:405–12. Rosi-Schumacher M, Baker J, Waris J, Seiffert-Sinha K, Sinha AA. Worldwide epidemiologic factors in pemphigus vulgaris and bullous pemphigoid. Front Immunol 2023;14:1159351. 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Mental health in patients with pemphigus: an issue to worth consideration. Indian J Dermatol 2011;56:541-5. Kianfar N, Dasdar S, Mahmoudi H, Daneshpazhooh M. Burden of pemphigus vulgaris with a particular focus on women: A review. Int J Womens Dermatol 2022 ;8:e056. Zhang XJ, Wang AP, Shi TY, et al. The psychosocial adaptation of patients with skin disease: a scoping review. BMC Public Health 2019;19:1404. Hatami P, Sadeghinia A, Mahmoudi H, et al. Drug Adherence and its Association with Health Literacy Among Patients with Autoimmune Bullous Diseases. J Clin Aesthet Dermatol 2023;16:38-42. Kotewicz M, Krajewski PK, Jaworek AK, Szepietowski JC. Psychological Aspects of Cutaneous Pain in Psoriasis. J Clin Med 2024;13:4890. Pandey K, Thurman M, Johnson SD,et al. Mental Health Issues During and After COVID-19 Vaccine Era. Brain Res Bull 2021;176:161-173. Herrera SN, Sarac C, Bilgrami ZR,et al. A case report and first-person account of an individual at risk for psychosis who improved during the COVID-19 pandemic. Psychosis 2022;14:190-199. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-136. Folkman S .Stress, appraisal, and coping[J].Springer New York.DOI:10.1007/978-1-4419-1005-9_215. De D, Hanumanthu V, Jinagal J, et al. Clinical and demographic characteristics of mucous membrane pemphigoid in India: A retrospective analysis. Indian J Dermatol Venereol Leprol 2024 ;90:763-768. Montagnon CM, Lehman JS, Murrell DF, Camilleri MJ, Tolkachjov SN. Subepithelial autoimmune bullous dermatoses disease activity assessment and therapy. J Am Acad Dermatol 2021;85:18–27. De D, Khullar G, Handa S, et al. Clinical, demographic and immunopathological spectrum of subepidermal autoimmune bullous diseases at a tertiary center: A 1-year audit. Indian J Dermatol Venereol Leprol 2016 ;82:358. Phan NQ, Blome C, Fritz F, et al. Assessment of pruritus intensity: prospective study on validity and reliability of the visual analogue scale, numerical rating scale and verbal rating scale in 471 patients with chronic pruritus. Acta Derm Venereol 2012;92:502-7. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 2011;63 Suppl 11:S240-252. Zitser J, Allen IE, Falgàs N, et al. Pittsburgh Sleep Quality Index (PSQI) responses are modulated by total sleep time and wake after sleep onset in healthy older adults. PLoS One 2022 ;17:e0270095. Tsai PS, Wang SY, Wang MY, et al. Psychometric evaluation of the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) in primary insomnia and control subjects. Qual Life Res 2005;14:1943-52. Riba MB, Donovan KA, Andersen B, et al. Distress Management, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology.J Natl Compr Canc Netw 2019;17:1229–49. McElroy JA, Waindim F, Weston K, Wilson G. A systematic review of the translation and validation methods used for the national comprehensive cancer network distress thermometer in non-English speaking countries. Psychooncology 2022;31:1267–74. Sousa H, Oliveira J, Figueiredo D, Ribeiro O. The clinical utility of the Distress Thermometer in non-oncological contexts: A scoping review. J Clin Nurs 2021;30:2131–50. Barskova T, Oesterreich R. Post-traumatic growth in people living with a serious medical condition and its relations to physical and mental health: a systematic review. Disabil Rehabil 2009;31:1709–33. Enns MW, Bernstein CN, Graff L,et al. A longitudinal study of distress symptoms and work impairment in immune-mediated inflammatory diseases. J Psychosom Res 2023;174:111473. Dan J, Sprow G, Diaz D, et al. Bullous pemphigoid: Comparing the prevalence and severity of itch and pain. J Am Acad Dermatol 2023;89:159–60. Gerrits MM, van Marwijk HW, van Oppen P, van der Horst H, Penninx BW. Longitudinal association between pain, and depression and anxiety over four years. J Psychosom Res 2015;78:64–70. Briand C, Gourier G, Poizeau F, et al. Characteristics of Pruritus in Bullous Pemphigoid and Impact on Quality of Life: A Prospective Cohort Study. Acta Derm Venereol 2020;100:adv00320. Zeidler C, Pereira MP, Huet F, Misery L, Steinbrink K, Ständer S. Pruritus in Autoimmune and Inflammatory Dermatoses. Front Immunol 2019;10:1303. Lee J, Suh H, Jung H, Park M, Ahn J. Association between chronic pruritus, depression, and insomnia: A cross-sectional study. JAAD Int 2021;21:54–60. Sun C, Feng S. Recent developments in the pathogenesis of pruritus in bullous pemphigoid. Int J Dermatol 2021;60:1441–8. Rolader R, Daugherty LN, Liu Y, Feldman RJ. Prevalence and predictors of pruritus in pemphigus compared with bullous pemphigoid: A cross-sectional study. J Am Acad Dermatol 2020;83:251–4. Sahin E, Hawro M, Weller K, et al. Prevalence and factors associated with sleep disturbance in adult patients with psoriasis. J Eur Acad Dermatol Venereol 2022;36:688–97. Myers B, Reddy V, Chan S, Thibodeaux Q, Brownstone N, Bhutani T. Sleep, Immunological Memory, and Inflammatory Skin Disease. Dermatology 2021;237:1035-1038. Guo M, Su J, Zheng S, Chen B. Sleep in psoriasis: A meta-analysis. J Psychosom Res 2024;176:111543. Pedroni MN, Hirotsu C, Porro AM, Tufik S, Andersen ML. The role of sleep in pemphigus: a review of mechanisms and perspectives. Arch Dermatol Res 2017;309:659–64. Henderson AD, Adesanya E, Mulick A, et al. Common mental health disorders in adults with inflammatory skin conditions: nationwide population-based matched cohort studies in the UK. BMC Med 2023;21:285. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 06 May, 2026 Editor assigned by journal 21 Mar, 2026 Submission checks completed at journal 21 Mar, 2026 First submitted to journal 19 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9173406","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":636497641,"identity":"9a476df1-008e-49f7-90c8-7f922f1857bd","order_by":0,"name":"Chenchen Feng","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Chenchen","middleName":"","lastName":"Feng","suffix":""},{"id":636497642,"identity":"693c6938-e364-4400-aaea-36b718793df2","order_by":1,"name":"Yanmin Zhao","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Yanmin","middleName":"","lastName":"Zhao","suffix":""},{"id":636497643,"identity":"a0aa0147-bd4d-4607-8ea5-7e1c8452a965","order_by":2,"name":"Yu Ou","email":"","orcid":"","institution":"West China School of Nursing, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Ou","suffix":""},{"id":636497644,"identity":"e6f57bb2-1ee7-40cb-9505-76b160194590","order_by":3,"name":"Lingxiao He","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Lingxiao","middleName":"","lastName":"He","suffix":""},{"id":636497648,"identity":"45c1f2db-1465-4fdb-a016-f83a25d6db2f","order_by":4,"name":"Dan Jia","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Jia","suffix":""},{"id":636497649,"identity":"108aa551-9392-4da1-a5bc-f60b56db1b7a","order_by":5,"name":"Wei Li","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Li","suffix":""},{"id":636497652,"identity":"87d14ff9-3557-41a1-8392-b1056a7bb3cc","order_by":6,"name":"Shuzhen Zhao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuElEQVRIiWNgGAWjYFAD9sbGBx9I08JzuNlwBmlaJNLbpDmIUSjff/zxxx9/6uzlZz5skGZgsJPTbSCgxeBGjoExDw9bYuPsxAbjAoZkY7MDhLRI8DAkM0jwJDBLJzYkz2A4kLiNkBagwx4c/GEgYc8mebDhMA8xWhgOJBg28CQYMPZIMDY2E6UF6BdjZp4DCYkzeBKbGWcYEOEXRIi1H3/+40OFnRxBLeiWkqZ8FIyCUTAKRgEOAABWVD77RZX4zAAAAABJRU5ErkJggg==","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Shuzhen","middleName":"","lastName":"Zhao","suffix":""}],"badges":[],"createdAt":"2026-03-20 00:08:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9173406/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9173406/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109296188,"identity":"5459c3a5-9b3f-4996-8515-8b20b5dbbe07","added_by":"auto","created_at":"2026-05-15 08:46:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":445365,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9173406/v1/2f75f235-c12c-4dff-b749-c6bb283c4d8b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological Distress and Associated Factors in Patients with Autoimmune Bullous Dermatoses: A Cross-sectional Study Using the Distress Thermometer","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAutoimmune bullous dermatoses (AIBD) are a group of rare chronic skin disorders characterized by blistering and erosions on the skin and mucous membranes. These conditions, including pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, and other autoimmune bullous diseases (AIBDs), may present with significant physical symptoms to varying degrees across subtypes, such as pain, pruritus, and refractory oral erosions.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The chronic nature of AIBD, coupled with the need for long-term treatment and the potential for severe complications and side effects, places a substantial burden on patients' physical health and overall quality of life.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Beyond the physical manifestations, AIBD also exerts a profound impact on patients' mental health, leading to emotional distress, anxiety, depression, and diminished self-esteem.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Studies have shown that the prevalence of anxiety and depression among patients with bullous dermatoses ranges from 40% to 80%.\u003csup\u003e6,7\u003c/sup\u003e It was also reported that the prevalence of anxiety and depression in patients with pemphigus vulgaris and pemphigus foliaceus was between 28\u0026ndash;77%, significantly higher than in the general population and patients with other chronic skin diseases.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e This underscores the critical need to address the psychological well-being of AIBD patients as an integral part of their overall care.\u003c/p\u003e \u003cp\u003eResearchers have further investigated the specific issues experienced by patients that contribute to psychological problems. White reported that AIBD patients experienced a high level of body image disturbance.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Wang discovered that approximately 14.8% of patients experienced stigmatization in the workplace due to their appearance, leading to varying degrees of impairment in work and activities, making them more susceptible to feelings of loneliness and social isolation.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Maione found that the quality of life, particularly in terms of sexual activity, was significantly affected in patients with pemphigus.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e AIBD patients may also suffer from feeding, pain, itching, and sleep disturbances, yet current studies on AIBD patients' psychological problems and the exploration of specific causes and factors of these psychological problems is insufficient.\u003c/p\u003e \u003cp\u003ePsychological distress is a broader psychological concept that refers to emotional experiences resulting from various causes, encompassing psychological (cognitive, behavioral, emotional) aspects, social and/or spiritual experiences. It manifests as emotional reactions such as vulnerability, sadness, and fear, or severe psychological problems such as depression, anxiety, fear, feelings of social isolation, and mental crises.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Existing research indicates that the Distress thermometer (DT) can serve as a rapid, effective, and reliable screening tool for identifying psychological distress in dermatology outpatients.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Furthermore, this tool can investigate specific distress issues experienced by patients, which may help improve healthcare professionals' understanding of the psychological problems.\u003c/p\u003e \u003cp\u003eExisting evidence highlights that mental health in chronic dermatosis patients is significantly associated with disease-related factors (e.g., pain, itch, sleep problems, systemic comorbidities, disease staging)\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e and socioeconomic determinants like educational attainment, social support,etc.\u003csup\u003e\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Additionally, the COVID-19 pandemic has exerted long-term impacts on the mental health of individuals with chronic diseases.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Maybe due to the rarity of the disease, there is a lack of study on AIBD patients\u003csup\u003e\u0026rsquo;\u003c/sup\u003e psychological distress and its related problems. Based on the Biopsychosocial Model and Stress \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e and Coping Theory \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, we hypothesize that psychological distress in AIBD patients is driven not by isolated factors but by the interplay of disease characteristics (e.g., number of skin lesions, pain), psychosocial factors (e.g., educational level, social support), and external events (e.g., COVID-19 infection history). Therefore, this study aimed to investigate the psychological distress and associated factors in AIBD patients, so as to provide theoretical support for the assessment, identification, and therapeutic intervention of psychological distress in AIBD patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSubjects\u003c/h2\u003e \u003cp\u003eThis cross-sectional observational study included 257 AIBD patients from XX hospital between June and October 2023. Finally, 252 valid questionnaires were retained. We included patients who visited the AIBD Specialty Clinic and had AIBD diagnosis, age no less than 18 years. Patients with poor cognitive function (inability to understand and cooperate in completing the questionnaire), a history of psychiatric disorders, the presence of other major diseases such as heart failure or malignant tumors were excluded.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasurement tools\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eSociodemographic characteristics form\u003c/strong\u003e \u003cp\u003eThis form was developed by researchers based on their own experiences and literature review.\u003csup\u003e\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003eIt included demographic and disease-related information. Demographic information included items such as gender, age, educational level, marital status, employment status, etc. Disease-related information included disease diagnosis, duration of illness, current skin lesions number, history of COVID-19 infection, etc.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eVisual Analogue Scale (VAS)\u003c/b\u003e: Pain and itch were assessed using the 10-centimeter line scale with a starting point of \"0\" and an endpoint of \"10\". The severity was divided into four levels: 0 for none, 1\u0026ndash;3 for mild, 4\u0026ndash;6 for moderate, and 7\u0026ndash;10 for severe. \u003csup\u003e26,27\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003ePittsburgh Sleep Quality Index (PSQI)\u003c/b\u003e: It consists of 19 self-rated items covering seven dimensions: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Additionally, there are five other-rated items that do not contribute to the scoring. Each self-rated item is scored from 0 to 3, and the cumulative score is the PSQI total score, ranging from 0 to 21. Sleep quality is categorized into four levels: 0\u0026ndash;5 for high quality, 6\u0026ndash;10 for good, 11\u0026ndash;15 for general, and 16\u0026ndash;21 for poor. \u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe Distress Thermometer (DT)\u003c/b\u003e: It includes a VAS with a numerical scale from 0 to 10, where 0 represents no psychological distress and 10 indicates extreme distress. Scores of 1\u0026ndash;3 indicate mild distress, 4\u0026ndash;6 moderate distress, and 7\u0026ndash;9 severe distress, with 10 being extremely severe.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e DT scoring 4 or above is the threshold for clinically significant distress that requires intervention. \u003csup\u003e31\u003c/sup\u003e DT also includes a Problem List (PL) with five dimensions: practical problems (6 items), family problems (4 items), emotional problems (10 items), physical problems (19 items), and spiritual/religious concerns (1 item). Each of these items is answered with yes or no, scoring 1 or 0 respectively. The average score for each dimension is calculated by dividing the total score by the number of items in that dimension, with scores ranging from 0 to 1.\u003csup\u003e12\u003c/sup\u003e A higher score indicates more issues in that dimension. This screening tool has shown good reliability and validity in non-cancer patient, with a Cronbach's alpha of 0.87 to 0.93.\u003csup\u003e32\u003c/sup\u003e A cut-off score\u0026thinsp;\u0026ge;\u0026thinsp;4 on the DT provided the optimal ratio of sensitivity (90.7%) to specificity (56.1%) in chronic skin disease patients.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eSample Size Calculation\u003c/h3\u003e\n\u003cp\u003eThe formula for calculating the sample size is n = (Z_(α/2)/δ)^2 * π(1-π), where Z_(α/2) represents the Z-value for the two-tailed probability α in the standard normal distribution, δ represents the allowable error, and π represents the incidence rate of psychological distress. For α\u0026thinsp;=\u0026thinsp;0.05, Z_(α/2)\u0026thinsp;=\u0026thinsp;1.96, δ\u0026thinsp;=\u0026thinsp;0.05, and π\u0026thinsp;=\u0026thinsp;0.15 (based on a pre-survey investigation rate of psychological distress of 15%), the calculated sample size is 245. Considering a 5% sample attrition rate, the planned survey sample size is 257 cases.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eTwo trained nurses from the AIBD Specialty Clinic conducted the survey. The purpose of the survey was explained to the patients when they visited AIBD Specialty Clinic, who then provided informed consent to participate. Patients completed the questionnaire independently, and if they were unable to do so, the survey staff completed the questionnaire based on the patients' statements.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData entry was conducted using Excel software with double-check verification. Data processing was performed using SPSS 25.0 software. Measured data were described using median and interquartile range; count data were represented by frequency and percentage (%).Univariable and multivariable binary logistic regression were performed. Multivariable analysis included variables with \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 in univariable testing and clinically important covariates. Collinearity among variables was assessed using variance inflation factor (VIF), with VIF\u0026thinsp;\u0026lt;\u0026thinsp;5 indicating no significant multicollinearity. Model goodness-of-fit was evaluated with the Hosmer-Lemeshow test. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePsychological Distress\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand related problems\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ein AIBD\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;patients\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe median age of patients was 53.0 years (IQR: 43.0\u0026ndash;60.0). Of these, there were 146 cases of pemphigus vulgaris, 39 cases of bullous pemphigoid, 30 cases of pemphigus foliaceus, as detailed in Table 1.The median DT score was 2.0 (IQR: 0.0\u0026ndash;4.0).33.33% of AIBD patients (84 cases) scored 4 or above. The Emotional problems dimension scored the highest, followed by Practical and Family problems dimension, as detailed in Table 2. The top three reported problems were worry (51.19%), appearance/body image (41.27%), and sleep problems (40.08%), as presented in Table 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003eParticipants\u0026rsquo; sociodemographic and clinical characteristics.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"95%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eVariable (N = 252)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge(years)\u003c/strong\u003e, [median (IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e53 (43-60)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e115 (45.63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e137 (54.37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducatio\u003c/strong\u003e\u003cstrong\u003en level\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eElementary school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e58 (23.02%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e88 (34.92%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eHigh school/vocational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e37 (14.68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eAssociate\u0026rsquo;s degree or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e69 (27.38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eNot-married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e36 (14.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e216 (85.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e134 (53.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eRetired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e65 (25.79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cpre\u003eUnemployed\u003c/pre\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e53 (21.03%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLong-term residence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e98 (38.89%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e154 (61.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidential origin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eSame city\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e76 (30.16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eSame province, other city\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e131 (51.98%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eOther province\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e45 (17.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiving\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003cstrong\u003elon\u003c/strong\u003e\u003cstrong\u003ee\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e25 (9.92%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e227 (90.08%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold monthly income per capita\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u0026le; 3,000 CNY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e138 (54.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e3,000\u0026ndash;6,000 CNY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e81 (32.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u0026ge; 6,000 CNY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e33 (13.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary caregiver\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eSelf\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e30 (11.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e222 (88.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePayment method\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eUninsured out-of-pocket payment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e59 (23.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eInsured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e193 (76.59%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003ePV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e146 (57.94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eBP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e39 (15.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003ePF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e30 (11.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e37 (14.68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of illness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u0026le; 3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e25 (9.92%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e3\u0026ndash;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e30 (11.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e6\u0026ndash;12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e41 (16.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e1\u0026ndash;3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e82 (32.54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u0026ge;3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e74 (29.37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003cstrong\u003eurrent skin lesions\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003enumber\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e42 (16.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e50 (19.84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u0026ge; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e160 (63.49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of COVID-19 infection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e153 (60.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e99 (39.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSystemic comorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e38 (15.08%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e214 (84.92%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent t\u003c/strong\u003e\u003cstrong\u003eherapeutic regimen\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eSteroids only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e144 (57.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eCombined with steroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e63 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e45 (17.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease staging\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003ePartial remission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e161 (63.89%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eComplete remission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e61 (24.21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003eRelapse/flare/failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e30 (11.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain score\u003c/strong\u003e, [median (IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e1 (0-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItch score\u003c/strong\u003e ,[median (IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e2 (0-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePSQI score\u003c/strong\u003e, [median (IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e8 (4-12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDT score\u003c/strong\u003e, [median (IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e2 (0-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u0026lt; 4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e168 (66.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67.6768%;\"\u003e\n \u003cp\u003e\u0026ge; 4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3232%;\"\u003e\n \u003cp\u003e84 (33.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations:\u003c/p\u003e\n\u003cp\u003eCNY:Chinese Yuan; DT: Distress Thermometer; IQR:Interquartile range; PV:Pemphigus vulgaris; BP:Bullous pemphigoid; PF:Pemphigus foliaceus;\u0026nbsp;PSQI: Pittsburgh Sleep Quality Index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003eDimension score of psychological distress problems in AIBD Patients (N = 252).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"583\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37.0497%;\"\u003e\n \u003cp\u003eDimension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.5798%;\"\u003e\n \u003cp\u003eMinimum Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.7804%;\"\u003e\n \u003cp\u003eMaximum Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4923%;\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.0978%;\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37.0497%;\"\u003e\n \u003cp\u003eEmotional problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.5798%;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.7804%;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4923%;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.0978%;\"\u003e\n \u003cp\u003e(0.00, 0.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37.0497%;\"\u003e\n \u003cp\u003ePractical problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.5798%;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.7804%;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4923%;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.0978%;\"\u003e\n \u003cp\u003e(0.00, 0.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37.0497%;\"\u003e\n \u003cp\u003eFamily problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.5798%;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.7804%;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4923%;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.0978%;\"\u003e\n \u003cp\u003e(0.00, 0.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37.0497%;\"\u003e\n \u003cp\u003ePhysical problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.5798%;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.7804%;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4923%;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.0978%;\"\u003e\n \u003cp\u003e(0.05, 0.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 37.0497%;\"\u003e\n \u003cp\u003eSpiritual/Religious\u0026nbsp;concerns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.5798%;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.7804%;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.4923%;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.0978%;\"\u003e\n \u003cp\u003e(0.00, 0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003ePsychological distress problems in AIBD Patients (N = 252).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"558\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eSpecific problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"10\" style=\"width: 167px;\"\u003e\n \u003cp\u003eEmotional\u0026nbsp;problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eWorry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e129 (51.19% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eSleep problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e101 (40.08%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eNervousness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e74 (29.37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eMemory decline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e68 (26.98%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e55 (21.83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eLoss of interest in usual activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e54 (21.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eDifficulty concentrating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e52 (20.63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eFears\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e44 (17.46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eSadness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e34 (13.49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eLoneliness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e24 (9.52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" style=\"width: 167px;\"\u003e\n \u003cp\u003ePractical problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eInsurance/Financial\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e81 (32.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eHousing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e46 (18.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eTransportation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e44 (17.46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eWork/School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e43 (17.06%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eCare for children/elderly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e41 (16.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eSurrounding environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e20 (7.94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 167px;\"\u003e\n \u003cp\u003eFamily problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eInteraction with children/elderly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e52 (20.63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eInteraction with partner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e43 (17.06%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eInteraction with relatives and friends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e39 (15.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eInteraction with medical staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e8 (3.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"19\" style=\"width: 167px;\"\u003e\n \u003cp\u003ePhysical problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eAppearance/body image\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e104 (41.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eMouth scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e72 (28.57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e69 (27.38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eBathing/Dressing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e62 (24.60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e50 (19.84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eDaily activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e41 (16.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eEating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e38 (15.08%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eSkin dry/itchy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e34 (13.49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eFeeling swollen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e29 (11.51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eTingling in hand/feet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e20 (7.94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eIndigestion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e19 (7.54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eChanges in urination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e16 (6.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eChanges in defecation (constipation/diarrhea)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e16 (6.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eDizziness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e15 (5.95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eNose dry/congested\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e12 (4.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eBreathing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e11 (4.37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eNausea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e7 (2.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eSexual\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e7 (2.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eFevers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e3 (1.19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eSpiritual/Religious concerns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e8 (3.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eUnivaria\u003c/strong\u003e\u003cstrong\u003ebl\u003c/strong\u003e\u003cstrong\u003ee\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand m\u003c/strong\u003e\u003cstrong\u003eultivariable b\u003c/strong\u003e\u003cstrong\u003einary logistic regression a\u003c/strong\u003e\u003cstrong\u003enalysis of Psychological Distress in AIBD Patients\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of the univariable analysis indicated that age (P = 0.021), educational level(P = 0.002), current skin lesions number(P = 0.002), history of COVID-19 infection(P = 0.014), disease staging(P = 0.002), pain(P \u0026lt; 0.001), itch(P \u0026lt; 0.001), and sleep quality(P \u0026lt; 0.001) were associated with psychological distress in AIBD patients, as detailed in Table 4. After adjusting for potential confounders, COVID-19 infection history, pain, itch, and sleep quality showed statistically significant associations with psychological distress in AIBD patients. Patients with no prior COVID-19 infection exhibited 2.3-fold higher odds of psychological distress (aOR = 2.311, 95% CI: 1.066\u0026ndash;5.014; P = 0.034). Each 1-point increase in pain score corresponded to 19.8% higher odds (aOR = 1.198, 95% CI: 1.009\u0026ndash;1.423; P = 0.039).Each 1-point increase in itch score was associated with 41.8% higher odds of distress (aOR = 1.418, 95% CI: 1.171\u0026ndash;1.717; P \u0026lt; 0.001).Each 1-point increase in PSQI score was linked to 20.2% higher odds (aOR = 1.202, 95% CI: 1.097\u0026ndash;1.316; P \u0026lt; 0.001), as detailed in Table 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003eUnivariable Logistic Regression Analysis of Factors Associated With Psychological Distress in AIBD Patients (N = 252).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003eOR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.022 [1.003, 1.040]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.021*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.826 [0.488, 1.396]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.475\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducatio\u003c/strong\u003e\u003cstrong\u003en level\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003eElementary school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.723 [0.370, 1.414]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.343\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eHigh school/vocational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.622 [0.266, 1.454]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.273\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eAssociate\u0026rsquo;s degree or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.195 [0.084, 0.453]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eNot-married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.753 [0.364, 1.561]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.446\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.366\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eRetired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.974 [0.513, 1.848]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.935\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cpre\u003eUnemployed\u003c/pre\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.555 [0.806, 2.999]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.188\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of residence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.673 [0.395, 1.146]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.145\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidential origin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.920\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eSame city\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eSame province, other city\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.067 [0.586, 1.943]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.831\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eOther province\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.921 [0.417, 2.034]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.839\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiving\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003cstrong\u003elone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.503 [0.219, 1.157]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold monthly income per capita\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.526\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u0026le; 3,000 CNY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e3,000\u0026ndash;6,000 CNY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.786 [0.438, 1.411]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.419\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u0026ge; 6,000 CNY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.660 [0.285, 1.530]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.333\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary caregiver\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eSelf\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.615 [0.283, 1.335]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.219\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePayment method\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eUninsured out-of-pocket payment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eInsured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.877 [0.476, 1.617]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.674\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.246\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003ePV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eBP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.387 [0.658, 2.924]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.390\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003ePF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e2.167 [0.972, 4.831]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.507 [0.709, 3.206]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.287\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of illness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u0026le; 3months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e3\u0026ndash;6months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.114 [0.383, 3.236]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.843\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e6\u0026ndash;12months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.467 [0.163, 1.333]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.155\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e1\u0026ndash;3years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.438 [0.172, 1.113]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u0026ge; 3years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.731 [0.291, 1.836]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.505\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003cstrong\u003eurrent skin lesions\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003enumber\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.895 [0.643, 5.584]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.246\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u0026ge; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e4.213 [1.679, 10.569]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of COVID-19 infection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.947 [1.142, 3.321]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.014*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSystemic comorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.833 [0.406, 1.709]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.619\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent therapeutic regimen\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.266\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eSteroids only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eCombined with steroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.616 [0.321, 1.181]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.677 [0.327, 1.402]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.293\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease staging\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003ePartial remission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e161\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.00 (Ref.) -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eComplete remission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e0.348 [0.164, 0.737]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eRelapse/flare/failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e2.030 [0.925, 4.455]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.375 [1.218, 1.553]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItch score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.546 [1.359, 1.758]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePSQI\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003escore\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1.223 [1.141, 1.311]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOR:Odds Ratio;CI :confidence interval;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*Statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e5:\u003c/strong\u003eMultivariable Binary Logistic Regression Analysis of Factors Associated With Psychological Distress in AIBD Patients (N = 252).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eaOR(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eReference Group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of COVID-19 infection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo(vs.Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.311(1.066-5.014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.034\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePain score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePer 1-point increase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.198(1.009-1.423)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.039\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eItch score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePer 1-point increase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.418(1.171-1.717)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePSQI score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePer 1-point increase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.202(1.097-1.316)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCI :confidence interval; OR:Odds Ratio; aOR = adjusted odds ratio (adjusted for all variables in final model)\u003c/p\u003e\n\u003cp\u003eReference groups (Ref) indicated for categorical variables\u003c/p\u003e\n\u003cp\u003e*Statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003ePsychological Distress and related problems in AIBD Patients\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research found that 33.33% of patients experienced psychological distress, consistent with Wang et al.\u0026rsquo;s report of 30.7% of pemphigus patients suffering from anxiety (25%) or depression (14.3%).\u003csup\u003e4\u003c/sup\u003e A systematic review noted that the prevalence of depressive symptoms among patients with bullous dermatoses ranged from 40% to 80%, and the prevalence of depression diagnosis among patients with bullous dermatoses ranged from 11.4% to 28%.\u003csup\u003e7\u0026nbsp;\u003c/sup\u003eVariations in detection rates may result from differences in sample size, assessment tools, psychological definitions, disease classifications, and disease stage, highlighting the need for a comprehensive approach to assess psychological health in AIBD patients.\u003c/p\u003e\n\u003cp\u003eThe analysis of specific dimensions and items of psychological distress in AIBD patients revealed prominent issues in three key dimension: emotional, family and practical. The top three reported items were \u0026quot;worry\u0026quot; (51.19%), \u0026quot;appearance/body image (41.27%)\u0026quot; and \u0026quot;sleep problems\u0026quot; (40.08%). This finding is consistent with prior research that has identified emotional distress as a significant burden for AIBD patients.\u003csup\u003e4\u003c/sup\u003e Our study also revealed that \u0026quot;appearance/body image\u0026quot; and \u0026quot;sleep problems\u0026quot; were among the primary concerns affecting AIBD patients.\u0026nbsp;These results provide a holistic view of psychological distress and related problems in AIBD patients. Healthcare professionals can better understand patients\u0026apos; challenges and develop tailored interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors Influencing Psychological Distress in AIBD Patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients without prior COVID-19 infection exhibited higher odds of psychological distress. This may be related to the changes in lifestyle and psychological state that people have experienced during the pandemic, challenging everyone\u0026apos;s adaptability.\u003csup\u003e19\u003c/sup\u003e This phenomenon aligns with the concept of \u0026quot;post-traumatic growth,\u0026quot; where individuals develop new coping strategies and psychological adaptation mechanisms after facing difficulties or trauma, which may help alleviate psychological distress and potentially improve cognitive function.\u003csup\u003e33\u003c/sup\u003e What\u0026rsquo;s more, patients who have recovered from COVID-19 may have undergone a positive psychological transformation, which may be associated with the reduced fear of the virus and the gradual establishment of herd immunity in the later stages of the pandemic.\u003csup\u003e20\u003c/sup\u003e Our study indicates that the history of COVID-19 infection may have long term influence on people\u0026rsquo;s health and requires further research.\u003c/p\u003e\n\u003cp\u003eIncrease in pain score was associated with higher odds of distress. This aligns with multiple studies, indicating pain is both a primary physical symptom and a mental health threat for AIBD patients.\u003csup\u003e18,34\u003c/sup\u003e In a study about the incidence of pain in BP patients and its association with disease activity, 53% of patients reported pain, with 26% experiencing moderate to severe pain.\u003csup\u003e35\u0026nbsp;\u003c/sup\u003ePrevious research has also confirmed the bidirectional relationship between pain and depression, with pain being both a predictor and a result of depression.\u003csup\u003e36\u003c/sup\u003e This suggests that pain management is not only necessary for treating physical symptoms but is also key to maintaining patients\u0026apos; mental health and improving their quality of life. Therefore, it is crucial to monitor AIBD patients\u0026apos; pain level associated with lesions and to develop long-term pain control strategies for them.Future research should explore pain-psychological distress mechanisms and develop interventions combining pharmacotherapy, psychological support, and lifestyle changes. Our study also found that the higher the level of itch in AIBD patients, the greater the odds of psychological distress. BP is characterized by severe itch accompanied by tense blisters on the trunk and limbs, significantly reducing patients\u0026apos; quality of life.\u003csup\u003e35\u003c/sup\u003e Itch not only leads to delayed sleep onset and frequent awakenings but also triggers a series of psychological issues such as restlessness, embarrassment, and social interaction difficulties.\u003csup\u003e37\u003c/sup\u003e BP patients often have scratching behaviors, which can result in scars, bleeding, and some patients may develop chronic pruritus over time.\u003csup\u003e38\u003c/sup\u003e Chronic pruritus not only poses a threat to patients\u0026apos; physical health but can also lead to severe psychological burdens, with patients suffering from moderate to severe itch being more likely to exhibit symptoms of depression.\u003csup\u003e39\u003c/sup\u003e The underlying mechanisms of AIBD-related itch are not fully understood, and the lack of effective treatment options for this problem has become a significant challenge.\u003csup\u003e40,41\u0026nbsp;\u003c/sup\u003eThis indicates that, in addition to focusing on pain, itch is also an issue worthy of attention from dermatologists.\u003c/p\u003e\n\u003cp\u003eOur research has found that the poorer the quality of sleep, the more likely individuals are to experience psychological distress. In the field of chronic skin diseases, the close relationship between sleep quality and mental health has been confirmed by numerous studies.\u003csup\u003e42,43\u003c/sup\u003e A research summary indicated that psoriasis patients have lower sleep quality than the healthy population, with an increased risk of sleep disturbances and more frequent symptoms of depression.\u003csup\u003e44\u0026nbsp;\u003c/sup\u003ePedroni pointed out that there is a complex bidirectional relationship between pemphigus and sleep disturbances. The inflammatory response and chronic pain of pemphigus may impair sleep quality, while sleep disturbances can exacerbate pemphigus symptoms. Additionally, there is a strong mutual interaction between sleep problems and depressive moods. Sleep disturbances not only increase the risk of depression but the presence of depression can also lead to further deterioration in sleep quality.\u003csup\u003e45\u0026nbsp;\u003c/sup\u003eHenderson\u0026apos;s research further confirmed the key mediating role of sleep problems in increasing the risk of anxiety and depression in patients with chronic skin diseases, showing a significant correlation between the decline in sleep quality and negative changes in the psychological state of patients with eczema and psoriasis.\u003csup\u003e46\u003c/sup\u003e Therefore, it is recommended that clinical doctors inquire about AIBD patients\u0026apos; current sleep quality and that further consultations should be arranged for patients with sleep disturbances to develop a more comprehensive treatment plan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis single-center study may lack generalizability, but AIBD is a rare disease and the inclusion of AIBD patients from various provinces across China, where few hospitals can diagnose and treat this rare disease, may partially mitigate this limitation.\u003c/p\u003e"},{"header":"Conclusion ","content":"\u003cp\u003eThis study revealed a high prevalence of psychological distress among AIBD patients and numerous issues troubling patients such as \u0026quot;worry\u0026quot;,\u0026quot;appearance/body image\u0026quot; and \u0026quot;sleep problems\u0026quot; have been identified. Absence of prior COVID-19 infection , pain, itch and sleep quality were found to be significant predictors of psychological distress. By utilizing the DT, clinicians can promptly identify psychological distress in AIBD patients and develop personalized interventions based on the specific contributing factors and individual needs. Comprehensive intervention strategies should encompass disease symptom management, psychological support, health education, and other measures, aiming to holistically improve the physical and mental well-being of patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIBD: autoimmune bullous dermatoses; aOR: adjusted odds ratio; BP: bullous pemphigoid; CI: confidence interval; COVID-19: Coronavirus disease 2019; DT: Distress Thermometer; IQR: interquartile range; PL: Problem List; PSQI: Pittsburgh Sleep Quality Index; SPSS: Statistical Package for the Social Sciences; VAS: Visual Analogue Scale; VIF: variance inflation factor.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll subjects provided informed consent and voluntarily participated in the research. The study was ratified by the Ethics Committee of West China Hospital (No. 2024/1617) and was carried out in accordance with the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChenchen Feng was responsible for study design and manuscript writing. Yanmin Zhao participated in data collection and analysis. Yu Ou participated in manuscript writing. Lingxiao He was in charge of questionnaire design and statistical guidance. Dan Jia, Wei Li, and Shuzhen Zhao provided guidance on study design, questionnaire revision, and manuscript revision. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank Dr. Lin Li and Dr. Lu Li for their expert guidance on the statistical methodology of this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHoltsche MM, Boch K, Schmidt E. Autoimmune bullous dermatoses. J Dtsch Dermatol Ges 2023;21:405\u0026ndash;12.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRosi-Schumacher M, Baker J, Waris J, Seiffert-Sinha K, Sinha AA. Worldwide epidemiologic factors in pemphigus vulgaris and bullous pemphigoid. 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Science 1977;196:129-136.\u003c/li\u003e\n \u003cli\u003eFolkman S .Stress, appraisal, and coping[J].Springer New York.DOI:10.1007/978-1-4419-1005-9_215.\u003c/li\u003e\n \u003cli\u003eDe D, Hanumanthu V, Jinagal J, et al. Clinical and demographic characteristics of mucous membrane pemphigoid in India: A retrospective analysis. Indian J Dermatol Venereol Leprol\u0026nbsp;2024 ;90:763-768.\u003c/li\u003e\n \u003cli\u003eMontagnon CM, Lehman JS, Murrell DF, Camilleri MJ, Tolkachjov SN. Subepithelial autoimmune bullous dermatoses disease activity assessment and therapy. J Am Acad Dermatol 2021;85:18\u0026ndash;27.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDe D, Khullar G, Handa S, et al. Clinical, demographic and immunopathological spectrum of subepidermal autoimmune bullous diseases at a tertiary center: A 1-year audit. Indian J Dermatol Venereol Leprol 2016 ;82:358.\u003c/li\u003e\n \u003cli\u003ePhan NQ, Blome C, Fritz F, et al. Assessment of pruritus intensity: prospective study on validity and reliability of the visual analogue scale, numerical rating scale and verbal rating scale in 471 patients with chronic pruritus. Acta Derm Venereol 2012;92:502-7.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 2011;63 Suppl 11:S240-252.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZitser J, Allen IE, Falg\u0026agrave;s N, et al. Pittsburgh Sleep Quality Index (PSQI) responses are modulated by total sleep time and wake after sleep onset in healthy older adults. PLoS One\u0026nbsp;2022 ;17:e0270095.\u003c/li\u003e\n \u003cli\u003eTsai PS, Wang SY, Wang MY, et al. Psychometric evaluation of the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) in primary insomnia and control subjects. Qual Life Res 2005;14:1943-52.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRiba MB, Donovan KA, Andersen B, et al. Distress Management, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology.J Natl Compr Canc Netw 2019;17:1229\u0026ndash;49.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMcElroy JA, Waindim F, Weston K, Wilson G. A systematic review of the translation and validation methods used for the national comprehensive cancer network distress thermometer in non-English speaking countries. Psychooncology 2022;31:1267\u0026ndash;74.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSousa H, Oliveira J, Figueiredo D, Ribeiro O. The clinical utility of the Distress Thermometer in non-oncological contexts: A scoping review. J Clin Nurs 2021;30:2131\u0026ndash;50.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBarskova T, Oesterreich R. Post-traumatic growth in people living with a serious medical condition and its relations to physical and mental health: a systematic review. Disabil Rehabil 2009;31:1709\u0026ndash;33.\u003c/li\u003e\n \u003cli\u003eEnns MW, Bernstein CN, Graff L,et al. A longitudinal study of distress symptoms and work impairment in immune-mediated inflammatory diseases. J Psychosom Res 2023;174:111473.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDan J, Sprow G, Diaz D, et al. Bullous pemphigoid: Comparing the prevalence and severity of itch and pain. J Am Acad Dermatol 2023;89:159\u0026ndash;60.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGerrits MM, van Marwijk HW, van Oppen P, van der Horst H, Penninx BW. Longitudinal association between pain, and depression and anxiety over four years. J Psychosom Res 2015;78:64\u0026ndash;70.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBriand C, Gourier G, Poizeau F, et al. Characteristics of Pruritus in Bullous Pemphigoid and Impact on Quality of Life: A Prospective Cohort Study. Acta Derm Venereol 2020;100:adv00320.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZeidler C, Pereira MP, Huet F, Misery L, Steinbrink K, St\u0026auml;nder S. Pruritus in Autoimmune and Inflammatory Dermatoses. Front Immunol 2019;10:1303.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLee J, Suh H, Jung H, Park M, Ahn J. Association between chronic pruritus, depression, and insomnia: A cross-sectional study. JAAD Int 2021;21:54\u0026ndash;60.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSun C, Feng S. Recent developments in the pathogenesis of pruritus in bullous pemphigoid. Int J Dermatol 2021;60:1441\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eRolader R, Daugherty LN, Liu Y, Feldman RJ. Prevalence and predictors of pruritus in pemphigus compared with bullous pemphigoid: A cross-sectional study. J Am Acad Dermatol 2020;83:251\u0026ndash;4.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSahin E, Hawro M, Weller K, et al. Prevalence and factors associated with sleep disturbance in adult patients with psoriasis. J Eur Acad Dermatol Venereol 2022;36:688\u0026ndash;97.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMyers B, Reddy V, Chan S, Thibodeaux Q, Brownstone N, Bhutani T. Sleep, Immunological Memory, and Inflammatory Skin Disease. Dermatology 2021;237:1035-1038.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGuo M, Su J, Zheng S, Chen B. Sleep in psoriasis: A meta-analysis. J Psychosom Res 2024;176:111543.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePedroni MN, Hirotsu C, Porro AM, Tufik S, Andersen ML. The role of sleep in pemphigus: a review of mechanisms and perspectives. Arch Dermatol Res 2017;309:659\u0026ndash;64.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHenderson AD, Adesanya E, Mulick A, et al. Common mental health disorders in adults with inflammatory skin conditions: nationwide population-based matched cohort studies in the UK. BMC Med 2023;21:285.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Autoimmune diseases, Bullous dermatoses, Cross-sectional Study, Distress Thermometer, Psychological distress, Rare disease","lastPublishedDoi":"10.21203/rs.3.rs-9173406/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9173406/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate psychological distress and its associated factors in Autoimmune bullous dermatoses patients using the Distress Thermometer.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted with 252 patients. Psychological distress was assessed using the Distress Thermometer. Univariable and multivariable binary logistic regression were performed to identify factors associated with psychological distress.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe median distress score was 2.0 (IQR: 0.0\u0026ndash;4.0), with 33.33% of patients exhibiting clinically significant psychological distress. Univariable analysis indicated age (P\u0026thinsp;=\u0026thinsp;0.021), educational level(P\u0026thinsp;=\u0026thinsp;0.002), current skin lesions number(P\u0026thinsp;=\u0026thinsp;0.002), history of COVID-19 infection(P\u0026thinsp;=\u0026thinsp;0.014), disease staging(P\u0026thinsp;=\u0026thinsp;0.002), pain(P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), itch(P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and sleep quality(P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly associated with psychological distress in Autoimmune bullous dermatoses patients. Multivariable analysis identified absence of prior COVID-19 infection (aOR\u0026thinsp;=\u0026thinsp;2.311, 95% CI: 1.066\u0026ndash;5.014; P\u0026thinsp;=\u0026thinsp;0.034), pain(aOR\u0026thinsp;=\u0026thinsp;1.198, 95% CI: 1.009\u0026ndash;1.423; P\u0026thinsp;=\u0026thinsp;0.039), itch(aOR\u0026thinsp;=\u0026thinsp;1.418, 95% CI: 1.171\u0026ndash;1.717; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and sleep quality (aOR\u0026thinsp;=\u0026thinsp;1.202, 95% CI: 1.097\u0026ndash;1.316; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) showed statistically significant associations with psychological distress in Autoimmune bullous dermatoses patients.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study highlights the high prevalence of psychological distress in Autoimmune bullous dermatoses patients and identifies key factors contributing to distress, including absence of prior COVID-19 infection, pain, itch, and sleep quality. These findings underscore the need for comprehensive psychological assessments and tailored interventions to address the multifaceted challenges faced by Autoimmune bullous dermatoses patients, ultimately improving their overall well-being through integrated care strategies.\u003c/p\u003e","manuscriptTitle":"Psychological Distress and Associated Factors in Patients with Autoimmune Bullous Dermatoses: A Cross-sectional Study Using the Distress Thermometer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-14 13:38:19","doi":"10.21203/rs.3.rs-9173406/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-05-06T04:21:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-21T12:20:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-21T12:20:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Dermatological Research","date":"2026-03-19T23:50:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b9703d83-6632-4a8a-989f-bfafe873e0a0","owner":[],"postedDate":"May 14th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewersInvited","content":"20","date":"2026-05-06T04:21:48+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T13:38:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-14 13:38:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9173406","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9173406","identity":"rs-9173406","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}