in assessing NB-UVB-induced response in vitiligo, and may also be used as a marker in monitoring disease progression. Acknowledgments: We wish to extend our thanks to the fund- ing agencies, resident doctors, biostatisticians, laboratory research staff and official staff of the departments at AIIMS for their kind support. A.S. Parihar, 1 M.K. Tembhre, 2 V.K. Sharma iD , 1 S. Gupta iD , 1 P. Chattopadhyay 3 and K.K. Deepak 4 1 Department of Dermatology and Venereology, 2 Department of Cardiac Biochemistry, 3 Department of Biochemistry and 4 Department of Physiology, AIIMS, New Delhi, India Correspondence: V.K. Sharma. Email: vksiadvl@gmail.com References 1 van den Boorn JG, Konijnenberg D, Dellemijn TA et al. Autoimmune destruction of skin melanocytes by perilesional T cells from vitiligo patients. J Invest Dermatol 2009; 129:2220–32. 2 Bae JM, Jung HM, Hong BY et al. Phototherapy for vitiligo: a sys- tematic review and meta-analysis. JAMA Dermatol 2017; 153:666–74. 3 Lodish HF, Zhou B, Liu G, Chen CZ. Micro management of the immune system by microRNAs. Nat Rev Immunol 2008; 8:120–30. 4 Shi YL, Weiland M, Li J et al. MicroRNA expression profiling identi- fies potential serum biomarkers for non-segmental vitiligo. Pigment Cell Melanoma Res 2013; 26:418–21. 5 Tembhre MK, Sharma VK, Sharma A et al. T helper and regulatory T cell cytokine profile in active, stable and narrow band ultraviolet B treated generalized vitiligo. Clin Chim Acta 2013; 424:27–32. 6 Tembhre MK, Parihar AS, Sharma VK et al. Alteration in regulatory T cells and programmed cell death 1-expressing regulatory T cells in active generalize vitiligo and their clinical correlation. Br J Dermatol 2015; 172:940–50. 7 Jia X, Li X, Shen Y et al. MiR-16 regulates mouse peritoneal macro- phage polarization and affects T-cell activation. J Cell Mol Med 2016; 20:1898–907. 8 Dynoodt P, Mestdagh P, Van Peer G et al. Identification of miR-145 as a key regulator of the pigmentary process. J Invest Dermatol 2013; 133:201–9. Funding sources: The present study was supported by the IADVL – L’  Oreal Indian Hair & Skin research grant and the Indian Council of Medical Research, New Delhi. Conflicts of interest: none to declare. Facets of shame are differently expressed in dermatological disease: a prospective observational study DOI: 10.1111/bjd.18899 DEAR EDITOR, Recent years have witnessed a growing interest in clinical research on the experience of shame and its associations with psychological functioning and well-being. 1 Shame is a self-regulatory function of the body in adapting to the social environment, as well as maintaining and restoring self-esteem and self-acceptance. 2 Feelings of shame have been reported to cause psychosocial restriction in patients with various derma- tological diseases such as infection, or diseases with visible skin lesions like psoriasis or acne. 3,4 These have a significant impact on the individual’s social interaction and well-being. 4 In a prospective single-centre observational study, approved by the ethics committee of the Medical University Graz (30-241 ex 17/18), we examined consecutive dermatological outpatients with a variety of diagnoses: psoriasis, tumours, inflammatory diseases, infections, allergic diseases and eczema. In total 296 individuals participated; 238 questionnaires were returned and the data from 201 were eligible for analysis. The mean Æ SD age was 43Á6 Æ 17Á7 years (range 23–80) and 113 were women (56Á2%). The subjective burden of disease was assessed on a 10-point scale. The patients completed two questionnaires. (i) Skin Shame Scale (SSS-24). This psychodermatological assessment captures an individual’s burden of skin shame. It consists of 24 items, which have to be answered on a Likert scale (1–5 points). 5,6 (ii) SHAME (Shame Assessment scale for Multifarious Expres- sion of shame). This questionnaire includes three subscales based on 21 items (bodily shame and cognitive shame as adaptive, and existential shame as pathological–dysfunctional shame), and a summary score. Answers are given on a six- point Likert scale. 2 For controls we used data from 488 indi- viduals (of 597 participants eligible for analysis) without skin disease, mean Æ SD age 38 Æ 15Á2 years (range 18–86), with 325 women (66Á6%). These controls were recruited via an online survey at the Medical University Graz, or were hospital residents or related persons. The only difference between con- trols and dermatological patients was the higher educational level of the former. 5 ANOVAs and v 2 -tests, and ANCOVAs (age as the control vari- able) were used for group comparisons. Tukey’s honestly sig- nificant difference test was used for post hoc comparisons. Patients with psoriasis, infection or eczema exhibited the highest skin shame levels (P < 0Á001) (Table 1). However, there were no differences between the patients in regard to all other shame aspects. Skin shame was more pronounced in patients with visible skin lesions (P < 0Á01) and a longer dura- tion of disease (P < 0Á05). Compared with controls without skin disease, dermatological patients had a higher level of skin shame (P < 0Á001). Disease burden was highest for eczema and infection (eczema = infection > allergic = tumours; F= 3Á55, P = 0Á004, g 2 = 0Á09). In summary, patients with psoriasis, inflammatory skin dis- ease or eczema had especially high levels of skin shame, but the patient groups did not differ in other aspects of shame. Dermatological patients had a higher level of existential shame (P < 0Á001), but lower cognitive shame (P < 0Á01) compared with controls. This can be explained by the fact that patients develop denial and cognitive avoidance strategies, as described in those with acne. 4 This aspect may also have played a role Research letters 169 © 2020 The Authors. British Journal of Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. British Journal of Dermatology (2020) 183, pp158–192