Psychosocial Impacts of Inflammatory Skin Conditions Must Be Addressed in Patient Care

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“These patients are suffering. We’ve got to look deeper beyond just asking them if they are itching or if they’re having pain,” said Lauren Miller, PA-C, MPAS, at the inaugural 2023 Inflammatory Disease Summit (IDS) in Las Vegas, Nevada. Miller, a board-certified physician assistant at Southern Skies Dermatology & Surgery in Oxford, Alabama, began the first IDS meeting with a presentation on the psychosocial impacts of inflammatory skin diseases. Miller’s main focuses were atopic dermatitis (AD), psoriasis, and hidradenitis suppurativa (HS).

Miller reviewed findings from a 5-year literature review that showed certain cytokines such as interleukin-6 and tumor necrosis factor-α can be found in serum during depressive episodes, but that biologics targeting the skin have shown efficacy in improving both inflammatory and depressive symptoms, as well as overall quality of life. “If you can improve the skin, you can also improve the depression and quality of life symptoms,” said Miller.

Regarding quality of life impact, approximately 30% of patients with an inflammatory skin condition are affected by psychosocial factors such as low self-esteem, anxiety, depression, social isolation, sexual dysfunction, and suicidal ideation. Miller emphasized clinicians’ concerns about patients’ suicidal ideations, as the suicide rate in the US is 14.4 deaths per 100,000, and suicide is the second leading cause of death among individuals aged 10-14 and 25-34.

Miller then shared an example of one of her psoriasis patients who presented with symmetrical and sharply demarcated erythematous plaques with scale, and who suffered from extreme itch and pain. Miller noted that while a patient’s physical symptoms may be extreme, clinicians then must ask the patient about the quality of life. A meta-analysis of PubMed papers that Miller referenced found that among patients aged 18-45 with psoriasis, 19% of them were asked to leave a public place when their disease was visible, and 40% reported a decline in sexual activity.

Another meta-analysis of PubMed papers for AD found that 60% of children with AD experience bullying and teasing, 3 times as many children with AD have risk factors for the development of behavioral problems compared to matched controls, and adults with AD tend to be more introverted and struggle to manage their anger.

For HS, patients are often frustrated with symptoms such as pain, drainage, and odor. Another meta-analysis Miller referenced found that the prevalence of depression (26.5% vs 6.6%) and anxiety (18.1% vs 7.1%) were higher in patients with HS compared to those without, and that HS was associated with higher antidepressant and anxiolytic use, as well as suicidality.

Miller strongly recommended the use of the Dermatology Life Quality Index (DLQI) during patient visits, especially for those with inflammatory skin conditions. The DLQI consists of 10 questions with scores ranging from 0 to 3. Total score ranges from 0 to 30, with 20-30 points suggesting an extremely large impact on quality of life. Miller encourages the use of the DLQI at a patient’s first visit, and then has the patient fill out the survey again after they have started on a treatment regimen.

“We want to look at a patient from a holistic approach and not just look at them from a cutaneous signs and symptoms approach. You want to validate the feelings that they have and let them know that you understand their struggles,” concluded Miller.

Reference

Miller L. Psychosocial impact of inflammatory skin disease. Presented at: 2023 Inflammatory Disease Summit; October 19, 2023; Las Vegas, Nevada.