Reviewing Concerns For Mental Health and Well-Being in Dermatologic Conditions

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May is Mental Health Awareness Month.

The link between skin conditions and psychiatric concerns such as anxiety, depression, hindered quality of life, and lowered overall well-being, have been well-documented.

According to the Association for Psychoneurocutaneous Medicine of North America (APMNP), dermatologist Joseph Klauder first wrote about psychosomatic interrelationships in 1925. However, much of this concept was picked up by psychiatrists as opposed to other medical specialties. Over the years, interest in psychodermatology has increased substantially, as providers have increasingly explored the relationship between common cutaneous concerns and patients' well-being.¹

This Mental Health Awareness Month, Dermatology Times is reviewing common dermatologic conditions and their relationship with patients' mental health.

Acne

Research focusing on investigating the impact of acne on the quality of life of patients in India considered various factors such as age, gender, location of lesions, severity of acne, acne scars, and post-acne pigmentation. In total, researchers found significant effects of acne across various domains.²

A high percentage (88%) of patients reported feeling embarrassed or self-conscious due to their acne, impacting their self-esteem and confidence. The severity of acne and its location on the face correlated with the degree of embarrassment.

Acne affected daily activities for 69% of patients, with difficulties linked to the severity of acne and post-acne pigmentation. This impact was attributed to avoidance behavior, anger, and frustration. Acne influenced social activities for 68% of patients, with avoidance of social gatherings during flare-ups, especially among females. Social anxiety and avoidance behaviors were common responses. Three-quarters of patients reported interpersonal problems, including teasing and inquiries about their acne. Female patients expressed concerns about marriage prospects due to acne.

Alopecia

A study from JAMA Dermatology reveals a higher risk and prevalence of psychological conditions among individuals with alopecia areata (AA). Researchers analyzed previous data to determine the occurrence of depressive and anxiety disorders, as well as related symptoms in patients with AA. They found that patients with AA had a 9% prevalence of depression disorders, 13% prevalence of anxiety disorders, with 37% experiencing symptoms of depression and 34% showing symptoms of anxiety. The research indicates that over one-third of AA patients display psychiatric symptoms, and 7 to 17% might need psychiatric treatment, including medication.³

Atopic Dermatitis

A systematic review and meta-analysis published in JAMA Dermatology examined 15 studies on suicidality in patients with atopic dermatitis (AD).⁴

Pooling data from 11 studies, the meta-analysis found that patients with AD were significantly more prone to suicidal thoughts. Similarly, based on data from 3 studies, patients with AD were more likely to attempt suicide.

In children with AD, one study showed increased risk of suicidal thoughts and attempts, while another found this risk only in female patients. Regarding disease severity, one study noted higher suicidal thoughts in severe cases.

Hidradenitis Suppurativa

Depression, anxiety, bipolar disorder, schizophrenia, and substance abuse are common psychiatric comorbidities in chronic inflammatory skin diseases such as hidradenitis suppurativa (HS), according to a review published in Life.⁵

Studies have indicated high rates of depression and anxiety in patients with HS, with prevalence ranging from 12% to 26.8% and 4.9% to 18%, respectively. Bipolar disorder and schizophrenia have also also showed significant associations with HS, with prevalence estimates ranging from 0.7% to 2% and 1% to 2%, respectively.

Psychosocial factors, including impaired quality of life due to pain, discomfort, and social stigma, contribute to depression and anxiety in HS. Additionally, the chronic inflammatory nature of HS, along with associated comorbidities such as obesity and metabolic disorders, may impact mental health.

Psoriasis

Psoriasis is often accompanied by psychiatric comorbidities, with sexual and sleep disorders being the most prevalent. Anxiety disorders, eating disorders, mood disorders (such as depression and bipolar disorder), personality disorders, schizophrenia, substance abuse, sexual dysfunction, sleep disorders, and somatoform disorders are all associated with psoriasis.⁶

The relationship between these psychiatric conditions and psoriasis can be bidirectional, with one potentially exacerbating the other. For instance, stress can worsen psoriasis, while psoriasis-related symptoms such as chronic itch and skin appearance, can lead to anxiety and depression.

Rosacea

Rosacea significantly affects the self-esteem and social interactions of patients due to its impact on facial appearance, according to a review published in Clinical, Cosmetic and Investigational Dermatology.⁷

Despite its prevalence, there is limited research on its psychological effects compared to other skin diseases such acne or psoriasis. Studies have shown that patients with rosaceaoften experience stigmatization, anxiety, and depression, with men and younger individuals being more affected. Comorbidity between rosacea and depression/anxiety has been confirmed, with rosacea exacerbating these conditions and vice versa. Facial erythema is particularly distressing and impairs health-related quality of life.

Skin Cancer

A study published in the European Journal of Cancer Prevention examined the link between mental health and skin cancer using 2016 Behavioral Risk Factor Surveillance System data.⁸

The analysis revealed a significant association between mental health issues and skin cancer development, even after adjusting for demographic and lifestyle factors. However, the direction of the association remains unclear, according to researchers. It is possible that distress from a skin cancer diagnosis contributes to mental health problems, or that mental health issues may biologically increase the risk of skin cancer.

Vitiligo

In a study surveying 3541 patients with vitiligo, researchers found that the global short-form Vitiligo Impact Patient Scale (VIPs) score was notably high, particularly among patients from India.⁹

Patients with larger affected body surface area, darker skin types, and lesions on the face or hands reported profound quality of life burden. Over half of patients reported diagnosed mental health conditions, with a substantial portion showing moderate to severe depressive symptoms.

References

1. Association for Psychoneurocutaneous Medicine of North America. History of psychodermatology in the United States. Psychodermatology.us. Accessed May 2, 2024. https://psychodermatology.us/page-1823653
2. Hazarika N, Archana M. The psychosocial impact of acne vulgaris. Indian J Dermatol. 2016;61(5):515-520. Accessed May 2, 2024. doi:10.4103/0019-5154.190102
3. Lauron S, Plasse C, Vaysset M, et al. Prevalence and odds of depressive and anxiety disorders and symptoms in children and adults with alopecia areata. JAMA Dermatology. 2023. Accessed May 2, 2024. doi:10.1001/jamadermatol.2022.6085
4. Sandhu JK, Wu KK, Bui TL, Armstrong AW. Association between atopic dermatitis and suicidality: A systematic review and meta-analysis. JAMA Dermatol. 2019;155(2):178-187. Accessed May 2, 2024. doi:10.1001/jamadermatol.2018.4566
5. Caccavale S, Tancredi V, Boccellino MP, Babino G, Fulgione E, Argenziano G. Hidradenitis suppurativa burdens on mental health: A literature review of associated psychiatric disorders and their pathogenesis. Life (Basel). 2023;13(1):189. January 9, 2023. Accessed May 2, 2024. doi:10.3390/life13010189
6. Ferreira BI, Abreu JL, Reis JP, Figueiredo AM. Psoriasis and associated psychiatric disorders: A systematic review on etiopathogenesis and clinical correlation. J Clin Aesthet Dermatol. 2016;9(6):36-43. Accessed May 2, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4928455/
7. Heisig M, Reich A. Psychosocial aspects of rosacea with a focus on anxiety and depression. Clin Cosmet Investig Dermatol. 2018;11:103-107. March 6, 2018. Accessed May 2, 2024. doi:10.2147/CCID.S126850
8. Tkachenko E, Singer S, Mostaghimi A, Hartman RI. Association of poor mental health and skin cancer development: a cross-sectional study of adults in the United States. Eur J Cancer Prev. 2020;29(6):520-522. Accessed May 2, 2024. doi:10.1097/CEJ.0000000000000567
9. Bibeau K, Ezzedine K, Harris JE, et al. Mental health and psychosocial quality-of-life burden among patients with vitiligo: Findings from the global VALIANT study [published correction appears in JAMA Dermatol. 2024 Jan 1;160(1):118]. JAMA Dermatol. 2023;159(10):1124-1128. Accessed May 2, 2024. doi:10.1001/jamadermatol.2023.2787