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There has been a stigma attached to diseases of the skin for centuries. Lepers were cast out from society in biblical and medieval times as they were considered 'unclean'. Some labelled and persecuted as lepers had other diseases such as eczema or psoriasis. The stigmatisation of lepers was not a public health measure to control spread but an expression of fear, ignorance and prejudice.
Skin disease is often obvious and very visible to others. Those who have skin diseases have not only to cope with the effects of their disease but also the reaction of others to their condition. There is stigma attached to a wide range of skin diseases, affecting many millions of people, just as there is for mental illness and sexually-transmitted infections.
The skin diseases are often incurable and treatments aim to reduce symptoms. Common examples include eczema, psoriasis, acne, rosacea and vitiligo. Whether these conditions are common or very rare, the impact on quality of life can be far-reaching and profound even without stigmatisation. Stigmatisation is an expression of prejudice and ignorance which the medical profession has a duty to combat with information and education. This should be extended to those with skin diseases, their families, schools and the wider community.
- Skin diseases are very common. Indeed it is true to say that everyone will at some time in their life have some form of skin disease.
- In any 12-month period about 24% of the population consult their GP to discuss a skin problem.
- About 14% of consultations with GPs are for skin conditions.
Acne is a common skin condition which illustrates some of the difficulties of living with skin disease. Many people will be able to relate first-hand to the impact of acne on their lives. Acne occurs at an age when those who have it are undergoing other physical changes which also have major psychological effects. Many papers have looked at the implications of acne for young people. For example:
- A study reported that acne can cause psychological abnormalities including depression, suicidal ideation and anxiety. Psychosomatic symptoms, including pain and discomfort, embarrassment and social inhibition, can also occur.Effective treatment of acne was accompanied by improvement in self-esteem, affect, obsessive compulsiveness, shame, embarrassment, body image, social assertiveness and self-confidence. Acne is associated with a greater psychological burden than a variety of other disparate chronic disorders.
- Acne is a common disorder in adolescents and appears to have a considerable impact on emotional health in this age group. Acne should be treated early to avoid scarring and the psychosocial consequences in adolescence.
- A study looked at patients with chronic acne, severe enough to merit treatment with isotretinoin. They found that treatment with oral isotretinoin alleviated depressive symptoms. Improvements in depression were directly related to acne-related life quality improvements rather than to improvement in acne grade.
- A Korean study found that psychological morbidity was better correlated with perceived degree of acne than objective assessment.
When treating patients with acne:
- It is important not to underestimate the impact of even mild acne on patients' well-being.
- Use the opportunity to educate and inform. Discuss causes, principles of treatment and popular myths.
- Anger is a common problem and it affects quality of life, emotional stability and satisfaction with treatment.
- It is important to identify those in need of intervention and to start treatment early before both dermatological morbidity and psychological morbidity become established.
Education can be given not only to individuals but also within schools and to the wider community. Campaigns to educate more widely serve to encourage patients to seek help and to raise awareness and greater empathy in the wider community. Such campaigns may or may not succeed but it is interesting to reflect that, if it is difficult in the case of so common a condition, the task with the myriad of other conditions seems daunting indeed.
Wider aspects of skin disease
The psychosocial impact
Skin diseases can be difficult to cope with and have a big psychological impact on patients. Even mild skin diseases can have an adverse effect and disrupt enjoyment of life for those who have the diseases. Such disruption can range from embarrassment and concerns about self-image to low self-esteem and severe depression. For example:
- Patients with eczema, vitiligo or psoriasis face embarrassment, worry and depression. A survey of patients with psoriasis revealed that many deliberately avoid swimming.In addition, few wear short sleeves, shorts or skirts because they feel that people regard them as 'untouchable' or 'contagious'.
- Playing sport is a problem for psoriasis sufferers.Children with psoriasis are more likely to be bullied.
- Impairment of quality of life (QOL) correlates poorly with severity of disease. A Polish survey found that disease severity was related to impact on employability and family finances.
- The poor correlation of QOL with severity of disease and other demographic variables, such as gender and education, has also been reported.[12, 13]
- Stress, either environmental or psoriasis-induced, has important implications for the management of psoriasis. Depression and even suicide may occur.
- Cognitive behavioural therapy in vitiligo improved QOL.
- Childhood atopic eczema affects not just the child but the whole family and education may be of benefit to all. It can affect sleep, schooling, development and relationships within families. It can lead to unfair criticism of parents who may be deemed to be neglectful by those who may underestimate the severity of a child's eczema.
The impact of treatment
The treatment of skin disease can be complicated and will often place restrictions on the lives of those who have a skin disease. For example:
- The application of creams or pastes to large areas of the body is time-consuming and can require help from others. Remember this when prescribing for someone who lives alone. Medications can be unpleasant to apply. For example, coal tar is smelly (short-contact dithranol is preferable, as it is washed off after a few hours).
- Some preparations have to be left on overnight. Whilst this is preferable to having them on by day, they may stain bedding and nightwear.
- Skin disease may cause pruritus. This is distracting by day and causes insomnia by night. If itching is caused by histamine, as in urticaria, antihistamines may be useful.
- Psoriasis and eczema are common conditions but there are some that are much more severe and fortunately rare, such as epidermolysis bullosa in which the body is covered with painful bullae and every morning starts with changing dressings from painful, oozing lesions. Strong analgesia such as morphine may be required to cover this time.
- For some skin diseases including vitiligo, blemishes or scars, it is possible to use camouflage to cover them.
The holistic approach to treatment
An holistic approach is essential in dealing with dermatological disorders because of the profound and the far-reaching effects not only of the diseases but also of treatments. Talk to patients and discuss the impact of their disease, how they cope and how they feel about it. An empathetic approach is important given the psychological and social morbidity associated with skin disease.
- Consider the impact of the disease on the patient at work, at home, in leisure activities and in all aspects of their relationships with others.
- Consider the practicalities of applying medication and the possible effects.
- Consider the impact of discomfort and itching. Think of a wider list of complications arising from the condition. For example, with eczema think not just of secondary infection but also of the impact on sleep and psychosocial functioning.
- Consider the side-effects of medication.
- Do not underestimate the effects of being visibly different, especially for children. Be aware of bullying in schools and the adverse effects of this on children.
- The impact of the disease is not necessarily related to objective measurement of severity.
- Be prepared to consider a wide variety of treatments and a wide variety of different professional expertise to help patients. The concept of a multidisciplinary team approach can be helpful in encouraging improvements for the patient and collaboration between professionals from different disciplines. For example, specialist nurses can provide valuable support to patients and can demonstrate how to apply treatments correctly.
- There is much myth and misunderstanding and so education for all is often very important. There are many common myths, and beliefs can be hard to dispel. For example, acne is not caused by poor hygiene and patients with rosacea are not necessarily alcoholic!
Further reading and references
Ghosh S, Behere RV, Sharma P, et al; Psychiatric evaluation in dermatology: an overview. Indian J Dermatol. 2013 Jan58(1):39-43. doi: 10.4103/0019-5154.105286.
Care of People with Skin Problems; Royal College of General Practitioners, 2010 (updated 2014).
Pruthi GK, Babu N; Physical and psychosocial impact of acne in adult females. Indian J Dermatol. 2012 Jan57(1):26-9. doi: 10.4103/0019-5154.92672.
Ayer J, Burrows N; Acne: more than skin deep. Postgrad Med J. 2006 Aug82(970):500-6.
Hahm BJ, Min SU, Yoon MY, et al; Changes of psychiatric parameters and their relationships by oral isotretinoin in acne patients. J Dermatol. 2009 May36(5):255-61. doi: 10.1111/j.1346-8138.2009.00635.x.
Do JE, Cho SM, In SI, et al; Psychosocial Aspects of Acne Vulgaris: A Community-based Study with Korean Adolescents. Ann Dermatol. 2009 May21(2):125-9. doi: 10.5021/ad.2009.21.2.125. Epub 2009 May 31.
Isaacsson VC, de Almeida HL Jr, Duquia RP, et al; Dissatisfaction and acne vulgaris in male adolescents and associated factors. An Bras Dermatol. 2014 Jul-Aug89(4):576-9.
Walker N, Lewis-Jones MS; Quality of life and acne in Scottish adolescent schoolchildren: use of the Children's Dermatology Life Quality Index (CDLQI) and the Cardiff Acne Disability Index (CADI). J Eur Acad Dermatol Venereol. 2006 Jan20(1):45-50.
Ni C, Chiu MW; Psoriasis and comorbidities: links and risks. Clin Cosmet Investig Dermatol. 2014 Apr 177:119-32. doi: 10.2147/CCID.S44843. eCollection 2014.
Moon HS, Mizara A, McBride SR; Psoriasis and psycho-dermatology. Dermatol Ther (Heidelb). 2013 Dec3(2):117-30. doi: 10.1007/s13555-013-0031-0. Epub 2013 Jul 10.
Magin P; Appearance-related bullying and skin disorders. Clin Dermatol. 2013 Jan-Feb31(1):66-71. doi: 10.1016/j.clindermatol.2011.11.009.
Hawro T, Zalewska A, Hawro M, et al; Impact of psoriasis severity on family income and quality of life. J Eur Acad Dermatol Venereol. 2014 May 22. doi: 10.1111/jdv.12572.
Fernandez-Torres RM, Pita-Fernandez S, Fonseca E; Quality of life and related factors in a cohort of plaque-type psoriasis patients in La Coruna, Spain. Int J Dermatol. 2014 Nov53(11):e507-11. doi: 10.1111/ijd.12294. Epub 2014 Sep 30.
Darjani A, Heidarzadeh A, Golchai J, et al; Quality of life in psoriatic patients: a study using the short form-36. Int J Prev Med. 2014 Sep5(9):1146-52.
Chan MF, Chua TL; The effectiveness of therapeutic interventions on quality of life for vitiligo patients: a systematic review. Int J Nurs Pract. 2012 Aug18(4):396-405. doi: 10.1111/j.1440-172X.2012.02047.x.
Chamlin SL; The psychosocial burden of childhood atopic dermatitis. Dermatol Ther. 2006 Mar-Apr19(2):104-7.