Review of mental health and wellness concerns in dermatological conditions

May is Mental Health Awareness Month.

The link between skin conditions and psychiatric concerns such as anxiety, depression, impaired quality of life and reduced general well-being has 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 in difference from other medical specialties. Over the years, interest in psychodermatology has increased substantially as providers have increasingly explored the relationship between common skin concerns and patient well-being.¹

This Mental Health Awareness Month, Dermatology time is reviewing common dermatological conditions and their relationship to patients’ mental health.

Acne

Research focused on investigating the impact of acne on the quality of life of patients in India considered various factors such as age, sex, location of lesions, severity of acne, scarring acne and post-acne pigmentation. Overall, the researchers found significant effects of acne in several domains.²

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

Acne affected daily activities in 69% of patients, with difficulties related to acne severity and post-acne pigmentation. This impact was attributed to avoidance behavior, anger and frustration. Acne influenced the social activities of 68% of patients, avoiding social gatherings during outbreaks, especially among women. Social anxiety and avoidance behaviors were common responses. Three-quarters of patients reported interpersonal problems, including teasing and questions about their acne. Patients expressed concerns about marriage prospects due to acne.

alopecia

A study of JAMA Dermatology reveals an increased risk and prevalence of psychological conditions among individuals with alopecia areata (AA). The 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 AA patients had a 9% prevalence of depressive disorders, a 13% prevalence of anxiety disorders, with 37% having symptoms of depression and 34% having symptoms of anxiety. Research indicates that more than one-third of AA patients have psychiatric symptoms, and that 7-17% may require psychiatric treatment, including medication.³

Atopic dermatitis

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

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

In children with AD, one study showed an increased risk of suicidal thoughts and attempts, while another found this risk only in female patients. In terms of disease severity, one study observed 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 shown 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. In addition, the chronic inflammatory nature of HS, along with associated comorbidities such as obesity and metabolic disorders, may affect mental health.

psoriasis

Psoriasis is often accompanied by psychiatric comorbidities, with sexual and sleep disorders being the most common. 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 associated with psoriasis.⁶

The relationship between these psychiatric conditions and psoriasis may be bidirectional, with one potentially exacerbating the other. For example, stress can make psoriasis worse, while psoriasis-related symptoms, such as chronic itching and the appearance of the skin, can lead to anxiety and depression.

rosacea

Rosacea significantly affects patients’ self-esteem and social interactions due to its impact on facial appearance, according to a review published in Clinical, aesthetic and research dermatology.⁷

Despite its prevalence, there is limited research on its psychological effects compared to other skin diseases such as acne or psoriasis. Studies have shown that patients with rosacea often experience stigmatization, anxiety and depression, and men and younger individuals are 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 European Journal of Cancer Prevention examined the link between mental health and skin cancer using data from the 2016 Behavioral Risk Factor Surveillance System.⁸

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

Vitiligo

In a study that surveyed 3,541 patients with vitiligo, researchers found that the Vitiligo Short Form Patient Impact Scale (PIP) overall score was remarkably high, especially among patients in India.⁹

Patients with larger affected body surface area, darker skin type, and lesions on the face or hands reported a profound burden on quality of life. More than half of the patients reported diagnosed mental health problems, with a substantial proportion reporting 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 probabilities 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 suicide: 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. Burdens of hidradenitis suppurativa 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 the development of skin cancer: 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 burden and psychosocial quality of life among patients with vitiligo: results 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