Current reports estimate that anywhere between 15% and 40% of dermatology patients suffer from comorbid psychological issues that are directly attributed to the skin condition, but there are a number of simple, powerful steps that dermatologists can take to help patients manage — and overcome — these issues.
Last month, in conjunction with Rosacea Awareness Month, the National Rosacea Society (NRS) released the results of a survey that demonstrated that nearly 70% of patients surveyed (69%) had experienced a flare of rosacea in the past month that was due to stress.1 In addition, the survey, which focused on the psychological issues that patients with rosacea often face, demonstrated that just over three-quarters of respondents (76%) said that rosacea’s effect on their facial appearance had lowered their self-confidence and self-esteem.1 Respondents also reported feelings of embarrassment, difficulty establishing new relationships and problems in the workplace because of rosacea.1
A growing body of literature and anecdotal evidence from physicians suggests that anywhere from 15% to 40% of dermatology patients feel that their skin disease has had a negative impact on their psychological well-being.2-5 Patients with a cutaneous condition can develop psychological comorbidities for a number of reasons; the most significant factor in this progression is the fact that the skin is the biggest — and most visible — organ in the body. While almost any medical condition can cause psychological issues for a patient, such as fear and anxiety, skin disease is uniquely problematic, according to John Koo, MD, a professor in, and vice chairman of, the University of California, San Francisco, department of dermatology who is Board-certified in psychiatry and dermatology.
“Usually, when I am asked to discuss psychodermatology, I cover topics such as delusions of parasitosis,” explains Dr. Koo. “However, the mind/skin connection involves more than psychosis. One aspect that is unique to patients with skin disorders is that they are hit with a ‘double-whammy’ — physically, in terms of discomfort and disability, and psychologically, in terms of body image and self esteem. On the other hand, other medical conditions such as heart disease or diabetes can be serious, but do not ordinarily affect self-image.”
Other aspects of skin disease that can contribute to psychological comorbidity include trouble sleeping,6 severity of disease, impact on daily activities and social interaction, timing of onset and disease course.7 In addition, the way in which a patient is psychologically affected by the skin condition can vary greatly; some individuals may find the condition a nuisance, while others are so troubled that it becomes a significant psychiatric issue.
The good news is that there are a number of strategies dermatologists can use to manage psychological issues in patients. This article will review the common psychological issues in dermatology, methods for evaluating patients for comorbid psychological issues and strategies for resolving them.
Scope Of The Problem
Psychological issues can arise in patients with almost any dermatologic condition, explains Richard G. Fried, MD, PhD, a clinical psychologist and dermatologist who is in private practice in Yardley, PA.
“I think anybody who has a diagnosable dermatosis, whether it’s psoriasis, rosacea, acne vulgaris, whether it’s eczema, whether it’s chronic urticaria, whether it’s hair loss — they’ve all got psychological issues related to the condition,” says Dr. Fried. “Now, if we take the word psychological issue in quotes, the psychological issue may be, ‘Eh, this really isn’t that great, I’m not happy about it, I wish it wasn’t there, I guess life isn’t always what I wish’ — that’s one experience; then there’s the other extreme — counting the pills, swallowing with a glass of water and taking your own life. That is the spectrum.”
Chronic skin conditions impact patients in all areas of life.8 One study that evaluated the impact of pruritus on quality of life found that the condition may be comparable to chronic pain in terms of its impact on patients’ ability to function normally.9 Numerous studies have shown that skin conditions can lead to feelings of isolation, trouble initiating and maintaining social and romantic relationships and unequal treatment when applying to jobs and in the workplace, as well as depression and anxiety.2,4,5,7,8 Stress can have a wide-ranging impact on skin disorders; many dermatologic conditions, such as acne, rosacea, hyperhidrosis and urticaria, are exacerbated by stress.2,4,5,8-10 This can become a problematic cycle when the higher-than-normal level of stress exacerbates the skin disorder, which upsets the patient more and increases stress, further exacerbating the skin disorder.2,4,5,8-10 Trouble sleeping has also been identified as a significant psychological comorbidity of skin disorders.6,10
Madhulika Gupta, MD, is a professor of psychiatry at the University of Western Ontario in London, Ontario, Canada, who also researches sleep medicine. As Dr. Gupta explains, “dermatologists must manage the sleep-related complaints of patients, because sleep deprivation is a huge, huge confounding factor in increasing the psychiatric morbidity in this population.”
Sleep deprivation can enhance the inflammatory process, according to Dr. Gupta, which has been implicated in many skin disorders, including psoriasis, acne, rosacea and others. As a result, sleep deprivation can have a negative, cyclical impact for dermatology patients, Dr. Gupta explains — the skin disorder leads to trouble sleeping, and lack of sleep enhances the inflammatory process, which exacerbates the skin disorder further. Sleep disturbances can impact patients as well as family members; atopic dermatitis in infants and children is an example of a disease that can cause family-wide sleep deprivation.11
The Dermatologist’s Role
Even when dermatologists are aware of the psychological impact that skin disease can have, there may still be some disconnect when it comes to managing the problem.
“In a busy dermatology practice, it is all too easy to miss the full extent of the psychosocial and sometimes even occupational impact of skin disease,” explains Dr. Koo. “Even though dermatologists are experts at making accurate physical assessments of the skin instantly, it is important to talk to the patients regarding how they feel about their skin disease and not assume that we understand their experience based on what we see. For some conditions such as psoriasis, there is a quick one page questionnaire available to assess this aspect called the Koo-Menter Psoriasis Instrument (KMPI), which can be accessed from the Journal of the American Academy of Dermatology.”
As Dr. Koo mentions, there is a danger in judging a patient’s psychological well being based on clinical severity, because the extent of the dermatologic condition may not be an accurate, direct reflection of the patient’s feelings.
“All of us in the business of ‘skin and emotion’ very vocally attest to, and exclaim from pulpits — no clinical dare ever have the audacity to judge emotional impact based upon clinical severity,” Dr. Fried explains. “Sometimes we call it marvelously, sometimes there is zero correlation. You have some people with one blackhead on their chin who are devastated, and you can have people with nodular, cystic, scarring acne who aren’t happy about it, but they’re not particularly psychologically disturbed or devastated. I think what is really one of the most important things is to recognize that all skin conditions do have psychological impact — it’s a matter of how much, how often and whether or not that changes your approach to the patient.”
There are a number of simple changes dermatologists can make to their normal routine with patients to address these psychological issues, and tools to employ that evaluate the overall well being of patients. The most significant step dermatologists can take to evaluate and treat patients from a psychological point of view is also quite simple.
“Evaluating the psychological impact accurately is important because the critical decision on how aggressively we should treat skin conditions, such as psoriasis or acne, should depend on not just a physical assessment, but also the psychological assessment,” explains Dr. Koo. “This will help avoid a doctor-patient disconnect in terms of the patient perceiving that the treatment given is inadequately aggressive.”
According to Dr. Fried, taking a few extra minutes to talk with patients about how they feel about a skin condition can make a significant, lasting difference (see “A Holistic Approach," below).
“Every patient should be embraced — not literally, but figuratively, embraced with warmth, with acceptance, in a non-judgmental fashion, in a way that they feel safe enough to trust, so that they comply with whatever regimens we give, safe enough to tell us valuable information that might be very important in their diagnosis and treatment plan, safe enough that they can have some degree of anxiety reduction, because the number one thing that dermatologic problems do is take away control,” Dr. Fried explains. “Most dermatologic conditions are capricious — you never know when your acne will flare, when your rosacea will flare… I can reduce anxiety and give people a sense of trust and a sense that I’m there with them to help them take control and heal.”
There are tools that dermatologists can use in conjunction with talking to patients to get a more distinct picture of any psychological issues. The Dermatology Life Quality Index (DLQI) was developed by Findlay and Khan in 1992 and provides physicians with a 10-question survey for patients about the impact of a skin condition on work, leisure activities, social interactions and more.12 The Koo-Menter Psoriasis Instrument (KMPI) is another scale that is filled out by the patient and the physician; the KMPI asks questions about feelings of self-consciousness and helplessness, the physical symptoms of the disease and more.13 The Patient Health Questionnaire is a combination of different scales that can also be helpful.14
What To Do When The Issues Are More Severe
However, there is still the possibility that a patient may need more help than the dermatologist can offer. When this occurs, referring the patient to a psychologist or psychiatrist, or prescribing drugs for the comorbid psychological issue, may be necessary.
“Often, for psychodermatologic patients, as they move further down the spectrum, where their overt psychological manifestations are more problematic and disabling, where the anxiety is really interfering with stability and quality of life, where the depression is worsening, using more traditional anti-anxiety medicines is part of the healing process,” explains Dr. Fried.
At the 2012 Annual American Academy of Dermatology meeting, Dr. Gupta gave a presentation about the prescribing of psychotropic drugs in dermatology. The results of the study revealed that nearly 3% of dermatology patients (2.78%) were using at least one psychotropic drug, although there were no psychiatric diagnoses in the patient population. In addition, the study results also reflected a significant increase in the prescribing of these drugs to dermatology patients, according to Dr. Gupta: between the 1995 to 2000 and 2001 to 2006 study periods, there was a significant increase in the use of psychotropic drugs in dermatology, from nearly 3% to about 5%.
“I think one of the biggest things is that the clinicians recognize the psychological impact of the skin condition, and they prescribe a psychotropic drug as part of the treatment regimen,” Dr. Gupta explains. “One implication, for sure, is that one has to be more cognizant of the psychosocial comorbidities and address them, because managing the psychosocial comorbidities will more effectively manage the primary skin disorder.”
Referring patients to a psychologist or psychiatrist is another strategy that can have a significantly positive impact.
“Dermatologists are in uniquely advantageous positions because we can help these patients not only psychologically, but also dermatologically, by eliminating or minimizing their skin condition,” says Dr. Koo. “Of course, referral to a psychologist or psychiatrist may rarely be indicated. If this is done in a sympathetic way, the patients will greatly appreciate it.”
The Power of Empathy
While the issues that a patient is having about his or her skin may be significant enough to warrant psychotropic drugs or referral to a psychiatrist or psychologist, the potential impact of a conversation — even just one — should never be underestimated.
“I think the overlying umbrella of the whole field (of psychodermatology) is recognizing that every interaction we have with patients has powerful psychological implications,” explains Dr. Fried. “When someone comes in with alopecia areata, for example, if we touch their scalp and say, ‘You know what, I treat hundreds of patients with this, you’ll be fine,’ that’s powerful, powerful psychological medicine. If someone comes in with chronic itch, and you look at them and say, ‘Look, I think itch is awful. It’s worse than pain. I promise you, I will get your itch under control. I don’t know if I’m going to make it disappear, but, I swear, I’m going to make your itch better’ — that one empathetic statement that took literally five seconds can profoundly change the patient’s perception of the healthcare provider. Sometimes that simple act of compassion can save a life or change a life.”
SIDEBAR: A Holistic Approach
Ladan Mostaghimi, MD, is an associate professor in the department of dermatology at the University of Wisconsin, Madison. Dr. Mostaghimi is also the director of the Psychocutaneous Clinic at UW-Madison and a diplomat of the American Board of Psychiatry and Neurology. She believes that dermatology patients with a comorbid psychological issue are most effectively treated with a holistic approach.
“Considering the high prevalence of mood and anxiety disorders in chronic skin diseases, the
dermatologists should evaluate their patients within the Bio-Psycho-Social model,” Dr. Mostaghimi explains. “With this model, in addition to usual dermatology evaluation and treatment, they will evaluate patients’ psychosocial wellbeing, their current stressors, interpersonal relationships and coping styles. Once the problems are identified, then they could offer strategies to improve quality of life and improve compliance with treatments.”
Dr. Mostaghimi suggests asking patients a series of questions to evaluate their psychological state:
1. How do they feel about their skin disease?
2. How are they coping with the disease?
3. Has the skin disease affected their sleep or mood?
4. Are they avoiding any activities or social functions due to their disease?
5. Do they need to drink or use any medications or drugs before and during social events to help
6. What is their expectation from treatment?
7. How easy or hard it is to comply with the treatments provided so far?
If a psychological issue is suspected after hearing the answers, Dr. Mostaghimi suggests further
evaluation of the patient with short questionnaires like the Patient Health Questionnaire-4 (see
above). Once this evaluation is complete, it is up to the dermatologist to determine if they feel
capable of handling the psychological issue themselves or if the patient should be referred to a
mental healthcare provider.
“It is important to know that psychological issues affect the quality of life of patients and
their compliance with the treatment,” Dr. Mostaghimi explains. “We do have many effective
treatments for mental health issues — psychotropic medications, psychotherapy, relaxation
techniques, hypnosis, biofeedback, to name a few. Offering these options at the same time as
conventional dermatology treatments will improve patients’ satisfaction and quality of life. Since
stress is an aggravating factor in many chronic skin disorders, decreasing the level of stress will
help with better therapeutic response to conventional treatments.”
1. The Dermatologist. New survey highlights significant psychological impact of rosacea. Available at: http://www.the-dermatologist.com/content/new-survey-highlights-significant-psychological-impact-rosacea. Accessibility verified April 25, 2012.
2. Shenefelt PD. Psychological interventions in the management of common skin conditions. Psychol Res Behav Manag. 2010;3:51-63.
3. Rodríguez-Cerdeira C, Pera-Grasa JT, Molares A, Isa-Isa R, Arenas-Guzmán R. Psychodermatology: Past, present and future. Open Derm Jour. 2011;5:21-27.
4. Rasoulian M, Ebrahimi AA, Zare M, Taherifar Z. Psychiatric morbidity in dermatological conditions. Int J Psychiatry Clin Pract. 2010;14(1):18-22.
5. Gupta MA, Gupta AK. Psychiatric and psychological co-morbidity in patients with dermatologic disorders. Am J Clin Dermatol. 2003;4(12):833-842.
6. Mostaghimi L. Prevalence of mood and sleep problems in chronic skin diseases: A pilot study. Cutis. 2008;81(5):398-402.
7. Zachariae R, Zachariae C, Ibsen HHW, Mortensen JT, Wulf HC. Psychological symptoms and quality of life of dermatology outpatients and hospitalized dermatology patients. Acta Derm Venereol. 2004;84(3):205-212.
8. Hong J, Koo B, Koo J. The psychosocial and occupational impact of chronic skin disease. Dermatol Ther. 2008;21(1):54-59.
9. Kini SP, DeLong LK, Veledar E, McKenzie-Brown AM, Schaufele M, Chen SC. The impact of pruritus on quality of life: The skin equivalent of pain. Arch Dermatol. 2011;147(10):1153-1156.
10. Gupta MA. Commentary: Psychodermatology. Clin Dermatol. 2011; doi: 10.1016.j.clindermatol.2011.11.018.
11. Derm for the Pediatrician. Atopic dermatitis update. Available at: http://pedderm.com/atopic-dermatitis-update. Accessibility verified April 25, 2012.
12. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) – a simple practical measure for routine clinical use. Clin Exper Dermatol. 1994;19(3):210-216.
13. Feldman SR, Koo JYM, Menter A, Bagel J. Decision points for the initiation of systemic treatment for psoriasis. J Am Acad Dermatol. 2005;53(1):101-107.
14. Löwe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2010;122(1-2):86-95.