Psychologic consequences of facial dermatoses Edith Orion MD, Ronni Wolf MD PII: DOI: Reference:
S0738-081X(14)00050-9 doi: 10.1016/j.clindermatol.2014.02.016 CID 6833
To appear in:
Clinics in Dermatology
Please cite this article as: Orion Edith, Wolf Ronni, Psychologic consequences of facial dermatoses, Clinics in Dermatology (2014), doi: 10.1016/j.clindermatol.2014.02.016
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
SC
RI P
T
Psychologic consequences of facial dermatoses
Edith Orion, MD¹ ²
MA NU
Ronni Wolf, MD³
ED
From:
1. The Dermatology Department, Sourasky Medical
PT
Center, Tel Aviv, Israel.
CE
2. The psychodermatology clinic, Sourasky Medical Center,
AC
Tel Aviv, Israel
3. The Dermatology Unit, Kaplan Medical Center, Rehovot,
Israel
Address for correspondence: Edith Orion, MD, Dermatology Department, Sourasky Medical Center, Tel Aviv, Israel. Fax 972-3-6436086, E-mail:[email protected]
ACCEPTED MANUSCRIPT Abstract
AC
CE
PT
ED
MA NU
SC
RI P
T
The attractiveness of the human body has always been an important issue in the fields of sociology, psychology, psychiatry, and also in the field of dermatology. In psychodermatology, one often finds how all the above mentioned fields intermingle with each other to produce elaborate situations and extreme human difficulties. Perfect skin is widely adored in literature, poetry and biblical texts as well as in advertisements, movies and television. Because in most societies the face is usually a body part that is visible, imperfections of its skin is also visible, therefore its flawed appearance bears the potential to become a source of misery to some.
ACCEPTED MANUSCRIPT Introduction
T
A healthy, normal looking skin is essential for an individual's physical and mental well-being. Facial skin diseases can create an impact on the patient's life in various aspects; it can have an impact on his/hers social status, romantic relationships, as well as on his/hers emotional health and self-esteem. It is the patient's "visible self". Facial skin diseases have the potential to affect an individual's quality of life to a great extent.
SC
RI P
Psychodermatology is concerned with skin conditions that are influenced by psychologic difficulties as well as with psychologic difficulties arising due to skin conditions. In this article we will discuss the effects of the soma on the psych – the somatopsychic aspect of facial skin diseases.
MA NU
We will focus on the psychologic impact of skin conditions that are typically facial (not dermatoses that affect other body areas but can appear also on the face). Although we will discuss those facial dermatoses that their psychologic impact is the most investigated, there are reasons to assume that the emotional burden exists in most facial dermatoses.
The emotional impact of facial dermatoses - Stigmatization
PT
ED
In ancient times, skin diseases were often seen as an expression of the wrath of a god, who visited on those who had sinned. Skin disease sufferers were sometimes even condemned to live separately, and their approach announced by a bell or a horn due to the belief that their disease was contagious (1). Although occasional patients are able to take in stride disease that is disfiguring and visible, for many of them, the experience of being "different" is frightening, leading to feelings of embarrassment and shame (1).
AC
CE
The attractiveness of the human body has always been an important issue in the fields of sociology, psychology, psychiatry, and also in the field of dermatology. In psychodermatology, one often finds how all the above mentioned fields intermingle with each other to produce elaborate situations and human difficulties. One important problem deals with the feeling of stigmatization resulting from a visible skin condition. Stigma was defined by the sociologist Ervin Goffman as a process by which the reaction of others spoils normal identity. It is thus easily understood why many skin patients feel stigmatized (2-3). In this context, skin conditions that alter skin color, complexion, texture or appearance can provoke negative reactions and emotions in others. This can lead to disapproval, rejection, exclusion and discrimination (4). Most information we have about the nature and extent of the situation concerns perceived stigmatization among psoriasis or vitiligo patients (2-3,5), less focused information exists about stigmatization among patients with facial dermatoses (6). The reason is probably less research rather than lesser degree of perceived stigmatization. It is expected that imperfections on the face would cause more psychologic problems than imperfections in other body areas since it is more exposed to others, and it is harder to hide or camouflage successfully. Acne
ACCEPTED MANUSCRIPT Acne, a common skin disease, is prevalent mainly during adolescence, but may be present also in adulthood. The disease's major complications include physical scarring and psychologic effects which may persist long after thedermatitis have disappeared (7-8).
T
Acne's impact on psychosocial and emotional problems is so significant that it is comparable to the effects of those imposed by arthritis, back pain, diabetes, epilepsy and asthma (9).
SC
RI P
Panconesi finds acne a facial dermatosis with a high incidence of psychoemotional factors (10). He also makes an important distinction between adolescent acne, which causes psychologic problems secondary to the skin disease (somato-psychic), and adult acne which can mainly be evoked or exacerbated by psychologic problems or even by a psychiatric disease (psycho-somatic) (10).
ED
MA NU
From a psychoanalytical point of view, not able to compete with the perfection of the idealized personalities or peers, even minimal acne lesions may serve to confirm for adolescents their worst fears of being ugly, dirty and flawed (1). The negative feelings lead to low self-esteem, and self-conscious feelings that everyone is staring with criticism (11). Because of the age-appropriate adolescent physical changes and the early arousal of sexual feelings, guilt about sexuality is often relevant and present, and the outbreak of acne dermatitis may be experienced as a loss of control and as a punishment. The stress of integrating into the body image age-appropriate physical changes as well as acne may lead to the fragility of that image, with the possible development of body dysmorphic disorder (1).
CE
PT
Data shows that late adolescents feel stigmatized by their visible facial skin condition (12). In adolescence, the individual usually becomes more autonomous, relationships with family members change, and peer or romantic relationships become more important (13). The appearance of the skin is important for successful social interactions and for high self-image in this age group (14).
AC
It seems that adolescents are more influenced by the psychosocial effects of acne than older patients (15). Although acne can pose psychologic problems at any age, the condition itself is much more prevalent in adolescence (therefore the larger bulk of acne sufferers would come from this age group) and, more importantly, adolescents are psychologically vulnerable, and tend to be more sensitive to modifications in their appearance (16). Therefore, this volatile combination can have a long-lasting impact on their lives: It can affects self-esteem and assertiveness, factors that are crucial in forming relationships as well as to the development of personality traits (15). Interviews with patients revealed explicit links between appearance and subjects' self-image, self-concept and self-esteem, which gave rise to much of the psychologic morbidity in those patients (17). Embarrassment and self-consciousness were found to be directly linked to self-image and self-esteem. Important exacerbating factors in the relationship between acne, embarrassment and selfconsciousness were taunting or teasing and a perception of being judged by others (17). Anxiety and depression are the two most prevalent psychiatric morbidities linked to acne. In a small series of 34 patients with severe acne, significant levels of anxiety were found in 44% of patients, and depression in 18% (18).
ACCEPTED MANUSCRIPT In a study of 72 adolescents and young adults with mild to moderate noncystic acne, active suicidal ideation was elicited in 5.6% (19).
RI P
T
In a cross-sectional survey among 9567 teenagers aged 12-18 years, "problem acne" was associated with increased probability of depressive symptoms (24%), anxiety (9%), suicide thoughts (34%), and suicide attempts (13%) (20).The association of "problem acne" with suicide attempts was found to be independent of anxiety and depressive symptoms.
ED
MA NU
SC
In a recent large population-based study of 3775 adolescents aged 18-19, the relationship of acne severity to suicidal ideation, mental health problems and social functioning was explored. Among those with severe acne, suicidal ideation was twice as frequently reported among girls and three times more frequently reported among boys in comparison to the mild/no acne patients (13). Suicidal ideation remained significantly associated with substantial acne even after adjustments of symptoms of depression, ethnicity and family income were done. The study also demonstrated a significant association of substantial acne and mental health problems, low attachment to friends, lack of thriving at school, lack of romantic relationships and sexual intercourse (13). These results are in accordance to previous works showing impaired self- image and self- esteem (21), impaired psychologic well-being (12), and inhibition of social interactions (22). So the immediate impact of acne on multiple aspects of patients' lives is immense, moreover, it may have a huge influence on their well-being in later life.
AC
CE
PT
Regardless of the degree of severity, patients with acne are at increased risk to develop anxiety and depression and even suicidal ideation in comparison with acne-free population. Acne negatively affects quality of life, and the greater the impairment secondary to the disease, the greater the level of anxiety and depression (15). Unlike this correlation, other studies show that in adult females, acne can cause impairment in quality of life regardless of its severity. Also, age and disease duration do not necessarily correlate with quality of life as well (23). The link between depression, suicide ideation, and the use of isotretinoin is controversial. In a critical review of the literature, it was concluded that although some drugs could induce depressive symptoms, drug-induced depression seems to differ symptomatically from classical major depression. Interestingly, evidence was not presented linking isotretinoin to depression (24). There have been several reviews examining possible linkage between isotretinoin, depression and suicide. Most reviews conclude that at present there is no conclusive evidence that either support such an association or rejects it (25). In epidemiological studies, the results have been conflicting. No association was found between isotretinoin treatment and depression, psychotic symptoms, suicide or suicide attempts in a cohort of more than 7000 isotretinoin users (26). However, in a recent retrospective cohort study of 5756 patients aged 15 to 49 years prescribed with isotretinoin for severe acne, observed before, during and after treatment found an increased risk of attempted suicide up to six months after the end of treatment. In this study, however, the risk of attempted suicide was already rising before treatment, so an additional risk due to isotretinoin treatment cannot be established (27). Also, many case reports and case series have reported serious adverse psychiatric events associated with isotretinoin (27). To make
ACCEPTED MANUSCRIPT matters more confusing, depression, anxiety, and overall psychiatric morbidity have been found to improve when acne is treated, especially with isotretinoine (17). Rosacea
SC
RI P
T
Rosacea is a common chronic inflammatory facial dermatosis that is characterized by facial blushing, erythema, telangiectasiae, burning sensation and a papulopustular acneiform eruption. It occurs most often in middle-aged people, 30-50 years old, with fair skin (28). Rosacea may be overlooked in non-whites because of low index of suspicion or because skin pigmentation results in an atypical presentation (29). Women are affected 2-3 times more frequently than men (30); nevertheless, the most obvious stigma of rosacea, rhinophyma, occurs more often in men (31).
MA NU
Patients with rosacea suffer from a variety of emotional and social stigmas. They may inaccurately be stigmatized as alcohol abusers due to their red face, or phymatous nose (28). Patients often have feelings of low self-esteem when facial dermatitis progresses (28). They may report feelings of embarrassment, frustration, shame or anxiety about their facial flushing and erythema in social situations. This anxiety may resemble panic disorder or may even worsen, causing some patients to become reclusive due to social phobia (32). Impaired contacts are a frequent finding (33).
PT
ED
Psychologic studies among rosacea patients have revealed a weak ego, autoaggression, tendency to self-accusation, excessive feelings of responsibility for oneself and others, low tolerance for frustration, and discrepancy between what the person is and what he or she wishes to be. The measured forms of anxiety- both situational fear and anxiety as a personal trait – had the highest values in rosacea patients (34).
AC
CE
Patients with rosacea are also prone to develop depression, as was proven in a large survey of 608 million dermatology visits (35). In this study, 1.04% of patients had a comorbid psychiatric diagnosis, about 70% of them were depressive disease. Depression was attributed to the cosmetic impact of the disease (36). Of importance is the observation that use of cosmetic products to conceal skin lesions can help improve self-image and quality of life (37). A rosacea-specific quality of life index demonstrated that flushing and skin appearances are some of the most critical factors for patients (38). Both physicians and relatives of patients with rosacea tend to underestimate the effect of the disease on patient' quality of life. Apparently, it should be recognized and addressed also in the dermatologist office. Seborrheic Dermatitis Seborrheic dermatitis affects mainly the central face, but can also involve the scalp and anterior chest. It can affect patients from infancy to old age, but is most frequent in infants within the first three months of life, and in adults at 30-60 years of age (39). In adolescents and adults it manifests as dandruff, and as erythema and greasy scaling of the nasolabial folds. It can also affect the postauricular skin and central face (auricles, bearded area, eyebrows, and eyes) as well as other body areas (39).
ACCEPTED MANUSCRIPT
T
There are only limited data concerning the psychologic consequences of seborrheic dermatitis. It is surprising, considering the high prevalence of this condition, its visibility and potential disfiguring properties. Obviously, the disfiguration problems must be emphasized because of sociophobic tendencies, communication impairments, and avoidance and social withdrawal may result (34).
MA NU
SC
RI P
Patients with mood depression have a high prevalence of seborrheic dermatitis (40) as was shown in a group of patients with psychiatric disorders. The other way round - an increased predisposition to depression in seborrheic dermatitis patients was also found (41). These investigators also demonstrated a decrease in DLQI among seborrheic dermatitis patients, as well as an increased level of stress patients encounter in their lives, perhaps due to their disease-related stigmas. Another group of researchers demonstrated that the impact of seborrheic dermatitis on quality of life is significantly greater among female patients, and among the age groups 16-25 years and 41-60 years (42). Port-wine stains
PT
ED
Port-wine stain (PWS) is a benign, congenital disfiguring vascular malformation that persists throughout life. It is a common dermatosis, occurring in an estimated 3-5:1000 births and approximately 80% of stains are found on the face or neck (43-44). The lesions tend to darken with age and become thicker with possible nodule formation, causing substantial disfigurement and potential psychological problems (44). At mediaeval times, birthmarks such as PWS were taken as evidence of the bearer's service to the devil (45), while nowadays they may be just as well prejudiced against.
AC
CE
Some authors share their experience with PWS patients, mentioning that unexpectedly, most of their patients seem well adjusted and psychologically normal people (45). Several investigations concerning psychologic effects of laser therapy in patients with PWS have revealed that these patients were no different than normal controls, although they were found to be perfectionistic and had unrealistic expectations of the outcome of therapy. These patients felt they were at considerable personal, professional and social disadvantage due to their nevus (46-48). Nevertheless, later investigations, using different research questionnaires, indicate that PWS patients suffer a significant degree of psychologic morbidity (45). Over 50% of patients felt embarrassed and depressed because of their birthmark. Forty one percent felt that people avoided looking at them. The authors suggest that PWS patients suffer psychologic distress which is not apparent in their social interactions or when applying indirect psychologic testing. They found that these difficulties do not improve with advancing age and thus may cause further problems for patients adapting to their social environment (45). In another study, 47% of PWS patients rated their self-esteem as lower compared with other people of the same age group. After treatment, only 8% had this thought (49). An interesting and unexpected observation in this study was that non-facial PWS disturbed the patients as much as facial ones, but in other ways. Conclusions Body image of oneself is of fundamental importance in the development of personality and interpersonal relationships. The above information highlights the need to screen for
ACCEPTED MANUSCRIPT depression, anxiety and suicidal ideation among patients (especially teenagers) who come to be treated for acne. Dermatologists who see young people with moderate to severe acne have an important role since a significantly large portion of them may have psychiatric difficulties and even a record of a suicide attempt related to their skin disease.
RI P
T
Other facial dermatoses may be related to psychologic difficulties as well. Although there is less research among those patients, one would conclude that stigmatization and flawed appearance may result in lower quality of life and the consequent development of depression, anxiety, social phobia, shame and embarrassment, among other difficulties.
AC
CE
PT
ED
MA NU
SC
It is of outmost importance for the dermatologist to acknowledge those psychologic "side effects" of facial dermatoses, which patients rarely report, for the sake of prescribing the right treatment (e.g. isotretinoin), but also for offering appropriate psychological/psychiatric support.
ACCEPTED MANUSCRIPT References 1. Koblenzer CS. The emotional impact of chronic and disabling skin disease: A psychoanalytic perspective. Dermatol Clin 2005; 23 : 619-627.
T
2. Gupta M, Gupta A, Watteel G. Perceived deprivation of social touch in psoriasis is associated with morbidity: an index of the stigma experience in dermatologic disorders. Cutis 1998; 61: 339-342.
RI P
3. Ginsburg I, Link B. Feeling of stigmatization in patients with psoriasis. J Am Acad Dermatol 1989; 20: 53-63.
SC
4. Chaturvedi S, Singh G, Gupta N. Stigma experience in skin disorders: An Indian perspective. Dermatol Clin 2005; 23: 635-642.
MA NU
5. Kent G, Al'Abadie M. Psychologic effects of vitiligo: a critical incident analysis. J Am Acad Dermatol. 1996; 35:895-8. 6. Lowe JG. The stigma of acne. Br J Hosp Med 1993; 49(11): 809-812. 7. Niemeier V, Kupfer J, Demmelbauer-Ebner M, Stangier U, Effendi I, Gieler U. Coping with acne vulgaris: evaluation of the chronic skin disorder questionnaire in patients with acne. Dermatology 1998; 196: 108-115.
ED
8. Koo JY, Smith LL. Psychologic aspects of acne. Pediatr Dermatol 1991; 8: 185-188.
PT
9. Mallon E, Newton JK, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY. The quality of life in acne: A comparison with general medical conditions using generic questionnaires. Br J Dermatol 1999; 140: 672-676.
CE
10. Panconesi E. Psychosomatic factors in dermatology: Special perspectives for application in clinical practice. Dermatol Clin 2003; 23: 629-233.
AC
11. Koblenzer CS. Psychodermatology of girls and women. In: Women's dermatology. Parish CP, Brenner S, Ramos-e-Silva M, eds. Parthenon Publishing Group; 2001: 1027. 12. Roosta N, Black DS, Peng D, Riley LW. Skin disease and stigma in emerging adulthood: impact on healthy development. J Cutan Med Surg 2010; 14: 285-290. 13. Halvorsen JA, Stern RS, Delgard F, Thoresen M, Bjertness E, Lien L. Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: A population-based study. J Invest Dermatol 2011; 131: 363-370. 14. Dalgard F, Gieler U, Holm JO, Bjertness E, Hauser S. Self-esteem and body satisfaction among late adolescents with acne: results from a population survey. J Am Acad Dermatol 2008; 59: 746-751. 15. Urpe M, Pallanti S, Lotti T. Psychosomatic factors in dermatology. Dermatol Clin 2005; 23: 601-608.
ACCEPTED MANUSCRIPT 16. Misery L. Consequences of psychological distress in adolescents with acne. J Invest Dermatol 2011; 131: 290-292.
T
17. Magin P, Adams J, Heading G, Pond D, Smith W. Psychological sequelae of acne vulgaris. Can Fam Physician. 2006; 52: 978-979.
RI P
18. Kellett SC, Gawkrodger DJ. The psychological and emotional impact of acne and the effect of treatment with isotretinoin. Br J Dermatol. 1999; 140: 273-282.
SC
19. Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol. 1998; 139(5):846-50.
MA NU
20. Purvis D, Robinson E, Merry S, Watson P. Acne, anxiety, depression and suicide in teenagers: a cross-sectional survey of New Zealand secondary school students. J Paediatr Child Health 2006; 42: 793-796. 21. Shuster S, Fisher GH, Harris E, Binnel D. The effects of skin disease on self- image. Br J Dermatol 1978; 99 (suppl. 16): 18-19.
ED
22. Van Der Meeren HL, Van Der Schaar WW, Van Der Hub CM. The psychological impact of severe acne. Cutis 1985; 36: 84-86.
PT
23. Kokandi A. Evaluation of acne quality of life and clinical severity in acne female adults. Dermatol Res Pract. 2010; Article ID 410809, 3 pages.
CE
24. Patten SB, Barbui C. Drug-induced depression: a systematic review to inform clinical practice. Psychother Psychosom. 2004; 73: 207-215. 25. Hull PR, D'Arcy C. Acne, depression, and suicide. Dermatol Clin. 2005; 23: 665-674.
AC
26. Jick SS, Kremers HM, Vasilakis-Scaramozza C. Isotretinoin use and risk of depression, psychotic symptoms, suicide, and attempted suicide. Arch D ermatol. 2000; 136: 1231-1236. 27. Sundstrom A, Alfredsson L, Sjolin-Forsberg G, Gerden B, Bergman U, Jokinen J. Association of suicide attempts with acne and treatment with isotretinoin: retrospective Swedish cohort study. Br Med J. 2010 Nov 11;341:c5812. doi: 10.1136/bmj.c5812. 28. Wayne Blount B, Pelletier AL. Rosacea: a common, yet commonly overlooked condition. Am Fam Physician 2002; 66: 435-440. 29. Rosen T, Stone MS. Acne rosacea in blacks. J Am Acad Dermatol 1987; 17: 70-73. 30. Berg M, Liden S. An epidemiological study of Rosacea. Acta Dermatol Venereol 1989; 69: 419-423. 31. Wilkin JK. Rosacea. Int J Dermatol 1983; 22: 393-400.
ACCEPTED MANUSCRIPT 32. Su D, Drummond PD. Blushing propensity and psychological distress in people with rosacea. Clin Psychol Psychother 2011; 23. Doi:10.1002/cpp.763 [epub ahead of print]. 33. Koblenzer CS. Flushing reactions and rosacea. In: Psychocutaneous Disease. Grune &
T
Stratton, Inc. 1987; 230-237.
RI P
34. Multifactorial cutaneous diseases. In: Clinical management in psychodermatology. Harth W, Gieler U, Kusnir D, Tausk FA, eds. Springer-Verlag. 2009; 79-121.
MA NU
SC
35. Gupta MA, Gupta AK, Chen SJ, Johnson AM. Comorbidities of rosacea and depression: an analysis of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey- Outpatient Department data collected by the U.S. National Center for Health Statistics from 1995 to 2002. Br J Dermatol 2005; 153: 1176-1181. 36. Marks R. Concepts in the pathogenesis of rosacea. Br J Dermatol 1968; 80: 170-177.
ED
37. Boehncke WH, Ochsendorf F, Paeslack I, Kaufmann R, Zollner TM. Decorative cosmetics improve the quality of life in patients with disfiguring skin disease. Eur J Dermatol 2002; 12: 577-580. 38. Nicholson K, Abramova L, Chren MM, Yeung J, Chon SY, Chen SC. A pilot quality-oflife instrument for acne rosacea. J Am Acad Dermatol 2007; 57: 213-221.
PT
39. Schwartz RA, Janusz CA, Janniger CK. Seborrheic dermatitis: an overview. Am Fam Physician. 2006; 74: 125-130.
AC
CE
40. Maietta G, Fornaro P, Rongioletti F, Rebora A. Patients with mood depression have a high prevalence of seborrheic dermatitis. Acta Dermatol Venereol. 1990; 70: 432434. 41. Oztas P, Calikoglu E, Cetin I. Psychiatric tests in seborrheic dermatitis. Acta Dermatol Venereol. 2005; 85: 68-69. 42. Peyri J, Lleonart M. Clinical and therapeutic profile and quality of life of patients with seborrheic dermatitis. Actas Dermosifiliogr. 2007; 98: 476-482. 43. Cate Miller A, Pit-ten Cate IM, Watson HS, Geronemus RG. Stress and family satisfaction in parents of children with facial port-wine stains. Pediatric Dermatology. 1999; 16: 190-197. 44. Powell J. Update on hemangiomas and vascular malformations. Curr Opin Pediatr. 1999; 11: 457-463. 45. Lanigan SW, Cotterill JA. Psychological disabilities amongst patients with port wine stains. Br J Dermatol. 1989; 121: 209-215. 46. Kalick SM, Goldwyn RM, Noe JM. Social issues and body concerns of port wine stains patients undergoing laser therapy. Lasers Surg Med 1981; 1: 205-313.
ACCEPTED MANUSCRIPT 47. Kalick SM. Laser treatment of port wine stains; observations concerning psychological outcome. In: Cutaneous laser therapy: Principles and methods. Arndt KA, Noe JM, Rosen S, eds. John Weily & Sons LTD, 1983; 215-229.
RI P
T
48. Dixon JA, Rotering RH, Huether SE. Patients' evaluation of argon laser therapy of port wine stains, decorative tattoos and essential telangiectasia. Lasers Surg Med 1984; 4: 181-190.
AC
CE
PT
ED
MA NU
SC
49. Troilius A, Wrangsjo B, Ljunggren B. Potential psychological benefits from early treatment of port wine stains in children. Br J Dermatol. 1998; 139: 59-65.
S0738-081X(14)00050-9 doi: 10.1016/j.clindermatol.2014.02.016 CID 6833
To appear in:
Clinics in Dermatology
Please cite this article as: Orion Edith, Wolf Ronni, Psychologic consequences of facial dermatoses, Clinics in Dermatology (2014), doi: 10.1016/j.clindermatol.2014.02.016
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
SC
RI P
T
Psychologic consequences of facial dermatoses
Edith Orion, MD¹ ²
MA NU
Ronni Wolf, MD³
ED
From:
1. The Dermatology Department, Sourasky Medical
PT
Center, Tel Aviv, Israel.
CE
2. The psychodermatology clinic, Sourasky Medical Center,
AC
Tel Aviv, Israel
3. The Dermatology Unit, Kaplan Medical Center, Rehovot,
Israel
Address for correspondence: Edith Orion, MD, Dermatology Department, Sourasky Medical Center, Tel Aviv, Israel. Fax 972-3-6436086, E-mail:[email protected]
ACCEPTED MANUSCRIPT Abstract
AC
CE
PT
ED
MA NU
SC
RI P
T
The attractiveness of the human body has always been an important issue in the fields of sociology, psychology, psychiatry, and also in the field of dermatology. In psychodermatology, one often finds how all the above mentioned fields intermingle with each other to produce elaborate situations and extreme human difficulties. Perfect skin is widely adored in literature, poetry and biblical texts as well as in advertisements, movies and television. Because in most societies the face is usually a body part that is visible, imperfections of its skin is also visible, therefore its flawed appearance bears the potential to become a source of misery to some.
ACCEPTED MANUSCRIPT Introduction
T
A healthy, normal looking skin is essential for an individual's physical and mental well-being. Facial skin diseases can create an impact on the patient's life in various aspects; it can have an impact on his/hers social status, romantic relationships, as well as on his/hers emotional health and self-esteem. It is the patient's "visible self". Facial skin diseases have the potential to affect an individual's quality of life to a great extent.
SC
RI P
Psychodermatology is concerned with skin conditions that are influenced by psychologic difficulties as well as with psychologic difficulties arising due to skin conditions. In this article we will discuss the effects of the soma on the psych – the somatopsychic aspect of facial skin diseases.
MA NU
We will focus on the psychologic impact of skin conditions that are typically facial (not dermatoses that affect other body areas but can appear also on the face). Although we will discuss those facial dermatoses that their psychologic impact is the most investigated, there are reasons to assume that the emotional burden exists in most facial dermatoses.
The emotional impact of facial dermatoses - Stigmatization
PT
ED
In ancient times, skin diseases were often seen as an expression of the wrath of a god, who visited on those who had sinned. Skin disease sufferers were sometimes even condemned to live separately, and their approach announced by a bell or a horn due to the belief that their disease was contagious (1). Although occasional patients are able to take in stride disease that is disfiguring and visible, for many of them, the experience of being "different" is frightening, leading to feelings of embarrassment and shame (1).
AC
CE
The attractiveness of the human body has always been an important issue in the fields of sociology, psychology, psychiatry, and also in the field of dermatology. In psychodermatology, one often finds how all the above mentioned fields intermingle with each other to produce elaborate situations and human difficulties. One important problem deals with the feeling of stigmatization resulting from a visible skin condition. Stigma was defined by the sociologist Ervin Goffman as a process by which the reaction of others spoils normal identity. It is thus easily understood why many skin patients feel stigmatized (2-3). In this context, skin conditions that alter skin color, complexion, texture or appearance can provoke negative reactions and emotions in others. This can lead to disapproval, rejection, exclusion and discrimination (4). Most information we have about the nature and extent of the situation concerns perceived stigmatization among psoriasis or vitiligo patients (2-3,5), less focused information exists about stigmatization among patients with facial dermatoses (6). The reason is probably less research rather than lesser degree of perceived stigmatization. It is expected that imperfections on the face would cause more psychologic problems than imperfections in other body areas since it is more exposed to others, and it is harder to hide or camouflage successfully. Acne
ACCEPTED MANUSCRIPT Acne, a common skin disease, is prevalent mainly during adolescence, but may be present also in adulthood. The disease's major complications include physical scarring and psychologic effects which may persist long after thedermatitis have disappeared (7-8).
T
Acne's impact on psychosocial and emotional problems is so significant that it is comparable to the effects of those imposed by arthritis, back pain, diabetes, epilepsy and asthma (9).
SC
RI P
Panconesi finds acne a facial dermatosis with a high incidence of psychoemotional factors (10). He also makes an important distinction between adolescent acne, which causes psychologic problems secondary to the skin disease (somato-psychic), and adult acne which can mainly be evoked or exacerbated by psychologic problems or even by a psychiatric disease (psycho-somatic) (10).
ED
MA NU
From a psychoanalytical point of view, not able to compete with the perfection of the idealized personalities or peers, even minimal acne lesions may serve to confirm for adolescents their worst fears of being ugly, dirty and flawed (1). The negative feelings lead to low self-esteem, and self-conscious feelings that everyone is staring with criticism (11). Because of the age-appropriate adolescent physical changes and the early arousal of sexual feelings, guilt about sexuality is often relevant and present, and the outbreak of acne dermatitis may be experienced as a loss of control and as a punishment. The stress of integrating into the body image age-appropriate physical changes as well as acne may lead to the fragility of that image, with the possible development of body dysmorphic disorder (1).
CE
PT
Data shows that late adolescents feel stigmatized by their visible facial skin condition (12). In adolescence, the individual usually becomes more autonomous, relationships with family members change, and peer or romantic relationships become more important (13). The appearance of the skin is important for successful social interactions and for high self-image in this age group (14).
AC
It seems that adolescents are more influenced by the psychosocial effects of acne than older patients (15). Although acne can pose psychologic problems at any age, the condition itself is much more prevalent in adolescence (therefore the larger bulk of acne sufferers would come from this age group) and, more importantly, adolescents are psychologically vulnerable, and tend to be more sensitive to modifications in their appearance (16). Therefore, this volatile combination can have a long-lasting impact on their lives: It can affects self-esteem and assertiveness, factors that are crucial in forming relationships as well as to the development of personality traits (15). Interviews with patients revealed explicit links between appearance and subjects' self-image, self-concept and self-esteem, which gave rise to much of the psychologic morbidity in those patients (17). Embarrassment and self-consciousness were found to be directly linked to self-image and self-esteem. Important exacerbating factors in the relationship between acne, embarrassment and selfconsciousness were taunting or teasing and a perception of being judged by others (17). Anxiety and depression are the two most prevalent psychiatric morbidities linked to acne. In a small series of 34 patients with severe acne, significant levels of anxiety were found in 44% of patients, and depression in 18% (18).
ACCEPTED MANUSCRIPT In a study of 72 adolescents and young adults with mild to moderate noncystic acne, active suicidal ideation was elicited in 5.6% (19).
RI P
T
In a cross-sectional survey among 9567 teenagers aged 12-18 years, "problem acne" was associated with increased probability of depressive symptoms (24%), anxiety (9%), suicide thoughts (34%), and suicide attempts (13%) (20).The association of "problem acne" with suicide attempts was found to be independent of anxiety and depressive symptoms.
ED
MA NU
SC
In a recent large population-based study of 3775 adolescents aged 18-19, the relationship of acne severity to suicidal ideation, mental health problems and social functioning was explored. Among those with severe acne, suicidal ideation was twice as frequently reported among girls and three times more frequently reported among boys in comparison to the mild/no acne patients (13). Suicidal ideation remained significantly associated with substantial acne even after adjustments of symptoms of depression, ethnicity and family income were done. The study also demonstrated a significant association of substantial acne and mental health problems, low attachment to friends, lack of thriving at school, lack of romantic relationships and sexual intercourse (13). These results are in accordance to previous works showing impaired self- image and self- esteem (21), impaired psychologic well-being (12), and inhibition of social interactions (22). So the immediate impact of acne on multiple aspects of patients' lives is immense, moreover, it may have a huge influence on their well-being in later life.
AC
CE
PT
Regardless of the degree of severity, patients with acne are at increased risk to develop anxiety and depression and even suicidal ideation in comparison with acne-free population. Acne negatively affects quality of life, and the greater the impairment secondary to the disease, the greater the level of anxiety and depression (15). Unlike this correlation, other studies show that in adult females, acne can cause impairment in quality of life regardless of its severity. Also, age and disease duration do not necessarily correlate with quality of life as well (23). The link between depression, suicide ideation, and the use of isotretinoin is controversial. In a critical review of the literature, it was concluded that although some drugs could induce depressive symptoms, drug-induced depression seems to differ symptomatically from classical major depression. Interestingly, evidence was not presented linking isotretinoin to depression (24). There have been several reviews examining possible linkage between isotretinoin, depression and suicide. Most reviews conclude that at present there is no conclusive evidence that either support such an association or rejects it (25). In epidemiological studies, the results have been conflicting. No association was found between isotretinoin treatment and depression, psychotic symptoms, suicide or suicide attempts in a cohort of more than 7000 isotretinoin users (26). However, in a recent retrospective cohort study of 5756 patients aged 15 to 49 years prescribed with isotretinoin for severe acne, observed before, during and after treatment found an increased risk of attempted suicide up to six months after the end of treatment. In this study, however, the risk of attempted suicide was already rising before treatment, so an additional risk due to isotretinoin treatment cannot be established (27). Also, many case reports and case series have reported serious adverse psychiatric events associated with isotretinoin (27). To make
ACCEPTED MANUSCRIPT matters more confusing, depression, anxiety, and overall psychiatric morbidity have been found to improve when acne is treated, especially with isotretinoine (17). Rosacea
SC
RI P
T
Rosacea is a common chronic inflammatory facial dermatosis that is characterized by facial blushing, erythema, telangiectasiae, burning sensation and a papulopustular acneiform eruption. It occurs most often in middle-aged people, 30-50 years old, with fair skin (28). Rosacea may be overlooked in non-whites because of low index of suspicion or because skin pigmentation results in an atypical presentation (29). Women are affected 2-3 times more frequently than men (30); nevertheless, the most obvious stigma of rosacea, rhinophyma, occurs more often in men (31).
MA NU
Patients with rosacea suffer from a variety of emotional and social stigmas. They may inaccurately be stigmatized as alcohol abusers due to their red face, or phymatous nose (28). Patients often have feelings of low self-esteem when facial dermatitis progresses (28). They may report feelings of embarrassment, frustration, shame or anxiety about their facial flushing and erythema in social situations. This anxiety may resemble panic disorder or may even worsen, causing some patients to become reclusive due to social phobia (32). Impaired contacts are a frequent finding (33).
PT
ED
Psychologic studies among rosacea patients have revealed a weak ego, autoaggression, tendency to self-accusation, excessive feelings of responsibility for oneself and others, low tolerance for frustration, and discrepancy between what the person is and what he or she wishes to be. The measured forms of anxiety- both situational fear and anxiety as a personal trait – had the highest values in rosacea patients (34).
AC
CE
Patients with rosacea are also prone to develop depression, as was proven in a large survey of 608 million dermatology visits (35). In this study, 1.04% of patients had a comorbid psychiatric diagnosis, about 70% of them were depressive disease. Depression was attributed to the cosmetic impact of the disease (36). Of importance is the observation that use of cosmetic products to conceal skin lesions can help improve self-image and quality of life (37). A rosacea-specific quality of life index demonstrated that flushing and skin appearances are some of the most critical factors for patients (38). Both physicians and relatives of patients with rosacea tend to underestimate the effect of the disease on patient' quality of life. Apparently, it should be recognized and addressed also in the dermatologist office. Seborrheic Dermatitis Seborrheic dermatitis affects mainly the central face, but can also involve the scalp and anterior chest. It can affect patients from infancy to old age, but is most frequent in infants within the first three months of life, and in adults at 30-60 years of age (39). In adolescents and adults it manifests as dandruff, and as erythema and greasy scaling of the nasolabial folds. It can also affect the postauricular skin and central face (auricles, bearded area, eyebrows, and eyes) as well as other body areas (39).
ACCEPTED MANUSCRIPT
T
There are only limited data concerning the psychologic consequences of seborrheic dermatitis. It is surprising, considering the high prevalence of this condition, its visibility and potential disfiguring properties. Obviously, the disfiguration problems must be emphasized because of sociophobic tendencies, communication impairments, and avoidance and social withdrawal may result (34).
MA NU
SC
RI P
Patients with mood depression have a high prevalence of seborrheic dermatitis (40) as was shown in a group of patients with psychiatric disorders. The other way round - an increased predisposition to depression in seborrheic dermatitis patients was also found (41). These investigators also demonstrated a decrease in DLQI among seborrheic dermatitis patients, as well as an increased level of stress patients encounter in their lives, perhaps due to their disease-related stigmas. Another group of researchers demonstrated that the impact of seborrheic dermatitis on quality of life is significantly greater among female patients, and among the age groups 16-25 years and 41-60 years (42). Port-wine stains
PT
ED
Port-wine stain (PWS) is a benign, congenital disfiguring vascular malformation that persists throughout life. It is a common dermatosis, occurring in an estimated 3-5:1000 births and approximately 80% of stains are found on the face or neck (43-44). The lesions tend to darken with age and become thicker with possible nodule formation, causing substantial disfigurement and potential psychological problems (44). At mediaeval times, birthmarks such as PWS were taken as evidence of the bearer's service to the devil (45), while nowadays they may be just as well prejudiced against.
AC
CE
Some authors share their experience with PWS patients, mentioning that unexpectedly, most of their patients seem well adjusted and psychologically normal people (45). Several investigations concerning psychologic effects of laser therapy in patients with PWS have revealed that these patients were no different than normal controls, although they were found to be perfectionistic and had unrealistic expectations of the outcome of therapy. These patients felt they were at considerable personal, professional and social disadvantage due to their nevus (46-48). Nevertheless, later investigations, using different research questionnaires, indicate that PWS patients suffer a significant degree of psychologic morbidity (45). Over 50% of patients felt embarrassed and depressed because of their birthmark. Forty one percent felt that people avoided looking at them. The authors suggest that PWS patients suffer psychologic distress which is not apparent in their social interactions or when applying indirect psychologic testing. They found that these difficulties do not improve with advancing age and thus may cause further problems for patients adapting to their social environment (45). In another study, 47% of PWS patients rated their self-esteem as lower compared with other people of the same age group. After treatment, only 8% had this thought (49). An interesting and unexpected observation in this study was that non-facial PWS disturbed the patients as much as facial ones, but in other ways. Conclusions Body image of oneself is of fundamental importance in the development of personality and interpersonal relationships. The above information highlights the need to screen for
ACCEPTED MANUSCRIPT depression, anxiety and suicidal ideation among patients (especially teenagers) who come to be treated for acne. Dermatologists who see young people with moderate to severe acne have an important role since a significantly large portion of them may have psychiatric difficulties and even a record of a suicide attempt related to their skin disease.
RI P
T
Other facial dermatoses may be related to psychologic difficulties as well. Although there is less research among those patients, one would conclude that stigmatization and flawed appearance may result in lower quality of life and the consequent development of depression, anxiety, social phobia, shame and embarrassment, among other difficulties.
AC
CE
PT
ED
MA NU
SC
It is of outmost importance for the dermatologist to acknowledge those psychologic "side effects" of facial dermatoses, which patients rarely report, for the sake of prescribing the right treatment (e.g. isotretinoin), but also for offering appropriate psychological/psychiatric support.
ACCEPTED MANUSCRIPT References 1. Koblenzer CS. The emotional impact of chronic and disabling skin disease: A psychoanalytic perspective. Dermatol Clin 2005; 23 : 619-627.
T
2. Gupta M, Gupta A, Watteel G. Perceived deprivation of social touch in psoriasis is associated with morbidity: an index of the stigma experience in dermatologic disorders. Cutis 1998; 61: 339-342.
RI P
3. Ginsburg I, Link B. Feeling of stigmatization in patients with psoriasis. J Am Acad Dermatol 1989; 20: 53-63.
SC
4. Chaturvedi S, Singh G, Gupta N. Stigma experience in skin disorders: An Indian perspective. Dermatol Clin 2005; 23: 635-642.
MA NU
5. Kent G, Al'Abadie M. Psychologic effects of vitiligo: a critical incident analysis. J Am Acad Dermatol. 1996; 35:895-8. 6. Lowe JG. The stigma of acne. Br J Hosp Med 1993; 49(11): 809-812. 7. Niemeier V, Kupfer J, Demmelbauer-Ebner M, Stangier U, Effendi I, Gieler U. Coping with acne vulgaris: evaluation of the chronic skin disorder questionnaire in patients with acne. Dermatology 1998; 196: 108-115.
ED
8. Koo JY, Smith LL. Psychologic aspects of acne. Pediatr Dermatol 1991; 8: 185-188.
PT
9. Mallon E, Newton JK, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY. The quality of life in acne: A comparison with general medical conditions using generic questionnaires. Br J Dermatol 1999; 140: 672-676.
CE
10. Panconesi E. Psychosomatic factors in dermatology: Special perspectives for application in clinical practice. Dermatol Clin 2003; 23: 629-233.
AC
11. Koblenzer CS. Psychodermatology of girls and women. In: Women's dermatology. Parish CP, Brenner S, Ramos-e-Silva M, eds. Parthenon Publishing Group; 2001: 1027. 12. Roosta N, Black DS, Peng D, Riley LW. Skin disease and stigma in emerging adulthood: impact on healthy development. J Cutan Med Surg 2010; 14: 285-290. 13. Halvorsen JA, Stern RS, Delgard F, Thoresen M, Bjertness E, Lien L. Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: A population-based study. J Invest Dermatol 2011; 131: 363-370. 14. Dalgard F, Gieler U, Holm JO, Bjertness E, Hauser S. Self-esteem and body satisfaction among late adolescents with acne: results from a population survey. J Am Acad Dermatol 2008; 59: 746-751. 15. Urpe M, Pallanti S, Lotti T. Psychosomatic factors in dermatology. Dermatol Clin 2005; 23: 601-608.
ACCEPTED MANUSCRIPT 16. Misery L. Consequences of psychological distress in adolescents with acne. J Invest Dermatol 2011; 131: 290-292.
T
17. Magin P, Adams J, Heading G, Pond D, Smith W. Psychological sequelae of acne vulgaris. Can Fam Physician. 2006; 52: 978-979.
RI P
18. Kellett SC, Gawkrodger DJ. The psychological and emotional impact of acne and the effect of treatment with isotretinoin. Br J Dermatol. 1999; 140: 273-282.
SC
19. Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol. 1998; 139(5):846-50.
MA NU
20. Purvis D, Robinson E, Merry S, Watson P. Acne, anxiety, depression and suicide in teenagers: a cross-sectional survey of New Zealand secondary school students. J Paediatr Child Health 2006; 42: 793-796. 21. Shuster S, Fisher GH, Harris E, Binnel D. The effects of skin disease on self- image. Br J Dermatol 1978; 99 (suppl. 16): 18-19.
ED
22. Van Der Meeren HL, Van Der Schaar WW, Van Der Hub CM. The psychological impact of severe acne. Cutis 1985; 36: 84-86.
PT
23. Kokandi A. Evaluation of acne quality of life and clinical severity in acne female adults. Dermatol Res Pract. 2010; Article ID 410809, 3 pages.
CE
24. Patten SB, Barbui C. Drug-induced depression: a systematic review to inform clinical practice. Psychother Psychosom. 2004; 73: 207-215. 25. Hull PR, D'Arcy C. Acne, depression, and suicide. Dermatol Clin. 2005; 23: 665-674.
AC
26. Jick SS, Kremers HM, Vasilakis-Scaramozza C. Isotretinoin use and risk of depression, psychotic symptoms, suicide, and attempted suicide. Arch D ermatol. 2000; 136: 1231-1236. 27. Sundstrom A, Alfredsson L, Sjolin-Forsberg G, Gerden B, Bergman U, Jokinen J. Association of suicide attempts with acne and treatment with isotretinoin: retrospective Swedish cohort study. Br Med J. 2010 Nov 11;341:c5812. doi: 10.1136/bmj.c5812. 28. Wayne Blount B, Pelletier AL. Rosacea: a common, yet commonly overlooked condition. Am Fam Physician 2002; 66: 435-440. 29. Rosen T, Stone MS. Acne rosacea in blacks. J Am Acad Dermatol 1987; 17: 70-73. 30. Berg M, Liden S. An epidemiological study of Rosacea. Acta Dermatol Venereol 1989; 69: 419-423. 31. Wilkin JK. Rosacea. Int J Dermatol 1983; 22: 393-400.
ACCEPTED MANUSCRIPT 32. Su D, Drummond PD. Blushing propensity and psychological distress in people with rosacea. Clin Psychol Psychother 2011; 23. Doi:10.1002/cpp.763 [epub ahead of print]. 33. Koblenzer CS. Flushing reactions and rosacea. In: Psychocutaneous Disease. Grune &
T
Stratton, Inc. 1987; 230-237.
RI P
34. Multifactorial cutaneous diseases. In: Clinical management in psychodermatology. Harth W, Gieler U, Kusnir D, Tausk FA, eds. Springer-Verlag. 2009; 79-121.
MA NU
SC
35. Gupta MA, Gupta AK, Chen SJ, Johnson AM. Comorbidities of rosacea and depression: an analysis of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey- Outpatient Department data collected by the U.S. National Center for Health Statistics from 1995 to 2002. Br J Dermatol 2005; 153: 1176-1181. 36. Marks R. Concepts in the pathogenesis of rosacea. Br J Dermatol 1968; 80: 170-177.
ED
37. Boehncke WH, Ochsendorf F, Paeslack I, Kaufmann R, Zollner TM. Decorative cosmetics improve the quality of life in patients with disfiguring skin disease. Eur J Dermatol 2002; 12: 577-580. 38. Nicholson K, Abramova L, Chren MM, Yeung J, Chon SY, Chen SC. A pilot quality-oflife instrument for acne rosacea. J Am Acad Dermatol 2007; 57: 213-221.
PT
39. Schwartz RA, Janusz CA, Janniger CK. Seborrheic dermatitis: an overview. Am Fam Physician. 2006; 74: 125-130.
AC
CE
40. Maietta G, Fornaro P, Rongioletti F, Rebora A. Patients with mood depression have a high prevalence of seborrheic dermatitis. Acta Dermatol Venereol. 1990; 70: 432434. 41. Oztas P, Calikoglu E, Cetin I. Psychiatric tests in seborrheic dermatitis. Acta Dermatol Venereol. 2005; 85: 68-69. 42. Peyri J, Lleonart M. Clinical and therapeutic profile and quality of life of patients with seborrheic dermatitis. Actas Dermosifiliogr. 2007; 98: 476-482. 43. Cate Miller A, Pit-ten Cate IM, Watson HS, Geronemus RG. Stress and family satisfaction in parents of children with facial port-wine stains. Pediatric Dermatology. 1999; 16: 190-197. 44. Powell J. Update on hemangiomas and vascular malformations. Curr Opin Pediatr. 1999; 11: 457-463. 45. Lanigan SW, Cotterill JA. Psychological disabilities amongst patients with port wine stains. Br J Dermatol. 1989; 121: 209-215. 46. Kalick SM, Goldwyn RM, Noe JM. Social issues and body concerns of port wine stains patients undergoing laser therapy. Lasers Surg Med 1981; 1: 205-313.
ACCEPTED MANUSCRIPT 47. Kalick SM. Laser treatment of port wine stains; observations concerning psychological outcome. In: Cutaneous laser therapy: Principles and methods. Arndt KA, Noe JM, Rosen S, eds. John Weily & Sons LTD, 1983; 215-229.
RI P
T
48. Dixon JA, Rotering RH, Huether SE. Patients' evaluation of argon laser therapy of port wine stains, decorative tattoos and essential telangiectasia. Lasers Surg Med 1984; 4: 181-190.
AC
CE
PT
ED
MA NU
SC
49. Troilius A, Wrangsjo B, Ljunggren B. Potential psychological benefits from early treatment of port wine stains in children. Br J Dermatol. 1998; 139: 59-65.
