Body image, the psyche and the skin

The stress of having skin disease

The potentially harsh psychological effects of chronic skin disease tend to be underestimated. Up to 30% of skin outpatients suffer ‘psychological distress’ from their condition. This is understandable in the teenager with acne, or in someone who has extensive psoriasis or eczema. In both, the individual’s devalued body image may be out of proportion to the objective severity of his or her skin problem. Skin diseases can make patients into ‘social lepers’ who feel that their social lives are restricted because other people do not want to mix with them. The effects on ‘quality of life’ can be assessed by specific questionnaires, e.g. the Dermatology Life Quality Index (DLQI).

Patients sometimes feel that their disorder is either caused directly by or exacerbated by ‘stress’. This is difficult to prove, as it is often impossible to differentiate reactive from aetiological states. Many dermatologists believe that psychological factors can, e.g. make eczema and psoriasis worse, but most would also agree that these are stressful conditions in their own right. However, it is accepted that there are a small number of conditions that are of psychogenic origin. Management with a liaison psychiatrist can be helpful.

Anxiety and depression, not surprisingly, may be precipitated by skin diseases of any type, and dermatologists need to be continually aware of this in the management of their patients. Vitiligo, affecting skin pigmentation (often on the face and hands), and alopecia areata, causing hair loss on the scalp, especially affect the way an individual appears to the outside world. Both can cause considerable social embarrassment and may result in discrimination. It is not surprising that anxiety, depression and adjustment disorder are found in a third or more of patients affected by these conditions.

The connection between an individual having a skin disease and their psychological and social functioning is a good illustration of the so called ‘biopsychosocial’ approach of looking at someone’s health through more than just the medical aspects. Most medical graduates are now trained in this anyway. Psychocutaneous medicine is a specific element in the UK training curriculum for dermatology.

Skin disorders of psychogenic origin

‘ Psychodermatology ’ is a relatively recent subspecialty that deals with the management of patients in whom there are manifestations from the interaction of the psyche and the skin ( Box 15.1 ). Special psychodermatology clinics adopt a multidisciplinary approach twinning dermatologists with liaison psychiatrists.