Clinical psychologist and psychodermatology specialist Dr Reena Shah explains the powerful link between skin disorders and the mind
Having unblemished skin is perceived as a sign of beauty, an idea that is arguably perpetuated in the media.
According to recent research, the first thing teenagers and adults notice about a person with acne is their skin, seeing them as shy, less socially active, more likely to be bullied and less successful in terms of finding a job.
Some people with skin conditions report becoming preoccupied with covering their skin and often avoid activities where it might be on display.
Living this way, day in and day out, can sometimes lead to the development or exacerbation of mental health problems. But, interestingly, the severity of a skin condition does not always correlate with the amount of psychological distress and dysfunction experienced.
For example, someone with a small patch of vitiligo could feel the same way as someone who has eczema all over their body, showing that other factors, such as past experiences, relationships, personal beliefs and upbringing, can play a part.
Anything from a small blemish on the face to having a widespread skin disorder can lead to embarrassment, humiliation and other negative body-image experiences
Consultant dermatologist and head of the London psychodermatology service Anthony Bewley comments: “It is increasingly recognised that the physical and psychological aspects of a disease are very intimately linked. For example, in psoriasis, sufferers usually indicate that a stressful life event initiated the psoriasis and that living with psoriasis is at least as bad as living with cancer or diabetes.”
It is acknowledged that having a skin disorder may have numerous physical and psychological consequences for people of all ages. The level of psychological morbidity found in research has been supported within clinical practice.
A survey I conducted earlier this year, within an NHS general dermatology clinic, indicated that 29 per cent of females and 24 per cent of males scored within the clinical range for anxiety, with 47 per cent of females and 36 per cent of males reaching the borderline range for anxiety. Some 89 per cent of females and 97 per cent of males had a high degree of appearance-related concerns.
Anything from a small blemish on the face to having a widespread skin disorder can lead to embarrassment, humiliation and other negative body-image experiences. These negative experiences, together with the influence of other considerations and society’s expectations, can diminish self-esteem and self-confidence, increase self-consciousness and create a loss of sense-of-self and isolation.
Conversely, research also shows a link between stress and the exacerbation of skin disorders. For example, people with eczema have reported having flare-ups when stressed and people with vitiligo have reported that, when they feel stressed, they have noticed new patches of the skin condition.
It is often difficult to ascertain which element comes first, the physical or the psychological. One theory is that a vicious circle occurs with the spread of the condition being an increasing cause of both worry and possibly rejection, consequently exacerbating a psychological problem such as anxiety or depression.
The most widely cited difficulties are those around social anxiety. People report difficulty with social interactions and can have relationship problems. Coping strategies may include trying to conceal the skin disorder by avoidance of social situations, such as swimming and other sporting activities. However, some who have learnt to cope very positively with their visible difference, may report few problems.
So what can be done to help? According to one patient, who has irregular scars as a result of acne: “When I was being treated, I was not given any support concerning how I felt about my appearance. My scars did affect my confidence and self-esteem, and I wished I was treated as a person rather than an NHS number.”
Optimising medical treatment via your GP and/or dermatologist is the first step. There are also charities, such as Changing Faces, that are at the forefront of promoting better healthcare and providing a supportive environment for people with skin disorders.
There are a number of talking therapies that could help people with skin conditions. However, there is a need for more quality research to guide best practice. Some intervention studies have reported the effectiveness of cognitive behavioural therapy (CBT) for conditions including psoriasis, acne, eczema and vitiligo.
For other conditions that lead to mainly scratching, such as urticaria, habit reversal therapy may help to reduce the desire to scratch. This has also been shown to be effective for people with eczema and skin picking.
“We are beginning to wake up in the UK to what our patients have been telling us for years… that the psychological effects of having a skin disease are a priority for our patients,” says Dr Bewley. “For this reason, the British Association of Dermatologists has just issued a report outlining the psychological support services which should be available for patients with skin disease.”
Due to the limited budget available in the NHS, provision of psychological healthcare for people with skin disorders is arguably inadequate. In some areas within the UK, psychological services are offered but, perhaps due to the stigma attached to being referred to mental health services, some clients have reported that they prefer to see someone within dermatology.
A 2012 UK survey, which I conducted with Dr Bewley, showed there are only four dermatology departments that have a dedicated psychologist; only one post, covering two hospitals, was full-time and within dermatology.
Given new national guidelines for the treatment of vitiligo and skin cancer, and increased media coverage of the importance of psychological interventions for people with skin conditions, it is hoped such research findings will create impetus for change and lead to development of services within the NHS.
Dr Reena Shah is a chartered clinical psychologist who has conducted recent research in psychodermatology.