The psychosocial impact of acne, vitiligo, and psoriasis: a review
Authors Nguyen CM, Beroukhim K, Danesh MJ, Babikian A, Koo J, Leon A
Received 29 July 2015
Accepted for publication 9 February 2016
Published 20 October 2016 Volume 2016:9 Pages 383—392
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 4
Editor who approved publication: Dr Jeffrey Weinberg
Catherine M Nguyen,1 Kourosh Beroukhim,2 Melissa J Danesh,3 Aline Babikian,4 John Koo,3 Argentina Leon3
1University of California, Irvine School of Medicine, Irvine, 2David Geffen School of Medicine at UCLA, Los Angeles, 3Department of Dermatology, University of California San Francisco School of Medicine, San Francisco, 4Touro University College of Osteopathic Medicine, Vallejo, CA, USA
Introduction: Chronic skin conditions have been well reported to affect a patient's quality of life on multiple dimensions, including the psychosocial domain. Psychosocial is defined as the interrelation of social factors with an individual's thoughts and behavior. The assessment of the psychosocial impact of skin disease on a patient can help direct the dermatologists' treatment goals. To evaluate the psychosocial impact of skin disease, we conducted a review of the literature on three skin conditions with onsets at various stages of life: acne, vitiligo, and psoriasis.
Methods: A PubMed search was conducted in March 2015 using the terms “psychosocial” AND “acne”, “psychosocial” AND “vitiligo”, and “psychosocial” AND “psoriasis”. The results were limited to articles published in English in the past 5 years studying patients of all ages. Results and their references were evaluated for relevance according to their discussion of psychosocial qualities in their patients and the validity of psychosocial assessments. The search for acne yielded 51 results, and eleven were found to be relevant; vitiligo yielded 30 results with ten found to be relevant; and psoriasis yielded 70 results with seven found to be relevant.
Results: According to the articles evaluated, 19.2% of adolescent patients with acne were affected in their personal and social lives. Social phobia was present in 45% of patients with acne compared to 18% of control subjects. Race and sex played a role in self-consciousness and social perceptions of the disease. Vitiligo negatively affected marriage potential and caused relationship problems in >50% of patients. Psoriasis negatively affected multiple domains of life, including work, relationships, and social activities. Anxiety and depression affected not only psoriasis patients but also their cohabitants; up to 88% of cohabitants had an impaired quality of life.
Conclusion: Though all three skin conditions resulted in an increase in anxiety and depression among their patient populations, the psychosocial focus varied slightly for each disease. Overall, acne, vitiligo, and psoriasis can have negative psychosocial impact in different stages of life development.
Keywords: psychosocial, acne, psoriasis, vitiligo
Chronic skin conditions have been well reported to affect a patient’s quality of life (QOL) on multiple dimensions, including the psychosocial domain. Psychosocial is defined as the interrelation of social factors with an individual’s thoughts and behavior.1 Because many skin conditions are commonly associated with social stigmatization, patients can suffer from lowered self-esteem, anxiety, or depression. The assessment of the psychosocial impact of skin disease on a patient can help direct the dermatologists’ treatment goals.
To evaluate the psychosocial impact of skin disease, we conducted a review of the literature on three skin conditions with onsets at various stages of life: acne, vitiligo, and psoriasis. Acne vulgaris is found in 85% of adolescents, and approximately two-thirds of adults 18 years and older2 with the most represented age group between 15 and 17 years.3–5 Vitiligo affects ~1% of the population, usually beginning either in the ages of 10–30 or later in life, with an average age of 56.5.6,7 Lastly, psoriasis has a bimodal age distribution of onset, which peaks in the 20s and 60s.8 Because each age group differs in terms of priorities and social activities, the psychosocial effects of these skin conditions can vary with age. By recognizing the psychosocial influence of these skin conditions, the dermatology provider can better understand the impact on the patient as a whole, including the physical, mental, and emotional domains, in order to guide treatment, and provide resources for group support and appropriate referrals.
A PubMed search was conducted in March 2015 using the terms “psychosocial” AND “acne”, “psychosocial” AND “vitiligo”, and “psychosocial” AND “psoriasis”. The results were limited to articles published in English in the past 5 years. The search was inclusive of papers addressing patient populations of all ages. Results and their references were evaluated for relevance according to their discussion of psychosocial qualities in their patients. Relevance was determined by reviewing the article in its entirety. Papers discussing the psychosocial impact of disease, including issues in relation to marriage, school, work, friendships, or team activities, were deemed to be relevant over paper discussing QOL issues that affected only the patient. Additionally, papers discussing anxiety and depression were deemed relevant due to the impact of these psychiatric conditions on the patient’s social activities. The search for acne yielded 51 results, and eleven were found to be relevant; vitiligo yielded 30 results with ten found to be relevant; and psoriasis yielded 70 results with seven found to be relevant.
Shahzad et al distributed the Cardiff Acne Disability Index to 950 college students and found that acne had a greater psychosocial impact on females when compared to males.9 Social phobia was diagnosed in 45.7% of high school patients with acne when compared to 18.4% of control subjects in a study by Bez et al.10 Thus, social phobia was concluded to be a common psychiatric comorbidity that greatly disabled the patients’ lives. Social bullying was perceived to be experienced by a significantly higher number of teenagers with acne when surveyed.11 Furthermore, using the Liebowitz Social Anxiety Scale, it was shown that patients with acne had higher avoidance scores than controls and were more negatively affected in their occupational, social, and familial lives. Intrapsychic consequences, such as self-consciousness, were found to be significantly increased in patients with acne after administration of the Acne Symptom and Impact Scale by Alexis et al.12 These patients also expressed annoyance, lowered confidence (in the majority of women, >75%), social withdrawal, and bothersomeness.13 Additionally, the likelihood of experiencing perceived stigma was three times higher for patients with acne.14 Racial differences in social perceptions and self-consciousness of female patients were studied by Callender et al.13 More White/Caucasian women felt self-conscious around other people (85%) when compared to non-White/Caucasian (68.3%, P<0.05). However, more non-White/Caucasian females felt that those without acne could not relate to experiencing adult acne (66.3% vs 57.9%, P<0.05).13 Indian women felt that physical attractiveness increased the ability to secure jobs and life partners but ultimately expressed that the true nature and qualities of a person were more important long term for these domains.15
General QOL also assessed in patients with acne, particularly pertaining to the social aspects. When the Dermatology Life Quality Index (DLQI) responses were analyzed individually by Tasoula et al, it was found that 21% of the adolescents were affected in their school work and personal activities due to acne.16 Approximately 19% were affected in their hobbies, and 19.2% were affected in their personal lives, particularly in relationship building. In terms of hobbies, 14% of patients avoided swimming and other sports due to embarrassments. In a study of 160 Saudi-Arabian patients, 13.3% stated that acne affected school performance, while 21.1% spousal relationship, 30% marriage willingness, and 17.2% friendship relations.17
Lastly, depression and anxiety were found to be increased in patients with acne. Marron et al also administered the Hospital Anxiety and Depression Scale to patients before and after isotretinoin treatment.18 The mean anxiety score was 8.9 out of 21 before treatment, which is higher than that of the general population denoting higher levels of anxiety. Approximately 26% of patients before treatment qualified as clinical cases (a high score >11). After treatment with isotretinoin, only 3.5% of patients met this criterion, supporting the role that acne plays in the development of anxiety. Depression was clinically significant in 12 of 346 patients (3.5%). Kubota et al distributed the Mental Health Inventory (MHI) or the Short Form-36 to Japanese adolescents.19 Students with acne were significantly more depressed than those without skin problems, and girls were more significantly affected than boys. The time span in which the patient was affected by acne also affected the MHI score, as patients with acne for >2 years had significantly lower MHI scores than those with acne for <6 months. Concerning adult females, it was found by Callender et al through administration of the Patient Health Questionnaire that 71%–73% of patients experienced some degree of anxiety or depression.13 There was no significant difference in the rate of depression or anxiety with regard to race (White/Caucasian vs non-White/Caucasian).13 Overall, anxiety and depression in patients with acne are multifactorial, with sex and duration, but not race, affecting severity.
Patients with vitiligo felt a perpetual burden due to the unpredictability of the disease and the measures needed to hide the disorder, either by makeup or clothing.20 The significant psychosocial impact is evident in the case of patients who reported that they thought about their condition all throughout the day, and were dissatisfied looking into a mirror, even with the lesions covered.21 This dissatisfaction with their appearance led to a weak self-perception, commonly resulting in worry, depression, and low self-esteem.21 While vitiligo does not pose a formidable challenge physically, it does have profound detrimental impact on a patient’s well-being and QOL unrelated to the extent of the disorder.22–24
In many patients, vitiligo has led to a sense of disfigurement and disempowerment. This negative mentality has behavioral consequences for patients with vitiligo in terms of social and physical involvement. According to a study by Talsania et al, >75% of patients experienced face and hand vitiligo, which are highly visible regions. A majority of patients believed this visible difference in color on their face and hands to be the most disfiguring and to have a profound effect on their self-esteem. Many patients avoided physical activities with significant sun exposure, such as swimming, in order to prevent sunburn to these areas.6 There are also cases of students with vitiligo who were compelled to withdraw from organized school events or from attending traditional schools, in exchange for correspondence courses, due to frequent doctor visits and the taunting they experienced at school.21
In many conservative male-dominated societies, vitiligo is a highly stigmatized disorder. For example, in Saudi Arabia, patients with vitiligo are often perceived as contagious (33.1%).25 In British South Asian societies, patients not only faced rejection from family and society but in many cases experienced detachment from their ethnicity as well. Many patients have developed a “spoiled identity”, or ruined and weakened sense of identity, to internalize the isolation and stigmatization they have endured.20
Vitiligo was also noted to be a barrier to marriage,20 which is a fundamental milestone of most traditional societies. Studies have shown that over half of those with vitiligo found it challenging to meet strangers or begin emotional or sexual relationships. Based on a questionnaire, over half (56.1%) of 898 male and female subjects residing in Saudi Arabia stated that they would not consider marrying an individual with vitiligo.20 Of those who did marry, the quality and stability of relationships were noted to be lower compared to those who did not have vitiligo.26 In a study of Indian patients with vitiligo, married females had a higher DLQI, and thus lower QOL, than married males, which was attributed to discrimination and relationships with the in-law relatives.27 There are cases of patients who did not disclose their disorder to their spouses before marriage for fear of rejection. Even after marriage, in-law conflicts were not uncommon, with one documented case of a patient who was encouraged to divorce if she was not cured.21
Depression is a serious repercussion of this disease. The degree of the relationship between vitiligo and depression may be culturally specific. In Singapore, depression was noted to be present in 16.2% of patients with vitiligo based on the Epidemiologic Studies Depression Scale, a 20-item test with scores ranging from 0 (none or rare) to 3 (most of the time) within 5–7 days, and a likely diagnosis of depression for total scores ≥16.22 Depression was also prevalent among patients with vitiligo in Italy, 31%, based on responses of “often” or “all the time” on the Skindex-29, which is a five-point dermatology-specific tool with answers that range from “never” to “all the time” to determine the impact of a disorder on QOL.24 The percentage of vitiligo associated with depression, as well as anxiety, was even higher (>50%) based on the illness perception questionnaire, in Arab society. Lastly, depression was found in 59% of Indian patients with vitiligo.27 This variance may be due to differences in base skin color or cultural ideations of vitiligo.25 In the Arabic and Italian studies, females were noted to be affected more frequently than males.24,25 Suicidal ideation is a documented consequence of the emotional burden inflicted upon patients, particularly among those who coped poorly with the disorder.21
Studies concerning the psychosocial aspects of psoriasis were focused on both the patient’s family and the public’s perception of psoriasis. Sampogna et al administered both the Skindex-29, which focuses on physical symptoms, and the Skindex-17, which focuses on the psychosocial aspects of disease, to patients with psoriasis.24 It was found that patients had both physical and psychosocial impairment. In terms of familial life, Martinez-Garcia et al found that 87.8% of cohabitants of patients with psoriasis also had impaired QOL.28 The DLQI for families was significantly associated with the psoriasis patient’s DLQI. In fact, anxiety and depression levels measured using the Hospital Anxiety and Depression Scale did not differ between patients and cohabitants but were higher than that of control groups. This suggests that the impact of psoriasis extends beyond the patients to include their cohabitants, impairing both the internal and external psychosocial dimensions.
In a web-based survey by Anstey et al, it was found that important social issues highlighted were a lack of understanding of psoriasis by the public, avoidance, or limitation of social activities.29 The abilities of patients to interact socially and make new friends were negatively affected, often leading them to cancel social engagements they previously agreed to attend. Bewley et al found that depressive symptoms in patients with psoriasis were associated with health-impairing behavior such as smoking, drinking, and decreased physical activity.30 Difficulties with work were particularly more prominent in patients with palmoplantar psoriasis.24 In fact, Armstrong et al noted that of 5,604 patients with psoriasis surveyed in the USA, 12% were unemployed, and 92% of those unemployed cited psoriasis as the sole cause.31 Of patients who continued to work, 49% missed days of work regularly due to their psoriasis. Patients with severe psoriasis had a 1.8 times greater chance of being unemployed.
Cather specifically studied women of childbearing age with psoriasis and found that there was a lower rate of pregnancy when compared to the control group.32 In women <35 years of age, the likelihood of pregnancy was 22% lower than the average, nondiseased population. Women with psoriasis also tended to have fewer children than controls. In a series of 60 interviews with women with psoriasis, all patients reported an adverse impact on their intimate relationships, with 91% related to sexual desire and 79% sexual ability.32 Thus, both psychological and clinical aspects may be contributing factors to the negative impact on work (Table 1).
Herein, we present a brief review of the psychosocial impact of three dermatological conditions with various ages of onset. The different ages of onset for acne, vitiligo, and psoriasis are reflected in the various psychosocial effects discussed for each disease. The psychosocial effects seem to correlate with the Erickson Stages of Development that address the psychosocial conflict and primary relationships formed in each age group (Table 2). For adolescents, the main internal conflict lies in identity vs confusion, with the development of peer relationships. For early adulthood of 20–25 years, intimacy is the core psychosocial issue with the development of friends and lovers. Lastly, for middle adulthood of 26–64 years, generativity vs stagnation is the conflict, with family and society as the dominant relationships formed. All three skin conditions were reported to result in similar intrapsychic effects among their patient population, such as increase in anxiety and depression. However, the literature revealed a specific psychosocial focus for each disease that varied from one another.
Table 2 Erickson stages of development outline the psychosocial conflict and primary relationships formed in each age group
Acne and social interactions
Acne has been shown to negatively impact self-esteem and identity formation in a majority of the adolescent population suffering from it. Of the literature reviewed, the psychosocial consequences were found to be focused on the patients’ social interaction, such as relationships with friends and hobbies. In contrast to vitiligo, long-term, serious relationships were not discussed, most likely due to the prevalence of the disease in a younger age group and the temporary nature of acne. Race and sex also played a role, with females suffering from a more negative psychosocial impact and White/Caucasians being more self-conscious around other people. Non-White/Caucasian females were more sensitive to how others without adult acne may relate to them.
Since the age of adolescence is often a time of identity formation and vulnerability to peer acceptance and opinions, patients’ social interactions are more impaired as symptom severity increases. Social phobia was found to be significantly higher in patients with acne, yet it was not mentioned in the literature for patients with vitiligo or psoriasis. Likewise, family and marriage were common themes in vitiligo and psoriasis, respectively, but they were not found to be relevant in studies on acne. This difference can be explained by a greater focus on oneself during adolescence. Social interaction during the years of adolescence can be said to be self-centered when compared to the priorities of a more mature age group, where family and marriage are of greater concern. The impact of acne on the self-centered psyche of adolescence can be demonstrated through severe cases of acne excoriée, in which patients are more likely to suffer from psychiatric conditions such as eating disorders. Furthermore, the severity of acne does not always correlate with the severity of emotional impact; even mild cases of acne have been reported to have significant emotional impact on the patients. This highlights the importance of the dermatologist to modify and adjust medical therapy to meet the patient’s individual needs on QOL. Psychotherapy may complement treatment for acne well.33 Thus, the recognition of the psychosocial impact of acne will create a platform for health care providers to guide treatment goals and connect to patients, especially those who are suffering in silence.
Vitiligo and marriage
The psychosocial effects of vitiligo were primarily discussed to affect marriage potential and encounters with a new partner. Because the disease often has an onset in late adulthood, there is less of a focus on social activities and more of an emphasis on long-term, serious relationships. This is especially important as the priorities of an older population shift toward stability and commitment. Unlike the often temporary and mild nature of most acne, vitiligo has more permanent effects and higher symptom visibility. Vitiligo is also more poorly understood by the general public than acne, with some cultures still considering vitiligo contagious or a sexually transmitted disease. Because of the severe social stigma associated with vitiligo, there may be a higher sense of concern for permanency of the disease. Due to the long-term nature of the disease, patients’ concerns focus on serious, lifelong potential relationships.
Psychosocial impact on vitiligo is also highly dependent on the individual’s culture. A majority of patients affected by vitiligo are considered minorities with darker skin tones. These can be seen in the patient population studied: Pahwa et al studied an Indian population, while Alghamdi et al studied an Arab patient population, Wang et al studied a Chinese population, and Chan et al studied a Singaporean population. Minorities often have different cultural values and traditions from the Western societies and many place high importance and special value in marriage. It has been reported that the USA and other Westernized countries with an individualistic mindset place an emphasis on love in marriage.34 However, eastern countries, such as India and Thailand, that have a collectivist economy view marriage as an opportunity to expand their collective workforce.34 In contrast, it has been suggested that in Westernized countries, the potential spouses are thought to be endowed only to each other and will not affect their extended families.34 This thought process is opposite to that of eastern countries, whose marital status affects their entire family.34 Thus, the prevalence of a visually prominent disease such as vitiligo can not only diminish the marriage potential of patients but also affect their families as a whole. Thus, one may also consider culture to play a strong role in the prevalence of discussion of marriage with patients with vitiligo.
Psoriasis and work, family, and social relationships
Lastly, psoriasis has a bimodal distribution of age of onset in early 20s or mid 50s, as well as high symptom visibility and impairment. This is reflected in the multidimensional impact of the disease encompassing work difficulties, social limitations, and family dysfunction. Psoriasis, unlike acne and vitiligo, can present on the palms and soles and interfere with their daily function. Patients suffer work impairment due to the pain from using their hands and feet. This functional debilitating effect of psoriasis is not seen in acne and vitiligo. Additionally, childbearing women are reportedly affected in reproductive capabilities, thus affecting their family lives.
Because psoriasis can interfere with work productivity, family life may suffer from an economic standpoint. Income serves as a foundation for a family to function. Thus, limitations on the inflow of income may cause stress and disruption among the family. Similarly, the high visibility of psoriasis as well as the pain experienced by the patients is a great discouragement to participation in social activities. With both work and social lives negatively affected, patients with psoriasis often suffer great intrapsychic distress, often developing anxiety and depression.
The psychosocial effects of skin disease vary from intrapsychic effects to marital and familial issues. One may also consider the prevalence of a disease in a particular ethnic group, as well as their cultural values, when evaluating the psychosocial effects as a whole. Overall, acne, vitiligo, and psoriasis have a strong impact on the patients’ psyche as well as their relationships with others, correlating with the Erickson Stages of Development. Multiple dimensions of patients’ life, such as work, relationships, social outings, and family, are affected by their skin. By recognizing these potential psychosocial impairments experienced by patients, dermatologists can guide their therapy to achieve positive physical, mental, and emotional health among their patients.
Dr John YM Koo is a speaker and/or consultant for Abbvie, Celgene, Jassen, Leo, Novartis and Promius Pharma. The authors report no other conflicts of interest in this work.
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