Dr. Vincent Piguet and Dr. Aaron Drucker

More than Skin Deep

Investigating the mental health impacts in dermatology

For many chronic health conditions, the physical symptoms may be burdensome to patients but not visible to the public. However, you can clearly see when someone is suffering from severe eczema, rosacea or acne. Across a wide range of skin conditions, dermatologists see that their patients are embarrassed by the visibility of their skin condition.

“It’s important that we recognize the significance of these skin conditions and the burden that they have on patients’ lives,” says Dr. Aaron Drucker, scientist at Women’s College Research Institute (WCRI) and dermatologist at Women’s College Hospital (WCH). “We need to validate the patient’s experience and explain that we understand it’s ‘not just a skin condition’ and we see the impact it is having on their mental health.”

Not only are patients bothered by the appearance of their skin conditions, the physical symptoms of these conditions also impact their mental health. Dr. Drucker’s research focuses on atopic dermatitis, commonly known as eczema, which can cause extreme itch and prevent patients from sleeping at night.

“We all know that when we don’t get a good sleep and try to continue our day while exhausted, that we don’t feel well. For eczema patients, this adds to the mental health burden of these conditions,” adds Dr. Drucker.

In patients with persistent eczema, Dr. Drucker’s research found a 22 per cent increased risk of suicide. While this risk is not high enough to warrant widespread screening across this population, it does highlight how significant the impacts of the disease can be for some patients and how it affects their quality of life.

Dermatology was one of the first specialities to develop a quality of life scale – research that Dr. Vincent Piguet, scientist at WCRI and head of dermatology at WCH, was closely involved with when the scale was developed at Cardiff University. The Dermatology Quality of Life Index (DQLI) is a questionnaire used to determine how a skin condition has affected a patient’s quality of life, with questions like “how embarrassed or self-conscious have you been because of your skin?”, “how much has your skin influenced the clothes you wear?” and “has your skin prevented you from working or studying?”

“Around the time of the first World War, our criteria of success in healthcare was whether or not the patient lived,” notes Dr. Piguet. “We’ve come quite a long way since then and now our focus is more about the quality of our patients’ lives, not just prolonging them.”

The DQLI is used in clinical care to adjust treatments for patients. It is also used as a metric for research studies and has become a gold standard in most clinical trials. Mental health conditions such as depression can be difficult to diagnose with skin conditions, whereas DQLI scores can be used to measure the broader impacts on quality of life, including mental health.

“One of the hallmarks of dermatological conditions is that they not only affect the body, but also the mind,” adds Dr. Piguet. “For patients with hidradenitis suppurativa, a chronic, inflammatory skin disease, symptoms such as pain and discharge can cause damage to patients’ psycho-social well-being and their ability to perform daily activities.”

Recent research from Dr. Piguet and his colleagues found that patients with hidradenitis suppurativa (HS), which predominantly affects women, had a 16.9 per cent prevalence of depression and 4.9 per cent prevalence of anxiety. These findings indicate that depression and anxiety are common comorbidities in patients with HS and warrant the development of strategies to recognize and treat psychiatric comorbidities in patients with HS.

“There is still much more research needed to be done to explore the relationship between dermatology and mental health, as well as the prevalence of these psychiatric comorbidities,” emphasizes Dr. Piguet. “By properly understanding the magnitude of the burden of skin conditions on mental health, clinicians can develop and implement targeted interventions to improve overall health in vulnerable populations.”