Psoriasis stigma can lead to depression, mental health problems

Psoriasis, like many other conditions of the skin, often has a degree of stigmatization, both internal and external, that leads to increased stress, depression, anxiety and an exacerbation of physical comorbidities.

“There is a strong interface between the mind and the body,” Richard G. Fried, MD, PhD, a board-certified dermatologist and clinical psychologist who often studies this connection, said.

Fried is an honorary life member of the Association for Psychoneurocutaneous Medicine of North America, a group dedicated to psychodermatology becoming a sub-specialty of dermatology.

“We are trying to understand why living with psoriasis, eczema, rosacea, hives or acne can be so depressing and conversely, trying to understand why stress and distress can make conditions like psoriasis so much worse,” Fried said.

External stigmatization

Stigma from external sources, be it in social, professional or intimate relationships, can be both implicit and explicit.

Many psoriasis patients have reported experiences in which they have been asked to leave a gym, a swimming pool or a hair salon due to the appearance of their skin lesions, according to Rebecca L. Pearl, PhD, assistant professor in the department of clinical and health psychology at the College of Public Health and Health Professions of the University of Florida.

A study conducted by Pearl and colleagues in 2019 evaluated stigma among laypersons and medical trainees toward those with psoriasis. The researchers used images of people with psoriatic lesions and found many desired to avoid individuals with visible psoriatic lesions in both social and work-related situations.

“People with psoriasis report having been denied work opportunities because of their skin, or in general receiving unwanted attention,” she said. “In addition, there’s research that documents the negative stereotypes or assumptions that are commonly made about people with psoriasis.”

These negative stereotypes include a belief that psoriasis lesions are contagious or from a contagious disease or that they are due to poor hygiene.

Direct or explicit stigmatization comes in the form of offensive language, demeaning statements and exclusion from groups or places, but implicit stigma can be just as hurtful and demeaning.

“People sometimes withdraw, pull away, refuse to touch, to shake hands — that kind of implicit stigma can take place,” Fried said. “If people are in fact terrified or repulsed by psoriasis or just don’t know how to deal with it, that little bit of recoil can be experienced by the psoriasis sufferers as them finding you hideous, not necessarily consciously.”

Internalized stigma

These actions from peers, family members or general society can then have an impact on a person’s feelings of self-worth and create an internalized stigma within themselves.

“There’s a lot of misinformation and a lot of ignorance when it comes to psoriasis,” Evan A. Rieder, MD, a board- certified dermatologist and psychiatrist and assistant professor of dermatology at New York University School of Medicine, said. “This can change how people interact with the world and it can have massive implications socially. Internally people respond to the perception of others and can develop a personality structure that is socially avoidant because of that.”

Individuals who are experiencing internalized stigma of psoriasis often retreat and slowly stop engaging in activities that they used to find enjoyable, added Fried.

“Living with chronic, distressing conditions like psoriasis often can — in a very capricious, subtle, unrecognized way — steal away our range of activities and our levels of happiness,” he said.

This reluctance to participate in social interactions, intimacy or other activities can also lead to loneliness and a failure-to-thrive scenario.

Mental health and quality of life

A 2017 study of 1,485 psoriasis patients found a connection between internalized stigma and psoriasis severity and hypothesized that internalized stigma could be one of the major factors responsible for the disease’s psychosocial burden.

There are multiple studies connecting depression and anxiety with psoriasis, and one August 2010 paper, published in the Journal of the European Academy of Dermatology and Venereology, introduced the concept that negative stigma toward psoriasis patients and the social and economic outcomes of this stigmatization, are cumulative over a patient’s lifetime.

The physical burden of psoriasis, combined with psychological co-morbidities of the disease, lead to what the authors describe as “Cumulative Life Course Impairment (CLCI).”

“Studies that include general and skin-specific measures of quality of life generally show that people who have perceived or internalized psoriasis stigma have poorer mental and physical health-related quality of life than those who do not have these experiences. Psoriasis stigma is associated with increased depression and anxiety, as well as impaired social functioning,” Pearl said.

A 2017 study evaluating depression and suicidality in psoriasis found depression and anxiety tend to increase with psoriasis disease severity and psychiatric disorders can also result from and contribute to psoriasis progression.

Severity, however, can be relative.

“There’s a subset of patients really impacted by their psoriasis, even though they may not have psoriasis that is particularly severe to the dermatologist’s eye in terms of body surface coverage. For example, they might have a coin-sized lesion, but they might be suffering from a lot of anxiety or low mood associated with their psoriasis,” Rieder said. “We are at the point where we are trying to figure out who those individuals are and if there’s something going on organically in the brain that we can put a biological marker on.”

Inflammatory connections

Research into psoriasis’s inflammatory nature continues to grow, and it is now believed to be connected to IL-23, IL-17 and IL-22, as well as the Th-17 and Th-22 cells. A question remains however, if the inflammation that causes psoriasis or psoriatic arthritis could also impact mental health.

“We now know the inflammatory cytokines cross the blood-brain barrier and they increase the reuptake of neurotransmitters at the synapse to deplete the brain of serotonin, epinephrine and dopamine,” Fried said. “One of the things we know about inflammation is that it is the evil-doer in our bodies across the board. If you look at the data around depression now, we’re beginning to think depression is a disorder of inflammation.”

A review article published in the American Journal of Clinical Dermatology discusses how depression and psoriasis could both be related to inflammatory cytokines and that reducing the inflammation could help reduce the symptoms of both conditions, however it is difficult to determine whether the drugs reduce the depression or if improved psoriasis leads to better psychological outcomes.

Reducing stigma and improving education

Improving one’s psoriasis is the best way to reduce the mental health impacts the disease brings, and there are currently a host of different treatments in order to do so.

“It has been shown over and over again that even modest improvement in psoriasis clinical severity and psoriatic arthritis can dramatically decrease feelings of stigmatization,” Fried said. “We have so many effective medications that we are always going to have something in our tool bag. And the medicines get better and better.”

Additionally, spreading awareness and increasing education both among patients and the general public can go a long way in reducing stigma, as can being an emotionally supportive clinician.

For clinicians, it is important to be aware of how nonverbal cues can be perceived by a patient and to reduce any potentially stigmatizing actions.

“Seeing patients as individual human beings can be an important first step to reducing some of the biases and increasing awareness of the social experiences they might have,” Pearl said.

Dermatologists and rheumatologists who are treating psoriasis patients should also be asking questions regarding mental health and be prepared to recommend additional resources if necessary.

“We can get quality of life and skin conditions like psoriasis better for almost everyone with the right medications,” Rieder said.

But if the skin is getting clearer and the depression is continuing, it is time for a multidisciplinary team to step in, he added.

• References:
• Pearl RL, et al. J Am Acad Dermatol. 2019;doi:10.1016/j.jaad.2018.08.014.
• Alpsoy E, et al. J Dermatol. 2017;doi:10.1111/1346-8138.13841.
• Kimball AB, et al. J Eur Acad Dermatol Venereol. 2010;doi:10.1111/j.1468-3083.2010.03705.x.
• Koo J, et al. J Eur Acad Dermatol Venereol. 2017;doi:10.1111/jdv.14460.
• Patel N, et al. Am J Clin Dermatol. 2017;doi:10.1007/s40257-017-0279-8.

• For more information:
• Richard G. Fried, MD, PhD, can be reached at Yardley Dermatology Associates, 903 Floral Vale Professional Park, Morrisville, PA 19067; email: dermshrink@gmail.com.
• Rebecca L. Pearl, PhD, can be reached at 1225 Center Drive, Gainesville, FL 32610; email: rebecca.pearl@phhp.ufl.edu.
• Evan Rieder, MD, can be reached at 222 E. 41st St., 24th Floor, New York, NY 10016; email: Evan. Rieder@nyulangone.org.