April 29, 2024 • 41 mins
This episode contains some eye-opening statistics revealing the staggering toll the likes of atopic dermatitis, rosacea, acne, psoriasis and alopecia areata take on an individual's mental wellbeing.
BUT, the episode doesn’t just shed light on the problem. Dr George Moncrieff and Dr Roger Henderson have enlisted the help of Professor Anthony Bewley, a world authority on psychodermatology, to help them break down the barriers to initiating vital conversations around mental health in primary care.
They also discuss the golden rule of psychodermatology - to treat the skin, and the psychosocial comorbidities, at the same time and as early as possible along with the impact this has on patient outcomes.
Discover how you, a primary care healthcare professional, can become a beacon of hope for these individuals, by integrating mental health support into dermatological care.
Thank you to our kind sponsor AproDerm, who provide a comprehensive range of quality emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
To simplify the process of finding the most suitable emollient for each patient, they have developed a remarkable solution: the AproDerm Emollient Starter Pack. This pack conveniently combines all four of their emollients in a single prescription, enabling patients to identify their ideal emollient more efficiently, aiding both compliance and adherence.
Find out more: https://aproderm.com/aproderm-emollient-starter-pack/
LI: https://www.linkedin.com/company/fontus-health-ltd/
Got some feedback for us? Please rate and review Rash Decisions to help us keep creating educational podcasts for you.
Is there a dermatology topic you’d like us to explore? Email us at info@aproderm.com, and we’ll do our best to cover it.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:08):
Well, I think one of the things that we'velearnt over many years, George, is that
a great many number of skin conditionsare actually a true two-edged sword,
and I'm thinking, for example, atopicdermatitis, alopecia areata, psoriasis.
Time and again, we've seen thoseworsened by stress of the individual
(00:28):
concerned and the flares and thetriggers seem to be powered up by stress.
Hello and welcome to this RashDecisions podcast, where once
again, we're looking at skin relatedissues, conditions and treatments
(00:51):
in an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standing interestin this particular area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I'm a former Chair
of the Dermatology Council for England.
Now, this is the second ofthree podcasts on the topic
(01:12):
of our skin and mental health.
And in this podcast, we'll befocusing on certain specific skin
conditions and how they can impacton our patient's mental health.
And once again, we're fortunateto be joined by our very special
guest, Professor Tony Bewley.
And if you were with us for thefirst podcast, you'll know just
what a wonderful guest he is.
(01:33):
Welcome, Tony.
Thanks very much, Roger.
Great to be here.
Now, many skin conditionsare a true two-edged sword.
And I suppose I'm thinking specificallyof the big hitters like atopic dermatitis,
psoriasis, alopecia areata, forexample, all being worsened by stress.
(01:53):
So I just want to run throughthese in a little bit of detail.
And let's start off with a common one wesee in our practices, atopic dermatitis.
As we all know, atopic dermatitiscommonly involves the face and the
hands with these dry, red, scaly, andof course uncomfortable areas of skin.
(02:14):
So it's hardly surprising that has quitea significant impact on how people feel.
Itch also can be relentless andoften disturbs the quality of sleep.
And of course, skincare can consume manyhours, as well as all the time taken
and the cost of accessing healthcare.
(02:35):
A study in 2006 found that over 80%of teenagers with atopic dermatitis
avoided at least one everyday activity.
And almost a third felt thatatopic dermatitis had a negative
impact on their schooling.
And 40% reported they hadbeen teased or bullied because
(02:55):
of their atopic dermatitis.
Another study in 2018 found that atopicdermatitis brought a doubling of the
risk of depression, and a four-foldincreased risk of suicidal ideation.
Interestingly, and importantly,it also showed that controlling
the atopic dermatitis resulted inthese, risks returning to normal.
(03:20):
More recently, a study in 2020 by theNational Eczema Society, supported by
a pharma company called Leo Pharma,they surveyed over 500 children and
500 adults with atopic dermatitis, andthey found that three quarters felt
their skin disease impacted negativelyon their mental health, and two thirds,
(03:42):
said that they felt lonely or sociallyisolated because of their eczema.
Worryingly, in this study, a thirdfelt that their healthcare professional
did not appreciate the impact thateczema had on their mental health.
Atopic dermatitis is a common conditionin children, especially young children,
(04:04):
but it also affects teenagers.
And it can persist into adultlife, and about 10% of adults
have atopic dermatitis.
It's clear from these studies, all ofwhich show alarmingly high levels of
mental illness associated with atopicdermatitis, that this area of care for our
patients needs to be taken very seriously.
(04:27):
It's particularly concerning that thestudy by the National Eczema Society found
that a third of our patients who wereaffected, do not feel that we appreciate
the impact it's having on their lives.
These findings are really disturbing.
Tony, do you have any particularthoughts on atopic dermatitis?
Yeah, I had atopic dermatitis as a childand an adolescent, and then grew out of
(04:51):
it, and I have the genetics for atopicdermatitis, but I have very little by way
of eczema, on my skin at the moment, and,yeah, no, I, fully understand where, these
young people or adults are coming from.
So the association with anxietyand/or depression is clear.
The association, sadly, withsuicidal ideation is also clear.
(05:12):
What is interesting is that we, ashealthcare professionals, again need to
get a little bit better if we get to thepoint where we think that a patient may
have some kind of self-harm type agenda.
We do need to address that.
We do need to ask that question.
So we do need to get better at sayingto the patient, as sympathetically as
(05:33):
we can, "Are you feeling so wretchedthat you'd consider harming yourself?"
Or "Are you, feeling so wretchedthat you'd consider suicide?"
Now, there are well validatedtools to be able to do this.
There is the PHQ-9 and thereis the HAD score, the Hospital
Anxiety and Depression score.
And there is a rather cumbersometool called the Columbia-Suicide
(05:54):
[Severity] Rating Scale, all of whichare fine and largely used in research,
but actually, really, just sayingto a patient, "How are you feeling?
What's going on?"
You, and I think we've talked aboutthis previously, George, then often
you get a really quite a clearsense of where the patient's at.
Yeah.
And then we as healthcare professionalsneed to not be afraid about opening
(06:18):
up that question, "Are you feeling soawful that you'd consider suicide?"
Or, "Are you feeling so awful that you'dconsider harming yourself in some way?"
Because if we identify that issue,then we can reduce the risk that
the patient will act on that.
And also the patient will feel engaged andembrace us and embrace the consultation.
(06:38):
And then, of course, with atopicdermatitis, it's the itch and
the sleeplessness and the familydysfunction, which is a real issue.
And I remember as a child, when my parentsor people would say to me, "For goodness
sake, Anthony, will you stop scratching?"
And it just doesn't help.
The itch is is irresistible.
(07:00):
It's a dreadful itch.
So to think that, you know, that somekind of willpower will stop scratching,
fine, but most of the time you'rescratching at night and, then if you
wake up the following day with blood onyour sheets and skin that has got worse
overnight, the guilt and the shame thatyou feel, and the out of controlness
that you feel is really quite palpable.
(07:21):
So that's why the golden rule, really,of psychodermatology is to treat the
skin, and the psychosocial comorbidities,at the same time, as early as possible.
So it's really important that wedo treat the skin, and we treat it
effectively, making sure that thepatient is at the centre of that choice.
(07:43):
And then we treat the psychosocialcomorbidities at the same time,
and that might be whateverway we need to treat them.
It might be accessing cognitivebehavioural therapy, it might just
be listening to the patient, itmight be considering medication
that might help if a patient hasclinical anxiety and or depression.
Extremely rarely, and it is extremelyrarely, it might involve a referral
(08:07):
to some psychiatric services.
That's incredibly useful.
Thank you so much, Tony.
I particularly like what you had to say,not only about itch, which I thought was
fascinating, but, uh, that, not to feelafraid to explore thoughts of suicide.
What I generally do is, I sit backand say, "Goodness, this is awful.
(08:31):
I can't begin to imagine how much you'resuffering and how rotten this feels."
And if I don't get much from that, Imight try and give the patient permission
by saying, "I've had patients who'vehad disease, perhaps less severe even
than yours, who've even consideredwhether life's worth going on."
And so introduce it slowly and graduallyand say, rather than just saying,
(08:52):
you know, "If you're going to commitsuicide, what are you going to do?
Have you got a rope?"
But to come at it much more gentlyand open the dialogue, and give the
patient permission and suggest areaswhere, almost say, encouraging them
to tell you about it, that it's okayand that you are ready to hear this.
And one I often use in practice,Tony, is really even simpler,
(09:13):
which is "How bad has it got?"
Yeah.
And that's a really nice one I find.
Yeah, it's a nice one.
Because it gives them carte blancheto just say what they want to say.
And, I think you allude to a reallyimportant point there, George, in
that, psychosocial comorbidity does notcorrelate directly with disease extent.
In other words, you can have patientswith really quite limited disease, and
(09:35):
they feel absolutely dreadful, and youcan have patients with quite severe
disease and actually, they're coping okay.
So we know for sure that psychosocialcomorbidities doesn't always
link in with with disease extent.
We also know that if we can get ontop of the disease, that can really
help with the family dysfunction.
(09:56):
So what we do know is that it's notjust the patient that is affected by the
atopic dermatitis, it's the whole family.
If you have a young person with atopicdermatitis who's scratching in the night,
and up and down and not sleeping andrestless and so on, often the parents
or the guardians have a similarlydisturbed night and the whole family can
(10:19):
find itself very dysfunctional or otherrelationships, partners or wives or...
And then of course, thechild can't go to school...
Right.
...and the parents have to, atshort notice, find either childcare
arrangements or not go to work and things.
Yeah.
Absolute nightmare.
I think that's really salutary, isn't it?
It really makes us think and wonder ifwe are actually doing everything we can
(10:41):
for our patients with atopic dermatitis,even just as something as simple as
asking how their mental health is.
And I said at the top, it's notjust atopic dermatitis, psoriasis,
obviously another big one.
And for those of you that listened to ourpsoriasis podcast, in it, I mentioned that
(11:01):
one of the reasons I got into dermatologyas an interest was because of seeing a
patient with psoriasis, that really justopened my eyes as to how much it was
impacting every single area of his life.
And I think you've had similarexperiences, haven't you George?
I have indeed.
I vividly recall a talk I heard at theRoyal College of Physicians in London.
(11:23):
It was given by a lovely guy, PeterLapsley, who was a good friend of
mine, but he sadly died 10 years ago.
And this was a talk to dermatologists.
And he opened his talk bysaying, "I have ischaemic heart
disease and ongoing angina.
I also have Type 2 diabetes andI've got some pretty rotten asthma.
(11:47):
Oh, and I also have psoriasis.
If I could be rid of one ofthese wretched conditions..."
And there he paused.
And, I think we all assumed he wouldchoose one of the first three major
conditions, but to my astonishment, hewent on, "...it would be the psoriasis."
(12:13):
Everyone in the audiencewas as stunned as I was.
He went on to describe how embarrassingit was, especially when he was
staying away from home, and in themorning his bed was covered in blood.
How he'd taken to packing a smallhoover in his overnight bag, to cope
(12:33):
with the scale he shed on the carpet.
How he'd even abandoned going to a publicswimming pool, it's the ignominy of
being asked to leave the pool becausepeople didn't like the look of his skin.
Psoriasis interfered withevery aspect of his life.
That really, if nothing else,that really brought it home to me.
(12:57):
A study in 2018, looking at patientperceptions about their psoriasis,
found that 84% had experienced, 84%,experienced discrimination or even
humiliation because of their psoriasis.
And over 40% admitted it hadaffected their relationships,
(13:19):
especially intimate relationships.
The British Skin Foundation haspreviously highlighted how psoriasis
impacts every aspect of everyday life.
The Dermatology Life Quality Index, whichI'm sure you're all familiar with, was
originally developed as a tool to measurethis impact in people with psoriasis.
(13:40):
And this intentionally exploresissues such as embarrassment,
choice of clothes, social or leisureactivities, and relationships.
In 2012, the 'See Psoriasis, LookDeeper' campaign highlighted these
issues for patients with psoriasis.
(14:01):
And they quoted figures of77% describing it as having an
impact on their quality of life.
20% of patients with psoriasis, severepsoriasis, were taking antidepressants.
And about a third had experienceddepression or anxiety.
20% had felt rejected and stigmatised.
And look at this.
10% of patients had contemplated suicide.
(14:26):
That is absolutely shocking.
And I wonder, Tony, have yougot any particular comments
here regarding psoriasis?
Yeah, that's right.
And the patients with psoriasisoften behave entirely different from
patients with atopic dermatitis.
Dermatology healthcare professionalsare very clear that if you go into a
(14:48):
waiting room, you can think, withoutlooking at the patient's skin, because
of, the way the patient behaves, youcan think, okay, that, that patient
probably has psoriasis, that patientprobably has atopic dermatitis.
So patients with psoriasisprobably do behave differently from
patients with atopic dermatitis.
And in particular, we know that somethingcalled alexithymia is particularly
(15:09):
common in patients with psoriasis.
Alexithymia is the, kind of, inabilityor the reduced ability to be able to
access what you're really thinking.
So, for example, and I always use thisexample, I have a friend who has psoriasis
and he went to a party and another friendof his was there who also has psoriasis.
(15:32):
And he said to his friend, let's callher Georgia, he said to his friend,
Georgia, you know, "how are you doing?"
And Georgia said, "I'm all right."
And my friend said, "Okay I knowyou've got psoriasis and I've got
psoriasis, how are you doing?"
And she said, "Oh, I'm all right."
You know, and then heasked for a third time.
"Look, you know, I know it's areal struggle when you have got
(15:53):
psoriasis, how are you doing?"
And at that point she brokedown in tears and, you know,
things weren't all right at all.
So alexithymia then is the relativeinability to be able to really
understand, or be able to express foryourself, to access for yourself, and
then be explicit about what's going on.
And that matters for us as healthcareprofessionals because sometimes
(16:14):
we have to dig a little bit deeperwith patients who we know may be
having, struggling with alexithymia.
And then the second thing to rememberabout alexithymia is that it gets worse
if you get depressed and/or anxious.
So the greater the depression,the greater the the alexithymia.
But I go back again to the pointwe mentioned a bit earlier on,
(16:35):
which was about the golden ruleof psychodermatology, which is,
treating the skin condition and thepsychosocial comorbidities at the
same time, and as early as possible,and as comprehensively as possible,
remembering to keep the patient atthe centre of the decision making.
What is interesting about psoriasis,particularly these days, is that
(16:56):
there is a growing momentum ofinterest in neuroinflammation.
So the whole concept that theanxiety and depression that patients
with psoriasis may experience,may be related to neuro changes.
So brain changes, and notabout neurotransmitter changes.
So we know that the idea ofneuroinflammation, the brain
(17:19):
being involved, and part of theinflammatory process, can be relevant.
And there is a growing body of evidencethat is explaining the anxiety and
depression associated with psoriasis,which may be neuroinflammatory in origin.
And that's quite helpful to patientsbecause patients often feel guilty and
stigmatised about having mental healthdisease, as well as skin disease.
(17:44):
So if you take away that stigma and say,"Well, do you know what, it's not your
fault that you're feeling like this, itis part of the inflammatory process."
Then patients can actually find thatquite, well, (A) therapeutically
appealing and (B) relieving really.
You know, their shoulders drop andthey think, okay, all these years of
(18:07):
struggling actually at least part ofit is to do with neuroinflammation.
That's fascinating.
That's really absolutely extraordinary.
Yeah, I wasn't aware of that.
I think actually, something that ourlisteners may find really powerful, and
I certainly found it incredibly powerfulwhen I first watched it, and I've
(18:27):
watched it about, over 20 times now, andI'm sure you know this, it's a YouTube
called 'Psoriasis - The Skin I'm In'.
So you just look up on Google, you justgo YouTube, and then you put the word
'psoriasis', and then 'the skin I'm in'.
It's an initially slightly irritatingformat, in which the way they present
(18:48):
it, but it's two actors talking, as ifthey've got psoriasis, to each other,
and it's graphically illustrated withrather strange drawings and things.
It's about 11 minutes long, but I wouldsay if you're going to, go and watch
it, watch it in private, close the door,because I still, when I've watched it
over 20 times, it brings tears to my eyes.
(19:09):
It's a very powerful piece.
Really does bring home to youwhat it feels like to have a
condition that people can see, thatthey, um, are revolted by often.
And the humiliation and theembarrassment it can cause, as
well as all these other elements aswell, that Tony's been highlighting.
Well, those are two enormous areas,atopic dermatitis and psoriasis.
(19:34):
But we mustn't forget a third one.
And this brings this to mind, just becauseit was one of the last patients I saw in
my surgery yesterday, an 18 year old withpretty dreadful acne, and I have to be
perfectly honest, that the doctors who'dseen them previously had not covered
themselves in glory with both theirtreatments and their attitude and acne is
(19:55):
so common, I think that some people canconsider it as normal and trivialise it.
Nothing could be furtherfrom the truth in my view.
It could hardly develop at a moredevastating time in someone's life,
especially during the teen years.
It's a long time ago for us.
But think back to our teen years, justhow important things like validation
(20:16):
with your peers, fitting in, isat that sort of time in your life.
And if you've got a faciallydisfiguring, often painful condition,
such as acne, especially if it'ssevere, then it can inevitably have
dire consequences on self-esteem, onrelationships, mood, and even choice
(20:36):
of career and career opportunities.
So there's almost this unholy trinityI think, we're looking at, of atopic
dermatitis, psoriasis and acne.
Acne comes at a pretty devastatingtime in people's lives.
And if it affected people our sort ofage , who've got stable relationships,
with careers behind them , it wouldn'tbe quite so disastrous, but it
(20:58):
occurs in teenagers and young adults.
And for them, how you look,particularly how you look on social
media, how your face looks and so on.
My heart goes out to them.
And hardly surprisingly, studies haverepeatedly shown strong links between
acne and mental health problems,including depression and suicide attempts.
It's a complicated area.
(21:18):
Complicated to some extent becausethe best treatment we have for acne,
and the treatment that gives completecontrol, such that the majority of
patients, never have any more acne,no more antibiotics, no more doctor's
appointments, no more treatment, nomore acne, is, of course, isotretinoin.
And rightly, there are concerns aboutthe use of isotretinoin because of
(21:43):
reports of this drug being associatedwith patients committing suicide.
And it's a thorny issue that taxes us,the profession, quite significantly.
I was reassured by a huge meta-analysispublished in the BMJ in 2019, that
concluded that those patients whoseacne was causing such severe depression
(22:07):
that they were already contemplatingsuicide, or even patients with just severe
depression, because isotretinoin is themost effective treatment we have for them,
controlling their acne with isotretinoinwas the right thing to do for this group.
Clearly they needed to bemonitored more carefully.
But the use of isotretinoin significantlyimproves depressive symptoms in
(22:31):
patients with depression, already gotdepression associated with their acne.
And I was intrigued by a paperpublished in 2022, which concluded
that isotretinoin was not independentlyassociated with adverse neuropsychiatric
outcomes at the population level.
(22:55):
Indeed, they found that the risk ofsignificant neuropsychiatric outcomes,
such as depression or suicide, wasworse with oral or topical antibiotics,
probably because those aren'tcontrolling the acne, whereas the
patients on isotretinoin had control.
Now this is a thorny issue, and I thinkit's not one that we can go into in great
(23:18):
detail here, but clearly managing theacne effectively, which may involve using
isotretinoin, resulted in better overalloutcomes, including lower suicide rates.
There are going to be some patients,almost certainly, very rare, where
(23:41):
the isotretinoin played a part inthem deciding to commit suicide.
But if you look at the populationlevel, it's doing more good than harm.
And I think this is an areathat's going to continue to be
really difficult for us all.
And I think it's one thatwe have to watch this space.
I think the important thing is to be surethat patients who are prescribed this get
(24:04):
the right degree of monitoring, duringthe course, and for a year afterwards.
It's a very importantelement of their management.
So hearing all that, Tony, it's areally difficult issue, isn't it?
We have a drug that works,but it could have problems.
And, this is a condition affectingyoung people and having a big impact on
(24:25):
their self-esteem, their relationships,as well as causing depression and
suicidal thoughts, inevitably.
Have you got any particularwords of wisdom for us?
Yeah, I think acne is apernicious disease, isn't it?
And it's often underweighted.
We, as healthcare professionals,can sometimes consider it to
(24:45):
be somewhat lesser than it is.
But it's a perniciousdisease for our patients.
It really, really matters and it tendsto strike at an age, it's perniciousness
is, at least partly, related to theage it strikes, which is adolescence
usually or early adulthood, thoughwe are beginning to understand that
(25:07):
there is a group of, usually women,who get later onset acne in their 30s.
Yes.
And that is interesting too.
But it's a pernicious disease because it'ssore, it's obvious that you've got acne.
And it strikes at an age when your bodyis changing and you're trying to come to
terms with a changing body and changingdynamics with your peers and with partners
(25:32):
and an increasing awareness of sexuality.
So it's not surprising then thatthe psychosocial comorbidities
of living with acne are huge.
And one thing we do know isthat acne strikes together often
with body dysmorphic disorder.
Body dysmorphic disorder is thatcondition where you have a change on
(25:54):
your skin and your focus on that changeis in excess of the disease extent.
So it can be acne scarring, it can bemilder acne, but the patients often feel
very, very debilitated with recurringthoughts about their appearance.
Huge amounts of time mirror checkingor huge amounts of time avoiding
(26:15):
mirrors, and often social avoidance.
So they might stay at home and notgo into school because their acne
is bad or whatever it might be.
And then they might hide theirskin and believe narratives that
aren't necessarily the case.
So, for example, if they're on a bus,and somebody moves away from them, they
can assume that, that person has movedaway from them because they perceive the
(26:39):
acne and believed it to be ugly and sothey've moved away because of the acne.
So there can be narratives that peopleconstruct which aren't necessarily
at all what was happening in reality.
So it's a pernicious diseaseand it needs to be treated.
And again, I go back to the goldenrule of psychodermatology, which is to
treat the skin disease appropriatelyand to treat the psychosocial
(27:01):
comorbidities at the same time.
So, for milder acne, it's absolutelyright to start treating with topical
agents, and then you step up tosystemic anti-inflammatories, and
you can consider contraceptivemedications, and then you can step up
to other treatments, and eventuallyyou can step up to isotretinoin.
And there is no doubt thatisotretinoin is an effective
(27:21):
drug for the management of acne.
However, we need to be very respectfulof isotretinoin because there is
an association, not a proof, butan association with mood changes
and with changes in impulsivity.
In other words, an association with eitheracquiring or acting on suicidal ideation.
(27:46):
As a consequence, and I think we'vealluded to this, the MHRA and the
British Association of Dermatologistshave made it very clear that we, as
healthcare professionals, need to doa very careful assessment before a
patient goes on to isotretinoin andthen during the isotretinoin treatment.
However, I would argue that weneed to be doing that for all of
our patients with acne anyway.
(28:06):
So we need to be very mindful about thepsychosocial comorbidities, whatever
the patient, whether they have mild acneor moderate or severe acne, remembering
that, and we talked about this earlieron in the podcasts, remembering that
disease extent does not necessarilycorrelate with psychosocial comorbidities.
Sure, yeah.
So for all of these treatmentsand for the patient, we need to be
(28:28):
respectful about what's going on.
And if a patient does presentwith anxiety and/or depression
together with, in this case acne,then that becomes the co-priority.
So the skin and the psychosocialcomorbidities becomes the
co-priority at that point.
Well, that's the, the unholytrinity, the atopic dermatitis,
(28:48):
the acne, the psoriasis.
But again, thinking of patients I'veseen in the last few days, alopecia
areata, mustn't forget that one.
And if ever there's a condition wherethere's often such a clear link between
stressful life events and the onset,or worsening of, alopecia then, in my
(29:11):
book, there are very few worse than that.
And I'm sure you've seen that manytimes in your practice, George.
I have, yes.
And the fairly sudden appearanceof patches of hair loss on the
scalp, it's so visible, isn't it?
Yeah.
And no surprise, it can havequite a dramatic impact.
And that's borne out by studies.
(29:32):
A study looking at people with thiscondition in 2022 found that they had a
38% higher risk of depression and a 33%higher risk of anxiety, as well as needing
more time off work, and unemployment.
Alopecia areata, as we all know,often affects young people, and
(29:53):
the relapses are unpredictable.
And, in our society, where hair playssuch a critical role, and Roger, I
think you and I both agree that'ssomething we're painfully aware of.
Significant patches of hair loss canhave a potentially devastating impact
on self-confidence and mental wellbeing.
(30:14):
Almost certainly, stress playsa role in causing relapses.
So a vicious cycle can rapidly develop.
A study in 2023 showed that a history ofmajor depressive disorder increases the
risk of developing alopecia areata by 90%.
And alopecia areata increases riskof major mental illness by 34%.
(30:37):
Yeah.
Mustn't forget rosacea here.
As we all know, permanent backgroundredness of the face is its hallmark
and you can get really sudden,unpleasant, embarrassing facial
flushing, plus inflammatory patterns.
You get the red angrypimples and the pustules.
And again, if you haven't listened tothe podcast that George and I did on
(31:00):
rosacea, then do go back and have a listenbecause we covered this in great detail.
But obviously there's no doubt it canhave a major impact on self-esteem,
increase the risk of depression oranxiety, and I suspect Tony, this
might be why you've recently donequite a major body of work on this.
Is that correct?
Yeah, that's right, as it's common,you know, Roger, that's the thing.
(31:21):
It's such a common condition.
And, and also, it'sactually quite symptomatic.
So patients talk about the flushingand the heat and the stinging and
the burning sensation that they get.
And in terms of psychodermatology, oneof the things that they particularly
allude to is the absence of control.
(31:43):
You know, "I've taken the diet, I'vestopped alcohol, I don't go to, steamy
places, I don't sit in the jacuzzi.
Why is my skin doing this to me?"
And so the out of control sensationcan also contribute to that.
So with rosacea, again, we start talkingabout making sure that we recognise the
(32:03):
physical, issues, and the physical issuescan be different for different patients.
It can be the papular rosacea, andthen we need to treat that with
anti-inflammatories, or it can be theerythrotelangiectatic form of rosacea,
where there is persistent redness,and that can be fixed redness, or it
can be flushing and then, relativepallor, relative lack of flushing.
(32:27):
And it can be the symptoms thatgo with that, and sometimes if
you have quite extensive disease,it can become more phytomatous.
In other words, you can get sebaceoushyperplasia, which can involve, you know,
the nose and various parts of the face.
So rosacea, again, quite a perniciouscondition, and again, I allude back to the
golden rule of psychodermatology, whichis to treat the skin and psychosocial
(32:48):
comorbidities at the same time.
Now, the psychosocial comorbiditiesfor rosacea are really around
the out-of-controlness, theanxiety and/or depression, but
also it's about the symptoms.
So it's about recognising, andnot dismissing, the symptoms
of rosacea, the flushing, theburning, the soreness, and so on.
(33:09):
So treating that as wellas the rosacea itself.
So that's all really quite important.
Of course, in our society, having ared face has all sorts of connotations.
People assume, or the patient imaginespeople assume, that it's because
you've been drinking too much alcohol.
And we are aware that alcohol canbe one of the triggers for a flush.
(33:31):
Although, in my experience, it'snot the most important by any means.
I think it's ultraviolet light andit's stress and embarrassment and
temperature changes and foods, and things.
And I, when I ask about triggers, Ialways put alcohol at the very, very
bottom of my list, partly because I'mconscious that my patients probably think
that if they come in with a face that'sa bit red, I don't want them to think
that I'm assuming they're alcoholic.
(33:54):
And those value judgements andthose narratives, those myths that
come into patients' experiencecan be really destabilising.
Absolutely, yes.
So, uh, we know that kind of, that, kneejerk response to think, oh, well, you've
got rosacea, do you drink too much?
It can be really unfortunate.
Terrible isn't it?
But it's not just in rosacea,it's also in other conditions.
(34:17):
For example, like, vitiligo.
There can be narrativesthat come into vitiligo.
Oh, well, you know, you've got vitiligo,because you've eaten the wrong foods,
you've eaten, there is a narrative around,which is incorrect, that you get vitiligo
from eating fish and dairy together.
And there is, misperceptionsabout the absence of pigmentation.
(34:40):
So, you have vitiligo.
In fact, people can mistakethat for being something else,
like leprosy, or it could...
Yes, yes, I've heard that.
...be other conditions or an infection.
So people, other people, andin fact patients, can construct
unhelpful narratives that, thatadd to their burden, if you like.
(35:00):
And it is important for us, as healthcareprofessionals, to say, "okay, what do
you understand by rosacea or vitiligo?
What do you think is going on?"
And give the patients an opportunityto say, well, I have heard such and
such, or I wondered about whetherthis was some kind of punishment, some
kind of, I don't know, supernaturalpunishment for not living my life...
(35:21):
Retribution, yeah.
...as well as I should do.
Yeah.
You're then in the opportunity to say,okay, well, actually, the facts, the
science behind this is that rosacea,for example, is caused largely by
vasodilation, and nerves within thecutaneous microvasculature that allow
vasodilation and actually it's largelygenetic, it's just the way you're made.
But, we can treat this and we cantreat this and the psychosocial
(35:44):
comorbidities at the same time.
Well running through this long listof skin criminals that can impact
on our patients' mental health.
Vitiligo and birthmarks areperhaps two that I'd thought
about, that we mustn't forget.
Again, exactly becausethey can be so visible.
(36:05):
And unfortunately, if you have someonewith a very significant birthmark
on their face, for example, or abig patch of vitiligo, you do see
other people just staring at themand it's a horrible thing to see.
So George, I think just touchingbriefly on, on these two, vitiligo
(36:26):
and birthmarks, we do have some workshowing just how much they can impact
people's mental health, don't we?
Yes, and there should be nosurprise to us whatsoever.
They are very often on the face andvitiligo, particularly in dark skin.
If someone's got dark skin, the patchesof total depigmentation are quite
(36:46):
dramatic and dramatically disfiguring.
And a study in 2021 showed 76% experiencedstress, 78% anxiety and 80% depression,
which they attribute to their vitiligo.
Very high figures indeed.
It's a disfiguring condition.
(37:07):
Regarding birthmarks, especiallyon the face, things like port
wine stains I'm thinking...
Yep.
...those can be really devastatingand very hard to manage as well.
Again, it's hardly surprising peopleaffected by this would have an impact,
marked impact on their mental health.
I'm sure this isn't a comprehensive list.
There are many other things, but whatwe've tried to pick out is some of the
(37:27):
more obvious things that we can thinkof that involve the visible areas,
because they're going to have a biggerimpact, but it's also genital areas.
If you've got disease in the genitalarea, then that can inevitably have a
big impact on people's relationships.
And they may not want todiscuss that with you.
They will disclose it.
We may need to be quite sensitiveand even ask some very open,
(37:50):
careful, open questions to definejust how much trouble it's causing.
So for example, psoriasis commonlyinvolves the genital area, but other
conditions, like lichen sclerosus,which we could cover in another podcast
perhaps Roger, can be very itchy andyou can imagine how awkward it is
if you've got an itch in that area.
Society doesn't think it's acceptable.
(38:10):
It might be acceptable to scratchyour elbow, but it's not exactly
acceptable to grope around inyour groin and scratch there.
And what I would say is that it's reallyimportant that patients don't suffer in
silence and it's really important thatwe as healthcare professionals fully
weight the experience of the patient.
You couldn't have said a more importantstatement right at the end there.
(38:34):
We so endorse that.
That, one, you're not on your own.
Two, you shouldn't suffer in silence.
You must make this the purposeof coming to talk to a healthcare
professional, seek help.
And then for physicians, in our nextpodcast, we're going to reflect on
our approach, how our approach canbe improved and how we should be
(38:55):
looking at helping our patients.
But Tony, thank you so much.
I have learnt so much from you, asI always do, when I'm at your knees.
And it's been absolutely brilliant.
And I'm sure Roger will endorse that.
Absolutely.
It's been wonderful, Tony.
It's been an absolute delight and thankyou so much for your time with us.
Thanks, guys.
Always a pleasure.
Well, I do hope that you found thischat with myself, George and Tony about
(39:20):
skin and mental health interesting.
And as always, our thanks dogo to our wonderful guest, Tony
Bewley, for all his help with it.
Now next time, we'll discuss a fewconditions where the skin can be the
presentation of a mental health condition.
But we have discussed some prettyshocking facts and statistics.
One of the things that Tony highlighted,which in fact I took home, was that
(39:43):
if you can control the skin condition,so for example, if you've got eczema
and you use emollients properly,and you manage the eczema well, then
that's going to be the best treatmentfor any mental health complications
that the eczema might have caused.
Same with acne, the same with psoriasis.
So managing the skin condition reallywell is very, very important here.
(40:06):
But we've been really honoured tobe joined by Tony for this episode.
It's been absolutely brilliant.
And once again, thank you so muchfor your expertise and wisdom.
And we really are looking forward toyou joining us for our last podcast in
this series next time, where we'll bediscussing how the medical professions
can help patients with these problems.
So Roger and I do hope you will joinus for the next podcast, and we'd also
(40:28):
like to thank our sponsor, AproDerm®,for all their help in putting these
Rash Decisions podcasts together.
We couldn't have done it without them.
And don't forget, do get in touch.
We love to hear your feedback,or rate and review us.
It really does help us inputting these podcasts together.
But until the next time,it's goodbye from George.
(40:48):
Goodbye.
And as always, it's goodbye from me.
Goodbye.
Well, I think one of the things that we'velearnt over many years, George, is that
a great many number of skin conditionsare actually a true two-edged sword,
and I'm thinking, for example, atopicdermatitis, alopecia areata, psoriasis.
Time and again, we've seen thoseworsened by stress of the individual
(00:28):
concerned and the flares and thetriggers seem to be powered up by stress.
Hello and welcome to this RashDecisions podcast, where once
again, we're looking at skin relatedissues, conditions and treatments
(00:51):
in an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standing interestin this particular area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I'm a former Chair
of the Dermatology Council for England.
Now, this is the second ofthree podcasts on the topic
(01:12):
of our skin and mental health.
And in this podcast, we'll befocusing on certain specific skin
conditions and how they can impacton our patient's mental health.
And once again, we're fortunateto be joined by our very special
guest, Professor Tony Bewley.
And if you were with us for thefirst podcast, you'll know just
what a wonderful guest he is.
(01:33):
Welcome, Tony.
Thanks very much, Roger.
Great to be here.
Now, many skin conditionsare a true two-edged sword.
And I suppose I'm thinking specificallyof the big hitters like atopic dermatitis,
psoriasis, alopecia areata, forexample, all being worsened by stress.
(01:53):
So I just want to run throughthese in a little bit of detail.
And let's start off with a common one wesee in our practices, atopic dermatitis.
As we all know, atopic dermatitiscommonly involves the face and the
hands with these dry, red, scaly, andof course uncomfortable areas of skin.
(02:14):
So it's hardly surprising that has quitea significant impact on how people feel.
Itch also can be relentless andoften disturbs the quality of sleep.
And of course, skincare can consume manyhours, as well as all the time taken
and the cost of accessing healthcare.
(02:35):
A study in 2006 found that over 80%of teenagers with atopic dermatitis
avoided at least one everyday activity.
And almost a third felt thatatopic dermatitis had a negative
impact on their schooling.
And 40% reported they hadbeen teased or bullied because
(02:55):
of their atopic dermatitis.
Another study in 2018 found that atopicdermatitis brought a doubling of the
risk of depression, and a four-foldincreased risk of suicidal ideation.
Interestingly, and importantly,it also showed that controlling
the atopic dermatitis resulted inthese, risks returning to normal.
(03:20):
More recently, a study in 2020 by theNational Eczema Society, supported by
a pharma company called Leo Pharma,they surveyed over 500 children and
500 adults with atopic dermatitis, andthey found that three quarters felt
their skin disease impacted negativelyon their mental health, and two thirds,
(03:42):
said that they felt lonely or sociallyisolated because of their eczema.
Worryingly, in this study, a thirdfelt that their healthcare professional
did not appreciate the impact thateczema had on their mental health.
Atopic dermatitis is a common conditionin children, especially young children,
(04:04):
but it also affects teenagers.
And it can persist into adultlife, and about 10% of adults
have atopic dermatitis.
It's clear from these studies, all ofwhich show alarmingly high levels of
mental illness associated with atopicdermatitis, that this area of care for our
patients needs to be taken very seriously.
(04:27):
It's particularly concerning that thestudy by the National Eczema Society found
that a third of our patients who wereaffected, do not feel that we appreciate
the impact it's having on their lives.
These findings are really disturbing.
Tony, do you have any particularthoughts on atopic dermatitis?
Yeah, I had atopic dermatitis as a childand an adolescent, and then grew out of
(04:51):
it, and I have the genetics for atopicdermatitis, but I have very little by way
of eczema, on my skin at the moment, and,yeah, no, I, fully understand where, these
young people or adults are coming from.
So the association with anxietyand/or depression is clear.
The association, sadly, withsuicidal ideation is also clear.
(05:12):
What is interesting is that we, ashealthcare professionals, again need to
get a little bit better if we get to thepoint where we think that a patient may
have some kind of self-harm type agenda.
We do need to address that.
We do need to ask that question.
So we do need to get better at sayingto the patient, as sympathetically as
(05:33):
we can, "Are you feeling so wretchedthat you'd consider harming yourself?"
Or "Are you, feeling so wretchedthat you'd consider suicide?"
Now, there are well validatedtools to be able to do this.
There is the PHQ-9 and thereis the HAD score, the Hospital
Anxiety and Depression score.
And there is a rather cumbersometool called the Columbia-Suicide
(05:54):
[Severity] Rating Scale, all of whichare fine and largely used in research,
but actually, really, just sayingto a patient, "How are you feeling?
What's going on?"
You, and I think we've talked aboutthis previously, George, then often
you get a really quite a clearsense of where the patient's at.
Yeah.
And then we as healthcare professionalsneed to not be afraid about opening
(06:18):
up that question, "Are you feeling soawful that you'd consider suicide?"
Or, "Are you feeling so awful that you'dconsider harming yourself in some way?"
Because if we identify that issue,then we can reduce the risk that
the patient will act on that.
And also the patient will feel engaged andembrace us and embrace the consultation.
(06:38):
And then, of course, with atopicdermatitis, it's the itch and
the sleeplessness and the familydysfunction, which is a real issue.
And I remember as a child, when my parentsor people would say to me, "For goodness
sake, Anthony, will you stop scratching?"
And it just doesn't help.
The itch is is irresistible.
(07:00):
It's a dreadful itch.
So to think that, you know, that somekind of willpower will stop scratching,
fine, but most of the time you'rescratching at night and, then if you
wake up the following day with blood onyour sheets and skin that has got worse
overnight, the guilt and the shame thatyou feel, and the out of controlness
that you feel is really quite palpable.
(07:21):
So that's why the golden rule, really,of psychodermatology is to treat the
skin, and the psychosocial comorbidities,at the same time, as early as possible.
So it's really important that wedo treat the skin, and we treat it
effectively, making sure that thepatient is at the centre of that choice.
(07:43):
And then we treat the psychosocialcomorbidities at the same time,
and that might be whateverway we need to treat them.
It might be accessing cognitivebehavioural therapy, it might just
be listening to the patient, itmight be considering medication
that might help if a patient hasclinical anxiety and or depression.
Extremely rarely, and it is extremelyrarely, it might involve a referral
(08:07):
to some psychiatric services.
That's incredibly useful.
Thank you so much, Tony.
I particularly like what you had to say,not only about itch, which I thought was
fascinating, but, uh, that, not to feelafraid to explore thoughts of suicide.
What I generally do is, I sit backand say, "Goodness, this is awful.
(08:31):
I can't begin to imagine how much you'resuffering and how rotten this feels."
And if I don't get much from that, Imight try and give the patient permission
by saying, "I've had patients who'vehad disease, perhaps less severe even
than yours, who've even consideredwhether life's worth going on."
And so introduce it slowly and graduallyand say, rather than just saying,
(08:52):
you know, "If you're going to commitsuicide, what are you going to do?
Have you got a rope?"
But to come at it much more gentlyand open the dialogue, and give the
patient permission and suggest areaswhere, almost say, encouraging them
to tell you about it, that it's okayand that you are ready to hear this.
And one I often use in practice,Tony, is really even simpler,
(09:13):
which is "How bad has it got?"
Yeah.
And that's a really nice one I find.
Yeah, it's a nice one.
Because it gives them carte blancheto just say what they want to say.
And, I think you allude to a reallyimportant point there, George, in
that, psychosocial comorbidity does notcorrelate directly with disease extent.
In other words, you can have patientswith really quite limited disease, and
(09:35):
they feel absolutely dreadful, and youcan have patients with quite severe
disease and actually, they're coping okay.
So we know for sure that psychosocialcomorbidities doesn't always
link in with with disease extent.
We also know that if we can get ontop of the disease, that can really
help with the family dysfunction.
(09:56):
So what we do know is that it's notjust the patient that is affected by the
atopic dermatitis, it's the whole family.
If you have a young person with atopicdermatitis who's scratching in the night,
and up and down and not sleeping andrestless and so on, often the parents
or the guardians have a similarlydisturbed night and the whole family can
(10:19):
find itself very dysfunctional or otherrelationships, partners or wives or...
And then of course, thechild can't go to school...
Right.
...and the parents have to, atshort notice, find either childcare
arrangements or not go to work and things.
Yeah.
Absolute nightmare.
I think that's really salutary, isn't it?
It really makes us think and wonder ifwe are actually doing everything we can
(10:41):
for our patients with atopic dermatitis,even just as something as simple as
asking how their mental health is.
And I said at the top, it's notjust atopic dermatitis, psoriasis,
obviously another big one.
And for those of you that listened to ourpsoriasis podcast, in it, I mentioned that
(11:01):
one of the reasons I got into dermatologyas an interest was because of seeing a
patient with psoriasis, that really justopened my eyes as to how much it was
impacting every single area of his life.
And I think you've had similarexperiences, haven't you George?
I have indeed.
I vividly recall a talk I heard at theRoyal College of Physicians in London.
(11:23):
It was given by a lovely guy, PeterLapsley, who was a good friend of
mine, but he sadly died 10 years ago.
And this was a talk to dermatologists.
And he opened his talk bysaying, "I have ischaemic heart
disease and ongoing angina.
I also have Type 2 diabetes andI've got some pretty rotten asthma.
(11:47):
Oh, and I also have psoriasis.
If I could be rid of one ofthese wretched conditions..."
And there he paused.
And, I think we all assumed he wouldchoose one of the first three major
conditions, but to my astonishment, hewent on, "...it would be the psoriasis."
(12:13):
Everyone in the audiencewas as stunned as I was.
He went on to describe how embarrassingit was, especially when he was
staying away from home, and in themorning his bed was covered in blood.
How he'd taken to packing a smallhoover in his overnight bag, to cope
(12:33):
with the scale he shed on the carpet.
How he'd even abandoned going to a publicswimming pool, it's the ignominy of
being asked to leave the pool becausepeople didn't like the look of his skin.
Psoriasis interfered withevery aspect of his life.
That really, if nothing else,that really brought it home to me.
(12:57):
A study in 2018, looking at patientperceptions about their psoriasis,
found that 84% had experienced, 84%,experienced discrimination or even
humiliation because of their psoriasis.
And over 40% admitted it hadaffected their relationships,
(13:19):
especially intimate relationships.
The British Skin Foundation haspreviously highlighted how psoriasis
impacts every aspect of everyday life.
The Dermatology Life Quality Index, whichI'm sure you're all familiar with, was
originally developed as a tool to measurethis impact in people with psoriasis.
(13:40):
And this intentionally exploresissues such as embarrassment,
choice of clothes, social or leisureactivities, and relationships.
In 2012, the 'See Psoriasis, LookDeeper' campaign highlighted these
issues for patients with psoriasis.
(14:01):
And they quoted figures of77% describing it as having an
impact on their quality of life.
20% of patients with psoriasis, severepsoriasis, were taking antidepressants.
And about a third had experienceddepression or anxiety.
20% had felt rejected and stigmatised.
And look at this.
10% of patients had contemplated suicide.
(14:26):
That is absolutely shocking.
And I wonder, Tony, have yougot any particular comments
here regarding psoriasis?
Yeah, that's right.
And the patients with psoriasisoften behave entirely different from
patients with atopic dermatitis.
Dermatology healthcare professionalsare very clear that if you go into a
(14:48):
waiting room, you can think, withoutlooking at the patient's skin, because
of, the way the patient behaves, youcan think, okay, that, that patient
probably has psoriasis, that patientprobably has atopic dermatitis.
So patients with psoriasisprobably do behave differently from
patients with atopic dermatitis.
And in particular, we know that somethingcalled alexithymia is particularly
(15:09):
common in patients with psoriasis.
Alexithymia is the, kind of, inabilityor the reduced ability to be able to
access what you're really thinking.
So, for example, and I always use thisexample, I have a friend who has psoriasis
and he went to a party and another friendof his was there who also has psoriasis.
(15:32):
And he said to his friend, let's callher Georgia, he said to his friend,
Georgia, you know, "how are you doing?"
And Georgia said, "I'm all right."
And my friend said, "Okay I knowyou've got psoriasis and I've got
psoriasis, how are you doing?"
And she said, "Oh, I'm all right."
You know, and then heasked for a third time.
"Look, you know, I know it's areal struggle when you have got
(15:53):
psoriasis, how are you doing?"
And at that point she brokedown in tears and, you know,
things weren't all right at all.
So alexithymia then is the relativeinability to be able to really
understand, or be able to express foryourself, to access for yourself, and
then be explicit about what's going on.
And that matters for us as healthcareprofessionals because sometimes
(16:14):
we have to dig a little bit deeperwith patients who we know may be
having, struggling with alexithymia.
And then the second thing to rememberabout alexithymia is that it gets worse
if you get depressed and/or anxious.
So the greater the depression,the greater the the alexithymia.
But I go back again to the pointwe mentioned a bit earlier on,
(16:35):
which was about the golden ruleof psychodermatology, which is,
treating the skin condition and thepsychosocial comorbidities at the
same time, and as early as possible,and as comprehensively as possible,
remembering to keep the patient atthe centre of the decision making.
What is interesting about psoriasis,particularly these days, is that
(16:56):
there is a growing momentum ofinterest in neuroinflammation.
So the whole concept that theanxiety and depression that patients
with psoriasis may experience,may be related to neuro changes.
So brain changes, and notabout neurotransmitter changes.
So we know that the idea ofneuroinflammation, the brain
(17:19):
being involved, and part of theinflammatory process, can be relevant.
And there is a growing body of evidencethat is explaining the anxiety and
depression associated with psoriasis,which may be neuroinflammatory in origin.
And that's quite helpful to patientsbecause patients often feel guilty and
stigmatised about having mental healthdisease, as well as skin disease.
(17:44):
So if you take away that stigma and say,"Well, do you know what, it's not your
fault that you're feeling like this, itis part of the inflammatory process."
Then patients can actually find thatquite, well, (A) therapeutically
appealing and (B) relieving really.
You know, their shoulders drop andthey think, okay, all these years of
(18:07):
struggling actually at least part ofit is to do with neuroinflammation.
That's fascinating.
That's really absolutely extraordinary.
Yeah, I wasn't aware of that.
I think actually, something that ourlisteners may find really powerful, and
I certainly found it incredibly powerfulwhen I first watched it, and I've
(18:27):
watched it about, over 20 times now, andI'm sure you know this, it's a YouTube
called 'Psoriasis - The Skin I'm In'.
So you just look up on Google, you justgo YouTube, and then you put the word
'psoriasis', and then 'the skin I'm in'.
It's an initially slightly irritatingformat, in which the way they present
(18:48):
it, but it's two actors talking, as ifthey've got psoriasis, to each other,
and it's graphically illustrated withrather strange drawings and things.
It's about 11 minutes long, but I wouldsay if you're going to, go and watch
it, watch it in private, close the door,because I still, when I've watched it
over 20 times, it brings tears to my eyes.
(19:09):
It's a very powerful piece.
Really does bring home to youwhat it feels like to have a
condition that people can see, thatthey, um, are revolted by often.
And the humiliation and theembarrassment it can cause, as
well as all these other elements aswell, that Tony's been highlighting.
Well, those are two enormous areas,atopic dermatitis and psoriasis.
(19:34):
But we mustn't forget a third one.
And this brings this to mind, just becauseit was one of the last patients I saw in
my surgery yesterday, an 18 year old withpretty dreadful acne, and I have to be
perfectly honest, that the doctors who'dseen them previously had not covered
themselves in glory with both theirtreatments and their attitude and acne is
(19:55):
so common, I think that some people canconsider it as normal and trivialise it.
Nothing could be furtherfrom the truth in my view.
It could hardly develop at a moredevastating time in someone's life,
especially during the teen years.
It's a long time ago for us.
But think back to our teen years, justhow important things like validation
(20:16):
with your peers, fitting in, isat that sort of time in your life.
And if you've got a faciallydisfiguring, often painful condition,
such as acne, especially if it'ssevere, then it can inevitably have
dire consequences on self-esteem, onrelationships, mood, and even choice
(20:36):
of career and career opportunities.
So there's almost this unholy trinityI think, we're looking at, of atopic
dermatitis, psoriasis and acne.
Acne comes at a pretty devastatingtime in people's lives.
And if it affected people our sort ofage , who've got stable relationships,
with careers behind them , it wouldn'tbe quite so disastrous, but it
(20:58):
occurs in teenagers and young adults.
And for them, how you look,particularly how you look on social
media, how your face looks and so on.
My heart goes out to them.
And hardly surprisingly, studies haverepeatedly shown strong links between
acne and mental health problems,including depression and suicide attempts.
It's a complicated area.
(21:18):
Complicated to some extent becausethe best treatment we have for acne,
and the treatment that gives completecontrol, such that the majority of
patients, never have any more acne,no more antibiotics, no more doctor's
appointments, no more treatment, nomore acne, is, of course, isotretinoin.
And rightly, there are concerns aboutthe use of isotretinoin because of
(21:43):
reports of this drug being associatedwith patients committing suicide.
And it's a thorny issue that taxes us,the profession, quite significantly.
I was reassured by a huge meta-analysispublished in the BMJ in 2019, that
concluded that those patients whoseacne was causing such severe depression
(22:07):
that they were already contemplatingsuicide, or even patients with just severe
depression, because isotretinoin is themost effective treatment we have for them,
controlling their acne with isotretinoinwas the right thing to do for this group.
Clearly they needed to bemonitored more carefully.
But the use of isotretinoin significantlyimproves depressive symptoms in
(22:31):
patients with depression, already gotdepression associated with their acne.
And I was intrigued by a paperpublished in 2022, which concluded
that isotretinoin was not independentlyassociated with adverse neuropsychiatric
outcomes at the population level.
(22:55):
Indeed, they found that the risk ofsignificant neuropsychiatric outcomes,
such as depression or suicide, wasworse with oral or topical antibiotics,
probably because those aren'tcontrolling the acne, whereas the
patients on isotretinoin had control.
Now this is a thorny issue, and I thinkit's not one that we can go into in great
(23:18):
detail here, but clearly managing theacne effectively, which may involve using
isotretinoin, resulted in better overalloutcomes, including lower suicide rates.
There are going to be some patients,almost certainly, very rare, where
(23:41):
the isotretinoin played a part inthem deciding to commit suicide.
But if you look at the populationlevel, it's doing more good than harm.
And I think this is an areathat's going to continue to be
really difficult for us all.
And I think it's one thatwe have to watch this space.
I think the important thing is to be surethat patients who are prescribed this get
(24:04):
the right degree of monitoring, duringthe course, and for a year afterwards.
It's a very importantelement of their management.
So hearing all that, Tony, it's areally difficult issue, isn't it?
We have a drug that works,but it could have problems.
And, this is a condition affectingyoung people and having a big impact on
(24:25):
their self-esteem, their relationships,as well as causing depression and
suicidal thoughts, inevitably.
Have you got any particularwords of wisdom for us?
Yeah, I think acne is apernicious disease, isn't it?
And it's often underweighted.
We, as healthcare professionals,can sometimes consider it to
(24:45):
be somewhat lesser than it is.
But it's a perniciousdisease for our patients.
It really, really matters and it tendsto strike at an age, it's perniciousness
is, at least partly, related to theage it strikes, which is adolescence
usually or early adulthood, thoughwe are beginning to understand that
(25:07):
there is a group of, usually women,who get later onset acne in their 30s.
Yes.
And that is interesting too.
But it's a pernicious disease because it'ssore, it's obvious that you've got acne.
And it strikes at an age when your bodyis changing and you're trying to come to
terms with a changing body and changingdynamics with your peers and with partners
(25:32):
and an increasing awareness of sexuality.
So it's not surprising then thatthe psychosocial comorbidities
of living with acne are huge.
And one thing we do know isthat acne strikes together often
with body dysmorphic disorder.
Body dysmorphic disorder is thatcondition where you have a change on
(25:54):
your skin and your focus on that changeis in excess of the disease extent.
So it can be acne scarring, it can bemilder acne, but the patients often feel
very, very debilitated with recurringthoughts about their appearance.
Huge amounts of time mirror checkingor huge amounts of time avoiding
(26:15):
mirrors, and often social avoidance.
So they might stay at home and notgo into school because their acne
is bad or whatever it might be.
And then they might hide theirskin and believe narratives that
aren't necessarily the case.
So, for example, if they're on a bus,and somebody moves away from them, they
can assume that, that person has movedaway from them because they perceive the
(26:39):
acne and believed it to be ugly and sothey've moved away because of the acne.
So there can be narratives that peopleconstruct which aren't necessarily
at all what was happening in reality.
So it's a pernicious diseaseand it needs to be treated.
And again, I go back to the goldenrule of psychodermatology, which is to
treat the skin disease appropriatelyand to treat the psychosocial
(27:01):
comorbidities at the same time.
So, for milder acne, it's absolutelyright to start treating with topical
agents, and then you step up tosystemic anti-inflammatories, and
you can consider contraceptivemedications, and then you can step up
to other treatments, and eventuallyyou can step up to isotretinoin.
And there is no doubt thatisotretinoin is an effective
(27:21):
drug for the management of acne.
However, we need to be very respectfulof isotretinoin because there is
an association, not a proof, butan association with mood changes
and with changes in impulsivity.
In other words, an association with eitheracquiring or acting on suicidal ideation.
(27:46):
As a consequence, and I think we'vealluded to this, the MHRA and the
British Association of Dermatologistshave made it very clear that we, as
healthcare professionals, need to doa very careful assessment before a
patient goes on to isotretinoin andthen during the isotretinoin treatment.
However, I would argue that weneed to be doing that for all of
our patients with acne anyway.
(28:06):
So we need to be very mindful about thepsychosocial comorbidities, whatever
the patient, whether they have mild acneor moderate or severe acne, remembering
that, and we talked about this earlieron in the podcasts, remembering that
disease extent does not necessarilycorrelate with psychosocial comorbidities.
Sure, yeah.
So for all of these treatmentsand for the patient, we need to be
(28:28):
respectful about what's going on.
And if a patient does presentwith anxiety and/or depression
together with, in this case acne,then that becomes the co-priority.
So the skin and the psychosocialcomorbidities becomes the
co-priority at that point.
Well, that's the, the unholytrinity, the atopic dermatitis,
(28:48):
the acne, the psoriasis.
But again, thinking of patients I'veseen in the last few days, alopecia
areata, mustn't forget that one.
And if ever there's a condition wherethere's often such a clear link between
stressful life events and the onset,or worsening of, alopecia then, in my
(29:11):
book, there are very few worse than that.
And I'm sure you've seen that manytimes in your practice, George.
I have, yes.
And the fairly sudden appearanceof patches of hair loss on the
scalp, it's so visible, isn't it?
Yeah.
And no surprise, it can havequite a dramatic impact.
And that's borne out by studies.
(29:32):
A study looking at people with thiscondition in 2022 found that they had a
38% higher risk of depression and a 33%higher risk of anxiety, as well as needing
more time off work, and unemployment.
Alopecia areata, as we all know,often affects young people, and
(29:53):
the relapses are unpredictable.
And, in our society, where hair playssuch a critical role, and Roger, I
think you and I both agree that'ssomething we're painfully aware of.
Significant patches of hair loss canhave a potentially devastating impact
on self-confidence and mental wellbeing.
(30:14):
Almost certainly, stress playsa role in causing relapses.
So a vicious cycle can rapidly develop.
A study in 2023 showed that a history ofmajor depressive disorder increases the
risk of developing alopecia areata by 90%.
And alopecia areata increases riskof major mental illness by 34%.
(30:37):
Yeah.
Mustn't forget rosacea here.
As we all know, permanent backgroundredness of the face is its hallmark
and you can get really sudden,unpleasant, embarrassing facial
flushing, plus inflammatory patterns.
You get the red angrypimples and the pustules.
And again, if you haven't listened tothe podcast that George and I did on
(31:00):
rosacea, then do go back and have a listenbecause we covered this in great detail.
But obviously there's no doubt it canhave a major impact on self-esteem,
increase the risk of depression oranxiety, and I suspect Tony, this
might be why you've recently donequite a major body of work on this.
Is that correct?
Yeah, that's right, as it's common,you know, Roger, that's the thing.
(31:21):
It's such a common condition.
And, and also, it'sactually quite symptomatic.
So patients talk about the flushingand the heat and the stinging and
the burning sensation that they get.
And in terms of psychodermatology, oneof the things that they particularly
allude to is the absence of control.
(31:43):
You know, "I've taken the diet, I'vestopped alcohol, I don't go to, steamy
places, I don't sit in the jacuzzi.
Why is my skin doing this to me?"
And so the out of control sensationcan also contribute to that.
So with rosacea, again, we start talkingabout making sure that we recognise the
(32:03):
physical, issues, and the physical issuescan be different for different patients.
It can be the papular rosacea, andthen we need to treat that with
anti-inflammatories, or it can be theerythrotelangiectatic form of rosacea,
where there is persistent redness,and that can be fixed redness, or it
can be flushing and then, relativepallor, relative lack of flushing.
(32:27):
And it can be the symptoms thatgo with that, and sometimes if
you have quite extensive disease,it can become more phytomatous.
In other words, you can get sebaceoushyperplasia, which can involve, you know,
the nose and various parts of the face.
So rosacea, again, quite a perniciouscondition, and again, I allude back to the
golden rule of psychodermatology, whichis to treat the skin and psychosocial
(32:48):
comorbidities at the same time.
Now, the psychosocial comorbiditiesfor rosacea are really around
the out-of-controlness, theanxiety and/or depression, but
also it's about the symptoms.
So it's about recognising, andnot dismissing, the symptoms
of rosacea, the flushing, theburning, the soreness, and so on.
(33:09):
So treating that as wellas the rosacea itself.
So that's all really quite important.
Of course, in our society, having ared face has all sorts of connotations.
People assume, or the patient imaginespeople assume, that it's because
you've been drinking too much alcohol.
And we are aware that alcohol canbe one of the triggers for a flush.
(33:31):
Although, in my experience, it'snot the most important by any means.
I think it's ultraviolet light andit's stress and embarrassment and
temperature changes and foods, and things.
And I, when I ask about triggers, Ialways put alcohol at the very, very
bottom of my list, partly because I'mconscious that my patients probably think
that if they come in with a face that'sa bit red, I don't want them to think
that I'm assuming they're alcoholic.
(33:54):
And those value judgements andthose narratives, those myths that
come into patients' experiencecan be really destabilising.
Absolutely, yes.
So, uh, we know that kind of, that, kneejerk response to think, oh, well, you've
got rosacea, do you drink too much?
It can be really unfortunate.
Terrible isn't it?
But it's not just in rosacea,it's also in other conditions.
(34:17):
For example, like, vitiligo.
There can be narrativesthat come into vitiligo.
Oh, well, you know, you've got vitiligo,because you've eaten the wrong foods,
you've eaten, there is a narrative around,which is incorrect, that you get vitiligo
from eating fish and dairy together.
And there is, misperceptionsabout the absence of pigmentation.
(34:40):
So, you have vitiligo.
In fact, people can mistakethat for being something else,
like leprosy, or it could...
Yes, yes, I've heard that.
...be other conditions or an infection.
So people, other people, andin fact patients, can construct
unhelpful narratives that, thatadd to their burden, if you like.
(35:00):
And it is important for us, as healthcareprofessionals, to say, "okay, what do
you understand by rosacea or vitiligo?
What do you think is going on?"
And give the patients an opportunityto say, well, I have heard such and
such, or I wondered about whetherthis was some kind of punishment, some
kind of, I don't know, supernaturalpunishment for not living my life...
(35:21):
Retribution, yeah.
...as well as I should do.
Yeah.
You're then in the opportunity to say,okay, well, actually, the facts, the
science behind this is that rosacea,for example, is caused largely by
vasodilation, and nerves within thecutaneous microvasculature that allow
vasodilation and actually it's largelygenetic, it's just the way you're made.
But, we can treat this and we cantreat this and the psychosocial
(35:44):
comorbidities at the same time.
Well running through this long listof skin criminals that can impact
on our patients' mental health.
Vitiligo and birthmarks areperhaps two that I'd thought
about, that we mustn't forget.
Again, exactly becausethey can be so visible.
(36:05):
And unfortunately, if you have someonewith a very significant birthmark
on their face, for example, or abig patch of vitiligo, you do see
other people just staring at themand it's a horrible thing to see.
So George, I think just touchingbriefly on, on these two, vitiligo
(36:26):
and birthmarks, we do have some workshowing just how much they can impact
people's mental health, don't we?
Yes, and there should be nosurprise to us whatsoever.
They are very often on the face andvitiligo, particularly in dark skin.
If someone's got dark skin, the patchesof total depigmentation are quite
(36:46):
dramatic and dramatically disfiguring.
And a study in 2021 showed 76% experiencedstress, 78% anxiety and 80% depression,
which they attribute to their vitiligo.
Very high figures indeed.
It's a disfiguring condition.
(37:07):
Regarding birthmarks, especiallyon the face, things like port
wine stains I'm thinking...
Yep.
...those can be really devastatingand very hard to manage as well.
Again, it's hardly surprising peopleaffected by this would have an impact,
marked impact on their mental health.
I'm sure this isn't a comprehensive list.
There are many other things, but whatwe've tried to pick out is some of the
(37:27):
more obvious things that we can thinkof that involve the visible areas,
because they're going to have a biggerimpact, but it's also genital areas.
If you've got disease in the genitalarea, then that can inevitably have a
big impact on people's relationships.
And they may not want todiscuss that with you.
They will disclose it.
We may need to be quite sensitiveand even ask some very open,
(37:50):
careful, open questions to definejust how much trouble it's causing.
So for example, psoriasis commonlyinvolves the genital area, but other
conditions, like lichen sclerosus,which we could cover in another podcast
perhaps Roger, can be very itchy andyou can imagine how awkward it is
if you've got an itch in that area.
Society doesn't think it's acceptable.
(38:10):
It might be acceptable to scratchyour elbow, but it's not exactly
acceptable to grope around inyour groin and scratch there.
And what I would say is that it's reallyimportant that patients don't suffer in
silence and it's really important thatwe as healthcare professionals fully
weight the experience of the patient.
You couldn't have said a more importantstatement right at the end there.
(38:34):
We so endorse that.
That, one, you're not on your own.
Two, you shouldn't suffer in silence.
You must make this the purposeof coming to talk to a healthcare
professional, seek help.
And then for physicians, in our nextpodcast, we're going to reflect on
our approach, how our approach canbe improved and how we should be
(38:55):
looking at helping our patients.
But Tony, thank you so much.
I have learnt so much from you, asI always do, when I'm at your knees.
And it's been absolutely brilliant.
And I'm sure Roger will endorse that.
Absolutely.
It's been wonderful, Tony.
It's been an absolute delight and thankyou so much for your time with us.
Thanks, guys.
Always a pleasure.
Well, I do hope that you found thischat with myself, George and Tony about
(39:20):
skin and mental health interesting.
And as always, our thanks dogo to our wonderful guest, Tony
Bewley, for all his help with it.
Now next time, we'll discuss a fewconditions where the skin can be the
presentation of a mental health condition.
But we have discussed some prettyshocking facts and statistics.
One of the things that Tony highlighted,which in fact I took home, was that
(39:43):
if you can control the skin condition,so for example, if you've got eczema
and you use emollients properly,and you manage the eczema well, then
that's going to be the best treatmentfor any mental health complications
that the eczema might have caused.
Same with acne, the same with psoriasis.
So managing the skin condition reallywell is very, very important here.
(40:06):
But we've been really honoured tobe joined by Tony for this episode.
It's been absolutely brilliant.
And once again, thank you so muchfor your expertise and wisdom.
And we really are looking forward toyou joining us for our last podcast in
this series next time, where we'll bediscussing how the medical professions
can help patients with these problems.
So Roger and I do hope you will joinus for the next podcast, and we'd also
(40:28):
like to thank our sponsor, AproDerm®,for all their help in putting these
Rash Decisions podcasts together.
We couldn't have done it without them.
And don't forget, do get in touch.
We love to hear your feedback,or rate and review us.
It really does help us inputting these podcasts together.
But until the next time,it's goodbye from George.
(40:48):
Goodbye.
And as always, it's goodbye from me.
Goodbye.
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