Mental Health (Part 2) - Think skin, think mental health

These are often worst, by stress, but perhaps maybe look at atopic dermatitis first, because that is a real currency in our practice. Hello and welcome to this Skin Deep podcast where we look at skin related issues, conditions and treatments in an interesting and informed way. I'm Dr Roger Henderson. I'm a GP with a long-standing interest in this particular area of health.

So today, we'll be delving into a few specific skin conditions, and sharing with you some pretty dreadful statistics around how they can affect your mental wellbeing. We're also honoured to be joined once again by our very special guest, Professor Tony Bewley, a world authority in this area of skin and mental health. Now George, we both know just how much someone's mental and physical health is intrinsically linked.

And being both visible, and a very large organ, skin diseases can have a massive impact on someone's quality of life, especially when areas such as the face, the hair, or even the genitals can be involved, can't they?

But focusing on the mental health consequences, there have been a large number of studies looking at this, and they have found truly alarmingly high figures for the impact it's having. For example, 80% of teenagers have avoided at least one everyday activity because of their atopic dermatitis. People describing having a negative impact on their schooling, hardly surprisingly, and 40% reporting that they are teased or bullied because of their eczema.

Also, these studies have shown, I think, very high levels of depression, doubling the risk, and a four-fold increased risk of suicidal ideation, thinking about suicide, because of your atopic dermatitis. What I think is really important and very interesting, is that by controlling the eczema, those figures can return to normal. A very important study by the National Eczema Society showed some very interesting figures.

They looked at 500 children, with atopic dermatitis and 500 adults with atopic dermatitis, and they found that three quarters said it had a negative impact on their mental health, and two thirds felt socially isolated, because of their eczema. One of the things I think is really important for the medical profession to take on board, is that a third of the patients were saying that they felt that their healthcare professional had not appreciated the impact it was having.

So that's something that we need to take on board, Roger, and the profession needs to think about that.

This was a meeting of dermatologists, and despite that, we all assumed he would choose one of the first three major conditions. I was thinking, I'd hate to have heart disease and angina, type 2 diabetes, that brings so many problems, and asthma, that must be so awful not to be able to breathe, and frightening. So I was thinking he'd be one of those three. But he went on, "...it would be my psoriasis." Everyone in the audience was as stunned as I was.

But he went on to describe how embarrassing it was, especially when he was staying away from home, and in the morning his bed was covered in blood, where he'd been scratching all night. How he had taken to packing a small Hoover in his overnight bag to cope with the scale he shed on the carpet. And how he had abandoned going to any public swimming pool because of the ignominy of being asked to leave the pool because people didn't like the look of his skin.

Psoriasis had interfered with every aspect of his life. And we know from studies, that 80% to 90% of patients have experienced discrimination, or even humiliation, because of their psoriasis. And it affects, intimate relationships in particular, but ordinary relationships as well are affected in a large number of patients with psoriasis. So it affects every aspect of everyday life.

Another big campaign, the 'See Psoriasis: Look Deeper' campaign, which was actually about 10 years ago now, they highlighted these issues and they quoted figures of 77% of patients reporting it impacted things in everyday life. And it's more likely you were taking an antidepressant because of psoriasis, and about a third of patients have depression or anxiety. It's a really big area of mental health illness if you've got psoriasis.

And if we can dig really deep into our memory banks, George, and think as way back into our teenage years, you want to conform, you want to be the same, you want to be part of the club. And if you're different, and acne makes you different to a lot of your peers, then it can be devastating for you. It's devastating anytime in someone's life. And unfortunately, I think it can be sometimes trivialised because it's so common.

It can be almost considered as normal, but it's a painful condition sometimes, and it can have really severe consequences on self-esteem, relationships, mood, for sure, and even career choices and career opportunities. And there's a lot of chatter about the use of particular drugs, and I'm thinking of isotretinoin here, and suicide risk. And it's a bit of a thorny issue, but it really does work.

And, yeah, there are very legitimate concerns about isotretinoin, which have been highlighted in a recent guidance from the MHRA, who basically control the licensing of products. And they highlight, in particular, the need to be very careful about mood and suicidal thoughts in the under 18 age group, because there have been reports of patients on this drug committing suicide.

However, we all know that isotretinoin is the best possible treatment for acne, and we just need to be very sure that we're careful how we prescribe it and we monitor our patients, to make sure that if they are getting any drop in mood that we're ahead of the game, and we're looking out for that. But, a report in the BMJ, in 2019, concluded that patients with bad acne, who are depressed, deserve the best treatment. So even in that situation, isotretinoin should be considered.

And more recently, we've had a big paper that looked at these risks in a bit more detail. And because antibiotics, whether by mouth or on the skin, aren't that effective, and therefore leave the acne relatively under treated, they are associated with a higher risk of depression and suicide than isotretinoin. So I'm not trying to say that isotretinoin isn't at risk, I'm just saying that it needs to be prescribed very carefully.

We need to be thinking about how we're prescribing it and monitoring it very carefully. But because it works so well, it's something that I think still has a very important place, particularly in patients who've already got depression from their acne. So it's a very complicated issue, and I wonder, Tony, do you have any particular thoughts here?

Professor Anthony Bewley: Yeah I think acne is a very interesting inflammatory skin disease because it affects usually such a vulnerable population, the adolescent and younger adult population, and that's relevant. We also know that acne can be associated with body dysmorphic disorder. So if you have a visible difference on your skin, it's not surprising, especially in that age group, that some patients feel the other symptoms of body dysmorphic disorder.

What do I mean by body dysmorphic disorder? A degree of social avoidance. So not going out. A degree of recurrent thoughts, recurrent worries, concerns about the appearance of the skin and overstated kind of concern about any changes on the skin, whether it be the acne itself, or whether it be the consequences of the acne in terms of the pigmentation, or the scarring. So, we know for sure that some patients with acne also can shift into body dysmorphic disorder. Several things about acne.

First of all, it's really important to treat the acne and treat it appropriately. And that can be with topicals, with medication systemic medication, which can be antibiotics or it can be... So by mouth, yes.

Have you even felt so wretched that you'd consider ending your life or committing suicide?" And we want to do that for all of our patients with acne. And if the patient is fine and happily the vast majority of patients are absolutely fine, then we can think, okay well, that's fine. We're going to proceed, but we're still going to be mindful about the psychological consequences. And if it's not fine, then we need to address that absolutely as a priority, as well as the acne.

It goes back to the golden rule of psychodermatology to treat the psychological comorbidities and the disease at the same time and comprehensively.

Professor Anthony Bewley: And it is really important that throughout the treatment, with isotretinoin, we do need to monitor very carefully the psychological comorbidities of the patient. So, we do need to monitor throughout the treatment and after completion of the treatment.

And the MHRA the regulatory bodies within the UK and the British Association of Dermatologists have just recently issued guidelines about how, we as dermatology healthcare professionals can safely monitor, and that's guidelines issued together with the approval of the Royal College of Psychiatrists, how we can monitor patients and how we can signpost and manage patients who do have more of the more serious psychological or psychiatric comorbidities of living

with this disease and its consequences. Another condition where loss of control is a big part is rosacea. Here patients can suddenly flush, and blush, and there's a difference between those two. And they get pimples and pustules on their face, and it can certainly not look attractive if it's severe. So again, can have a big impact on someone's mental health and wellbeing and self-esteem. Professor Anthony Bewley: Yes, that's right.

So, for patients who have rosacea, it is often the flushing and the redness and the flushing can, as you alluded to, be completely involuntary. It seems to happen at the most inopportune times. Or it can be fixed and look like a ruddy face. And patients really don't like that at all.

And again, it goes back to the treatment of how do we best control this and how do we manage the psychological consequences of living with that kind of flushing propensity, that likelihood to get that flushing, and it is at least partly genetic. So some people are more likely to get this than others and it, itself carries a certain stigma because there are people around who don't understand rosacea.

And they think, "oh that's because this guy drinks too much alcohol, or this lady drinks too much alcohol." Or it's their fault because of whatever it might be. And that's absolutely not the case. So there are stigmas and associations and myths that patients with rosacea have to deal with, as well as living with their skin condition. And the sense of being not in control of the flushing the blood vessels in their face.

And we could go through the whole textbook of dermatology and I could pick out every single disease that's visible, but there are a lot of conditions that I think just deserve to be mentioned, but not necessarily explored in detail so for example vitiligo or birthmarks or burns an enormous number there and often there isn't a huge amount that can be done to control the disease.

There are fantastic treatments coming along for vitiligo and some of the alopecias, but I think maybe in this situation signposting can be as helpful, obviously acknowledging it, empathising, listening, but signposting can be probably one of the most useful things we can do. Professor Anthony Bewley: Yes, that's absolutely right. It goes back to our previous conversation about, "please don't suffer in silence" because there are treatments that are being developed, year in, year out.

So what was available a couple of years ago is likely to be out of date or could be out of date and there might be newer treatments. And certainly there are newer ways of applying older treatments as well. There are lots of things that can be done. Yes. Vitiligo is a condition where you get patches of complete loss of pigmentation. And that commonly affects the face and the hands, two very visible areas.

And uh, it's particularly a problem if you've got dark skin, the contrast can be very dramatic and someone can be very aware of it, and of course people will stop in the street and notice it, it's the first thing they might notice about somebody with this condition. So stigmatisation and other problems it regularly causes and the studies again support that showing extremely high levels of anxiety, depression and stress. About four out of five patients, with this condition have talked about that.

Professor Anthony Bewley: With things like vitiligo, where there is a visible difference that can lead to senses of change. It can lead to senses of change of your own identity, and it can lead to senses of change in terms of your ethnic identity too. So there are organisations which champion the patient at the centre of this, experience, which can take patients through choices about how they can manage their skin and choices about how they can learn to live with their skin changing in this way.

For example, there is an organisation called Changing Faces, which champions this. And they can be really useful. They can signpost people towards having camouflage to cover over areas, that are of a different skin tone, or they can encourage patients to live with it or to change how they perceive their body. And happily there are a growing number of celebrities that have vitiligo and are explicit about having vitiligo.

There are models and singers and so on who are saying, this is the way my body is. And actually that's the way it is and I quite like it like this, which I really encourage. So whenever I talk to medical students or patients, I always ask the audience, okay, "who here is totally happy with their body? Who here is totally happy with their body?" And you can guarantee that of an audience of about a hundred, one or two people will put their hand up.

So I look forward to the day, when everybody puts their hand up and says "I'm totally happy with my body." Awfully long way from there but I look forward to that day. There are just a few other conditions I think of when I'm considering that a skin condition can affect someone's mental health more than perhaps one would expect and one of those is alopecia areata. This is a situation where patients often without much warning can have a patch of hair loss, usually on the scalp.

And it can be very severe and go on until you just get a few patches of hair left and it can look very devastating and this occurs in young people. So it's hardly surprising that this can have a huge impact on their mental wellbeing. And we see figures of two out of five people with this have depression and the same sort of number also suffer with anxiety. And it can result in a lot of people losing time off work and even unemployment.

As I said, it's a condition that affects young people, and it's unpredictable, and it's the unpredictability that is one of the problems for it. And in our society, where hair plays such a critical role, and I think that's something Roger and I are probably very sensitive to, but having a patchy hair loss is so much more devastating.

And it works both ways because we know that if you've got mental problems already, if you've got a history of depression or stress, then that can aggravate and cause alopecia areata. So another condition that we need to be alert to. And very aware of, and remember to ask how it's affecting someone's mental wellbeing. And if your doctor doesn't do that, make sure that you raise it with them and discuss it with them.

It should come as no surprise that if you've got a birthmark on the face, sometimes called a port wine stain, that will be hugely awkward for the patient for the rest of their life. And the only way they can handle it often is with camouflage. But it can also cause the tissues underneath to become thickened, and so even more hard to mask that and hide it. Not surprising, that too can have a really important impact.

So we've highlighted just a few conditions, eczema, psoriasis, acne, rosacea, alopecia areata, vitiligo, birthmarks. There are many more that we could have talked about, but these are the ones that we feel are the most likely to cause disturbance to someone's mental health. And I think if your doctor isn't aware of it, or you feel your doctor's not aware of it then you should definitely take the opportunity to go and talk to them and say, "help me. It's not just my skin problem.

There's me as well." And ask where you can go for further help, what resources are out there. There are other mental health conditions that can present to dermatologists, I'm thinking, for example, the person who comes to see us, convinced that they've got bugs living on their skin, and the evidence for that is challenging to confirm.

Um, or the patient who picks at their skin to the point at which it is seriously damaged and they are convinced that there's an underlying skin condition, but the pattern doesn't fit in with anything that the books would suggest is due to a skin disease, it's because they are picking it, burning it, cutting it, doing it, because they have such underlying severe anxiety and stress and trauma mentally. That this is their way of seeking help.

Do you want to say any particular words on those sorts of conditions? Professor Anthony Bewley: Yeah. So we're alluding to two things here. We're alluding to a series of conditions which are called persistent delusional disorders. So patients who have some, belief system about their skin. I've got a patient or I've had a patient who believes that various aspects of the face are moving around of their own accord and there is no evidence for that.

So these persistent delusional disorder changes, or it can be a patient who experiences material growing within their skin. We definitely always take the patient seriously and we... So important. Professor Anthony Bewley: ...look to see if there is any reason, any organic reason, any foundation for that experience. And sometimes there is, and we must always put the patient at the centre of any choices.

If there isn't a foundation for that, then we have to negotiate with the patient about how we can get rid of the sensations of the skin and try and get them better because the whole experience of living with these problems can be so debilitating and repeatedly patients go and see healthcare professionals and they're dismissed, "this doesn't seem to be anything that I recognise" and they're dismissed.

So it's really important that we do embrace the patient as best as we can and say, "okay, I fully understand that this is a real problem for you and I'm going to manage this as best as I can and let's see if we can work together about that." Fantastic. Thank you.