Two months ago in Hong Kong, a 23-year-old woman was reportedly so tormented by chronic eczema that she killed her parents, then herself in an act that brought attention to the stress of living with a life-long skin condition.
This is not the first case in which the psychological distress of living with a skin disorder has led to suicide, but it is not the norm.
Anxiety and depression are far more common, shows a study of psoriasis patients published online in July in the British Journal of Dermatology.
Of 59,961 patients with psoriasis, researchers from the University of Manchester in the United Kingdom found a lower suicide risk in people with psoriasis as compared to a control group of 876,919 patients without psoriasis. However, the psoriasis group had a higher prevalence for having a history of alcohol misuse, bipolar disorder, depression, anxiety disorders, self-harm, and having psychotropic drug prescriptions.
The risk of suicide was found to be lower in psoriasis patients who were older than 40 years old. For patients younger than 40 years, the risk of suicide was not any better or worse than the control group, but there was a slight increase in self harm.
For some patients, a skin condition can become so unbearable, they request euthanasia as in the case of a patient treated by Michael J. Cork, M.B., Ph.D., of the University of Sheffield in the United Kingdom.
Dr. Cork treats some of the most severe cases of atopic dermatitis in the U.K. In 2016, he treated a young woman with atopic dermatitis who was so severely depressed, she requested euthanasia. Prior to seeing Dr. Cork she was treated with oral steroids. She attempted to enroll in a dupilumab trial, but wasn’t eligible.
“So I met the CEO of Regeneron and showed him her pictures and how desperately ill she was. He gave her immediate approval for compassionate use. It was four weeks before Christmas when she started dupilumab and by Christmas Eve, she was completely transformed,” Dr. Cork said.
PSYCHOLOGICAL BURDEN OF DISEASE
The psychologic burden of skin disorders has been documented in many studies. A review published in June in the journal Skin Pharmacology and Physiology, shows that approximately 30% of patients with skin disorders suffer from a psychological condition, such as anxiety and depression.
In one study cited in the review, of 3,207 patients with hidradenitis suppurativa (HS), 42% suffer from depression. Another study of 154 patients with HS reported 35% having depression or 21% having depressive symptoms.
Several studies cited in the review reported high rates of suicidality among patients with atopic dermatitis and HS. But among psoriasis patients, a 2017 systemic review published in the American Journal of Clinical Dermatology found no increased risk of suicide, but that study was deemed to be of low quality.
Adults with atopic dermatitis are 2.24 times more likely to suffer moderate depression and 5.64 times more likely to be severely depressed compared to adults without the disease, shows a clinical research letter published in 2015 in the Journal of Investigative Dermatology.
A 2015 article published in Medicine showed that in children, there is a dose-dependent relationship between atopic dermatitis severity and psychological distress. Adolescents with atopic dermatitis were more likely to suffer suicidal ideation than healthy teens.
HOW UNTREATED SKIN DISEASE CAN AFFECT THE BRAIN
Dr. Cork and colleagues are conducting research that examines the “atopic dermatitis psychiatric march,” which explains how untreated atopic dermatitis can affect the brain, leading to mental health disorders and suicide in severe cases.
“From a biological perspective, we suspect mental health disorders, like depression and anxiety, are related to atopic dermatitis because the inflammation in the skin alters the neurotransmitters in the brain,” Dr. Cork said. “There’s very good data in rheumatoid arthritis that the inflammation affects the brain. We’re basically proposing the same occurs in atopic dermatitis.”
Other researchers have explored this theory in dermatology. Writing in the June 28 online issue of Skin Pharmacology and Physiology, Farzanfar D. et al. wrote, “The potential relationships between cutaneous inflammation and central nervous system contributions form a chronic feedback loop.”
There are a number of underlying shared mechanisms between severe atopic dermatitis and psychiatric disorders, including genetic associations, stress, inflammation, sleep disturbance and environmental factors, according to Shatha Shibib, M.B., Ch.B., a child and adolescent psychiatrist at Sheffield Children’s Hospital NHS Foundation Trust in the United Kingdom. Dr. Shibib has a special interest in psycho-dermatology and is an author on the atopic dermatitis psychiatric march study with Dr. Cork.