Psychological sequelae relate to skin diseases

London - When patients present for dermatologic care, clinicians should keep in mind that poor self-esteem may be an underlying catalyst prompting the visit, according to Anthony Bewley, M.D., who spoke at the annual meeting of the European Academy of Dermatology and Venereology (EADV).

"Body image is one of the first things that is compromised in individuals with alterations in self-esteem, and so it is important to explore whether patients seeking care for a problem involving the skin are really bothered by an issue that is more than skin deep," Dr. Bewley tells Dermatology Times.

Dr. Bewley, a consultant dermatologist at Whipps Cross University Hospital in London, explains that concepts of body image are referenced internally as well as externally and are influenced by current social norms. However, individuals may have their own sets of ideas.

Currently, fueled by the interests of the aging baby-boomer population, there is a focus on maintenance of a youthful appearance. As the men and women who comprise that generation are passing through their 50s and reaching 60, they are esteeming youth and seeking interventions that can help them look and stay young.

"For persons seeking aesthetic surgery for age- and photo-induced skin changes, it is extremely important to first investigate issues about body image. That is not to say surgery should be withheld, but rather that self-esteem needs to be evaluated and managed as a priority," Dr. Bewley says.

Self-esteem issues are also a consideration for patients with disfiguring skin disorders and the impact of such dermatologic diseases can vary widely and in ways that are not predicted by disease severity. For example, while there are some patients with extensive psoriasis who cope without emotional or functional impairment, others with mild, localized disease will be greatly hampered in their interpersonal and social interactions.

"It is well documented that for some patients with inflammatory skin diseases, particularly eczema, psychotherapy has benefits not only for addressing the individual's emotional needs but can also be associated with skin improvement. Those observations lend support to the idea that stress is a trigger for some inflammatory skin disorders," Dr. Bewley says.

Investigating whether patients are affected by issues relating to body image and low self-esteem depends first on getting them to identify if they find anything disfiguring about their skin, and if so, what that is. Then it becomes possible to delve deeper to assess the severity of the impact and what can be offered in terms of psychological and/or medical interventions to improve their outlook.

Simple questionnaires

There are some simple questionnaires available that can be used to evaluate body image and self-esteem. For the dermatologist, however, success in exploring these problems and addressing them is also influenced by time constraints and training. Dr. Bewley notes that he has some advantages in that regard as he has some experience in psychotherapy and works in a clinic where a psychiatrist is also on staff. Nevertheless, for dermatology specialists in the United Kingdom, there is often not enough time available to thoroughly address the psychological dimensions of dermatologic disease.

"Assessing and addressing self-esteem issues is a complex and time-consuming endeavor and some practitioners simply do not have the necessary training or schedule. Therefore, patient referral to a dermatology colleague having the appropriate expertise, a counselor, or a psychiatrist liaison can be an important alternative," Dr. Bewley says.

He adds that patients who are referred may misinterpret the recommendation as a sign the physician considers them mentally ill.

"Make sure that patients don't leave your office with the impression you regard them as crazy. Reiterate to them that the support of others is thought to be in their best interest for helping them with their emotional and dermatologic needs," Dr. Bewley says.