Analysis

Common but crushing: how skin conditions can affect mental health

The resources and information you need to support patients coping with ‘just a skin condition’

With the right resources, nurses can improve quality of life for patients coping with just a skin condition

  • Healthcare professionals and patients often downplay or underestimate the seriousness of skin conditions, experts say
  • Some patients may see their disease as just a skin condition and not seek further treatment
  • How wider understanding of the mental health impact of common conditions, as well as possible treatments, can lead to vast improvement in patients quality of life

The mental health impact of living with skin disease is not widely recognised and understood by nurses and other healthcare professionals,

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With the right resources, nurses can improve quality of life for patients coping with ‘just a skin condition’

  • Healthcare professionals and patients often downplay or underestimate the seriousness of skin conditions, experts say
  • Some patients may see their disease as ‘just a skin condition’ and not seek further treatment
  • How wider understanding of the mental health impact of common conditions, as well as possible treatments, can lead to vast improvement in patients’ quality of life
Greater understanding is needed of the emotional impact of common skin conditions such as acne, experts say Picture: Shutterstock

The mental health impact of living with skin disease is not widely recognised and understood by nurses and other healthcare professionals, research suggests.

The report from the All-Party Parliamentary Group on Skin (APPG), published in September 2020, highlights among its findings a lack of education and training for healthcare staff on the issue.

Patients frustrated by lack of psychological support

Among 544 patients with skin disease surveyed by the APPG, almost all (98%) reported that their condition affected their emotional and psychological well-being.

Experiences of isolation, embarrassment, shame, depression and anxiety appear to be commonplace, along with stigmatisation, discrimination and a lack of social acceptance.

1 in 5

people with a skin condition receive psychological help

Source: All-Party Parliamentary Group on Skin

More than 5% of people surveyed reported having had suicidal thoughts linked to their skin condition.

‘I sometimes think “what is the point of living?”. The condition exhausts me,’ wrote one respondent with eczema.

However, just one in five (18%) reported receiving some form of psychological support, with many saying they felt ‘desperate’ and ‘frustrated’ at being unable to access the help they needed.

‘I have not been made aware of any psychological support by [my] NHS dermatologist,’ wrote a respondent with psoriasis. ‘I have broken down in tears at so many of my appointments.’

More than half the population will experience a skin condition in any given year

These findings come as no surprise to Lucy Moorhead, a nurse consultant in inflammatory skin disease at St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London, and a trustee of the British Dermatological Nursing Group (BDNG).

‘There was a previous report [in 2013] that was quite similar – so it’s a shame that not much has changed,’ Ms Moorhead says.

‘It should be part of holistic personalised care with any chronic condition to work out whether the patient’s mental health is impacted by their disease’

Lucy Moorhead, nurse consultant in inflammatory skin disease, St John’s Institute of Dermatology, London

According to the latest report, in any given year, more than half the UK population will experience a skin condition and approximately a quarter will visit a GP as a result.

There are around 2,000 possible skin diagnoses, ranging from mild to severe and life-limiting. The most common presentations are inflammatory skin conditions such as eczema, psoriasis and acne.

Eczema is one of the most common presenting skin conditions Picture: iStock

Perhaps because they are so common, skin diseases are often not taken seriously enough both by health professionals and by patients themselves.

‘If you talk to anyone, I think they realise that healthy skin and our appearance obviously impacts our mental health, but that doesn’t always seem to translate or be given high priority across all settings,’ Ms Moorhead says.

‘The [APPG] report found that there was a lack of education across the board for healthcare professionals, although there are some established pathways and guidance.

‘It should be part of holistic personalised care with any chronic condition to work out whether the patient’s mental health is impacted by their disease – and dermatology conditions are chronic health conditions.’

How to offer mental health support to patients with skin conditions

Lucy Moorhead, nurse consultant in inflammatory skin disease at St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London, has the following advice for nurses:

  • First, ask patients how they are feeling Simply say ‘how does your skin affect you?’ and give them the chance to respond
  • Be open to verbal and non-verbal cues For example, someone might say they are fine, but avoid making eye contact
  • Know your local patient pathways and if appropriate, use validated screening measures for depression and anxiety (such as PHQ-9, GAD-7 tools or distress thermometer)
  • Be aware of IAPT – the Adult Improving Access to Psychological Therapies programme, where in some areas patients can self-refer but in others they must be referred by primary care
  • If you suspect a patient may be suicidal, don’t be afraid to ask explicitly Know what to do in terms of escalation if a patient expresses thoughts of suicide. It can be a difficult topic to raise, but if a patient says yes, then you can get them help as soon as possible. The Samaritans can be reached on 116 123 or jo@samaritans.com
  • Recognise the impact that skin conditions can have on patients’ families Parents in particular can feel very ‘judged’ if their child has a skin condition, and may also be dealing with issues such as sleep deprivation and stress

Psychological and emotional support for patients

Ms Moorhead, who represents the British Dermatological Nursing Group on the APPG, believes more education and training is required across healthcare, including those working in specialist and non-specialist services.

Lucy Moorhead: Biologics can transform patients’ quality of life

‘Dermatology is something that you often touch on, regardless of your specialty, and it’s a huge part of primary care as well,’ she says.

‘It’s not just about having specialist psychodermatology services, although more of them are needed. Each service needs to integrate some aspect of mental health support into their care.

‘Psychologically and emotionally supporting your patient should happen across the board, and should start at the beginning of nurse training.

‘That’s true for all conditions, of course, but in dermatology you should always be considering the mental health and emotional impact of the skin disease on the patient and their family.’

Psychodermatology addresses the connection between skin health and mental well-being. The British Association of Dermatologists describes psychodermatology as the treatment of skin disease using psychological techniques. It typically complements physical therapies that treat the cause or symptoms of skin disease.

Examples of techniques include mindfulness, to reduce stress or anxiety, and habit reversal, for example, related to scratching or skin picking.

Where to access psychodermatology training and resources

The All-Party Parliamentary Group on Skin report suggests psychodermatology training and learning opportunities for nurses:

Source: Mental health and skin disease: report of the All Party Parliamentary Group on Skin

More than ‘just a skin condition’

One of the big challenges is that people are often only referred to specialist services quite late in their disease progression. There’s also a lack of awareness of what modern treatments – including biologics, which target cells in the immune system – can do to transform a patient’s condition and quality of life, says Ms Moorhead.

Furthermore, sometimes the patient views their condition as ‘not serious’ and doesn’t want to seek further treatment.

‘I’m thinking of one person who was very reluctant to start on any systemic treatment because he felt it was “just a skin condition” and was worried about side-effects,’ she says.

‘He eventually started on a biologic and his whole personality changed when he didn’t have to deal with it every day.

‘In his case, it was severe psoriasis and it was painful. He was dealing with bloody bedsheets, skin scale, but he didn’t realise how much he was coping with. People often downplay the seriousness of skin conditions, which really doesn’t help.’

In a National Eczema Society survey, the majority of respondents said the condition left them feeling depressed, anxious and socially isolated Picture: iStock

How eczema can affect quality of life, relationships and even careers

The findings of the APPG report chime with research published in September 2020 by the National Eczema Society (NES).

Its Eczema Unmasked patient survey found that 89% of respondents felt that having eczema had significantly reduced their quality of life, with nearly half saying it had affected their education and 28% their career.

One in ten reported having a romantic relationship end due to their condition. Almost three quarters (74%) of adults said it had negatively impacted their mental health, leaving them feeling depressed, anxious and socially isolated.

5%

of people with skin disease experience suicidal thoughts

Source: All-Party Parliamentary Group on Skin

Less than half said they had been offered access to emotional or psychological support.

NES chief executive Andrew Proctor says more needs to be done to help people with skin conditions.

‘The survey findings show how eczema can profoundly affect your physical health, mental health, quality of life and even your life choices,’ he says.

‘These realities often remain hidden or are left unspoken, but people are suffering. The findings on the impact on mental health are really shocking.’

Outbursts and anxiety: the emotional impact of eczema on my family

Specialist community public health school nurse Shal Henry-Treloar witnessed her older son suffering so badly with eczema that he became reluctant to go to school, refused to wear clothing that exposed the scarring, and was embarrassed to have friends over.

Shal Henry-Treloar

The whole experience had a huge impact on her own mental health, as well as on her son.

‘It felt as though I had lost my little boy, as he was becoming really angry and having emotional outbursts,’ says Ms Henry-Treloar, who works in a school health service in Essex, and is a patient advocate with the National Eczema Society.

‘When he took his clothes off there would be a shower of skin flakes, as he was really one big crust. We had to vacuum the bed every morning and he was embarrassed to have friends over because there would be remnants of his skin everywhere.’

Recognising the seriousness of the condition

Ms Henry-Treloar struggled to have her son’s symptoms taken seriously – it was only when he was eventually referred to a consultant dermatologist, who prescribed what she calls an ‘armoury’ of medicines, and later phototherapy, that his condition started to improve.

Unfortunately his younger brother also exhibited signs of serious eczema almost from the moment he was born. Looking after them both took its toll.

Ms Henry-Treloar says juggling a full-time job, caring for two children with a demanding condition, and not having enough sleep led to her being diagnosed with generalised anxiety disorder and being signed off from work.

‘My anxiety at its worst resulted in me spending an entire month in bed, at a time when the boys needed me the most. I would lie there listening to my children crying and feel powerless, as I’d done everything I possibly could and still they were suffering. I would ask myself “What more can I do?” over and over.’

Care for the whole family

The boys, now aged ten and seven, only suffer from occasional flare-ups, although they still have a daily regime of emollients. And Ms Henry-Treloar has recognised that she has to pay attention to her own mental health needs, as well as the needs of her family.

Being referred for cognitive behavioural therapy was a game changer for her. ‘It made me see that I had to stop beating myself up – and began to feel like myself again I was able to go back to work.

‘Crucially, I now recognise that, in order to support my children properly, I needed to also look after myself and I think that’s an important message to all parents out there faced with managing this condition 24/7.’

Holistic nursing assessment: asking simple questions

Cardiff University consultant clinical psychologist Andrew Thompson, a British Skin Foundation spokesperson, says that nurses have an important role to play in identifying patients that might benefit from further assessment and support.

‘Psychological distress often goes unnoticed in this group of patients, so it's important to ask simple questions such as “how much is your skin condition affecting you in your general life?”. It is possible to build very brief screening assessments into routine nursing assessment.

‘Setting up a context whereby patients can share the wider impacts of their skin condition is, of course, part of conducting a good holistic nursing assessment.’

Psoriasis on the scalp can cause scaly, red bumpy patches, silvery-white scales and dandruff-like flaking Picture: iStock

Another brief strategy that nurses can use is to ask a patient to rate the perceived severity of their skin condition on a one to ten scale, Professor Thompson adds.

‘Perceived physical severity can be a good marker of psychological distress, so looking for people that rate the clinical severity more highly than you might expect can be a good indicator that they might be experiencing psychological distress.’

1 in 4

of people with a skin condition who were referred for mental health support waited longer than the NHS 18-week target for the start of this specialist treatment

Source: All-Party Parliamentary Group on Skin

Where more time is available, there are short, standardised measures that can be used, such as PHQ (Patient Health Questionnaire) screeners, he adds.

Other free resources include dermatology specific quality of life measures, which can be used with both adult and child patients, as well as parents and family members.

‘For many patients, having a nurse ask about their condition can be enough to contain their concerns, or if needed, form a starting point for referring on for either secondary care dermatology treatment or/and psychological support,’ he says.

Skin disease: the experiences of patients and experts

Skin disease and mental health is one of the topics due to be covered in a news-style programme being produced in a partnership between ITN Productions and the British Skin Foundation.

More Than Skin Deep will be launched at the British Association of Dermatologists’ annual conference, scheduled to take place from 6-8 July 2021 at the ICC in Birmingham.

The programme will hear from experts, industry representatives and people living with skin conditions. It will also focus on skin stigma, misinformation and the connection between skin and mental health issues.


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