May 20, 2024 • 26 mins
Trigger Warning: In this episode, there is mention of suicide and self-harm, which we appreciate may be disturbing for some listeners. Please listen at your own discretion.
You’re not alone. In this episode Dr George Moncrieff and Dr Roger Henderson are once again joined by Professor Anthony Bewley, a world authority on the link between the skin and the mind, to discuss the devastating statistics that show the impact skin conditions can have on mental health.
The reason you’re not alone? Whether it’s atopic dermatitis, psoriasis, acne or vitiligo (to name a few!), the stats all show alarmingly high levels of stress, anxiety, depression, discrimination and stigmatisation.
The trio are here to remind you...
- Your feelings are valid and should be heard
- Healthcare professionals can help
- Don’t suffer in silence
- Getting your skin condition under control is a huge part of improving your mental wellbeing.
Listen along to feel supported and represented.
Thank you to our kind sponsor AproDerm, who provide a range of emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
Everyone’s skin is unique and what works for one person, may not work for another. That’s why AproDerm has developed the AproDerm Emollient Starter Pack. This pack contains all four of their emollients varying in their formulation, consistency and hydration, giving you the choice to find a routine that suits you.
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We hope you find this podcast interesting and helpful. Please leave us a review or email info@aproderm.com with any feedback on this episode or suggestions on dermatology topics that you would like to hear about in future podcasts.
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.
Dr Roger Henderson (00:00):
Content warning: this podcast discusses suicidal feelings,
(00:04):
which some listeners may find distressing.
Now, we know George, that in oursurgeries, many is the time that we
see patients with skin conditionsthat are worsened by stress.
And it's safe to say that we do havethese two-edged sword skin conditions.
(00:28):
And I'm simply thinking of the bigones, like eczema, atopic dermatitis,
alopecia areata, psoriasis.
These are often worst, by stress,but perhaps maybe look at atopic
dermatitis first, because that isa real currency in our practice.
(00:54):
Hello and welcome to this Skin Deep podcast where we look at skin related
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standing interestin this particular area of health.
Dr George Moncrieff (01:08):
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.
Dr Roger Henderson (01:19):
Now this is the second of two podcasts
on the skin and mental health.
Last time, we talked about how yourskin condition can have a negative
effect on your mental wellbeing, andthat we, as healthcare professionals,
don't always realise this, so we needyou to tell us if this is the case.
One thing that we want to stressis that you are not alone.
(01:43):
So today, we'll be delving into a fewspecific skin conditions, and sharing with
you some pretty dreadful statistics aroundhow they can affect your mental wellbeing.
We're also honoured to be joinedonce again by our very special guest,
Professor Tony Bewley, a world authorityin this area of skin and mental health.
(02:04):
Now George, we both know just howmuch someone's mental and physical
health is intrinsically linked.
And being both visible, and a verylarge organ, skin diseases can have
a massive impact on someone's qualityof life, especially when areas such
as the face, the hair, or even thegenitals can be involved, can't they?
Dr George Moncrieff (02:25):
Yes.
And of course, atopic dermatitis,particularly in children, often involves
the face and the hands, with dry,red, scaly and uncomfortable skin.
But the itch can be relentless andoften disturbs quality of sleep,
not just for the child affectedor the individual, but the family.
(02:48):
And of course, as you know, skincare can consume many hours, as
well as the time taken and thecost of accessing healthcare.
But focusing on the mental healthconsequences, there have been a large
number of studies looking at this, andthey have found truly alarmingly high
figures for the impact it's having.
For example, 80% of teenagers haveavoided at least one everyday activity
(03:13):
because of their atopic dermatitis.
People describing having a negative impacton their schooling, hardly surprisingly,
and 40% reporting that they are teasedor bullied because of their eczema.
Also, these studies have shown,I think, very high levels of
depression, doubling the risk, and afour-fold increased risk of suicidal
(03:36):
ideation, thinking about suicide,because of your atopic dermatitis.
What I think is really importantand very interesting, is that
by controlling the eczema, thosefigures can return to normal.
A very important study by theNational Eczema Society showed
(03:57):
some very interesting figures.
They looked at 500 children, withatopic dermatitis and 500 adults
with atopic dermatitis, and theyfound that three quarters said it
had a negative impact on their mentalhealth, and two thirds felt socially
isolated, because of their eczema.
One of the things I think is reallyimportant for the medical profession to
(04:19):
take on board, is that a third of thepatients were saying that they felt that
their healthcare professional had notappreciated the impact it was having.
So that's something that we needto take on board, Roger, and the
profession needs to think about that.
Dr Roger Henderson (04:33):
We do.
As George said, like atopic dermatitis,psoriasis is really common in our society,
affecting about 2% of the population.
I became so interested in dermatology,because of a patient who presented
to me with psoriasis, and that reallyopened my eyes as to the impact
(04:53):
that a skin condition could haveon someone's holistic lifestyle.
So we mustn't forgetabout psoriasis, George.
And I think you've had some jawdropping moments with people with
psoriasis as well, haven't you?
Dr George Moncrieff (05:05):
I've had many actually, but there's one I vividly
recall, when I was at a, talk at theRoyal College of Physicians in London.
A good friend of mine was giving oneof the main talks, Peter Lapsley, who
sadly, he died about 10 years ago.
And he opened his talk by saying, "I haveheart disease and I've got ongoing angina.
(05:29):
I've also got type 2 diabetes, andI've got some pretty rotten asthma.
Oh, and by the way, I have psoriasis.
If I could be rid of one ofthese wretched conditions..."
This was a meeting of dermatologists,and despite that, we all assumed
he would choose one of thefirst three major conditions.
(05:50):
I was thinking, I'd hate to have heartdisease and angina, type 2 diabetes,
that brings so many problems, andasthma, that must be so awful not to
be able to breathe, and frightening.
So I was thinking he'dbe one of those three.
But he went on, "...itwould be my psoriasis."
Everyone in the audiencewas as stunned as I was.
(06:14):
But he went on to describe howembarrassing it was, especially when he
was staying away from home, and in themorning his bed was covered in blood,
where he'd been scratching all night.
How he had taken to packing a smallHoover in his overnight bag to cope
with the scale he shed on the carpet.
And how he had abandoned going toany public swimming pool because
(06:36):
of the ignominy of being askedto leave the pool because people
didn't like the look of his skin.
Psoriasis had interfered withevery 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.
(07:00):
And it affects, intimate relationshipsin particular, but ordinary relationships
as well are affected in a largenumber of patients with psoriasis.
So it affects everyaspect of everyday life.
Another big campaign, the 'See Psoriasis: Look Deeper' campaign, which was (07:15):
undefined
actually about 10 years ago now, theyhighlighted these issues and they quoted
figures of 77% of patients reportingit impacted things in everyday life.
And it's more likely you weretaking an antidepressant because
of psoriasis, and about a third ofpatients have depression or anxiety.
(07:36):
It's a really big area of mentalhealth illness if you've got psoriasis.
Dr Roger Henderson (07:42):
That's two of the big three, psoriasis and atopic
dermatitis, that we so often see.
But I was reminded actually, thisweek, about a third, which is acne.
I saw a young adolescentwith really severe acne.
I have to say, previous doctors they'dseen had not covered themselves in glory.
(08:03):
And this was pretty severe acne, tothe point where it was really affecting
their self-esteem and confidence.
And if we can dig really deep intoour memory banks, George, and think as
way back into our teenage years, youwant to conform, you want to be the
same, you want to be part of the club.
And if you're different, and acne makesyou different to a lot of your peers,
(08:27):
then it can be devastating for you.
It's devastating anytimein someone's life.
And unfortunately, I think itcan be sometimes trivialised
because it's so common.
It can be almost considered asnormal, but it's a painful condition
sometimes, and it can have reallysevere consequences on self-esteem,
relationships, mood, for sure, and evencareer choices and career opportunities.
(08:53):
And there's a lot of chatter about theuse of particular drugs, and I'm thinking
of isotretinoin here, and suicide risk.
And it's a bit of a thornyissue, but it really does work.
Dr George Moncrieff (09:05):
It does, but you're absolutely right, it is a thorny issue.
And there's no doubt, studies haverepeatedly shown very strong links
between acne and mental healthproblems, hardly surprising really.
Um, but severe enough to includesevere depression, and even suicide.
So people have committedsuicide because of their acne.
(09:26):
And, yeah, there are very legitimateconcerns about isotretinoin, which
have been highlighted in a recentguidance from the MHRA, who basically
control the licensing of products.
And they highlight, in particular, theneed to be very careful about mood and
suicidal thoughts in the under 18 agegroup, because there have been reports of
(09:49):
patients on this drug committing suicide.
However, we all know that isotretinoinis the best possible treatment for
acne, and we just need to be very surethat we're careful how we prescribe
it and we monitor our patients, tomake sure that if they are getting any
drop in mood that we're ahead of thegame, and we're looking out for that.
(10:10):
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 abig paper that looked at these
risks in a bit more detail.
(10:31):
And because antibiotics, whether bymouth or on the skin, aren't that
effective, and therefore leave theacne relatively under treated, they
are associated with a higher risk ofdepression and suicide than isotretinoin.
So I'm not trying to say that isotretinoinisn't at risk, I'm just saying that it
(10:53):
needs to be prescribed very carefully.
We need to be thinking abouthow we're prescribing it and
monitoring it very carefully.
But because it works so well, it'ssomething that I think still has a
very important place, particularlyin patients who've already got
depression from their acne.
So it's a very complicated issue,and I wonder, Tony, do you have
(11:15):
any particular thoughts here?
Professor Anthony Bewley (11:17):
Yeah I think acne is a very interesting
inflammatory skin disease becauseit affects usually such a vulnerable
population, the adolescent and youngeradult population, and that's relevant.
We also know that acne can be associatedwith body dysmorphic disorder.
So if you have a visible differenceon your skin, it's not surprising,
(11:38):
especially in that age group,that some patients feel the other
symptoms of body dysmorphic disorder.
What do I mean by bodydysmorphic disorder?
A degree of social avoidance.
So not going out.
A degree of recurrent thoughts, recurrentworries, concerns about the appearance of
the skin and overstated kind of concernabout any changes on the skin, whether
(12:02):
it be the acne itself, or whether it bethe consequences of the acne in terms
of the pigmentation, or the scarring.
So, we know for sure that somepatients with acne also can shift
into body dysmorphic disorder.
Several things about acne.
First of all, it's really important totreat the acne and treat it appropriately.
And that can be with topicals, withmedication systemic medication, which
(12:25):
can be antibiotics or it can be...
Dr George Moncrieff (12:26):
So by mouth, yes.
Dr Roger Henderson (12:27):
Hmm....
Professor Anthony Bewley (12:28):
...so it's really important to treat it
physically, but also especially if we'rethinking about using isotretinoin as
healthcare professionals, it's reallyimportant that we formally assess the
psychological wellbeing of a patient.
Crucial in this particular disease thatwe really, address this concept of, okay,
(12:49):
"how are you feeling with your acne?
Has it made you feel low?
Has it made you feel anxious?
Have you even felt so wretchedthat you'd consider ending your
life or committing suicide?"
And we want to do that forall of our patients with acne.
And if the patient is fine andhappily the vast majority of patients
are absolutely fine, then we canthink, okay well, that's fine.
We're going to proceed, but we'restill going to be mindful about
(13:12):
the psychological consequences.
And if it's not fine, then we needto address that absolutely as a
priority, as well as the acne.
It goes back to the golden ruleof psychodermatology to treat
the psychological comorbiditiesand the disease at the same
time and comprehensively.
Dr George Moncrieff (13:32):
Couldn't agree more, it's a really tricky area, isn't it, and
one that we need to take very seriouslyand be very cautious with our treatment.
But of course we have this treatmentthat, as far as the acne is concerned,
can work really well and that canbe the best outcome for the patient.
But, it's not always the case andwe have to be so, so careful here.
Professor Anthony Bewley (13:50):
And it is really important that throughout the treatment,
with isotretinoin, we do need tomonitor very carefully the psychological
comorbidities of the patient.
So, we do need to monitorthroughout the treatment and
after completion of the treatment.
And the MHRA the regulatory bodies withinthe UK and the British Association of
Dermatologists have just recently issuedguidelines about how, we as dermatology
(14:15):
healthcare professionals can safelymonitor, and that's guidelines issued
together with the approval of the RoyalCollege of Psychiatrists, how we can
monitor patients and how we can signpostand manage patients who do have more
of the more serious psychological orpsychiatric comorbidities of living
(14:36):
with this disease and its consequences.
Dr George Moncrieff (14:39):
Another condition where loss of control
is a big part is rosacea.
Here patients can suddenlyflush, and blush, and there's
a difference between those two.
And they get pimples and pustuleson their face, and it can certainly
not look attractive if it's severe.
So again, can have a big impacton someone's mental health
(14:59):
and wellbeing and self-esteem.
Professor Anthony Bewley: Yes, that's right. (15:01):
undefined
So, for patients who have rosacea,it is often the flushing and the
redness and the flushing can, as youalluded to, be completely involuntary.
It seems to happen at themost inopportune times.
Or it can be fixed andlook like a ruddy face.
(15:22):
And patients reallydon't like that at all.
And again, it goes back to the treatmentof how do we best control this and
how do we manage the psychologicalconsequences of living with that
kind of flushing propensity, thatlikelihood to get that flushing,
and it is at least partly genetic.
So some people are more likely to getthis than others and it, itself carries
(15:45):
a certain stigma because there are peoplearound who don't understand rosacea.
And they think, "oh that's becausethis guy drinks too much alcohol, or
this lady drinks too much alcohol."
Or it's their fault becauseof whatever it might be.
And that's absolutely not the case.
So there are stigmas and associationsand myths that patients with rosacea
(16:07):
have to deal with, as well asliving with their skin condition.
And the sense of being not incontrol of the flushing the
blood vessels in their face.
Dr George Moncrieff (16:17):
And we could go through the whole textbook of dermatology
and I could pick out every single diseasethat's visible, but there are a lot of
conditions that I think just deserve tobe mentioned, but not necessarily explored
in detail so for example vitiligo orbirthmarks or burns an enormous number
there and often there isn't a huge amountthat can be done to control the disease.
(16:41):
There are fantastic treatments comingalong for vitiligo and some of the
alopecias, but I think maybe in thissituation 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. (16:56):
undefined
It goes back to our previous conversationabout, "please don't suffer in silence"
because there are treatments that arebeing developed, year in, year out.
So what was available a couple ofyears ago is likely to be out of
date or could be out of date andthere might be newer treatments.
And certainly there are newer waysof applying older treatments as well.
(17:18):
There are lots of things that can be done.
Dr George Moncrieff (17:20):
Yes.
Vitiligo is a condition where you getpatches of complete loss of pigmentation.
And that commonly affects the faceand the hands, two very visible areas.
And uh, it's particularly a problem ifyou've got dark skin, the contrast can
be very dramatic and someone can bevery aware of it, and of course people
(17:44):
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 itregularly causes and the studies again
support that showing extremely highlevels of anxiety, depression and stress.
About four out of five patients, withthis condition have talked about that.
Professor Anthony Bewley (18:04):
With things like vitiligo, where there
is a visible difference thatcan lead to senses of change.
It can lead to senses of changeof your own identity, and it can
lead to senses of change in termsof your ethnic identity too.
So there are organisations whichchampion the patient at the centre
(18:25):
of this, experience, which can takepatients through choices about how
they can manage their skin and choicesabout how they can learn to live
with their skin changing in this way.
For example, there is anorganisation called Changing
Faces, which champions this.
And they can be really useful.
They can signpost people towards havingcamouflage to cover over areas, that are
(18:50):
of a different skin tone, or they canencourage patients to live with it or
to change how they perceive their body.
And happily there are a growing numberof celebrities that have vitiligo and
are explicit about having vitiligo.
There are models and singers and so on whoare saying, this is the way my body is.
(19:14):
And actually that's the wayit is and I quite like it like
this, which I really encourage.
So whenever I talk to medicalstudents or patients, I always
ask the audience, okay, "who hereis totally happy with their body?
Who here is totallyhappy with their body?"
And you can guarantee that of anaudience of about a hundred, one or
(19:37):
two people will put their hand up.
So I look forward to the day, wheneverybody puts their hand up and says
"I'm totally happy with my body."
Awfully long way from therebut I look forward to that day.
Dr George Moncrieff (19:49):
There are just a few other conditions I think of when
I'm considering that a skin conditioncan affect someone's mental health
more than perhaps one would expectand one of those is alopecia areata.
This is a situation where patients oftenwithout much warning can have a patch
of hair loss, usually on the scalp.
(20:11):
And it can be very severe and go onuntil you just get a few patches of hair
left and it can look very devastatingand this occurs in young people.
So it's hardly surprising thatthis can have a huge impact
on their mental wellbeing.
And we see figures of two outof five people with this have
depression and the same sort ofnumber also suffer with anxiety.
(20:35):
And it can result in a lotof people losing time off
work and even unemployment.
As I said, it's a condition that affectsyoung people, and it's unpredictable,
and it's the unpredictability thatis one of the problems for it.
And in our society, where hair playssuch a critical role, and I think that's
something Roger and I are probablyvery sensitive to, but having a patchy
(20:58):
hair loss is so much more devastating.
And it works both ways because we knowthat if you've got mental problems
already, if you've got a history ofdepression or stress, then that can
aggravate and cause alopecia areata.
So another condition thatwe need to be alert to.
(21:18):
And very aware of, and remember to ask howit'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 ifyou've got a birthmark on the face,
sometimes called a port wine stain,that will be hugely awkward for the
(21:38):
patient for the rest of their life.
And the only way they can handleit often is with camouflage.
But it can also cause the tissuesunderneath to become thickened, and so
even more hard to mask that and hide it.
Not surprising, that too canhave a really important impact.
So we've highlighted just a fewconditions, eczema, psoriasis,
(22:01):
acne, rosacea, alopeciaareata, vitiligo, birthmarks.
There are many more that we could havetalked about, but these are the ones
that we feel are the most likely to causedisturbance to someone's mental health.
And I think if your doctor isn'taware of it, or you feel your doctor's
(22:21):
not aware of it then you shoulddefinitely 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 furtherhelp, what resources are out there.
There are other mental healthconditions that can present to
dermatologists, I'm thinking, forexample, the person who comes to see
(22:44):
us, convinced that they've got bugsliving on their skin, and the evidence
for that is challenging to confirm.
Um, or the patient who picks attheir skin to the point at which it
is seriously damaged and they areconvinced that there's an underlying
skin condition, but the patterndoesn't fit in with anything that the
(23:06):
books would suggest is due to a skindisease, 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 particularwords on those sorts of conditions?
Professor Anthony Bewley (23:26):
Yeah.
So we're alluding to two things here.
We're alluding to a series ofconditions 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 patientwho believes that various aspects of
the face are moving around of their ownaccord and there is no evidence for that.
(23:47):
So these persistent delusionaldisorder changes, or it can be a
patient who experiences materialgrowing within their skin.
We definitely always take thepatient seriously and we...
Dr George Moncrieff (24:00):
So important.
Professor Anthony Bewley: ...look to see if there is any (24:00):
undefined
reason, any organic reason, anyfoundation for that experience.
And sometimes there is, andwe 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 ridof the sensations of the skin and
(24:22):
try and get them better because thewhole experience of living with these
problems can be so debilitating andrepeatedly 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 doembrace the patient as best as we can and
say, "okay, I fully understand that thisis a real problem for you and I'm going
(24:45):
to manage this as best as I can and let'ssee if we can work together about that."
Dr George Moncrieff (24:51):
Fantastic.
Thank you.
Dr Roger Henderson (24:53):
Speaking for both of us, I know that these podcasts on
mental health and the skin have beensome of the most enjoyable we've done,
thanks in no small part to our wonderfulspecial guest, Professor Anthony Bewley.
And George and I do hope you foundthis chat as interesting as we have.
We also hope that they've given youthe confidence to ask your healthcare
(25:13):
professional more about your skin and anymental health issues that you may have.
Dr George Moncrieff (25:19):
So Roger and I do hope you'll join us for our next podcast.
And we'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
We couldn't have done it without them.
Dr Roger Henderson (25:31):
And if you're enjoying these podcasts, then do
rate and review us on whicheverplatform you use to receive them.
It really does help.
We'd also love to hear yourfeedback, so do get in touch, as
it's great to hear what you think,and to let us know if there are any
topics you'd like us to discuss.
But until the next time,it's goodbye from George.
Dr George Moncrieff (25:52):
Goodbye.
Dr Roger Henderson (25:53):
And as always, it's goodbye from me.
Goodbye.
Content warning: this podcast discusses suicidal feelings,
(00:04):
which some listeners may find distressing.
Now, we know George, that in oursurgeries, many is the time that we
see patients with skin conditionsthat are worsened by stress.
And it's safe to say that we do havethese two-edged sword skin conditions.
(00:28):
And I'm simply thinking of the bigones, like eczema, atopic dermatitis,
alopecia areata, psoriasis.
These are often worst, by stress,but perhaps maybe look at atopic
dermatitis first, because that isa real currency in our practice.
(00:54):
Hello and welcome to this Skin Deep podcast where we look at skin related
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standing interestin this particular area of health.
Dr George Moncrieff (01:08):
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.
Dr Roger Henderson (01:19):
Now this is the second of two podcasts
on the skin and mental health.
Last time, we talked about how yourskin condition can have a negative
effect on your mental wellbeing, andthat we, as healthcare professionals,
don't always realise this, so we needyou to tell us if this is the case.
One thing that we want to stressis that you are not alone.
(01:43):
So today, we'll be delving into a fewspecific skin conditions, and sharing with
you some pretty dreadful statistics aroundhow they can affect your mental wellbeing.
We're also honoured to be joinedonce again by our very special guest,
Professor Tony Bewley, a world authorityin this area of skin and mental health.
(02:04):
Now George, we both know just howmuch someone's mental and physical
health is intrinsically linked.
And being both visible, and a verylarge organ, skin diseases can have
a massive impact on someone's qualityof life, especially when areas such
as the face, the hair, or even thegenitals can be involved, can't they?
Dr George Moncrieff (02:25):
Yes.
And of course, atopic dermatitis,particularly in children, often involves
the face and the hands, with dry,red, scaly and uncomfortable skin.
But the itch can be relentless andoften disturbs quality of sleep,
not just for the child affectedor the individual, but the family.
(02:48):
And of course, as you know, skincare can consume many hours, as
well as the time taken and thecost of accessing healthcare.
But focusing on the mental healthconsequences, there have been a large
number of studies looking at this, andthey have found truly alarmingly high
figures for the impact it's having.
For example, 80% of teenagers haveavoided at least one everyday activity
(03:13):
because of their atopic dermatitis.
People describing having a negative impacton their schooling, hardly surprisingly,
and 40% reporting that they are teasedor bullied because of their eczema.
Also, these studies have shown,I think, very high levels of
depression, doubling the risk, and afour-fold increased risk of suicidal
(03:36):
ideation, thinking about suicide,because of your atopic dermatitis.
What I think is really importantand very interesting, is that
by controlling the eczema, thosefigures can return to normal.
A very important study by theNational Eczema Society showed
(03:57):
some very interesting figures.
They looked at 500 children, withatopic dermatitis and 500 adults
with atopic dermatitis, and theyfound that three quarters said it
had a negative impact on their mentalhealth, and two thirds felt socially
isolated, because of their eczema.
One of the things I think is reallyimportant for the medical profession to
(04:19):
take on board, is that a third of thepatients were saying that they felt that
their healthcare professional had notappreciated the impact it was having.
So that's something that we needto take on board, Roger, and the
profession needs to think about that.
Dr Roger Henderson (04:33):
We do.
As George said, like atopic dermatitis,psoriasis is really common in our society,
affecting about 2% of the population.
I became so interested in dermatology,because of a patient who presented
to me with psoriasis, and that reallyopened my eyes as to the impact
(04:53):
that a skin condition could haveon someone's holistic lifestyle.
So we mustn't forgetabout psoriasis, George.
And I think you've had some jawdropping moments with people with
psoriasis as well, haven't you?
Dr George Moncrieff (05:05):
I've had many actually, but there's one I vividly
recall, when I was at a, talk at theRoyal College of Physicians in London.
A good friend of mine was giving oneof the main talks, Peter Lapsley, who
sadly, he died about 10 years ago.
And he opened his talk by saying, "I haveheart disease and I've got ongoing angina.
(05:29):
I've also got type 2 diabetes, andI've got some pretty rotten asthma.
Oh, and by the way, I have psoriasis.
If I could be rid of one ofthese wretched conditions..."
This was a meeting of dermatologists,and despite that, we all assumed
he would choose one of thefirst three major conditions.
(05:50):
I was thinking, I'd hate to have heartdisease and angina, type 2 diabetes,
that brings so many problems, andasthma, that must be so awful not to
be able to breathe, and frightening.
So I was thinking he'dbe one of those three.
But he went on, "...itwould be my psoriasis."
Everyone in the audiencewas as stunned as I was.
(06:14):
But he went on to describe howembarrassing it was, especially when he
was staying away from home, and in themorning his bed was covered in blood,
where he'd been scratching all night.
How he had taken to packing a smallHoover in his overnight bag to cope
with the scale he shed on the carpet.
And how he had abandoned going toany public swimming pool because
(06:36):
of the ignominy of being askedto leave the pool because people
didn't like the look of his skin.
Psoriasis had interfered withevery 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.
(07:00):
And it affects, intimate relationshipsin particular, but ordinary relationships
as well are affected in a largenumber of patients with psoriasis.
So it affects everyaspect of everyday life.
Another big campaign, the 'See Psoriasis: Look Deeper' campaign, which was (07:15):
undefined
actually about 10 years ago now, theyhighlighted these issues and they quoted
figures of 77% of patients reportingit impacted things in everyday life.
And it's more likely you weretaking an antidepressant because
of psoriasis, and about a third ofpatients have depression or anxiety.
(07:36):
It's a really big area of mentalhealth illness if you've got psoriasis.
Dr Roger Henderson (07:42):
That's two of the big three, psoriasis and atopic
dermatitis, that we so often see.
But I was reminded actually, thisweek, about a third, which is acne.
I saw a young adolescentwith really severe acne.
I have to say, previous doctors they'dseen had not covered themselves in glory.
(08:03):
And this was pretty severe acne, tothe point where it was really affecting
their self-esteem and confidence.
And if we can dig really deep intoour memory banks, George, and think as
way back into our teenage years, youwant to conform, you want to be the
same, you want to be part of the club.
And if you're different, and acne makesyou different to a lot of your peers,
(08:27):
then it can be devastating for you.
It's devastating anytimein someone's life.
And unfortunately, I think itcan be sometimes trivialised
because it's so common.
It can be almost considered asnormal, but it's a painful condition
sometimes, and it can have reallysevere consequences on self-esteem,
relationships, mood, for sure, and evencareer choices and career opportunities.
(08:53):
And there's a lot of chatter about theuse of particular drugs, and I'm thinking
of isotretinoin here, and suicide risk.
And it's a bit of a thornyissue, but it really does work.
Dr George Moncrieff (09:05):
It does, but you're absolutely right, it is a thorny issue.
And there's no doubt, studies haverepeatedly shown very strong links
between acne and mental healthproblems, hardly surprising really.
Um, but severe enough to includesevere depression, and even suicide.
So people have committedsuicide because of their acne.
(09:26):
And, yeah, there are very legitimateconcerns about isotretinoin, which
have been highlighted in a recentguidance from the MHRA, who basically
control the licensing of products.
And they highlight, in particular, theneed to be very careful about mood and
suicidal thoughts in the under 18 agegroup, because there have been reports of
(09:49):
patients on this drug committing suicide.
However, we all know that isotretinoinis the best possible treatment for
acne, and we just need to be very surethat we're careful how we prescribe
it and we monitor our patients, tomake sure that if they are getting any
drop in mood that we're ahead of thegame, and we're looking out for that.
(10:10):
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 abig paper that looked at these
risks in a bit more detail.
(10:31):
And because antibiotics, whether bymouth or on the skin, aren't that
effective, and therefore leave theacne relatively under treated, they
are associated with a higher risk ofdepression and suicide than isotretinoin.
So I'm not trying to say that isotretinoinisn't at risk, I'm just saying that it
(10:53):
needs to be prescribed very carefully.
We need to be thinking abouthow we're prescribing it and
monitoring it very carefully.
But because it works so well, it'ssomething that I think still has a
very important place, particularlyin patients who've already got
depression from their acne.
So it's a very complicated issue,and I wonder, Tony, do you have
(11:15):
any particular thoughts here?
Professor Anthony Bewley (11:17):
Yeah I think acne is a very interesting
inflammatory skin disease becauseit affects usually such a vulnerable
population, the adolescent and youngeradult population, and that's relevant.
We also know that acne can be associatedwith body dysmorphic disorder.
So if you have a visible differenceon your skin, it's not surprising,
(11:38):
especially in that age group,that some patients feel the other
symptoms of body dysmorphic disorder.
What do I mean by bodydysmorphic disorder?
A degree of social avoidance.
So not going out.
A degree of recurrent thoughts, recurrentworries, concerns about the appearance of
the skin and overstated kind of concernabout any changes on the skin, whether
(12:02):
it be the acne itself, or whether it bethe consequences of the acne in terms
of the pigmentation, or the scarring.
So, we know for sure that somepatients with acne also can shift
into body dysmorphic disorder.
Several things about acne.
First of all, it's really important totreat the acne and treat it appropriately.
And that can be with topicals, withmedication systemic medication, which
(12:25):
can be antibiotics or it can be...
Dr George Moncrieff (12:26):
So by mouth, yes.
Dr Roger Henderson (12:27):
Hmm....
Professor Anthony Bewley (12:28):
...so it's really important to treat it
physically, but also especially if we'rethinking about using isotretinoin as
healthcare professionals, it's reallyimportant that we formally assess the
psychological wellbeing of a patient.
Crucial in this particular disease thatwe really, address this concept of, okay,
(12:49):
"how are you feeling with your acne?
Has it made you feel low?
Has it made you feel anxious?
Have you even felt so wretchedthat you'd consider ending your
life or committing suicide?"
And we want to do that forall of our patients with acne.
And if the patient is fine andhappily the vast majority of patients
are absolutely fine, then we canthink, okay well, that's fine.
We're going to proceed, but we'restill going to be mindful about
(13:12):
the psychological consequences.
And if it's not fine, then we needto address that absolutely as a
priority, as well as the acne.
It goes back to the golden ruleof psychodermatology to treat
the psychological comorbiditiesand the disease at the same
time and comprehensively.
Dr George Moncrieff (13:32):
Couldn't agree more, it's a really tricky area, isn't it, and
one that we need to take very seriouslyand be very cautious with our treatment.
But of course we have this treatmentthat, as far as the acne is concerned,
can work really well and that canbe the best outcome for the patient.
But, it's not always the case andwe have to be so, so careful here.
Professor Anthony Bewley (13:50):
And it is really important that throughout the treatment,
with isotretinoin, we do need tomonitor very carefully the psychological
comorbidities of the patient.
So, we do need to monitorthroughout the treatment and
after completion of the treatment.
And the MHRA the regulatory bodies withinthe UK and the British Association of
Dermatologists have just recently issuedguidelines about how, we as dermatology
(14:15):
healthcare professionals can safelymonitor, and that's guidelines issued
together with the approval of the RoyalCollege of Psychiatrists, how we can
monitor patients and how we can signpostand manage patients who do have more
of the more serious psychological orpsychiatric comorbidities of living
(14:36):
with this disease and its consequences.
Dr George Moncrieff (14:39):
Another condition where loss of control
is a big part is rosacea.
Here patients can suddenlyflush, and blush, and there's
a difference between those two.
And they get pimples and pustuleson their face, and it can certainly
not look attractive if it's severe.
So again, can have a big impacton someone's mental health
(14:59):
and wellbeing and self-esteem.
Professor Anthony Bewley: Yes, that's right. (15:01):
undefined
So, for patients who have rosacea,it is often the flushing and the
redness and the flushing can, as youalluded to, be completely involuntary.
It seems to happen at themost inopportune times.
Or it can be fixed andlook like a ruddy face.
(15:22):
And patients reallydon't like that at all.
And again, it goes back to the treatmentof how do we best control this and
how do we manage the psychologicalconsequences of living with that
kind of flushing propensity, thatlikelihood to get that flushing,
and it is at least partly genetic.
So some people are more likely to getthis than others and it, itself carries
(15:45):
a certain stigma because there are peoplearound who don't understand rosacea.
And they think, "oh that's becausethis guy drinks too much alcohol, or
this lady drinks too much alcohol."
Or it's their fault becauseof whatever it might be.
And that's absolutely not the case.
So there are stigmas and associationsand myths that patients with rosacea
(16:07):
have to deal with, as well asliving with their skin condition.
And the sense of being not incontrol of the flushing the
blood vessels in their face.
Dr George Moncrieff (16:17):
And we could go through the whole textbook of dermatology
and I could pick out every single diseasethat's visible, but there are a lot of
conditions that I think just deserve tobe mentioned, but not necessarily explored
in detail so for example vitiligo orbirthmarks or burns an enormous number
there and often there isn't a huge amountthat can be done to control the disease.
(16:41):
There are fantastic treatments comingalong for vitiligo and some of the
alopecias, but I think maybe in thissituation 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. (16:56):
undefined
It goes back to our previous conversationabout, "please don't suffer in silence"
because there are treatments that arebeing developed, year in, year out.
So what was available a couple ofyears ago is likely to be out of
date or could be out of date andthere might be newer treatments.
And certainly there are newer waysof applying older treatments as well.
(17:18):
There are lots of things that can be done.
Dr George Moncrieff (17:20):
Yes.
Vitiligo is a condition where you getpatches of complete loss of pigmentation.
And that commonly affects the faceand the hands, two very visible areas.
And uh, it's particularly a problem ifyou've got dark skin, the contrast can
be very dramatic and someone can bevery aware of it, and of course people
(17:44):
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 itregularly causes and the studies again
support that showing extremely highlevels of anxiety, depression and stress.
About four out of five patients, withthis condition have talked about that.
Professor Anthony Bewley (18:04):
With things like vitiligo, where there
is a visible difference thatcan lead to senses of change.
It can lead to senses of changeof your own identity, and it can
lead to senses of change in termsof your ethnic identity too.
So there are organisations whichchampion the patient at the centre
(18:25):
of this, experience, which can takepatients through choices about how
they can manage their skin and choicesabout how they can learn to live
with their skin changing in this way.
For example, there is anorganisation called Changing
Faces, which champions this.
And they can be really useful.
They can signpost people towards havingcamouflage to cover over areas, that are
(18:50):
of a different skin tone, or they canencourage patients to live with it or
to change how they perceive their body.
And happily there are a growing numberof celebrities that have vitiligo and
are explicit about having vitiligo.
There are models and singers and so on whoare saying, this is the way my body is.
(19:14):
And actually that's the wayit is and I quite like it like
this, which I really encourage.
So whenever I talk to medicalstudents or patients, I always
ask the audience, okay, "who hereis totally happy with their body?
Who here is totallyhappy with their body?"
And you can guarantee that of anaudience of about a hundred, one or
(19:37):
two people will put their hand up.
So I look forward to the day, wheneverybody puts their hand up and says
"I'm totally happy with my body."
Awfully long way from therebut I look forward to that day.
Dr George Moncrieff (19:49):
There are just a few other conditions I think of when
I'm considering that a skin conditioncan affect someone's mental health
more than perhaps one would expectand one of those is alopecia areata.
This is a situation where patients oftenwithout much warning can have a patch
of hair loss, usually on the scalp.
(20:11):
And it can be very severe and go onuntil you just get a few patches of hair
left and it can look very devastatingand this occurs in young people.
So it's hardly surprising thatthis can have a huge impact
on their mental wellbeing.
And we see figures of two outof five people with this have
depression and the same sort ofnumber also suffer with anxiety.
(20:35):
And it can result in a lotof people losing time off
work and even unemployment.
As I said, it's a condition that affectsyoung people, and it's unpredictable,
and it's the unpredictability thatis one of the problems for it.
And in our society, where hair playssuch a critical role, and I think that's
something Roger and I are probablyvery sensitive to, but having a patchy
(20:58):
hair loss is so much more devastating.
And it works both ways because we knowthat if you've got mental problems
already, if you've got a history ofdepression or stress, then that can
aggravate and cause alopecia areata.
So another condition thatwe need to be alert to.
(21:18):
And very aware of, and remember to ask howit'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 ifyou've got a birthmark on the face,
sometimes called a port wine stain,that will be hugely awkward for the
(21:38):
patient for the rest of their life.
And the only way they can handleit often is with camouflage.
But it can also cause the tissuesunderneath to become thickened, and so
even more hard to mask that and hide it.
Not surprising, that too canhave a really important impact.
So we've highlighted just a fewconditions, eczema, psoriasis,
(22:01):
acne, rosacea, alopeciaareata, vitiligo, birthmarks.
There are many more that we could havetalked about, but these are the ones
that we feel are the most likely to causedisturbance to someone's mental health.
And I think if your doctor isn'taware of it, or you feel your doctor's
(22:21):
not aware of it then you shoulddefinitely 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 furtherhelp, what resources are out there.
There are other mental healthconditions that can present to
dermatologists, I'm thinking, forexample, the person who comes to see
(22:44):
us, convinced that they've got bugsliving on their skin, and the evidence
for that is challenging to confirm.
Um, or the patient who picks attheir skin to the point at which it
is seriously damaged and they areconvinced that there's an underlying
skin condition, but the patterndoesn't fit in with anything that the
(23:06):
books would suggest is due to a skindisease, 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 particularwords on those sorts of conditions?
Professor Anthony Bewley (23:26):
Yeah.
So we're alluding to two things here.
We're alluding to a series ofconditions 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 patientwho believes that various aspects of
the face are moving around of their ownaccord and there is no evidence for that.
(23:47):
So these persistent delusionaldisorder changes, or it can be a
patient who experiences materialgrowing within their skin.
We definitely always take thepatient seriously and we...
Dr George Moncrieff (24:00):
So important.
Professor Anthony Bewley: ...look to see if there is any (24:00):
undefined
reason, any organic reason, anyfoundation for that experience.
And sometimes there is, andwe 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 ridof the sensations of the skin and
(24:22):
try and get them better because thewhole experience of living with these
problems can be so debilitating andrepeatedly 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 doembrace the patient as best as we can and
say, "okay, I fully understand that thisis a real problem for you and I'm going
(24:45):
to manage this as best as I can and let'ssee if we can work together about that."
Dr George Moncrieff (24:51):
Fantastic.
Thank you.
Dr Roger Henderson (24:53):
Speaking for both of us, I know that these podcasts on
mental health and the skin have beensome of the most enjoyable we've done,
thanks in no small part to our wonderfulspecial guest, Professor Anthony Bewley.
And George and I do hope you foundthis chat as interesting as we have.
We also hope that they've given youthe confidence to ask your healthcare
(25:13):
professional more about your skin and anymental health issues that you may have.
Dr George Moncrieff (25:19):
So Roger and I do hope you'll join us for our next podcast.
And we'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
We couldn't have done it without them.
Dr Roger Henderson (25:31):
And if you're enjoying these podcasts, then do
rate and review us on whicheverplatform you use to receive them.
It really does help.
We'd also love to hear yourfeedback, so do get in touch, as
it's great to hear what you think,and to let us know if there are any
topics you'd like us to discuss.
But until the next time,it's goodbye from George.
Dr George Moncrieff (25:52):
Goodbye.
Dr Roger Henderson (25:53):
And as always, it's goodbye from me.
Goodbye.
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