The Need for Psychological Support in Routine Dermatological Care Across the UK
Wiley Online Library
British Journal of Dermatology
The need for psychological support in routine dermatological care across the UK
First published: 28 June 2022 https://doi.org/10.1111/bjd.21720
Conflicts of interest: O.H. is a Patient Associate Editor for the BJD .
This article presents a patient perspective on the importance of having psychological support for skin conditions available in the dermatological treatment pathway in the UK.
As a dermatology patient and academic researcher in the field of psychodermatology, I have observed there is a lack of specialized psychosocial support available in the pathway of dermatological care across the UK.1 From a patient perspective, having been diagnosed with psoriasis during childhood and progressing through adolescence with a visible skin condition, my experience over the past two decades has led me to understand the importance of ensuring people are suitably equipped to live well with a skin condition. Being a young child and a teenager with severe psoriasis was both physically and emotionally challenging. My skin condition impacted every part of my life from overshadowing my time in school, influencing my hobbies and socializing, and dictating my clothing choices. But it was not just me who carried the burden of my skin condition. My parents shared in the stress of caring for a child with psoriasis: taking me to frequent clinic appointments for ultraviolet radiation therapy, overseeing systemic drug prescriptions, administering treatment, and visiting me in hospital every day when I was admitted with erythroderma.
Although many people might see skin diseases as ‘minor’ illnesses, the psychological implications of living with a visible condition can include feelings of embarrassment and shame, and behavioural responses such as social withdrawal and isolation, which can have a damaging impact on a person’s mental health.1 I have experienced the emotional burden of skin disease first hand, and there have been times during flare-ups of my psoriasis where my mood has been profoundly affected. Having to adapt to a condition where your appearance fluctuates is difficult, and managing the related anxiety about looking different from everyone else is even more difficult. I was fortunate that I had a strong family network behind me, but professional psychological support services were never openly available, and my parents’ wellbeing as carers of an unwell child was not addressed.
Across the UK, general psychodermatology services are unequally distributed, with approximately 10 clinics in England, two in Scotland, one in Northern Ireland, and no general services in Wales (some limited support for psoriasis).1 The lack of consistency in the availability of specialized services could leave patients experiencing anxiety and depression,1, 2 or even anger.3 For many inflammatory skin conditions, psychological stress and negative emotion can exacerbate illness severity by activating the body’s stress response and altering the functioning of the immune and nervous systems.4 By not addressing the potentially negative emotional burden, the psychological impact of living with a skin condition could become a barrier to successful treatment, or adherence to treatment itself, which could ultimately influence disease trajectory.
So, what can be done? Combining my perspective as a dermatology patient with my experience as a researcher has highlighted the value of ‘patient and public involvement’ (PPI). PPI has become a central concept in the design of sustainable health interventions, giving target users the opportunity to describe their needs and barriers to treatment (Figure 1). This approach is particularly relevant to dermatology as there have long been calls for more psychological support for patients,1 and in addressing these calls, we might promote empowerment in people who may be feeling a lack of control over their health from living with conditions that fluctuate in severity.
An example of how target users can be involved in the development of health interventions, as suggested by the person-based approach·5
We must ensure that patients asking for more psychological support are finally listened to, and have access to the appropriate care. To do this, the way skin conditions are routinely managed needs to be reviewed, and we must consider the impact on the whole person instead of primarily targeting physical symptoms, and the psychological sequelae as secondary. The emotions we experience, and the way we feel in our skin, can undoubtedly influence how skin conditions progress, so specialized services must be made available to optimize patient outcomes. Reflecting on my own experience of coming to terms with living with a chronic skin condition, I know I would have found some additional support beneficial.
Indeed, there may be many factors impeding clinicians across regions from incorporating psychological assessment into time-limited clinic appointments, including not having psychodermatology training, and being understaffed or underfunded.1, 5 These disparities must be reviewed if we are to prioritize the mental health of patients with skin conditions, and the appropriate resources must be allocated to systematically integrate specialized psychological services into the stepped model of dermatological care. In doing this, standardized pathways to access psychological support might be established regardless of geographical location, to equally improve the quality of life of people living with skin conditions across the UK.1
Olivia Hughes: Conceptualization (lead); project administration (lead); writing – original draft (lead); writing – review and editing (lead).
1 All Party Parliamentary Group on Skin. Mental health and skin disease. Available at: http://www.appgs.co.uk/wp-content/uploads/2020/09/Mental_Health_and_Skin_Disease2020.pdf (last accessed 28 June 2022).
2Samuels DV, Rosenthal R, Lin R et al. Acne vulgaris and risk of depression and anxiety: a meta-analytic review. J Am Acad Dermatol 2020; 83: 532– 41.
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3Hughes O, Hunter R. Understanding the experiences of anger in the onset and progression of psoriasis: a thematic analysis. Skin Health Dis 2022; in press; doi: https://doi.org/10.1002/ski2.111.
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4Hunter HJ, Griffiths CE, Kleyn CE. Does psychosocial stress play a role in the exacerbation of psoriasis? Br J Dermatol 2013; 169: 965– 74.
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5Morrison L, Muller I, Yardley L, Bradbury K. The person-based approach to planning, optimising, evaluating, and implementing behavioural health interventions. Eur Health Psychol 2018; 20: 464– 9.