Potential Psychological Effects of Dermatologic Diseases

Since the late 1940s, many studies have shown that the negative effects of dermatologic diseases such as acne, psoriasis, rosacea, eczema, and chronic urticaria can have negative impacts on the psychological well-being of both men and women. Every aspect of daily lives including work functioning, social functioning, home life, and intrapsychic functioning can be disrupted because of the anxiety, depression, feelings of stigmatization, confusion, social withdrawal, and difficulties at work and that are common in patients with these diseases. Unfortunately, these impacts are often difficult for clinicians and even patients to identify.

“One of the most important things that we can express today is that the psychological and functional impact of skin disease is often not ‘worn right on their sleeves’ of the sufferer,” said Richard Fried, MD, PhD, of Yardley Dermatology Associates in Yardley, PA. “The patient often is not very forthcoming and often not even aware of how much their psychosocial function has been impacted.”

Thus, clinicians should be vigilant and empathic with their patients, both men and women, in order to assess their psychological status and well-being living with dermatologic disease.

“The take-home here is never assume that objective clinical severity necessarily correlates with psychosocial and intrapsychic impact. Furthermore, never presume that by the ‘first round of questioning,’ you’re getting the honest answer,” stated Dr. Fried.

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Psoriasis stigma can lead to depression, mental health problems

Psoriasis, like many other conditions of the skin, often has a degree of stigmatization, both internal and external, tha
leads to increased stress, depression, anxiety and an exacerbation of physical comorbidities.

“There is a strong interface between the mind and the body,” Richard G. Fried, MD, PhD, a board-certified dermatologist and clinical psychologist who often studies this connection, said.

Fried is an honorary life member of the Association for Psychoneurocutaneous Medicine of North America, a group dedicated to psychodermatology becoming a sub-specialty of dermatology.

“We are trying to understand why living with psoriasis, eczema, rosacea, hives or acne can be so depressing and conversely, trying to understand why stress and distress can make conditions like psoriasis so much worse,” Fried said.

External stigmatization

Stigma from external sources, be it in social, professional or intimate relationships, can be both implicit and explicit.

Many psoriasis patients have reported experiences in which they have been asked to leave a gym, a swimming pool or a hair salon due to the appearance of their skin lesions, according to Rebecca L. Pearl, PhD, assistant professor in the department of clinical and health psychology at the College of Public Health and Health Professions of the University of Florida.

A study conducted by Pearl and colleagues in 2019 evaluated stigma among laypersons and medical trainees toward those with psoriasis. The researchers used images of people with psoriatic lesions and found many desired to avoid individuals with visible psoriatic lesions in both social and work-related situations.

“People with psoriasis report having been denied work opportunities because of their skin, or in general receiving unwanted attention,” she said. “In addition, there’s research that documents the negative stereotypes or assumptions that are commonly made about people with psoriasis.”

These negative stereotypes include a belief that psoriasis lesions are contagious or from a contagious disease or that they are due to poor hygiene.

Direct or explicit stigmatization comes in the form of offensive language, demeaning statements and exclusion from groups or places, but implicit stigma can be just as hurtful and demeaning.

“People sometimes withdraw, pull away, refuse to touch, to shake hands — that kind of implicit stigma can take place,” Fried said. “If people are in fact terrified or repulsed by psoriasis or just don’t know how to deal with it, that little bit of recoil can be experienced by the psoriasis sufferers as them finding you hideous, not necessarily consciously.”

Internalized stigma
These actions from peers, family members or general society can then have an impact on a person’s feelings of self-worth and create an internalized stigma within themselves.

“There’s a lot of misinformation and a lot of ignorance when it comes to psoriasis,” Evan A. Rieder, MD, a board- certified dermatologist and psychiatrist and assistant professor of dermatology at New York University School of Medicine, said. “This can change how people interact with the world and it can have massive implications socially. Internally people respond to the perception of others and can develop a personality structure that is socially avoidant because of that.”

Individuals who are experiencing internalized stigma of psoriasis often retreat and slowly stop engaging in activities that they used to find enjoyable, added Fried.

“Living with chronic, distressing conditions like psoriasis often can — in a very capricious, subtle, unrecognized way — steal away our range of activities and our levels of happiness,” he said.

This reluctance to participate in social interactions, intimacy or other activities can also lead to loneliness and a failure-to-thrive scenario.

Mental health and quality of life
A 2017 study of 1,485 psoriasis patients found a connection between internalized stigma and psoriasis severity and hypothesized that internalized stigma could be one of the major factors responsible for the disease’s psychosocial burden.

There are multiple studies connecting depression and anxiety with psoriasis, and one August 2010 paper, published in the Journal of the European Academy of Dermatology and Venereology, introduced the concept that negative stigma toward psoriasis patients and the social and economic outcomes of this stigmatization, are cumulative over a patient’s lifetime.

The physical burden of psoriasis, combined with psychological co-morbidities of the disease, lead to what the authors describe as “Cumulative Life Course Impairment (CLCI).”

“Studies that include general and skin-specific measures of quality of life generally show that people who have perceived or internalized psoriasis stigma have poorer mental and physical health-related quality of life than those who do not have these experiences. Psoriasis stigma is associated with increased depression and anxiety, as well as impaired social functioning,” Pearl said.

A 2017 study evaluating depression and suicidality in psoriasis found depression and anxiety tend to increase with psoriasis disease severity and psychiatric disorders can also result from and contribute to psoriasis progression.

Severity, however, can be relative.

“There’s a subset of patients really impacted by their psoriasis, even though they may not have psoriasis that is particularly severe to the dermatologist’s eye in terms of body surface coverage. For example, they might have a coin-sized lesion, but they might be suffering from a lot of anxiety or low mood associated with their psoriasis,” Rieder said. “We are at the point where we are trying to figure out who those individuals are and if there’s something going on organically in the brain that we can put a biological marker on.”

Inflammatory connections
Research into psoriasis’s inflammatory nature continues to grow, and it is now believed to be connected to IL-23, IL-17 and IL-22, as well as the Th-17 and Th-22 cells. A question remains however, if the inflammation that causes psoriasis or psoriatic arthritis could also impact mental health.

“We now know the inflammatory cytokines cross the blood-brain barrier and they increase the reuptake of neurotransmitters at the synapse to deplete the brain of serotonin, epinephrine and dopamine,” Fried said. “One of the things we know about inflammation is that it is the evil-doer in our bodies across the board. If you look at the data around depression now, we’re beginning to think depression is a disorder of inflammation.”

A review article published in the American Journal of Clinical Dermatology discusses how depression and psoriasis could both be related to inflammatory cytokines and that reducing the inflammation could help reduce the symptoms of both conditions, however it is difficult to determine whether the drugs reduce the depression or if improved psoriasis leads to better psychological outcomes.

Reducing stigma and improving education
Improving one’s psoriasis is the best way to reduce the mental health impacts the disease brings, and there are currently a host of different treatments in order to do so.

“It has been shown over and over again that even modest improvement in psoriasis clinical severity and psoriatic arthritis can dramatically decrease feelings of stigmatization,” Fried said. “We have so many effective medications that we are always going to have something in our tool bag. And the medicines get better and better.”

Additionally, spreading awareness and increasing education both among patients and the general public can go a long way in reducing stigma, as can being an emotionally supportive clinician.

For clinicians, it is important to be aware of how nonverbal cues can be perceived by a patient and to reduce any potentially stigmatizing actions.

“Seeing patients as individual human beings can be an important first step to reducing some of the biases and increasing awareness of the social experiences they might have,” Pearl said.

Dermatologists and rheumatologists who are treating psoriasis patients should also be asking questions regarding mental health and be prepared to recommend additional resources if necessary.

“We can get quality of life and skin conditions like psoriasis better for almost everyone with the right medications,” Rieder said.

But if the skin is getting clearer and the depression is continuing, it is time for a multidisciplinary team to step in, he added.

Book: Essential Psychiatry For The Aesthetic Practitioner

Below is a synopsis of “Essential Psychiatry for the Aesthetic Practitioner co-authored by Richard Fried MD PhD.

Trust Yardley Dermatology Associates In your quest to look and feel your best.

Making wise and healthy decisions in your quest to sustain, improve, enhance, or rejuvenate your skin can be extremely difficult. Miraculous claims, breathtaking photos, and exuberant testimonials tantalize us. They seem to be everywhere! We need look no further than our smartphone screens, computers, televisions, and print media. All of us are inundated with hard to believe, often contradictory, and confusing messages!

Oh, but it gets even dicier. Not only are we burdened with the daunting task of choosing which intervention or procedure to pursue, but perhaps of equal or greater importance, the task of choosing who and where to pursue it! The practitioner that you choose has the responsibility to guide you through this difficult process. This person must have the training, skill, and experience to help you make the best choices.

If I may speak succinctly, it’s not just what you plan to have done, it’s whether what you plan to have done will provide you with the optimal cosmetic emotional outcomes. One size doesn’t fit all. We have different skin texture, tone, vascularity, elasticity, laxity, thickness, and coloration. In addition, our underlying support structures including collagen and elastic fibers, subcutaneous fat, and bony structure vary widely.

Evaluation of skin sensitivity and reactivity is very important in short and long-term care of the skin. Products, interventions, and procedures must be carefully chosen based on skin type, sensitivity, and reactivity.

Since youth and beauty are a combination of “skin and the person within”, it is exquisitely important that your skin health and cosmetic choices enhance both your skin and your physical/emotional beauty.

Yardley Dermatology Associates has long been at the forefront of researching, publishing, and practicing expert dermatology for the preservation and enhancement of skin and emotional well-being. Our clinicians are superbly trained and meticulous professionals.

The clinical trials and research Center at Yardley dermatology continues to participate in clinical trials assessing safety and effectiveness of new and existing products and technologies. Our clinical trial center keeps our clinicians at the forefront of new and evolving knowledge and technologies.

With growing recognition that “who and where” matters when it comes to skin preservation,enhancement, and rejuvenation, Yardley dermatology is proud to report our own Dr. Richard Fried, MD PhD is the coeditor of a new book entitled “Essential Psychiatry For The Aesthetic Provider”. This is the first known textbook specifically designed to help aesthetic practitioners choose appropriate interventions for the cosmetic patients. The book has 23 chapters each written by an established world
expert in the various areas of cosmetic evaluation and intervention.

The editors are Evan Rieder MD, a board-certified dermatologist and psychiatrist and Richard Fried MD PhD, a board-certified dermatologist licensed clinical psychologist.

Redefining Our Risk Tolerance During “Re-entry” in the COVID-19 Era

By: Richard G. Fried, MD, PhD

Life is a dangerous and unpredictable endeavor. Sadly, in the end, no one gets out alive. Prior to Covid-19, most of us consciously or subconsciously made peace with the reality that life comes with risks that cannot be completely obviated. Attempts to decrease our risks such as healthy eating, regular exercise, weight control, moderation in indulgences, safe driving, medication adherence, and avoidance of people and places that are known to be dangerous provide for us a sense of control. These “healthy and smart” behaviors have been statistically proven to decrease the probability of premature illness and death. We believed that we were mitigating risk. Sadly, in addition, there was always a concomitant threat to our wellness and viability. Viral, bacterial, fungal, and parasitic infections have been well known threats for many millennia. With the advent of the Internet and the plethora of information sources available, we regularly heard warnings and horror stories about hepatitis, HIV, meningitis, Zika, Ebola, SARS, MEARS, Herpes, gonorrhea, chlamydia, flesh eating Strep, MRSA. Somehow, most of us maintained our equilibrium prior to COVID-19. We managed to assimilate these threats in such a manner that allowed us to engage sufficiently with others in order to work, maintain our family relationships and functioning, sustain and nurture our friendships, and engage in recreational activities without undue or overwhelming fear and anxiety. Now, things are different. As we contemplate and navigate re-entry into our “previous lives”, examination of our risk tolerance consciously or subconsciously is mandatory.

Disengagement-isolation risks. In the early months of the Covid pandemic, the mandated forced quarantine literally overnight ripped people away from their jobs, families, friends, houses of worship, and recreational activities. It was in many ways analogous to being kidnapped and held hostage. For many, the emotional sequelae were very severe including debilitating anxiety and depression accompanied by feelings of anger, helplessness, hopelessness, confusion, and desperation.  For some, as time passed, they responded to COVID-19 and its imposed human losses in emotional stages of grief analogous to those described by Elizabeth Kubler-Ross in her book on death and dying denial, anger, bargaining, depression, and acceptance. I believe that across the globe, it appears that many individuals are still progressing through these stages. Those who have successfully arrived at an emotional place of acceptance may be best suited to deal with their re-engagement into society. However, for others, arriving at emotional acceptance may be analogous to acquiescing to their COVID-19 capture and imprisonment, losing the drive for freedom. Clinically, this may be manifest by an apparent apathy. Many may have forgotten the simple joys of human contact and desires for it have been subjugated to ongoing fears and inability to even imagine taking the “risk” of re-engagement.

 The early work of Spitz during the second world war with orphaned children who were unexplainably wasting away despite being fed led to the concept of “failure to thrive”. Once human contact was reestablished during the attention and physical handling that occurred during their evaluations, these children reversed their physical deterioration and began to thrive. The present geriatric literature is replete with similar deteriorative occurrences with isolation and/or loss of a loved one.

How many have been unable to see their parents, children, grandchildren, friends, coworkers, co-exercisers, waiter or waitress, grocery store cashier? A looming and distressing question is how much isolation, for how long, and in whom, until there is irreparable damage done to the psyche, body, family, friends, and vocational viability?

Contemplating re-entry. The occurrence of the COVID-19 pandemic has forced every one of us to re-examine and potentially redefine our risk tolerance. How safe must the world be before we reengage with the people, places, and activities that previously defined our lives. Both personally and professionally, most of us have observed a wide range of perspectives and behavior. We have seen via remote telemedicine those who have not left their homes since March 2020, unwilling to take any perceived risk of acquiring Covid and its potential ravages on themselves and their family members. At the other end of the spectrum, there are those who deny the existence of Covid and have not curtailed their behaviors one iota since the beginning of the pandemic. As each day passes and the numbers of vaccinated persons increase, returning carefully and abiding by CDC recommendations will likely be a relatively safe endeavor (unless a resistant and more virulent Covid 19 variant occurs).

Risk tolerance during reentry from Covid captivity. Obviously, no matter how we redefine our risk tolerance, a “risk-free” life is not an attainable goal. Even if we stay confined to our own place of shelter and isolated lives, there are risks. Fire, carbon monoxide poisoning, burglary, falls, and meteorites crashing through the roof occur. Aspiration, myocardial infarction, fatal arrhythmias, cerebrovascular accidents, and ruptured aneurysms can and do occur. Thus, we are not necessarily “safer” living isolated from the outside world. Hugs, smiles, breaking bread with others, scintillation of the visual-auditory-gustatory-olfactory-tactile senses, all are hallmarks of meaningful engagement in life. Perhaps it can be stated succinctly: do we wish to “exist in life or live our life”. Human connectedness extends the quality and length of our lives. The pace and extent of re-entry into the outside world is a difficult and nuanced process for each of us. For some, “existing” in a largely isolated place removed from others with perceived personal safety is sufficient. For others, existence without engagement is intolerable. It is my sincere hope that each of us choose our re-engagement strategies carefully and judiciously allowing reasonable protection for ourselves and others. I also wish to assure you that with gradual re-engagement, your comfort level will return allowing you to find a “new normal”, which may or may not include contagion precautions that were not part of your pre-Covid 19 life.

I urge you to not be disheartened by the ubiquitous chants stating that “things will never be the same”.  This is a truism as it always has been. Historically, as time and life move on, things change both for the better and worse. Fear not, change is good and can be exhilarating for the mind and the body! Take a deep breath, look out your literal and metaphorical window. Carefully contemplate what are you willing to “risk” for your sustenance and happiness today and tomorrow.

 You obviously have survived today’s perils associated with venturing out of your bed and carrying out your morning routine and the necessary activities of the day. All other events and endeavors are relegated to your “daily possibility plate” for contemplation. Please remember that all of today’s contemplative decisions are not etched in stone. Each step during the reentry often does not necessarily “feel right” at first. And then before you know it, these steps feel natural and liberating. Please recall and be assured that the mind, body, and psyche have an amazing ability to bring us back to a comfortable place of health and happiness. Allow me to reiterate, life is a risky business. May each of us safely dip our toes, noses, and hearts into the post COVID-19 world of opportunity and reengagement.

Are you struggling with hair loss?

You may be a candidate for treatment with PRP, an innovative new therapy which uses your body’s own natural growth factors to stimulate hair growth. For more information read the article below, and feel free to schedule a consultation in our office (215) 579-6155).

Platelet Rich Plasma for Hair Loss

According to estimates from the National Institutes of Health, androgenic alopecia affects 30 million women and 50 million men in the United States.1 Oral finasteride and topical minoxidil comprise the currently approved non-surgical therapies for this condition. However, finasteride has been linked to undesirable adverse effects and is not indicated for female patients, and the long-term required daily use of minoxidil can become burdensome.2

These limitations underscore the need for additional treatment options for androgenic alopecia. Emerging research suggests that platelet-rich plasma (PRP) — an “autologous solution of plasma prepared from a patient’s own blood…. containing 4 to 7 times the baseline concentration of human platelets” — may be effective for this purpose.3 Some providers are already offering PRP in clinical practice and its popularity as a hair restoration therapy is growing.2

“The secretory α-granules within platelets release various growth factors…. [that] …induce tissue regeneration, collagen formation, re-epithelialization, and angiogenesis,” according to a 2018 review of PRP research.4 The investigators reported positive results for PRP as a treatment for androgenic alopecia, as have several other reviews and meta-analyses.,6

A 2018 meta-analysis by Gupta, et al, focused on studies in which PRP was directly injected into the scalp of human patients and that used quantifiable measures of treatment success (in this case, hair density).2The final analysis, based on 4 studies with a pooled sample of 60 participants, revealed an overall standardized mean difference of 0.51 (95% CI, 0.14-0.88; I2 = 0%) in favor of PRP compared with baseline.

In another meta-analysis published in the Journal of Cosmetic Dermatology in 2018, the investigators examined 6 studies (pooled N=177) describing quantitative outcomes of PRP vs controls in the treatment of androgenetic alopecia.7 Compared with the use of control treatments, PRP was associated with significant increases in hair number per cm2 (mean difference [MD], 17.90; 95% CI; 5.84-29.95; =.004) and hair cross-section thickness per 10−4 mm2 (MD 0.22; 95% CI, 0.07-0.38; =.005).

Across studies, PRP was linked to minimal adverse events and high patient satisfaction.2

Original article can be seen here