Body image, the psyche and the skin

The stress of having skin disease

The potentially harsh psychological effects of having chronic skin disease tend to be underestimated. Up to 30% of skin outpatients suffer ‘psychological distress’ from their condition. This is particularly understandable in the teenager with acne, or in someone who has extensive psoriasis or eczema. In both these situations, the individual’s devalued body image may be out of proportion to the objective severity of his or her skin problem. Skin diseases can thus make patients into ‘social lepers’ who feel that their social lives are restricted because other people do not want to mix with them. These effects on ‘quality of life’ can be assessed by specific questionnaires, e.g. the Dermatology Life Quality Index (DLQI).

Patients sometimes feel that their disorder is either caused directly by, or exacerbated by, ‘stress’. This is difficult to prove, as it is often impossible to differentiate reactive from aetiological states. Many dermatologists believe that psychological factors can, for example, make eczema and psoriasis worse, but most would also agree that these are stressful conditions in their own right. However, it is accepted that there are a small number of conditions that are of psychogenic origin. Management with a liaison psychiatrist can be helpful.

Skin disorders of psychogenic origin

Dermatitis artefacta

Dermatitis artefacta (Fig. 1) should be suspected from the presence of lesions with bizarre shapes (often linear or angular and in accessible sites) that do not conform to natural disease. The lesions are often ulcerated or crusted and do not heal as expected, although they do heal if occluded. Blisters or bruises are also sometimes found.

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