Addressing acne from a psychodermatology perspective

Generally speaking, skin diseases have been the leading cause for seeking medical advice, and it is estimated that around one quarter of family physician office visits are skin-related; of these, inflammatory skin conditions similar to acne, psoriasis and eczema make up the highest percentage.Acne is a common skin condition that we encounter as family physicians regularly, affecting specific age groups. Depending on the severity of acne vulgaris and associated scarring, it can usually be managed by a family physician, a dermatologist, or if needed, an aesthetic medicine practitioner using a variety of interventions similar to laser therapy and microneedling.We often encounter patients with different concerns related to their skin; we often hear statements similar to: “When I turned 15, my acne became so angry-looking that I could no longer engage in life as I used to; I missed school days as I had no more confidence in the way I looked.”“I developed anxiety and depression due to my bad acne. I have literally spent hours visiting my GP and my dermatologist trying to find a cure for my facial acne outbreak. I was given many creams and ointments and even oral antibiotics, but my acne never responded. My acne ruined my life.”“Believe me, it is soul-destroying; it destroys every part of me physically and mentally, so I sometimes think, what am I doing here.” “I stay home more than ever, as I feel so embarrassed to go out; I don’t like how I look anymore.”Acne vulgaris is a skin condition with profound psychosomatic and psychosocial elements that has a significant impact on a patient’s life, leading to social withdrawal, anxiety, dissatisfaction with appearance, embarrassment, depression and low self-esteem. It can also affect family relationships and increase suicidal ideation. It can disturb sleep patterns as a result of acne-related anxiety, pain or skin picking, which in turn leads to reduced concentration on schoolwork, affecting school performance, participation in school sports or social events.What adds to this is the effect of social media platforms by promoting non-realistic appearance parameters, leading to further exacerbation of acne-related mental disorders. Adolescents may experience mental health challenges resulting from stigmatization and social rejection associated with their appearance. These experiences can diminish self-esteem and self-confidence, contributing to depression, social anxiety, body dysmorphic disorder and avoidance behaviours, which may further impair academic performance. Our patients, especially those with skin diseases, are entitled to receive adequate and appropriate support to manage and adapt to their condition, regardless of their age, ethnicity, background or culture. Incorporating resilience and effective coping strategies in children and adolescents’ psychotherapeutic counselling becomes crucial for preventing long-term mental health burdens, such as anxiety and depression, at both individual and societal levels. Being a family physician for over 24 years with advanced training in both dermatology and psychotherapy, a diploma and a master’s degree holder in psychodermatology and being a pioneer in integrating spirituality in psychodermatology, I frequently encounter patients with inflammatory skin conditions alongside mental health complaints; I have observed significant improvement in outcomes, including better therapeutic alliance, patient compliance to treatment plan, understanding, and skin healing outcomes, all with noticeable improvement in the holistic wellbeing approach.I have observed an increase in patient interaction and curiosity has significantly improved as they understand the mind-skin relationship and receive psychoeducation in this field, allowing them to answer questions they have been looking for answers to for a long time. For instance, I had a patient who deeply believed that her acne was not merely a skin problem and that her thoughts, emotions and mood had “something” to do with the flare-ups of her acne and for her to arrive at my office was a journey she decided to go on. Keeping in mind the importance of considering any cultural influences, such as beliefs about health and illness, as they can shape individuals’ health-seeking behaviours and responses to treatment and that individuals with chronic dermatological conditions often require more extensive psychological support than those without such conditions. When these are acknowledged, patients are less likely to find it stigmatising to approach their physician for mental health issues. Trust develops over the years, especially when the clinical setting fosters confidentiality, reduces stigma, and facilitates open communication and reassurance, ultimately leading to better cooperation and health outcomes.Another important point to be considered when dealing with adolescents with acne, is that their families can also be suffering from the psychological burden while providing support and care for their loved ones with acne that is overlooked and/or not addressed by the treating physician.Conducting holistic assessments on a routine basis that address the mental health impact of skin conditions, and vice versa, on patients and their families, together with providing psychological support when appropriate, can elevate the patient's experience in a given encounter. Allowing a 20-minute counselling/screening time to conduct a biopsychosocial intake and fill out a questionnaire promotes a more comprehensive understanding of the multifaceted effect of the skin disease on the patient’s life.Introducing routine mental health screening tools is recommended, using validated instruments such as the Cardiff Acne Disability Index (CADI), Dermatology Life Quality Index (DLQI), Patient Health Questionnaire-9 (PHQ-9), and Generalised Anxiety Disorder Scale (GAD-7). These tools are accessible, easy to administer, and assist in identifying mental health conditions that might otherwise be overlooked.A short 10-minute cognitive behavioural therapy counselling session helps shape the patient’s understanding of the root of his skin problem and reshape his thoughts in a way that supports overall well-being, with a simple action plan to follow between visits.As you may know, acne, being an inflammatory skin condition, can be significantly exacerbated by psychological stress that disrupts the epidermal barrier homeostasis and triggers the release of mediators from the neuro-immuno-cutaneous system when not adequately addressed, resulting in turn into major depressive disorder and/or general anxiety disorder. Counselling can be effective in 40% to 60% of cases, with potentially higher rates of success when coupled with prescribed medications.Having said that, and despite the clear need and increasing demand for psychodermatology services, a substantial shortage of psychological support for individuals with skin conditions persists across Canada. The need for a primary care physician trained in psychodermatology who is equipped to manage common dermatological cases, conduct psychotherapy sessions, and prescribe antidepressant or antipsychotic medications when indicated becomes an important need.Implementing a multidisciplinary approach enables timely referrals or consultations with dermatologists or psychiatrists for complex cases, reduces the need for multiple appointments and unnecessary referrals and may help alleviate the stigma some patients associate with psychiatric care, improve patient satisfaction, reduce frustration, enhance the physician alliance, and improve overall health outcomes.It is a call to reconsider how we shape the delivery of our primary care services in a way that serves our patients holistically at the clinical, educational, provincial and cross-Canada levels.Dr. Yasmin Hummadi is an FP with a focused practice in psychodermatology and spiritual psychotherapy in Oakville, Ont.

Addressing acne from a psychodermatology perspective

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