Reviewed by: Bernard A Cohen, MD, and Kelly Cordoro, MD
Among the stressors that can have a significant negative impact on the quality of life of children are skin diseases, particularly those that affect physical appearance such as psoriasis, atopic dermatitis (AD), and acne. In 2002, the psychosocial effect of these three skin diseases was examined in a literature review that found that these skin diseases seriously affected patients’ lives by causing a host of psychological problems, including depression and anxiety.1 Based on the evidence at that time, the investigators concluded that the effect of skin disease on the psychological well-being of patients is underappreciated.
To date, this may still be true for some pediatricians. Although certain pediatricians recognize the importance of skin-related psychosocial issues, Bernard A. Cohen, MD, professor of Dermatology and Pediatrics at Johns Hopkins University School of Medicine, Baltimore, Maryland, says that he doesn’t think it is universally accepted among pediatricians—and it should be. “It is important to involve the pediatrician in the management of an underlying skin problem because of the positive impact it has on developmental and behavioral issues in addition to making the skin better,” he says.
The need for pediatricians to be aware of the substantial negative effects of skin diseases on children is highlighted by the fact that many children under their care will have a skin condition that could contribute to emotional and behavioral problems if not identified and managed. Both AD and acne are among the most prevalent skin conditions in childhood, with AD associated with early childhood and acne associated with older children. Of the children who develop AD, 60% do so in the first year of life and another 30% before age 5 years. It is estimated that about 40% of children who develop AD will carry the skin disease into adulthood. Unlike AD, acne is most common in adolescents, particularly between ages 15 to 17 years, and is estimated to affect 85% of adolescents.2
In another very recent literature review published in 2016 that looked at the psychosocial effects of AD and acne on children’s self-esteem and identity, investigators found that the effect of AD on a child’s quality of life is comparable to the effect of other chronic diseases, such as diabetes and hypertension.2,3 The effect on mental health and social functioning can be even more severe, with data showing that AD has a more severe impact on mental health than diabetes and more severe impact on social functioning skills than hypertension.2,4 For older children, acne has been shown to have a more negative effect on mental health and social function than other chronic conditions such as asthma, arthritis, back pain, diabetes, and epilepsy.2,5
When examining the effect of AD and acne specifically on identity and self-esteem in children, the literature review showed that multiple factors contribute to difficulties in these areas.2 For children with AD, the investigators found little data on the direct impact of AD on identify and self-esteem but found that most studies focused on the development of behavioral problems associated with AD and the effect of AD on activities and relationships. Data on preschool children with AD show that these children have increased dependency, fearfulness, and nighttime sleep disturbances, and that the incidence of behavioral problems, family disruption, and stressed parenting are all significantly greater with these children. Many of these children can develop behavioral problems that affect their sense of identity (ie, some children may see themselves as “outcasts”).
Other important factors contributing to behavioral problems in children with AD include their relationship with authority figures and peers. Data show that parents and other authority figures of children with AD may unwittingly hinder their child’s ability to develop coping skills, and therefore reinforce behavioral problems and identity issues by not exerting sufficient discipline and giving in to their child’s demands.2 In addition, data show that children with AD often feel stigmatized and fear interacting with others, which results in social isolation and poor self-esteem; bullying and teasing also negatively affect self-esteem and self-identity.
For children with acne, studies show a direct link between acne and identify and self-esteem issues.2 Many of these children feel embarrassed by their acne and have problems with low self-esteem, which is exacerbated by reported teasing and bullying from others. Children with severe acne experience these difficulties even more, which often leads to changes in areas that affect their lifestyle and identity (ie, choices they make in dress, activities, hobbies, and schoolwork).
Critical to helping children with the psychosocial issues potentially developing from skin diseases is first the recognition that skin diseases can and do cause much suffering in children, and this suffering can have negative consequences that carry into adulthood. Emphasizing that the appearance of the skin can have significant effects on the development of self-esteem, social interactions, relationships, school performance, extracurricular activities, and overall emotional and psychological health that can persist into adulthood, Kelly Cordoro, MD, associate professor of Clinical Dermatology and Pediatrics at the University of California, San Francisco, and senior author of the 2016 literature review, emphasized the need for pediatricians to take the concerns of children who are struggling with skin issues seriously.
“When we see severe skin disease it is obvious that it requires referral to dermatology for management, but even minor or limited skin problems may be interpreted as “flaws” by patients and can result in disproportionate impact on the child’s body image and lead to body image pathology,” she says.
Armed with this recognition, pediatricians play an important role in helping to identify and address potential psychosocial problems in these children early to stem the negative effects that can become more difficult to address over time. Once identified, pediatricians can then also help children and their families develop coping skills.
This article summarizes some of the evidence cited in the 2016 review article on clinical tools used in dermatology practices to assess whether a child is experiencing psychosocial difficulties related to his or her skin disease, as well as coping strategies that can be used to help children and their families manage these potentially difficult psychosocial issues.
Assessing the potential psychosocial effect of a skin disease on a child can be difficult because it relies on the child’s mental perception of his or her appearance and how this affects him/her. As such, assessment is highly subjective.6
One way to assess the potential psychosocial effects of skin diseases is to measure what is called cutaneous body image (CBI), which refers to a person’s mental representation of his or her skin, hair, and nails.6 Assessment of CBI generally involves 3 major areas (Table 1).
To measure CBI specifically, a well-validated Cutaneous Body Image Scale (CBIS) can be used. Comprised of 7 items, the CBIS provides a composite score based on the mean ratings of the 7 items with a high score indicating greater satisfaction with CBI (Table 2).2,6
Cordoro emphasizes that the CBIS is very easy to use, is written in easy to understand language, and takes only minutes for patients to complete. An alternative to using the full test, she says, is to simply ask the child directly during the clinic visit how he or she feels about his/her skin disease.6 “This will allow assessment of body image and validate an adolescent’s concerns as medically relevant and not a sign of vanity,” she says.
Assessment of CBI is seen as both a way to evaluate skin-related psychosocial effects as well as a way for clinicians to acknowledge the validity of such effects on their patients. As such, regular monitoring of CBI is recommended to take into account its subjectivity and changeability over time as well as a way to build a trusting relationship between the clinician and patient.2,6
According to Cordoro, the responses made on the assessment “can then be used to guide interventions such as counseling and/or the need for referrals to dermatology.”
Interventions and coping skills
No studies to date provide specific data on strategies to intervene to help children and parents cope with skin-related psychosocial problems. In the absence of such data, Cordoro and colleagues culled data from a number of sources to offer clinicians a “stepwise” approach to promoting healthy body image and self-esteem in patients with skin-related psychosocial issues (Table 3).2
Cordoro emphasizes that the coping strategies adopted depend on various factors, including patient age, type of skin disease, and the patient and family’s reaction to the skin problem. Saying that some kids cope very well with their skin disease, she points out that even minor skin disease in some children can create an enormous social and psychological burden. “We try to individualize our discussions of coping strategies to the patient’s specific scenario because there really is no ‘one-size-fits-all’ approach,” she says, stressing the imperative to address cutaneous body image in the office given the evidence on the many deleterious effects that skin diseases, such as acne, can have on patients.
Along with providing children with good coping tools, Cordoro and colleagues emphasize the critical role played by parents and caregivers to help their child develop good coping skills. To that end, parents and families also need coping strategies (Table 4).2
For children who may need more help than can be offered in the pediatrician office, referral to a psychologist or other counseling professional can be considered. Saying that he thinks pediatricians are good at assessing major distress in children or disruption of family dynamics, Cohen says that he also thinks most will be good judges at when the need for counseling goes beyond their capabilities. He says he routinely works with a psychologist who has a special interest in AD and who will even come to his clinic to see patients when they are evaluated in pediatric dermatology.
All these proposed coping strategies are only suggestions and not based on any evidence. Evidence on specific interventional techniques for children with AD and acne who have poor CBI does not yet exist.2 Other suggestions for pediatricians to help children and their families cope with skin-related psychosocial issues are provided in “General tools and resources for managing skin-related psychosocial issues.”
Skin diseases can and do have a significant impact on the psychosocial health of children and adolescents. Atopic dermatitis and acne are among the most common skin diseases in children that can have a negative impact on the quality of their lives. As described in a recent review, children with these diseases often have issues with identity and self-esteem.
For children with AD, problems with identity can be associated with behavioral problems that result from not developing healthy coping skills. Parents can unwittingly participate in this by not asserting the discipline a child needs to form good coping skills. For children with acne, self-esteem and identity are more directly connected to their skin disease. The embarrassment many of these children feel because of their acne leads to low self-esteem. For all these children, teasing and bullying by peers is a major contributor to the negative psychosocial affects of having a skin disease.
Pediatricians play an important role in helping to identify and address potential psychosocial problems in children with skin diseases. Clinical assessment is aimed at determining the effect of the skin disease based on a child’s mental representation of his or her skin. Once psychosocial difficulties are identified, pediatricians can then help children and their families develop coping skills.
1. Barankin B, DeKoven J. Psychosocial effect of common skin diseases. Can Fam Physician. 2002;48:712-716.
2. Nguyen CM, Koo J, Cordoro KM. Psychodermatologic effects of atopic dermatitis and acne: a review on self-esteem and identity. Pediatr Dermatol. 2016;33(2):129-135.
3. Aziah MS, Rosnah T, Mardziah A, Norzila MZ. Childhood atopic dermatitis: a measurement of quality of life and family impact. Med J Malaysia. 2002;57(3):329-339.
4. Kiebert G, Sorensen SV, Revicki D, et al. Atopic dermatitis is associated with a decrement in health-related quality of life. Int J Dermatol. 2002;41(3):151-158.
5. Mallon E, Newton JN, Klassen A, Stewart-Brown SL, Ryan TJ. Finlay AY. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br J Dermatol. 1999;140(4):672-676.
6. Gupta MA, Gupta AK. Evaluation of cutaneous body image dissatisfaction in the dermatology patient. Clin Dermatol. 2013;31(1):72-79.
Ms Nierengarten, a medical writer in Minneapolis, Minnesota, has over 25 years of medical writing experience, authoring articles for a number of online and print publications, including various Lancet supplements, and Medscape. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.