It’s not just skin deep

It is an understatement of somewhat heroic proportions to say that the Covid-19 pandemic has altered all our lives. In the field of medical education, traditional medical meetings have been replaced by webinars and online conferences with all the pros and cons that go with these. It has been interesting to see just how quickly people have adapted to attending and enjoying such live events – often from the comfort of their own home – as well as being able to catch up with them afterwards if work or home commitments prevent them attending at time of airing.

Almost 100 health care professionals chose to watch the Thornton and Ross evening webinar on June 30^th, which brought together a panel of experts to discuss skin problems and their link to mental health issues and Covid, with the feedback received afterwards showing this to have been a huge success and a very popular topic.

Watch a recording of the Mental health, Covid and skin problems webinar now!

The timing of this webinar tied in nicely with the news from several days beforehand that the first ever NICE guideline for acne vulgaris was recommending that GPs should consider mental health support for severely affected patients. Such advice is long overdue – the 2020 report by the All Party Parliamentary Group on Skin (APPGS) that looked at mental health and skin disease found that specialist mental health support for people with skin disease was limited throughout the UK, despite a growing need for such services.

This is particularly worrying since the COVID-19 pandemic has exacerbated mental health distress in a skin community known to already experience significant appearance-related distress, with 98% of the APPGS study respondents reporting that their skin condition had affected their emotional wellbeing, and 93% saying their skin condition affected their self-esteem. Throughout the survey, respondents’ qualitative responses indicated the psychological impact of their skin condition was extremely significant and this message underlined the presentations given by each speaker on the evening.

I was delighted to be able to chair the event, and began by giving a very brief precis of some important points as I saw them, including the fact that skin disease is very common with approximately a quarter of the UK population consulting a GP each year due to a skin complaint. Despite this, access to specialist mental health support for people with skin disease remains extremely limited throughout the UK, despite a growing demand and subsequent need for such services – my experience over many years with patients suffering from long-term skin problems consistently highlights this need – and as a general point I believed we should always now be looking at the health of the whole person with a skin problem rather than just focusing on their skin appearance.

This led to the main presentation of the evening by Dr Padma Mohandas, consultant dermatologist at Bart’s Health London. Padma has a special interest in psychodermatology and is part of the team running a dedicated complex needs clinic at the Royal London Hospital, which has received the ‘BMJ Dermatology Team of the Year’ award. She is on the executive committee of Psychodermatology U.K. and her expertise was apparent after only a few moments of her presentation. This was called ‘Mental health, Covid and skin problems – where are we now?’ and was a great overview of this area, condensing a huge range of information into 25 minutes and giving clear and succinct practical advice along the way. Padma looked at presentations of chronic inflammatory skin disease during the Covid pandemic, its impact on mental health and what we can do as health professionals to help our patients. She looked at studies showing – among other things – that following the implemented hygiene regimen caused by Covid, a high proportion of young children rapidly developed hand eczema, and that PPE and hygiene habits had a mild to moderate impact on the majority of health care worker’s dermatologic quality of life. She also looked at the ‘Maskne’ phenomenon of facial skin problems caused by prolonged mask wearing and found this was likely to be a disorder of follicular occlusion and directly related to mechanical stress (pressure, occlusion, friction) and microbiome dysbiosis (heat, pH, moisture from biofluids).

Her key take-home points were that skin and mental health problems were closely linked and that Covid had highlighted the quality of life issues related to skin health. She also pointed out that adequate maintenance of skin barrier function was integral to healthy skin functioning, and that identifying at risk groups and having proactive prophylactic interventions to maintain a healthy mind/skin balance were essential to our medical practice.

The webinar then moved onto the other speakers, with each of us saying a few words as to our experiences with patients and how they had influenced our working practices. I began by discussing a successful professional man in his 30’s with psoriasis who broke down in my consulting room because he was unable to enter any relationship due to his fear of anyone seeing him having to sweep the skin out of his bed each morning – a dreadfully sad revelation and one he had hidden from the world for a decade.

The next speaker was Julie Van Onselen, a dermatology lecturer practitioner with a background of 30 years as a dermatology clinical nurse specialist and educator. Julie confirmed she had similar experiences with her patients and emphasised why psychodermatology should be part of every skin problem consultation. She also touched on her helpline experience over the recent lockdowns and talked positively about the virtual clinics she had held in her NHS primary care dermatology clinics.

Following on from Julie, Ash Aggarwal took centre stage. Ash is a lead clinical pharmacist in south Birmingham, looking after his team of pharmacists and technicians ensuring that local GP practices are supported and has a postgraduate diploma in dermatology in clinical practice. Although this was Ash’s first such online event he gave an extremely assured and thorough outline as to how he was able to help both healthcare professionals who may have questions about dermatology treatments and members of the public with skin conditions, and why it was so vital to have a multi-disciplinary team approach in this area.

We then moved on to general questions (pre-pandemic this would have been when all the panel members got up on stage to answer queries from the audience!) and this not only highlighted the passion the speakers had about helping improve the mental health of dermatology patients but also how interested and involved the audience were with many questions coming in to the experts. Interestingly, many of these concerned the practicalities of setting up local psychodermatology services in their area showing not only a desire for these to exist but also the current lack of such services in many local CCGs. When each panel member was asked to give a simple take-away message from the evening, I began by saying that whenever we have a skin-related consultation with a patient we should begin not by asking that person how their skin is but how they are feeling. This was mirrored by Padma who said that shame and low self-esteem can plague patients with poorly controlled skin disease, and that we need to be proactive in asking our patients how their skin condition is affecting them and not focus solely on the physical aspects of their condition. Adding further to this strong message, both Julie and Ash reminded the audience that we must always take a holistic approach to anyone with a skin problem, and never assume it is not affecting their sense of wellbeing and self-esteem, even if the skin condition appears relatively mild at first sight.

As with all events where there is such a high level of involvement between the audience and the speakers, time ran out all too quickly but the meeting was such a success that further ones are now planned as – unlike many of our patients with chronic skin problems – we have only started to scratch the surface here.

Key take-home points from the webinar

• People with a skin condition can have a high incidence of psychological distress linked to it
• This can range from a mild impact on self-esteem to severe anxiety, clinical depression and suicidal ideation
• When talking to someone with a skin problem, always treat them holistically and enquire about their mental health as well as their skin health
• Always check how someone with dry skin knows how they should be using their emollient and how often
• The Covid-19 pandemic has adversely affected the mental health of people with skin conditions, as well as worsening dry skin problems in many of them
• There is a significant need for psychodermatology services to be provided in every CCG
• The key to successfully helping improve mental health issues in someone with skin problems is to have a multi-disciplinary team approach.

Useful resources

• British Association of Dermatologists: www.bad.org.uk
• Primary Care Dermatology Society: www.pcds.org.uk
• Psychodermatology UK: https://www.psychodermatology.co.uk/royal-london

The National Eczema Society

The National Eczema Society has a range of useful materials for patients and professionals. There is an excellent article by Dr Anthony Bewley, Consultant Dermatologist at Barts Health NHS, who explains the complex links between eczema and psychological well-being

https://eczema.org

The Psoriasis Association

The Psoriasis Association has useful information for patients, including hints and tips for patients navigating the covid pandemic, from Professor Chris Bundy. The Association also facilitates confidential patient forums and has a private Facebook Group to offer a safe space to connect with others living with psoriasis, and seek support.

https://www.psoriasis-association.org.uk

The Ichthyosis Support Group

The Ichthyosis Support Group offers a helpline and email advice service to support patients.

https://www.ichthyosis.org.uk/

Acne Support

Offers emotional support for patients with acne.

http://www.acnesupport.org.uk/

Skin Support

The Skin Support website was developed by the British Association of Dermatologists (BAD) and offers a range of materials for patients including emotional support tools and a Skin Support Personal Evaluation questionnaire.

http://skinsupport.org.uk/