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Severe Depression Very Common in Hidradenitis Suppurativa

LIVERPOOL – Over 70% of patients with hidradenitis suppurativa (HS) report moderate to severe depression, while around one quarter of patients with immunobullous (blistering) and hair disorders report the same, study data show. 

Reporting the results of her study at this year's British Association of Dermatologists (BAD) 103rd annual meeting, Sarah Ryan, MBChB, speciality registrar in dermatology from the University of Sussex NHS Trust, Brighton, said a high incidence of depression, as well as poor quality of life, was identified across all participants comprising immunobullous, HS, and hair-related skin disorders.

Despite around a third of skin disease patients having a co-morbid psychological disease, it is difficult to untangle the impact of living with a chronic disease from the impact of the condition itself, she noted. "Data from studies suggest that, overall, rates vary with different dermatological diseases, but are highest in inflammatory diseases such as HS where around 43% of patients have depression."

In her study, Dr Ryan found that HS emerged as the skin disorder with greatest depression and anxiety burden, as well as a moderate or greater effect on quality of life.  

With a special interest in the psychosocial aspects of skin disorders, Dr Ryan recommends psychological assessment of all patients with immunobullous (blistering) conditions, hair loss and HS, as well as those on oral steroids. 

"If anxiety and depression scores are high, then doctors need to establish whether anxiety and depression is primarily related to the skin disorder," she pointed out. "If it is skin-related then refer on to a specialist psychologist, but if it is not skin-related, then we recommend self-referral to IAPT [Improving Access to Psychological Therapies] services or through the GP."

Referring to her 53-year-old female patient with severe bullous pemphigoid, she stressed how debilitating and extremely symptomatic living with an immunobullous condition could be. "It affected her skin and mucous membranes and following resolution of disease she was left with debilitating anxiety and depression."

Study of Mood Disorders Across Immunobullous Disease, HS, and Hair Disorders

The case prompted Dr Ryan and her colleagues to look at the incidence of mood disorders in patients with immunobullous disease, as well as patients with HS and hair disorders. 

Patients were asked to complete questionnaires, namely the Patient Health Questionnaire (PHQ) 9- for depression, GAD (Generalised Anxiety Disorder) 7 for anxiety and the Dermatology-Life Quality Index (DLQI) for quality of life. "We also assessed pain and previous diagnoses of mental health disease," explained Dr Ryan. Pain was assessed through a numerical rating scale and participants were questioned on previous mental health diagnoses.  

A total of 56 patients completed the questionnaires (23 with immunobullous disease, 10 with HS, and 25 with hair disorders). Thirteen patients had previous mental health diagnoses including depression, anxiety and post-traumatic stress disorder (PTSD), notably 13%, 30%, and 24% had prior mental health issues in the immunobullous, HS, and hair groups, respectively.

Turning to results of the questionnaires, Dr Ryan reported that, PHQ-9 scores were mostly high amongst participants with HS (80% had a severe score), were more moderate in the immunobullous disease, and hair disorder patients (patients scoring for moderate to severe depression were 26% and 24%, respectively).

Interestingly, in the hair cohort, incidence of moderate to severe depression dropped to 0% from an initial 80%, if pre-existing mental problems were excluded. "This could indicate that diagnosis of previous mental health problems were skewing the results and this may indicate that there is less of an effect on mood by their conditions than the other two cohorts," said Dr Ryan, offering one possible explanation for this finding. 

"Patients with immunobullous disease had a had higher incidence of depression than anxiety with over one quarter of patients scoring for moderate to severe depression. Hair patients had similar rates across all the parameters used," she said.  

Overall, all patient groups - immunobullous, HS, and hair disorders - reported moderate to severe depression in 24% or more of participants. 

Diagnosis of anxiety (via GAD-7) was less common, with minimal to no anxiety diagnosed in 70%, 70% and 60% in the immunobullous, HS, and hair groups respectively. 

"Anxiety was found to be less prevalent than depression across all groups. However, 30% of HS patient scored for severe anxiety," reported Dr Ryan.  

The trend for an effect on quality of life reflected that of the pain score, she added.

Oral steroids are first line therapy for bullous disorders, Dr Ryan said, but added that many patients taking oral steroids experience mild psychiatric adverse effects and sometimes serious conditions including delirium, psychosis and mood disorders.

Commenting on both the research and the psychological issues related to skin disorders generally was session moderator, Alia Ahmed, MD, consultant dermatologist at King Edward VII Hospital, Windsor, with a specialism in psychodermatology. "The idea that depression and anxiety are associated with both chronic and acute skin conditions, and that the severity of the skin disorder doesn't dictate the psychological impact has been known about in psychodermatology for a while, but nonetheless is a really interesting concept," she began. 

"It is often the visibility of skin conditions – even if just to the patient, for example, in an intimate area – when in fact, it can be more disabling," she explained. 

Dr Ahmed pointed out that skin disorders are often overlooked for their psychological significance. "Skin has also been talked down compared other conditions, but there is a substantial link to depression and anxiety. People say 'it's just my skin, not cancer', but actually it's impacted some people more than cancer. I've known patients say that their skin problem is actually worse [psychologically] than their breast cancer was, for example. Body image, stigma, general mood and anxiety can go on for a long time," she highlighted.

"Now we have firmly established the link, let's treat both what we see symptomatically, but also treat the other things [less visible] including with diet, exercise, and sleep but also psychological interventions or medications if necessary."

Dr Ryan has no relevant disclosures. Dr Ahmed has previously carried out educational roles for various pharmaceutical companies.