It is little known that skin conditions are the most frequent reason for people to visit a GP with a new problem. About a year and a half ago, I found myself visiting my GP with one for the first time. My legs, bum and lower back were covered with round, red and itchy sores, which I later found out were Seborrhoeic dermatitis – a condition that affects one to three percent of healthy adults. It's fair to say that my confidence began to fade away, as did my sex life.
The first time the sores appeared, my doctor prescribed the wrong treatment, which made the condition much worse. When it reappeared about six months later, I went back to the doctor, who proceeded to nonchalantly Google what these parasitic red blotches might be. It seemed to me that my doctor's cluelessness might be symptomatic of a wider problem, and a report published in 2013 by the All Party Parliamentary Group on Skin (APPGS) confirms that many patients felt that treatment from doctors regarding their skin was totally inadequate.
There is a severe shortage of dermatologists in the UK, which is particularly alarming given that it is estimated that around 54 percent of the UK population experiences a skin condition in any given twelve-month period. Research has also highlighted the "extensive impact skin diseases have on all aspects of people's lives from schooling, relationships, self-esteem and career choices to social, sexual and leisure activities."
It found that while there is a vast spectrum of skin conditions: eczema psoriasis, acne, vitiligo, urticarial and many more, each condition has the potential to impact on one's mental wellbeing. Studies have also shown a correlation between skin conditions and a higher risk of drug and alcohol misuse, as well as suicidal thoughts. In 2011, a study involving 510 acne patients, for example, found that the vast majority reported levels of social and psychological problems that were as great as those reported by patients with long-term conditions such as chronic disabling asthma, epilepsy and diabetes.
Stats like these have led to calls for more psychological support to be offered to those with skin conditions, but as of yet, very little has been done.
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Dr Andrew Thompson, who has been doing research in the field of psychodermatology for over 15 years tells me that: "Most dermatology services don't have easy access, or dedicated access to psychological services." Only 7 out of 127 hospitals have a dedicated psychodermatology service and although other hospitals may have access to clinical psychology services this is somewhat patchy.
The 2013 APPGS report makes it very clear that there is a real gap in services, but Dr Thompson highlights that "what's really disappointing is that that's actually a follow-on report – the report in 2003 basically reported the same issues." So, a whole decade has gone by and the issues are still the same – poor access to psychological support, poor access to treatment and little research. It's not as if the issues are not understood; they are articulately and extensively outlined in the APPGS report, but perhaps that's a testament to the low productivity of an All Party Parliamentary Group.
Dr Thompson explains that the root of the problem stems in part from a lack of research: "The research simply hasn't been done, it hasn't been funded to have been done." Research is key because if you demonstrate that treatments are effective, the government, commissioners of NHS services, hospitals and so on are more likely to dip into their pockets and fund these services.
The next question is, why hasn't the research itself been funded? Dr Thompson answers candidly: "Maybe because both mental health and skin health are still considered Cinderella-services. It could be because a significant amount of the psychological distress associated with skin conditions is associated with appearance concern, and that might be considered vain" In other words, skin conditions have often been dismissed as cosmetic and consequently seen as unimportant in comparison to other forms of health-care.
Jennifer White is a 32-year old psoriasis blogger. She agrees with Dr Thompson when she discusses her illness: "It's definitely perceived to be quite trivial I think." Jenny continues, "I think the other thing is that, for young medics, dermatology is not considered the most glamorous of specialties – rheumatologists get to deal with the grittier stuff – whereas dermatology doesn't necessarily come out as seeming that serious."
Another factor is that dermatology is rarely, if ever, considered to be a core module in university medical courses. Until dermatology is recognised as a key field in medical care, standards of provision are only likely to get worse. Very few skin conditions are life-threatening, so it is understandable that at times priority must lie elsewhere, but this doesn't mean skin conditions should be marginalised or under-prioritised as a whole.
Jenny has had psoriasis since she can remember and has never been offered any sort of psychological support, something she thinks would have been helpful because of how "hugely connected it is to [her] stress levels." She goes on, "The lack of control over your own skin is really horrible. I got engaged recently and I'd rather not be covered in psoriasis on my wedding day. But, if that happens, there's nothing I can do." Psoriasis, like many other skin conditions, waxes and wanes, it gets better and worse depending on a number of factors including tiredness, stress or a low immune system.
The trouble is that your skin – especially when on your face – is subject to public judgment. Skin is the first thing that people look at; it's not something we can get away from. Jenny tells me many stories of strangers asking about her conditions in bathrooms and on the street. Other times people are just purposefully offensive. "I've actually had strangers tap on my shoulder in a pub and go, 'excuse me love, do you realise you've got dandruff? Its disgusting.' That was pretty mortifying at the age of twenty." It wasn't dandruff; it was flakes from the psoriasis Jenny had on her scalp.
Much of the problem seems to be the lack of understanding around skin conditions; Jenny says that most people she meets have never heard of psoriasis. "It can be especially embarrassing when you're at school because people don't understand what it is. I've definitely had experiences of being very young and having parents go, 'What is that? Is it contagious?" The assumption that it is contagious is so common that the National Psoriasis Foundation's twitter picture directly quotes, "We won't ask you... Is it contagious?"
Alongside the risks of bullying, Dr Thompson adds that, "There is research that indicates that [skin conditions] might have a real impact on things like employment prospects because interviewers might actually not recall as much information from the interview as a result of attraction biases; essentially they are distracted by differences in appearance." People have automatic responses which mean that initially they may overly focus on visible differences, rather than the person.
Evidence submitted by a woman to the 2013 APPGS report confirmed Dr Thompson's suspicion of a weakening in job prospects: "I feel that in applying for jobs over the last few years, since my vitiligo has become more extensive, I've been passed over in favour of other candidates."
The British Skin Foundation conducted a survey in 2012 which found that, of 729 people who had suffered skin diseases, 47 percent said that they had been victims of verbal abuse one or more times and one in six of the respondents admitted to having self-harmed as a result of their skin disease. Disturbingly, 17 percent (125 people) said they had contemplated suicide at some stage in their lives.
Dr Thompson often works with NHS patients with a range of skin conditions; he recently worked with someone with acne scarring who had made several attempts at suicide. He told me that she would always compare herself to other women: "She'd constantly say, 'Oh, that girl's skin is so much better than mine, I'm hideous.'" Thompson points out that, often, people with skin conditions can experience symptoms similar to social anxiety and to some extent body dysmorphic disorder, becoming obsessed with their perceived skin imperfections. "We do need pathways into intense forms of psychological support, such as cognitive behavioural therapy for the people who might need it."
I was lucky enough not to be seriously affected by my condition, but I did experience higher levels of anxiety due to the critical gaze of strangers. And I only had it for a couple of months. The risk of developing a mental health problem is invariably higher for those with visible physical health problems. Far from being trivial, our skin encases our whole body, it is our largest organ and our most visible one and yet it is still being ignored. As long as there is an increased risk of anxiety or depression for those with skin conditions, there needs to be a better medical infrastructure to deal with it.
A new website provided by The British Association of Dermatologists provides some self-help leaflets – a good place for people distressed by their skin condition to access information.
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