Psychiatric morbidity in children and adolescents with dermatological disorders

Skin is a perfect protective coating with crucial functions somatic communication, sensory stimuli, and physical and emotional development (1, 2). The central nervous system and epidermis originate from the same embryological tissue and their interactions with each other in the later stages of life have become the subject of numerous studies (3). It is a prevalent opinion that in many cases psychological factors cause the dermatological disorders, or dermatological disorders are associated with certain personality traits, or dermatological disorders appear as a complication of psychiatric morbidity (4). Psychiatric comorbid diagnoses are estimated to be as high as 30% in all dermatology patients (5). Compared to adult population, our knowledge in the area of the co-occurrence of the dermatological disorders with psychiatric morbidity in the pediatric age group and their effects on the clinical course and treatment process is limited.

Studies show that in adolescence when secondary sexual characteristics start to develop, dermatological diseases may emerge concomitant with many psychiatric diseases, especially depression. While it is known that in children with dermatological disorders, information about the symptoms, triggers, and treatment is important, it has been shown that chronic dermatological disorders in particular can negatively affect the quality of life (6, 7). Dermatologists can play an important role in the management of psychocutaneous disorders because patients seek help from dermatology clinics for treatment of their skin problems but generally refuse psychiatric intervention. Undetected psycho-pathology can greatly decrease a patient’s quality of life and even contribute significantly to the clinical severity of their skin disease. Therefore, a multidisciplinary approach is important for evaluating the patients from this point of view and to provide them with appropriate support (8). The aim of this study was to determine the sociodemographic and clinical characteristics affecting psychiatric comorbidity by examining pediatric patients that were treated in the dermatology outpatient clinic.

The study was approved by the local ethics committee (Ethics Committee of the Inonu University, Faculty of Medicine, 04.12.2013 and 2013/163) and performed in accordance with the Declaration of Helsinki. Participants were assured of data confidentiality, and permission to use data for reports that ensured the protection of the participants’ identities were obtained from all participants through informed written consent to participate, and their parents consented to their and their children’s participation.

A total of 502 children and adolescents were included in the study. Of the 251 children in the study group, 93 (37.1%) were boys and 158 (62.9%) were girls; the control group consisted of 111 (44.2%) boys and 140 (55.8%) girls (p = 0.102). The sociodemographic characteristics of both groups are shown in Table 1.

The diagnoses in the study group included 55 (21.9%) inflammatory dermatoses (psoriasis, lichen planus); 43 (17.1%) eczematous (seborrheic dermatitis, atopic dermatitis, hand eczema) and allergic dermatoses such as chronic urticarial; 42 (16.7%) acneiform dermatoses (acne vulgaris, rosacea); 36 (14.3%) hair and nail disorders (telogen effluvium, alopecia areata, nail changes); 32 (12.7) chronic infectious dermatoses (bacterial, viral, parasitic, and fungal), 24 (9.6%) pigmentation disorders such as vitiligo; 3 (1.2%) genetic dermatoses (incontinentia pigmenti, epidermolysis bullosa); and 16 (6.4%) chronic cutaneous disorders like dermatitis herpetiformis and other acute/transient conditions such as insect bites and pruritus. The distribution of the diagnoses of dermatological diseases is shown in Table 2.

The rates of general psychiatric comorbidity, mood disorders, anxiety disorders and adjustment disorders were significantly higher in the study group than in the control group (psychiatric comorbidity: χ ² = 29.8, p = 0.0001; mood disorders: χ ² = 11.14, p = 0.001; anxiety disorders: χ ² = 11.54, p = 0.001; adjustment disorder: χ ² = 30.77, p = 0.0001). There was no significant difference between the groups in terms of the other psychiatric disorders (Table 3).

The CDI, STAI-1, STAI-2 and SDQ (and subscales) scores were significantly higher in the study group compared to the control group (Table 4).

Among the dermatological disease subgroups only inflammatory, eczematous and allergic dermatoses had significantly higher rate of comorbidity with psychiatric disorders (p = 0.016 for psychiatric disorder frequency in inflammatory dermatoses; p = 0.037 for eczematous and allergic dermatoses) (Table 5). In addition, we also found that having a dermatological disorder increased the risk of psychiatric comorbidity by limiting physical activity (p = 0.009) (Table 6).

In this study, we aimed to determine sociodemographic and clinical features that affect concomitant occurrence of dermatological diseases and psychiatric disorders in pediatric patients that were treated in a dermatology outpatient clinic. Analysis of the demographic distribution showed that a higher number of individuals in the control group lived in the city (Table 1). Although Kaplan et al. (1995) reported that living in a rural area may be a risk factor for depression, Erol et al.’s study (1998) conducted in Turkey showed that people living in cities had higher rates of depression (17, 18). Therefore, in our study, the effect of place of residence on psychopathology can be interpreted as limited. The children’s school success levels in the questionnaire were determined by parents as level I – very bad, level II – bad, level III – medium, level IV – good and level V – the best. Levels 4 and 5 were grouped as successful, while levels 1, 2 and 3 were grouped as struggling. The school success rate of the study group was determined to be significantly lower than in the control group (Table 1). According to one study, school absenteeism (36.6%) and grade repetition (23.3%) constitute a significant problem in children with chronic illness, physical disability, and mental problems (19). Psychiatric disease history in the family was detected in 30 (12%) patients from the study group and in 23 (9.2 %) individuals in the control group (Table 1).

When dermatological diseases were divided into groups, the most common diseases were inflammatory dermatoses, followed by eczematous and allergic dermatoses (Table 2). Among the studies made in Turkey, Tekin et al. investigated the prevalence of dermatological diseases in children living in Zonguldak and the surrounding area and found eczema to be the most common disease (20). We believe that this difference can be attributed to the fact the in the aforementioned study they investigated the distribution of dermatological diseases individually, whereas in our study we looked at the distribution of the diseases classified according to their broader diagnosis. In our study, the rate of children and adolescents diagnosed with any psychiatric disease was significantly higher in the study group than in the control group. Similarly, psychiatric diagnoses were found in approximately one quarter (25.2%) of the patients with dermatological disease in a study of psychiatric comorbidity with 2579 patients (21). In our study, the scores for mood disorders were significantly higher in the study group compared to the control group. Since data on the relationship between dermatological diseases and mood disorders in the pediatric age group are limited compared to data for adult patients, we believe that our study provides important information in that regard. In a study by Dornelles da Silva Manzoni et al. (2012), evaluating the life qualities of 118 children aged 5–16 years who were treated at the dermatology polyclinics in Brazil, the rates of shyness, low self-confidence, anxiety, and depressive mood were found to be higher compared to control (22). In another study, anxiety and depression were found to be the most common psychiatric problems associated with dermatological diseases. The common and visible characteristics of skin diseases are often associated with anxiety, depression and low self-esteem (23). In our study, anxiety disorders were significantly higher in the dermatological disorders group (Table 3). In an epidemiological study conducted in Turkey, it has been shown that anxiety disorders were the most frequently seen disorder (14.45%) in adolescents being treated in children’s psychiatry clinics (24). Moreover, in a study on dermatological diseases by Vargas et al., anxiety disorder was screened by separating the dermatology patients into subgroups (psoriasis, acute urticaria, atopic dermatitis, and others) and anxiety disorder was detected in 48% of the psoriasis group and 39% of the atopic dermatitis group (25). In our study, the diagnosis of adjustment disorder was found to be significantly higher in the study group. Studies have shown that children and adolescents had difficulty in adjusting to their new condition after the disease was diagnosed, however in time they adjusted to the disease and their initial low quality-of-life perceptions improved (26). In a medical record review study that covered dermatology patients, it was found that the most prevalent psychiatric diagnoses in the patients were depressive disorder and adjustment disorders (27). Similarly, in our study, adjustment disorder was determined in 29 (11.6%) of the patients in the study group, as opposed to none in the control group (Table 3).

The CDI, STAI-1 and STAI-2 scores of the children in the study group were significantly higher compared to the control group (Table 4). These results indicate that the severity of both anxiety and depressive mood is higher in adolescents with dermatological disease than in healthy children. In one study, some adolescents with dermatological disease felt that they should be different by avoiding certain activities because they felt embarrassed about their appearance (28). Because adolescence is a special age with great physical and hormonal changes, it is also an important period for body image and self-presentation (29).

The SDQ-P (and subscales) scores filled out by the parents of the children were higher in the study group, indicating that these patients experienced more behavioral and emotional difficulties compared to the control group. It is expected that children and adolescents with dermatological diseases will have more difficulties than their otherwise healthy counterparts and that their mechanisms to cope with these difficulties might be less efficient.

The social behaviors subscale of the SDQ-P is a scale in which the current social strengths of the child and adolescent are questioned and evaluated. The higher the score, the lower the risk of psychiatric disorder. In our study, the evaluation of the SDQ-A and SDQ-P scores showed a significant difference between the study and control groups in all subscales except for the social behaviors subscale. This finding may be due to the fact that children and adolescents are not aware of their current strengths and mechanisms for dealing with problems.

In our study, the incidence of psychiatric morbidity was found to be significantly higher in the inflammatory, eczematous and allergic dermatosis groups (Table 5). We believe that this increased rate is due to proinflammatory cytokines and some inflammatory processes being involved in the pathophysiology of depression and inflammatory diseases (30). Eczematous and allergic dermatosis groups may be intensively pruritic, or the angioedema may present with mild pain and burning sensation (31), symptoms that affect the patient’s quality of life significantly and may account for stress, negative self-image, disability in social functions and adverse emotions such as anger and depression (32-4).

In our study, we investigated the frequency of psychiatric morbidity in the clinical variables of pediatric age group with dermatological diseases. It has been determined that restricted physical activity related to dermatological disease is a significant risk factor for frequency of psychiatric disorders (Table 6). One study has shown that the various clinical involvements associated with psoriasis have a direct effect on physical activity (35). In fact, physical limitation caused by dermatological disease decreases the quality of life and may result in emotional stress and psychiatric disease.

There is a real threat of psychiatric morbidity associated with dermatological disorders in the pediatric age group and if neglected this threat can negatively impact the children’s mental health and quality of life. We would like to emphasize the need for close collaboration between psychiatry and dermatology disciplines in treating patients with psychocutaneous conditions.

We believe that our study is a valuable addition to the literature because we focused on investigating psychiatric comorbidity in dermatological disorders in a child and adolescent population, which is an underrepresented study population. In addition, we used structured interview techniques and had a relatively large sample size and a control group that had matching sociodemographic characteristics.