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Dr Jonathan Smith reveals the underestimated impact that skin issues have on one’s quality of life…
The tall teenage male entered my consulting room with barely a greeting, a nod, or even an attempt at making eye contact. However, as soon he sat down and faced me, I immediately understood the reason behind his sullen behaviour.
This patient suffered from severe nodulocystic facial acne – an acute form of inflammatory acne that is characterized by the presence of nodular breakouts and cysts.
His father, who had led him into my rooms, proceeded to be his spokesman, while the teenager just stared at the floor. Verbally bullied by his fellow learners, he had lost all his confidence, performed poorly at school, confined himself to his bedroom, had no friends and had become a severely depressed introvert. What’s more, he was unable to communicate with others, never had any fun, and, as such, had an appalling quality of life.
After the consultation had ended, I once more reflected on the true meaning of the term ‘quality of life’: what it meant to him, and to all my other patients who were suffering from low self-esteem due to their skin disorders.
- To this young man, it meant being able to look the world in the eye and not be judged by the devastating effect of his facial acne.
- To my 22-year-old female patient with psoriasis, it meant being able to wear black clothes without having to constantly brush off white flakes that she was continuously shedding. To wear a bikini with confidence, without the worry of being stared at for the wrong reasons.
- For my 9-year-old gymnast with atopic eczema (the itch that “rashes”), it meant waking up with clean sheets; to be able to focus on his sport without having to scratch continuously.
- For my 42-year-old politician with excessive sweating of the armpits, it meant being able to deliver an address without his shirt becoming more discoloured and wet with every sentence uttered.
Self-Image… Yes, it’s that important
From the above, it is safe to say that while the term ‘quality of life’ means different things to different people, for a person with skin issues, it all comes down to self-image and confidence.
Self-image is an essential element in the personality structure, which not only affects mental health, but also plays an important role in the attitude towards the environment. A favourable self-image leads to positive emotions, while a negative self-image leads to anxiety, fear, anger, depression and social maladjustment.
Psychological effects of skin disorders on patients’ self-esteem
The importance of skin disease is often underestimated because of its chronic nature and low mortality. Indeed, dermatologists are often teased about not being able to cure anything and are also taunted that the only dermatological emergency they have is when a blister bursts.
Yet jokes aside, the hard truth is that the prevalence of skin disorders is, in fact, incredibly high.
To verify this, one just has to look at the determined average of the world population suffering from skin issues: a notable 25-75%. Studies have additionally shown that up to 50% of patients with severe eczema and psoriasis would be willing to spend two hours each day treating their condition, should this result in them having normal skin for the rest of the day!
The DLQI (Dermatology Life Quality Index)
In dermatology, the search for a ‘life worth living’ is expressed in terms of a better skin perception, which has become more apparent in recent years (for both men and women alike).
Furthermore, the effect of skin issues on sexuality, work performance and leisure activities has become increasingly recognised. This has resulted in the development of the DLQI, the Dermatology Life Quality Index questionnaire that is designed for use in patients 16 years and older.
The DLQI consists of ten questions, each scored on a scale of 0 to 3 (0 for when the relevant question has no influence on the quality of life, and 3 when it has a major influence).
These questions are based on one’s skin issues and skin symptoms, psyche, leisure activities, clothing, sport, work, studying, relationships, sex life and treatment issues.
The DLQI is calculated by totalling the 10 scores, resulting in a minimum score of 0 and a maximum of 30. The higher the score, the greater bearing on the quality of life. Scores lower than 10 reflect a small influence on a patient’s life, while scores of 20 and above reflect a huge impact on quality of life.
Most notably, the DLQI is used to motivate medical aid coverage for those treatments that are not only more effective, but also carry a hefty price tag (such as isotretinoin for acne, and biologic treatments for eczema and psoriasis).
A relatively recent multicentre study conducted in Colombia (using a Colombian validated version of a questionnaire similar to the DLQI), reinforced previous research regarding the burden of skin diseases on one’s well-being. A total of 1896 questionnaires were analysed, resulting in the following conclusions:
- Even the most localised or asymptomatic skin lesion leads to a disruption of a patient’s wellness at some level. Unfortunately, many health systems have misinterpreted cutaneous disorders as having a “cosmetic” origin, instead of them being a disease which could affect a person’s socialisation, mental and physical health, as well as general satisfaction.
- The highest DLQI scores were found in patients with psoriasis, atopic dermatitis, urticaria, hair disorders, scars, hyperhidrosis (excessive sweating), genital human papillomavirus disease (anogenital warts), and disorders of pigmentation.
- Although women consult dermatologists more often than men (and are generally more affected emotionally by skin issues than their male counterparts), men are still functionally distressed, especially when physical work plays a major role in their jobs.
- Quality of life is marked when a skin disease is chronic.
- The involvement of exposed areas impacted more on the DLQI than that of covered areas.
- Inflammatory skin diseases made more of a negative impression on the DLQI than non-inflammatory skin diseases.
- Treatment leads to a significant improvement in the DLQI scores.
The impact of skin issues on a patient’s general well-being, happiness, self-esteem and self-love has been grossly underestimated in the past, and sadly, remains a pressing issue that has not received the attention it deserves.
- Finlay AY, Khan GK.Dermatology Life Quality Index (DLQI) – a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:2010 – 6
- Sanclemente G, Burgos C et al.The Impact of Skin Disease on Quality of Life: A Multicentre Study. Actas Dermosifiliogr. 2017;108(3):244 – 52.
Written by Dr Jonathan Smith
MBChB (UCT), MMed (Derm) (US)
- Dermatologist www.lasermed.co.za
- Received the Hoechst Award for best student in pharmacology
- Received the SASA Medal for best undergraduate student in anaesthetics, the JS Du Toit Prize for best undergraduate student in ophthalmology.
- Elected president of the DSSA (Dermatology Society of South Africa) www.derma.co.za
Find a Dermatologist www.dermatology.co.za
A2 Disclaimer: This article is published for information purposes only, nor should it be regarded as a replacement for sound medical advice.
This article was written by Dr Jonathan Smith and edited by the A2 team EXCLUSIVELY for the A2 Aesthetic & Anti-Ageing Magazine Autumn Edition (Mar – Jun 2022: Issue 40).
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