Stigmatization and Mental Health Impact of Chronic Pediatric Skin Disorders
Authors: Paller Amy S. , Rangel Stephanie M. , Chamlin Sarah L. , Hajek Aleena , Phan Sheshanna , Hogeling Marcia , Castelo-Soccio Leslie , Lara-Corrales Irene , Arkin Lisa , Lawley Leslie P. , Funk Tracy , Castro Porto Silva Lopes Fabiana , Antaya Richard J. , Ramien Michele L. , Vivar Karina L. , Teng Joyce , Coughlin Carrie C. , Rehmus Wingfield , Gupta Deepti , Bercovitch Lionel , Stein Sarah L. , Boull Christina , Tom Wynnis L. , Liang Marilyn G. , Hunt Raegan , Luu Minnelly , Holland Kristen E. , Schoch Jennifer J. , Cella David , Lai Jin-Shei , Griffith James W. ,   Pediatric Dermatology Research Alliance
Published: April 2024

Importance

Chronic skin disorders in children frequently are visible and can cause stigmatization. However, the extent of stigmatization from chronic skin disease and association with mental health needs further study.

Objective

To examine the extent of stigma, dependence on disease visibility and severity, and association with mental health and quality of life (QOL) in chronic pediatric skin disease.

Design, Setting, and Participants

A cross-sectional, single-visit study was conducted at 32 pediatric dermatology centers in the US and Canada from November 14, 2018, to November 17, 2021. Participants included patients aged 8 to 17 years with chronic skin disease and 1 parent.

Main Outcomes and Measures

Using the Patient-Reported Outcomes Measurement Instrumentation System (PROMIS) Stigma-Skin, the extent of stigma with child-, caregiver-, and physician-assessed disease visibility (primary outcome) and severity was compared, as well as reduced QOL (assessed by Skindex-Teen), depression, anxiety, and poor peer relationships (PROMIS child and proxy tools) (secondary outcomes).

Results

The study included 1671 children (57.9% female; mean [SD] age, 13.7 [2.7] years). A total of 56.4% participants had self-reported high disease visibility and 50.5% had moderate disease severity. Stigma scores significantly differed by level of physician-assessed and child/proxy-assessed disease visibility and severity. Among children with chronic skin disorders, predominantly acne, atopic dermatitis, alopecia areata, and vitiligo, only 27.0% had T scores less than 40 (minimal or no stigma) and 43.8% had at least moderate stigma (T score ≥45) compared with children with a range of chronic diseases. Stigma scores correlated strongly with reduced QOL (Spearman ρ = 0.73), depression (ρ = 0.61), anxiety (ρ = 0.54), and poor peer relationships (ρ = −0.49). Overall, 29.4% of parents were aware of bullying of their child, which was strongly associated with stigma (Cohen d = −0.79, with children who were not bullied experiencing lower levels of stigma). Girls reported more stigma than boys (Cohen d = 0.26). Children with hyperhidrosis and hidradenitis suppurativa were most likely to have increased depression and anxiety.

Conclusions and Relevance

The findings of this study suggest that physician assessment of disease severity and visibility is insufficient to evaluate the disease impact in the patient/caregiver. Identifying stigmatization, including bullying, and tracking improvement through medical and psychosocial interventions may be a key role for practitioners.