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'silent suffering': below the surface of a skin disorder often lies depression, low self-esteem and anxiety

disorders like psoriasis and rosacea are far more than skin deep, not only causing pain and relentless itch, but also impacting mental health and quality of life, says dr. ian landells.

by robin roberts

may 10 2022

6 minute read

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saving face: treatments offer hope for those living with skin disorders

five and a half million canadians suffer from acne, according to the canadian dermatology association. getty

in the middle ages, skin conditions like psoriasis, eczema and rosacea were often mistaken for leprosy, a chronic, infectious disease that can cause permanent damage to skin, nerves and eyes. because it was contagious and hard to look at, sufferers were sometimes hung with cowbells to warn their fellow villagers to change course and avoid running into them. later, they were taken from their families and banished to leper colonies.

today, thankfully, we’re much more sympathetic to anyone with skin issues, but many of those affected still feel shame. in fact, many people with common skin disorders — eczema, psoriasis, rosacea and acne — can experience severe depression, to the point of suicide. but dr. ian landells, a medical director at the landells clinic in st. john’s, newfoundland, says no one should lose hope because there are effective treatments for all these conditions.

eczema

healthy skin acts as a barrier to keep irritants out and moisture in, says landells. when that barrier is compromised, we lose moisture, become very dry and irritants find their way through, which creates an inflammatory response, like eczema, and we get very itchy.

he says roughly five-and-a-half million canadians have eczema , also known as atopic dermatitis . it often begins in babies and children but fades over time, with two-thirds clear by their mid-teens. the rest carry it well into their adult life.

most of the symptoms — scales, redness, bumps, sores, crusting, thickening of the skin — are caused by scratching, says landells. it’s not contagious, and minimizing the itch means avoiding irritants such as harsh shampoos, soaps, detergents, dryer sheets, rough fabrics like wool and animal dander. also, he says “aggressively moisturizing” (creams containing ceramide help) after a quick bath or shower, using warm, not hot, water while the skin is still damp helps to lock in moisture.

there’s also evidence pointing to our hyper-clean environment as a culprit. “by keeping children and their skin super clean, using anti-bacterial soaps and not exposing them to germs, bacteria and viruses we are impacting the maturation of their immune system,” he says. “and that may increase the likelihood of these abnormally inflamed reactions when they do encounter normal pathogens.”

‘switch the itch off’

eczema can appear anywhere on your skin, but it’s more common on hands, neck, inner elbows, ankles, knees, feet and around your eyes. you’re more likely to be affected if you’re female, black, or have a family history. stress can also cause or worsen attacks.

while there currently is no cure, symptoms can be managed with medications, including prescription topical steroid and non-steroidal agents, prescription topical steroids and antibiotics, and, if there’s infection, oral antibiotics. landells treats severe cases with oral and injectable biologic agents that, he says, “literally switch the itch off.”

he says there’s a common misconception that if you have eczema, it’s triggered by a food allergy: “but that’s rarely the case, so allergy testing is of little benefit.”

psoriasis

while eczema and psoriasis look similar — red, dry, itchy, bumps and scaly patches called plaques — they’re quite different. psoriasis is an auto-inflammatory condition, “a misstep of our immune system that creates these inflamed lesions in the skin,” says landells, and affects three per cent of canadians.

as for what causes it, he says that while there have been some genes identified, psoriasis is more of a condition with many co-morbidities with psoriatic arthritis — a disabling form of arthritis — being one of them.

“up to 30 per cent of people with psoriasis will go on to develop psoriatic arthritis,” he says.

while psoriasis is mostly genetic, there can be environmental triggers because it can occur at around age 20 as well as in your 40s, adds landells. but those triggers have yet to be identified.

people with psoriasis are susceptible to heart disease and cancer

people with psoriasis are also susceptible to diabetes, heart disease, hypertension, inflammatory eye conditions, even cancer.

“people with severe inflammatory psoriasis are also more likely to have inflammatory bowel disease [ibd], such as crohn’s and colitis,” says landells. “and people with ibd are more likely to have psoriasis. there’s some early evidence to suggest that if we can control the chronic inflammatory state in the body we may be able to prevent the development of these other co-morbidities.”

effective treatments include topical steroids, topical vitamin d, light treatment and retinoids for mild cases. for more severe cases, systemic and injectable biologic agents work well, and also have the side benefit of treating the attendant arthritis.

rosacea

if you regularly flush red and you’re not embarrassed or sunburnt, chances are you have rosacea. the condition, characterized by burning, itching, and stinging in the face that turns it very red, affects about three million canadians.

a combination of genetics and environment cause mostly women and fair-skinned people to get it, which is why it’s known as the “curse of the celts”. the most common environmental source is sunlight, which causes sensitive blood vessels to overact and expand. extremes of temperature, alcohol (especially red wine), spicy foods and stress can also spark outbreaks.

“the blood vessels over time expand and contract, become like balloons that have been blown up one too many times and they lose their elasticity and they remain enlarged and look red all the time,” says landells. “you get these visible blood vessels on the cheeks, the nose, the chin, the middle of the forehead — the areas that get the most sun exposure.”

he says there is no cure for rosacea, and treatments comprise topical agents for the bumps that may break out, as well as laser to tone down the redness. it’s best to avoid whatever causes the flare-ups and use sunscreen daily, no matter the weather.

acne

usually associated with teens and raging hormones, acne can last well into adulthood. in fact, five and a half million canadians suffer from acne , according to the canadian dermatology association, but 90 per cent of adolescents will get it at some point.

when the pores of your skin become blocked by oil, hair, bacteria and dead skin cells, blackheads, whiteheads, cysts and other pimples pop up. they can be aggravated by clothing and headgear, air pollution, high humidity, oily creams, lotions and waxes, stress and genetics.

you can also inherit a tendency to shed skin constantly and in clumps rather than individual cells, which, when combined with increased oil production thanks to hormones, plug up the opening of the follicle, causing the acne.

diet may also play a big role.

“people used to blame milk but studies have shown milk isn’t the problem, except a bit from skim milk, which has higher carbohydrates and sugars,” says landells. “it’s the insulin surge that seems to have an effect on the sebum [oil].”

skin disorders have a psychological impact

treatments for mild to moderate acne include a combination of topical retinoids, which prevent the follicle from plugging, and benzoyl peroxide and topical antibiotics, which control the bacteria. birth control pills have also been effective for some women. for severe acne, which can cause scarring, isotretinoin [accutane] has a cure rate of 80 per cent, says landells. oral antibiotics can also help.

regardless of the physical skin disorder, the negative psychological effects for many sufferers can be worse, impacting a person’s sense of well-being and self-esteem.

“they tend to avoid social situations because they think people are staring at them,” he says. “we should never underestimate how much they suffer, and suffer silently in most cases. it’s far more than skin deep; people suffer horrible physical symptoms, pain, relentless itch, they lose sleep.

“[but] it’s important to know there are treatments for these conditions, and more are coming out every day. so there’s hope.”

robin roberts is a vancouver-based writer.

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robin roberts

'silent suffering': below the surface of a skin disorder often lies depression, low self-esteem and anxiety