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Rosacea And Psychology

  • RosaQoL is one of the first QoL reports on rosacea. [1]

    Another report published this:

    Objective: Although not well-understood, dermatologic diseases studied in clinical trials often demonstrate substantial response to placebo. The study objective is to determine if optimism, public self-consciousness and other personality traits predict response to placebo or active treatment in a dermatology clinical trial.

    Conclusion: Although this pilot study is small, there was no meaningful difference in levels of optimism or public self-consciousness among those who responded to placebo. Placebo responders were more likely to report that they were not sensitive to most drugs/medications, raising the possibility that they are actually less likely to detect when they are on medications. [2]

    [article updated 1/15/2020]

A report published in France in 2020 discussed the "prevalence of psychological disorders in patients with common skin diseases" including rosacea. [34]

A report in 2018 states, "In the study of Bewley et al, it was shown that facial erythema in rosacea caused significantly more impairment of health-related quality of life (HRQoL) than inflammatory lesions. Furthermore, rosacea patients often demonstrate low self-esteem and present a higher incidence of anxiety compared with the rest of the population. Recurrent flushing seems to play an important role in developing anxiety among rosacea patients. Fear of blushing may lead to social anxiety. Transient erythema could be misinterpreted by other people as an intense emotional response, and, as a coping mechanism, patients with rosacea may avoid social situations. In some patients, anxiety may even resemble panic disorders. Rosacea individuals may also feel that their facial defect diminishes their sexual attractiveness and limits career development." [31]

One report done in 2002 on this subject puts the matter clearly, "Dermatoses may have a significant impact on a patient's quality of life, namely the relationship to others, self-image and self-esteem.' [2] The same report concluded, "Improvement of quality of life reached statistical significance among patients with acne (2.8 versus 7.8, p = 0.0078) and among individuals with a less severe initial impairment of quality of life (2.4 versus 4.2, p = 0.007)."

It has been stated that in "some cases, rosacea patients are so psychologically disturbed that they may be unable to form a therapeutic alliance with their dermatologist or other skin specialist. In such cases, psycho-tropic medication and/or psychological therapy are essential." [3]

Understanding the placebo/nocebo effect is at the heart of this issue. 

Another source says, "The problem is that many dermatologists are operating in the dark when it comes to how badly rosacea might be impacting their patients' quality of life." [4]

However, another report says just the opposite, and states, "In treating patients with rosacea, we are well aware of the psychological effects of this disease, and the depression, anxiety and social isolation it can cause," but both reports substantiate the psychological impact rosacea may have on those suffering from this disease. [5]

So it obviously depends on your dermatologist and you. Does your dermatologist 'operate in the dark' when it comes to understanding rosacea and psychology or 'aware of the psychological effects' and treats accordingly? Are you operating in the dark with your own psychological issues that your rosacea is impacting on you? Have you considered that you may need psychological professional help to deal with your rosacea?

No one likes to think that rosacea is all in our mind, yet, there is evidence that at the very least your mind can aggravate this disease. Could rosacea have a psychological factor? One report says, "Recalcitrant dermatoses may be a manifestation of a symbolic transition object. Psychologically, the patient uses his skin eruption to assure himself that he is a separate person with his own boundaries." [6]

A whole field of medicine, psychodermatology or psychocutaneous medicine, addresses this aspect of rosacea and how experts in the field may be of help to some rosaceans. One article on the subject encourages health care practioners to consider their role in the treatment of a skin disease saying, "Quoting W. Mitchell Sams, Jr., 'although the physician is a scientist and clinician, he or she is and must be something more. A doctor is a caretaker of the patient's person--a professional advisor, guiding the patient through some of life's most difficult journeys. Only the clergy share this responsibility with us.' This commitment is and must always be the guiding force in the provision of comprehensive and compatient patient care." [7]

This is very important to a rosacean because if a physician is not trusted then this can have a detrimental effect on treatment. Note what this article pointed out:

"If the dermatologist allows the contemptuous patient to use his disdain to discredit him, the patient loses, for he can no longer respect his doctor." [8] If the physicians 'bed side manner' is not respected by the rosacea patient this can damage the treatment. Many rosaceans complain how physicians seem to have little compassion for their problem or little time to listen, moving quickly on to the next patient, sending a message of disinterest in the individual's feelings. Trusting your physician or treatment has a huge impact on whether the treatment works. When rosaceans find a treatment doesn't work and this happens over and over again, depression can set in and disappointment in a health care practioner, treatment or regimen can be affected. This can add stress to an already frustrating emotional mental state triggered by rosacea!

One study showed that "patients who were prescribed combination therapy had significantly greater improvement than those who were prescribed azelaic acid gel alone," which was a study designed "to examine both the short-term clinical efficacy and quality-of-life changes resulting from treatment of rosacea with regimens that reflect the participating physicians' standards of care while incorporating azelaic acid gel." [9]

Another psychological effect not to underestimate is the placebo effect, which has been researched extensively. One paper says, "Potential biological mechanisms for the placebo response are discussed, including the possibility of genetic predisposition to be a placebo responder." [10] While this editorial doesn't go into the placebo effect, this often misunderstood mystery is worth mentioning here since it is a psychological factor in rosacea. Pascoe's article on the Placebo Effect is worth reading.

Several research papers conclude that emotional and psychological factors are involved in skin diseases. One report done in 2005 says:

"CONCLUSIONS: (1) Patients with rosacea in the period before the occurring of first symptoms of the disease, comparatively with persons from the control group, they experienced the bigger number of critical life events. (2) The stress intensity resulting from the number of critical life events, is significantly higher at sick people in the relation to the control group. (3) At patients with rosacea emotions resulting of the estimation of the primary stressful situation tightening symptoms of the disease. (4) The subjective estimation of patients' health is essential predicate of psychodermatological therapy releasing potential health possibilities at the patient." [11]

Another report in 2005 about quality of life says, "Change in Investigator's Global Assessment score, measuring the severity of rosacea symptoms, from baseline to follow-up, and change in scores on the RosaQoL, a rosacea-related quality-of-life instrument with 4 component measures (Overall, Emotion, Symptom, and Function) completed by patients at both baseline and follow-up. RESULTS: Over the course of treatment, the mean Investigator's Global Assessment score dropped from 3.52 to 2.10 (P < .0001)." [12]

One report in 1986 on anxiety and skin problems said, "The test results proved a marked correlation between psychological factors and the activity of the adrenergic system. High level of activity, emotional unstableness, as well as tendencies to neurotic activities are connected with increased secretion of adrenaline and decreased secretion of noradrenaline++ and dopamine." [13]

There is one report of a young man who committed suicide due to his not being able to deal with blushing. [14]

Vicky Norfolk threw herself off the Humber Bridge because of her rosacea [15]

A new subtype has developed called, Neurogenic Rosacea which is related to this subject.

A report concluded, "In all groups of patients partial correlation between the examined determinants of psychological and subjective assessment of symptoms and effects of its treatment was shown. The higher rating of the variables was most associated with a higher intensity of stress and anxiety." [16]

Found this interesting quote which appeared in an article published in 1886, "The depressing effect on the mind of the patients produced by the steadily lasting eruption, kept up by the thought that the disease was incurable, and thought upon by others as possibly venereal, has frequently been noticeable. I fully believe that patients with this disease suffer, in mind, at least as greatly as those afflicted with the most serious maladies, not even excepting smallpox. I have known patients to lock themselves from the gaze of the world for months, to forego all society pleasures, to become as treatment after treatment failed, as physician after physician gave up the case, utterly despondent of ever becoming rid of their tormenting malady." [17]

Another report related to this subject concluded:

"Depression or other affective disorders were not associated with incident rosacea, whereas patients with schizophrenia were at a decreased risk of this skin disease in our study population. The materially decreased risk of rosacea among people with chronic lithium exposure may lead to new insights into the pathomechanism of rosacea." [18]

One report says, "Dermatologists need to become more adept at diagnosing and treating causative, concomitant, and resultant psychiatric disturbances in patients with acne." [19] And the same could be said for rosacea.

"Acne and rosacea impact HRQL to a similar degree as other major medical conditions by indirect comparison to psoriasis, a skin condition causing significant disability, and by direct comparison for acne. In the setting of limited health care resources, allocation should be grounded in the evidence that acne and rosacea are not trivial in their effects." [20]

"Patients with rosacea have higher incidences of embarrassment, social anxiety, depression, and decreased QoL compared with the rest of the population." [22]

Anti-anxiety medications have been prescribed by physicians for rosacea. [23]

"Rosacea can have more debilitating symptoms than routinely ascribed to it by dermatologists. These symptoms can interfere with and even completely disrupt the lives of these patients." [24]

"The physical pain of rosacea is often overshadowed by the changes in appearance and the emotional impact of the condition, but all aspects deserve to be addressed," said Dr. Julie Harper, clinical associate professor of dermatology at the University of Alabama-Birmingham." [25]

Many rosaceans report a burning sensation, which can cause emotional issues. [26]

One QoL study done on SD states, "SD can significantly reduce QoL particularly in severe disease and facial involvement."[27]

"Mindfulness, defined as purposively and nonjudgementally paying attention in the present moment, could be used within psychosocial interventions to reduce the distress associated with social anxiety and avoidance found in many skin conditions....The findings indicate that higher levels of mindfulness are associated with lower distress. This suggests that facilitating mindfulness may be helpful in reducing distress in dermatology patients, and the use of mindfulness techniques warrants further investigation." [28]

Diet is associated with the risk of depression. [29]

"Rosacea had significant psychological impact on Chinese patients and had substantial influence on their QOL. Physicians should address the psychosocial needs of rosacea patients as much as its physical symptoms." [30]

"Rosacea had wide-ranging, negative effects on self-perceptions and emotional, social, and overall well-being as well as rosacea-specific quality of life. Overall, both erythematotelangiectatic rosacea and papulopustular rosacea cohorts reported a substantial negative impact of rosacea on quality of life on a range of instruments." [32]

"Individuals who were diagnosed with an anxiety and/or depressive disorder were more common in patient group (24.7% vs. 7.2%, p<0,01)." [33]

"Due to the chronic nature of rosacea and facial presentation of the disease, patients with rosacea suffer from poor psychological well-being. Psychological aggravating factors such as stress, anxiety, immature personality with excessive feelings of shame and guilt, and social anxiety secondary to easy blushing could worsen the flushing in patients with rosacea and be a factor involved in the vicious cycle of rosacea. [35]

End Notes

[1] A pilot quality-of-life instrument for acne rosacea.
Nicholson K, Abramova L, Chren MM, Yeung J, Chon SY, Chen SC.
J Am Acad Dermatol. 2007 Aug;57(2):213-21. Epub 2007 Apr 18.

Lack of "appropriately assessed" Patient-Reported Outcomes in randomised controlled trials assessing the effectiveness of interventions for rosacea.
van Zuuren EJ, Fedorowicz Z.
Br J Dermatol. 2012 Jul 14. doi: 10.1111/j.1365-2133.2012.11148.x.

[2] Dermatology Quality of Life Instruments: Sorting Out the Quagmire
Suephy C Chen Associate Editor
Journal of Investigative Dermatology (2007) 127, 2695–2696. doi:10.1038/sj.jid.5701176

[3] Rosacea, An Introduction
Dr. J. Prarie

[4] Instrument measures quality of life among rosacea patients
Sheds light on emotional, social impact
Lisette Hilton, Dermatology Times, Modern Medicine

[5] Literature review highlights renewed interest in rosacea research
Cheryl Guttman, Dermatology Times, Modern Medicine

[6] Psychocutaneous medicine: recalcitrant dermatoses seen as a transition object through the psychiatric periscope.
Novak M., Cutis. 1981 Jun;27(6):662-3.

[7] Nonpharmacologic treatments in psychodermatology.
Fried RG., Dermatol Clin. 2002 Jan;20(1):177-85.

[8] Psychocutaneous medicine. How to recognize and handle the hostile dermatologic patient and the contemptuous dermatologic patient.
Novak M., Cutis. 1980 Jan;25(1):66, 73

[9] The Face and Mind Evaluation study: an examination of the efficacy of rosacea treatment using physician ratings and patients' self-reported quality of life
Journal of Drugs in Dermatology, Sept-Oct, 2005 by Alan Fleischer, Suephy Chen

[10] Placebos in clinic and research: experimental findings and theoretical concepts
Klosterhalfen S, Enck P., Psychother Psychosom Med Psychol. 2005 Sep-Oct;55(9-10):433-41.

[11] Role of psychological factors in course of the rosacea.
Sowińska-Gługiewicz I, Ratajczak-Stefańska V, Maleszka R.
Rocz Akad Med Bialymst. 2005;50 Suppl 1:49-53.

[12] The face and mind evaluation study: an examination of the efficacy of rosacea treatment using physician ratings and patients' self-reported quality of life.
Fleischer A, Suephy C., J Drugs Dermatol. 2005 Sep-Oct;4(5):585-90.

[13] Anxiety structure and catecholamine parameters in patients with rosacea, alopecia areata and lichen ruber planus
Puchalski Z., Z Hautkr. 1986 Feb 1;61(3):137-45.

[14] RRDi Post

[15] The Daily Mail

The Telegraph

[16] Subjective evaluation of symptoms and effects of treatment and the intensity of the stress and anxiety levels among patients with selected diseases of the skin and gastrointestinal tract
Orzechowska A, Talarowska M, Zboralski K, Florkowski A, Gałecki P.
Psychiatr Pol. 2013 Mar-Apr;47(2):225-37.

[17] Proceedings of the American Society of Microscopists, Vol. 8, 1886, page 123, Published by: Wiley
Demodex Folliculorum in Diseased Conditions of the Human Face
Geo. E. Fell

[18] The association between psychiatric diseases, psychotropic drugs and the risk of incident rosacea.
Br J Dermatol. 2013 Nov 14;
Spoendlin J, Bichsel F, Voegel JJ, Jick SS, Meier CR, Geo. E. Fell

[19] Cutis. 2002 Aug;70(2):133-9.
The interaction between acne vulgaris and the psyche.
Baldwin HE.

[20] J Drugs Dermatol. 2014 Jun 1;13(6):692-7.
The quality of life impact of acne and rosacea compared to other major medical conditions.
Cresce ND, Davis SA, Huang WW, Feldman SR.

[21] J Drugs Dermatol. 2014 Jun 1;13(6):719-22.
Only skin deep: optimism and public self-consciousness did not associate with the placebo response in a dermatology clinical trial.
Garshick MK, Chang AL, Kimball AB.

[22] J Am Acad Dermatol. 2014 Jun 30. pii: S0190-9622(14)01523-0. doi: 10.1016/j.jaad.2014.05.036.
The psychological impact of rosacea and the influence of current management options.
Moustafa F, Lewallen RS, Feldman SR.

[23] RRDi Post

[24] Rosacea—Beyond the Redness
Harvey Jay, M.D.
the dermatologist, Volume 15 - Issue 8 - August 2007

[25] The Physical Pain of Rosacea – What You Don’t See
NRS Weblog, Posted: 05/29/2014

[26] Rosacea Burning and How to Relieve It
Rosacea Skin Care

[27] Effect of itraconazole on the quality of life in patients with moderate to severe seborrheic dermatitis: a randomized, placebo-controlled trial
Zaheer Abbas, Seyedeh Z. Ghodsi, and Robabeh Abedeni
Dermatol Pract Concept. 2016 Jul; 6(3): 11–16.
Published online 2016 Jul 31. doi:  10.5826/dpc.0603a04

[28] The importance of mindfulness in psychosocial distress and quality of life in dermatology patients

[29] Diet is associated with the risk of depression

[30] Psychol Health Med. 2017 Aug 10:1-6. doi: 10.1080/13548506.2017.1361540. [Epub ahead of print]
The dermatology life quality index (DLQI) and the hospital anxiety and depression (HADS) in Chinese rosacea patients.
Wu Y, Fu C2, Zhang W, Li C1, Zhang J.

[31] Clin Cosmet Investig Dermatol. 2018; 11: 103–107.
Published online 2018 Mar 6. doi:  10.2147/CCID.S126850
PMCID: PMC5844253 PMID: 29551906
Psychosocial aspects of rosacea with a focus on anxiety and depression
Monika Heisig and Adam Reich

[32] J Clin Aesthet Dermatol. 2018 Feb;11(2):47-52
Quality of Life in Individuals with Erythematotelangiectatic and Papulopustular Rosacea: Findings From a Web-based Survey.
Zeichner JA, Eichenfield LF, Feldman SR, Kasteler JS, Ferrusi IL

[33] An Bras Dermatol. 2019 Nov - Dec;94(6):704-709. doi: 10.1016/j.abd.2019.03.002. Epub 2019 Oct 26.
Rosacea associated with increased risk of generalized anxiety disorder: a case-control study of prevalence and risk of anxiety in patients with rosacea.
Incel Uysal P, Akdogan N, Hayran Y, Oktem A, Yalcin B.

[34] Acta Derm Venereol. 2020 May 25;:
Psychological Consequences of the Most Common Dermatoses: Data from the Objectifs Peau Study.
Misery L, Taïeb C, Schollhammer M, Bertolus S, Coulibaly E, Feton-Danou N, Michel L, Seznec JC, Versapuech J, Joly P, Corgibet F, Ezzedine K, Richard MA

[35] Int J Mol Sci. 2020 Nov 10;21(22):
Updates on the Risk of Neuropsychiatric and Gastrointestinal Comorbidities in Rosacea and Its Possible Relationship with the Gut-Brain-Skin Axis.
Woo YR, Han YJ, Kim HS, Cho SH, Lee JD

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