Psychodermatology and Rosacea

Psychodermatology and Rosacea


Dr Livia Soriano & Dr Anthony Bewley


Rosacea is a common persistent facial skin disease. Signs and symptoms of rosacea include red or pus-filled spots, dilated blood vessels, facial redness which can resemble blushing, and in some cases, it can be disfiguring. It tends to begin between 30 and 60 years of age and persists in later life.

Symptoms can be worsened by regular day-to-day activities such as drinking hot caffeinated drinks, alcohol, eating spicy foods, staying in hot environments and under direct sunshine. Its impact on one’s quality of life results in psychological stress, and over time it impairs an individual’s emotional well-being.

Patients with rosacea have higher rates of depression, anxiety and embarrassment compared with the rest of the population. (1) The presence of depression is often not related to the objective severity of rosacea, rather in individuals who perceive their condition to be severe. (2) Psychological distress is common in patients who are anxious about social consequences of facial redness and blushing, and relates to feelings of stigmatization, reducing self-esteem and self-confidence. (3) (4) Patients affected by rosacea often find that it affects their social activities, work, diet, exercise and even sleep. Symptoms can lead individuals to avoid public contact, cancel social engagements, and resign from work. It is important to recognize the impact of rosacea on one’s emotional well-being and seek help. (5)

Currently, there is no permanent cure for rosacea, but symptoms can be controlled by avoiding triggering factors and by using medication. Treatments are targeted to the different forms of the disease, and often a combination of treatments is recommended. For example, red spots can be treated with anti-inflammatory agents such as ivermectin cream, oral doxycycline or isotretinoin tablets. Dilated blood vessels can be treated with ND:Yag or Pulse Dye Laser, and redness can be controlled with brimonidine gel. Cosmetic camouflage can also be used to conceal redness and irregularities of the skin and has been shown to provide emotional benefit for individuals with skin conditions. (6) (7)

As rosacea often affects a person’s emotional health, an assessment of an individual’s psychological well-being and appropriate treatment is also recommended. Psychological treatments are tailored to a patient’s individual needs, which include oral medications and talking therapies such as cognitive behavioural therapy, which is helpful for managing social anxiety in patients with a fear of blushing (4).

A psychodermatology clinic enables access to both skin and psychological expertise and treatments. Management of patients in this clinic is recommended for patients with skin conditions with mental illness, from both patient and cost perspective. (8) Where a patient suffers from depression or anxiety associated with rosacea, referral to a psychodermatology clinic is recommended.

Talking to other individuals with similar experiences can also help one cope with rosacea. Online support groups available such as the Skin Support Group, Talk Health Partnership, Rosacea Support Group and National Rosacea Society can provide emotional support and advice. It is important to realise that you are not alone and there is hope for recovery.



Dr Livia Soriano is a Clinical Fellow in Dermatology at Barts Health NHS Trust, London.












Dr Anthony Bewley is a Dermatology Consultant at Barts Health NHS Trust, London.



  1. Moustafa F, Lewallen RS, Feldman SR. The psychological impact of rosacea and the influence of current management options. J Am Acad Dermatol. 2014 Nov;71(5):973-80.
  2. Abram K, Silm H, Maaroos HI, Oona M. Subjective disease perception and symptoms of depression in relation to healthcare-seeking behaviour in patients with rosacea. Acta Derm Venereol. 2009;89(5):488-91.
  3. Halioua B, Cribier B, Frey M, Tan J. Feelings of stigmatization in patients with rosacea. J Eur Acad Dermatol Venereol. 2017 Jan;31(1):163-168.
  4. Su D, Drummond PD. Blushing propensity and psychological distress in people with rosacea. Clin Psychol Psychother. 2012 Nov-Dec;19(6):488-95.
  5. Dirschka T, Micali G, Papadopoulos L, Tan J, Layton A, Moore S. Perceptions on the Psychological Impact of Facial Erythema Associated with Rosacea: Results of International Survey. Dermatol Ther (Heidelb). 2015 Jun;5(2):117-27. doi: 10.1007/s13555-015-0077-2.
  6. Mikkelsen CS, Holmgren HR, Kjellman P, Heidenheim M, Kappinnen A, Bjerring P, Huldt-Nystrøm T. Rosacea: a Clinical Review. Dermatol Reports. 2016 Jun 23;8(1):6387. eCollection 2016.
  7. Levy LL, Emer JJ. Emotional benefit of cosmetic camouflage in the treatment of facial skin conditions: personal experience and review. Clin Cosmet Investig Dermatol. 2012;5:173-82.
  8. Altaf K, Mohandas P, Marshall C, Taylor R, Bewley A. Managing patients with delusional infestations in an integrated Psychodermatology clinic is much more cost effective than a general dermatology or primary care setting. Br J Dermatol. 2016 Sep 28. doi: 10.1111/bjd.15088.



The SKINS project: young people’s experiences of acne, eczema, psoriasis and alopecia


The SKINS project: young people’s experiences of acne, eczema, psoriasis and alopecia


By Abi McNiven

Researchers at University of Oxford, in partnership with the DIPEx charity, have been running a project on young people’s experiences of skin conditions (acne, eczema, psoriasis, alopecia). The study involved interviewing 97 young people aged between 13-24 years about their experiences of having a dermatological condition to produce new resources on Researcher, Dr Abi McNiven, writes here about the study and the online resources now available.

I joined the Health Experiences Research Group (HERG) at the University of Oxford in late 2014 and began working on an ambitious new project about young people’s experiences of four common skin conditions: acne, eczema, psoriasis and alopecia. Having personal experience of both acne and eczema, the psychosocial impact of skin conditions is a topic I felt strongly about when I arrived to the research. This commitment to highlighting the impact that skin conditions can have only grew stronger and stronger as I heard the stories of 97 young people in the UK who volunteered to take part in the project.

Some readers will not be surprised to hear that many of the people we interviewed had experienced difficulties because of their skin conditions. Sometimes the distress was due to the condition itself causing them pain and discomfort (itchiness, soreness, throbbing or stinging, flaky skin, loose hair) or because the treatments had unpleasant aspects to them (sticky and smelly topical creams, stinging the skin, painful procedures, medicine side-effects). Often, though, the thing that hurt the young people most about their skin/hair condition was the way it made them feel about themselves and the way others might think about or behave towards them. As Harry, a participant who was interviewed about having alopecia since the age of 14, explained:

“It’s a journey. I don’t think any one [person’s experience] is the same. […] There’s ups and downs. And I felt like at first it was down when I was first losing my hair before I shaved it. It was just down, down, down. There was no up-side to that whatsoever. After I shaved my head I’d say it made me feel better, a bit better, and then I lost my eyebrows and it was down again. And I just think the emotional bit is the fact that you’re out of control and the fact that you can’t do [anything about] it. I think that’s the hardest thing.”

The emotional impact of having a skin condition could ripple across all aspects of a young person’s life. In particular, adolescence and young adulthood is often seen as a time when lots of changes and new experiences are happening – for example, changing schools, starting college or university, getting a job, moving out, having relationships, building friendships, socialising and hobbies. When Abbie was interviewed about having acne since age 13, she talked about the relationship between stress in her wider life and acne symptoms and treatments affecting one another: 

“It used to stress me out a lot, like all the exams like plus me having acne as well and I was doing all the treatments and things. And it was quite a build-up of things [which] kind of made [it] worse. And especially when I went on the Accutane [isotretinoin tablets], cos then I got the side-effects. And obviously Sixth Form, cos I started A-levels. So it was all a big like change. And that was all quite stressful as well. So I think the acne didn’t help with that either.”

The multiple layers of young people’s lives can mean that the practical and emotional energy involved in a skin condition can have a huge impact on young people’s sense of identity. Tania, a participant who has had eczema since she was 4 years old, found that make-up irritated her eczema but that being unable to wear it was difficult when she was younger:

“I just wanted to do what everyone else was doing cos I was that age when everyone wore the same clothes, awful clothes, and everyone was like trying make-up for the first time and everyone was kissing boys for the first time. And I just wanted to be doing all of that. And because I couldn’t do the make-up thing, then I felt like I’ve been robbed of everything. I felt like all of that was because of the lack of make-up and therefore the double lack of confidence, it all kind of started to knock onto all the other stuff.”

The project was unusually large for a qualitative study: conducting the interviews, analysing the data and writing website content illustrated with hundreds of clips from the interviews was quite a task. Thanks to the generosity of the participants in sharing their experiences, four in-depth resources for have been created and evaluated before being officially launched at an event in Oxford on the 3rd April 2017. These four resources combine both factual medical information and a range of personal experiences for the benefit of other young people affected by skin/hair conditions, their families and friends, and, importantly for improving medical and social care, health professionals seeking more insight into what it’s like for the young people they see with these conditions. This latter aspect was a key point made by Louis who had a post-viral episode of psoriasis lasting two months when he was 18 years old:

“It’s a strange experience to just walk in [to a GP’s or dermatologist’s] and just sort of be this rash. So I think for anyone who’s coming into contact with someone who’s got a skin condition, whether they’re a GP or whether they’re a friend, whether they’re a stranger – try to think that this person isn’t just a rash or a boil or a whatever. They are a person who happens to have this quite inconvenient problem with their skin. And they’d much rather you treated them as the person they are than just a skin condition.”

The website sections are resources offering information about the conditions and what it’s like for young people, taking into account the wider context of their lives (e.g. their social lives, friendships, relationships, hobbies, school/university and work). We hope that the websites will be a source of support for young people affected in finding out about the experiences of others. The resources can also help medical professionals more fully understand the specific information and support needs of young patients with skin/hair conditions, to further medical teaching and training.


By Dr Abi McNiven






All the clips featured in this post, and many more, can be found on the websites:

acne –

eczema –

psoriasis –

alopecia –


Disclosure statement

This article summarises independent research funded by the National Institute for Health Research (NIHR) under Grant Reference Number PB-PG-0213-30006. The views expressed are those of the authors, and not necessarily those of the NHS, the NIHR or the Department of Health.


Psychodermatology Explained


Psychodermatology Explained 


Recently i wrote an article for LEO Pharma called “Psychodermatology Explained” where i talk about  body image in relation to current technology and the infamous “selfie”. The article can be viewed here:

My hope is that new research can be generated to further our understanding into body ideals and their role with technology. This I believe will become a very important issue for younger generations, whom will grow up with technology where our “social selves” are on constant display.

I would personally like to say thank you to Lisa Warner, Julie Wong and Anita Ralli from LEO Pharma for their ongoing support and time.







LEO Pharma website:




Psychological Impact of Skin Disease


Psychological Impact of Skin Disease


By Dr Mughal


The skin is not the largest organ in the body.

There are many misconceptions about the skin and skin disease. The above statement is just one. Whilst the skin is certainly the largest visible organ in the body, the liver definitely wins out on sheer mass. As for physical surface area, every schoolchild knows the lungs flattened out would cover a tennis court.

However, being the largest visible organ, the skin is holds a special place in psychological impact when it varies from a perceived norm. Ninety percent of the public make judgements about people based on their appearance1. Your appearance can even improve your performance in exams2. The skin is the organ of physical appearance. It conveys emotion, health and through touch, communicates in a complexity only second to the voice. When people talk about communicating with the eyes, they are really talking about the skin of the eyelids and their various configurations.

The reason why so many people are so quick to judge on the basis of appearance is multifactorial. At the core is a perceived image of what constitutes beauty. Some authors have even suggested a commonality across cultures as to what is considered beautiful in both men and women. Beauty is used consistently in imagery for profit from a mouth wash advertisement to Hollywood blockbusters, the good are beautiful, with flawless skin whilst the bad are in some way deformed, ugly or have severe skin problems.

Beauty sells. Beauty is wanted and through mass media, we also have an idea of what beauty looks like. Deviation from this constant bombardment of what one should look like will automatically create a subconscious judgement simply by Pavlovian conditioning.

Then there is the physiological repulsion of illness including skin disease. When medical students are first taught examination skills, the various skin changes that can happen in the hands is considered a veritable treasure trove of signs that will aid diagnosis3. Many infectious diseases that used to be prevalent before the onset of vaccination and antibiotics did manifest on the skin. Thus a certain physical repulsion of skin eruptions may be a manifestation of self protective behaviour.

However, this aspect of repulsion is not as relevant as it once was. The vast majority of chronic skin diseases are no longer as a result of an infection and even if they are, are very unlikely to be infectious.

The effect having a skin problem is on someone’s psychological wellbeing is complicated therefore on two fronts. Firstly the physical problem the disease actually causes on their wellbeing and secondarily by the alteration in appearance that results from the condition. Atopic eczema in children and adults causes physical discomfort in pain, itching and lack of sleep. This leads to tiredness and mood changes in itself. When apparent on the hands and face, it causes further psychological distress as a result of increases in stares, negative comments and physical repulsion (unwilling to shake hands)4. If there is a physical repulsion in seeing it on someone else, imagine it being on your own skin. Similarly the treatment regimes that are required can have a devastating impact on life. Psoriasis (and eczema) sufferers often have a complex regime of treatments that are time consuming, not very pleasant to apply and sometimes smelly in themselves5.

The impact on the family is also quite great. Extra time may be needed in the bathroom for treatments, lack of sleep in a child inevitably leads to lack of sleep for a parent. Siblings may feel resentment for the child that has to have more attention than the others due to their condition and as a child grows, they may feel guilt with respect to this6.

Psychological stress as a result of skin disease can be severe and eventually lead to a chronic cycle of depressive illness. However, sometimes psychological illnesses can manifest as skin diseases. In the condition, dermatitis artefacta, people will inflict damage to their own skin for a variety of reasons but often as a physical manifestation of psychological distress7. Embarrassment or threat of revealing the underlying condition may make it hard for the patient to reveal why it is they are doing this to themselves. However, these people do know what they are doing and why. This does not reduce the distress caused such as changes in appearance as a result.

Then there are those that do not even realise what they are doing. Some people will inflict considerable damage to their skin due to a fixed delusion (such as infestation with parasites). Here the illness is psychological and no amount of telling them there is nothing wrong will work. For them, this is real. This can be all consuming, devastate lives and relationships and at the same time, also cause the physical disfigurement that can cause public embarrassment and attract negative comments.

Skin diseases have a wide variety of severe psychological effects. An appreciation of this in others only takes a minute when we see it but by doing so we can help people greatly. This is the importance of education.



Dr Mughal is a consultant Dermatologist in Singleton Hospital (Swansea) and is a clinical lecturer at Swansea University. He also sits on the board for the charity Skin Care Cymru.



  1. Spalding H et al. Living well with a skin condition: what it takes. In Bewley A et al (Eds). Practical Psychodermatology.2014. Wiley Blackwell. Singapore.
  2. Malouff JN et al. Preventing halo bias in grading the work of university students. Cogent Psychology; (2014) 1: 988937: p1-9.
  3. Kumar P and Clark ML. Clinical Medicine 8th Ed. 2012. Saunders Ltd. Spain
  4. Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. International Journal of Clinical Practice. 2006;60(8):984-92.
  5. Jobling R. Psoriasis. British Medical Journal. 2007;334(7600):953-4.
  6. Al Shobaili HA. The impact of childhood atopic eczema on the patients’ family. Paediatric Dermatology. 2010; 27(6):618-23.
  7. Mohandas P et al. Dermatitis artefacta and artefactual skin disease: the need for a psychodermatology multidisciplinary team to treat a difficult condition. British Journal of Dermatology. 169(3):600-6.






Q&A with Dr Christopher Bridgett


Q&A with Dr Christopher Bridgett


CB: Dr Christopher Bridgett


1. As a psychiatrist, what initially made you interested in the field of psychodermatology?


CB: As a medical student, at St Bartholomew’s Hospital in London,UK, we had inspirational teachers of psychosomatic medicine, including in the skin department. As a hospital doctor I worked in both Dermatology and Psychiatry at Addenbrooke’s Hospital in Cambridge, and then trained as a Psychiatrist in Oxford. Later, in 1989, a Dermatologist friend Dr Richard Staughton asked me to join him running a psychodermatology clinic at Westminster Hospital, here in London again, with a focus on atopic eczema. It has been a very interesting experience.


2. What struggles do you face in treating psychodermatology conditions?


CB: Although there is a greater acceptance of the mind-body connection these days, some doctors still take some persuading to take psychology and psychiatry seriously. And there are similar challenges sometimes from our patients, though not so much perhaps. I can be told –

“Thank goodness. I have been referred to you at last”.

Dermatology services however are under-resourced generally – it is good that psychodermatology is now part of the curriculum for trainee dermatologists. The best psychodermatologists have been Dermatologists with a special interest in Psychiatry, Psychology and Dermatology. I think that is the best way of ensuring holistic treatment is offered to everyone with skin complaints.


3. What tips would you give patients in managing the psychological effects of their skin conditions?


CB: If possible, understand the condition, as an expert-patient. Discover how to manage the condition, try and not let it manage you. Know who and where to get advice about your skin condition, when you need it. The stress caused by having one of the common skin conditions – eczema, acne, psoriasis – is sometimes more important than the way stress can make the condition worse. Stress management can be learnt alongside a dermatological treatment, and the two approaches can work very well together. For example, Mindfulness Based Stress Reduction can be great for the skin – but it doesn’t suit everyone.


4. What advice would you give specifically to young people in managing their conditions?


CB: As a psychiatrist it is rare that a young person comes to see me on their own initiative. It is usually a parent that is worried. Assessment and treatment has this to deal with at the beginning: what is the problem from the young person’s point of view, as a child’s parents are usually there to ensure a skin condition like eczema is treated properly. As the child grows up, if the skin problem continues, they need to learn how to take responsibility themselves for the management of their skin condition – or suffer the consequences. This is not always easy and straightforward.


5. Tell us about your website, AtopicSkinDisease.Com


CB: In the psychodermatology clinic that I set up with Dr Staughton we got the help of Dr Peter Norén, a Dermatologist from Sweden. Dr Noren had researched the effectiveness of habit reversal, a behaviour therapy, in the treatment of the habitual scratching that leads to chronic atopic eczema. His treatment programme is called The Combined Approach. We wrote a book about it, and the website, AtopicSkinDisease.Com makes our book available to everyone.


6. Can you tell us a bit more about habit reversal as a technique for treating habitual scratching?


CB: Habit reversal is a well-known, established behaviour modification technique introduced into clinical practice in 1973. Then it was used for eliminating nervous habits, and some involuntary movements called tics. Peter Norén and his colleagues in Uppsala, Sweden, showed how a simple, short course habit reversal training quickly eliminates habitual scratching in people with chronic atopic eczema. When this is combined with optimal topical treatment chronic atopic eczema can be successfully treated in only a few weeks. This is important, as otherwise resistant and troublesome chronic atopic eczema is now routinely treated with systemic drugs that can have unpleasant side-effects.


7. What tips would you give patients for managing stress?


CB: The stress associated with common skin conditions is understandable, and goes two ways: stress can make a condition worse, but it is important that a skin condition can be very stressful to have. This vicious circle between skin and stress needs tackling first – by ensuring the skin condition is treated effectively. Thus, within two weeks of using The Combined Approach for atopic eczema most people say their stress levels have gone right down, as their skin condition has improved – and no additional specific stress management method needs to be considered. If they are needed, the simplest tactics to reduce stress include regular relaxation, getting a balanced life, and avoiding bad habits. At AtopicSkinDisease.Com there is a section devoted to stress, with more tips on how to understand it, and how to deal with it.





Christopher is a Consultant in Adult General Psychiatry. From 1981 to 2008 he worked for the UK National Health Service, as a community psychiatrist in the The Royal Borough of Kensington & Chelsea, London. He now works in part-time private practice, based at Chelsea & Westminster Hospital, London. Christopher has a special interest and clinical experience in the field of psychodermatology, in particular the treatment of atopic skin disease-also known as atopic eczema, or atopic dermatitis. For more information, please visit AtopicSkinDisease.Com


Acne and Psoriasis in young patients

Acne and Psoriasis in young patients

By Charalambos Costeris


The intensity of negative emotions as a result of a chronic illness mainly depends on the personality of the patient. During adolescence and early adulthood, students’ personalities are not sufficiently developed. For this reason, disorders affecting the skin mantle, such as acne and psoriasis, can affect the emotional state of young people since appearance at this age has a huge impact on their body image, interaction with peers and their self-esteem.

Behaviors such as avoiding social activities, not going out of the house, school refusal, isolation and frequent crying are often mentioned in the offices of Dermatologists, where school/university students often seek medical interventions that could improve their skin appearance.

Experiences like being bullied or being called names by peers for a skin condition in order to tease, negative mood, intense anxiety and negative thoughts that result from these experiences are not often detected by Dermatologists. This is because Physicians mainly focus on the improvement of the skin’s appearance and also because young patients do not mention them due to feelings of shame.

This has as a result the continuity of young patients’ social withdrawal, the strengthening of negative thoughts about themselves and as a consequence the increase of their stress and emotional discomfort. This isolation can strengthen the intense preoccupation with their skin’s appearance, which can manifest itself with recurrent mirror checking, resulting in increasing the dissatisfaction associated with their skin, which in the end may be generalized as dissatisfaction concerning the overall appearance of the individual. This vicious cycle of stress, of dissatisfaction associated with the skin and of negative thoughts, can be prevented and treated if information and education concerning the psychological effect of skin conditions (such as acne and psoriasis) is provided to Dermatologists by Clinical Psychologists who have specialised in the field of Psycho-dermatology.

If the intervention that concerns the psychological support of young dermatological patients who suffer from acne and psoriasis is combined in conjunction with the medical intervention by Dermatologists, patients’ satisfaction with their medical treatment result may be greater. Moreover, patients’ stress will be reduced whilst negative emotional reactions will be prevented as young patients will have the opportunity to verbalize their negative emotions and thoughts regarding the way they perceive themselves, their body image, the teasing of their peers and their overall quality of life.


Charalambos Costeris holds a Bachelor’s degree in Psychology from the University of Crete (Greece), a Master’s in Health Psychology from the University of Bedfordshire (UK) and a Master’s in Clinical Psychology from Lomonosov State University of Moscow. Charalambos is a licensed Clinical Psychologist in Cyprus and a PhD candidate at the University of Nicosia where he conducts research in the field of Psychodermatology.







Seeing a dermatologist: Psoriasis

Seeing a dermatologist: Psoriasis

By Professor Peter Farr

This article, written by a dermatologist, sets out to describe what a patient with psoriasis may expect from a first hospital appointment with a dermatology specialist. Some of the content is quite general and would apply to those with a skin problem other than psoriasis.

You have got psoriasis, and your general practitioner has referred you to see a dermatologist. If you are anxious in any way about the appointment, it would be fine to come with a relative or friend. Medical Students sometimes attend dermatology clinics. If this is the case, the students will be introduced, and you will be asked if it is okay for them to sit in during the consultation. If you would prefer them not to be there, then don’t be afraid to say this. The dermatologist will introduce himself or herself, and then start to ask you some basic questions such as how long you have had psoriasis, how it has changed recently, and what treatments you have used and whether these have been effective. It might be helpful to bring along a list of the treatments you have used. You will also be asked about any other current or previous important medical problems, and whether you are taking any regular medication for these. Sometimes psoriasis can be linked to arthritis, so there will be questions to see whether you have any problems with your joints. Psoriasis can run in families, especially for younger patients, and this may be discussed.

The dermatologist will want to know a little bit about your background, such as whether you are working, and if so what job you do; and what sort of support you have – whether you live alone, or with friends or family. Knowing more about you will help you and the dermatologist discuss how having psoriasis impacts on your life in general; from issues relating to work or pastimes, relationships with other people, and your self-esteem. Remember that the dermatologist will be used to seeing patients with psoriasis of every severity, and will be knowledgeable and sympathetic about how it is to have psoriasis.

The dermatologist will want to look at your skin. If you have psoriasis on the face, then it will be best if you come to the appointment without make-up covering these areas. If this is a problem, then there should be time and a suitable place provided to remove the make-up, and then reapply it after the consultation. You will go into an examination room, and be asked to take off your clothes (but you will keep your underwear on), and put on a gown provided by the hospital – this can be fastened either at the front or the back. It is standard practice for a male dermatologist to be chaperoned, usually by a nurse or a healthcare assistant, when examining a female patient, and a chaperone may be appropriate in other circumstances. If a chaperone is not offered and you would feel more comfortable with one present, then you should ask about this. The dermatologist will look at the areas of psoriasis, in particular noting how extensive the rash is, and the sites involved. You may be asked about whether psoriasis involves covered areas, such as in the genital area or buttocks. The dermatologist or a nurse may estimate the severity of your psoriasis using a “PASI” score. This is a widely-used measure which incorporates a score for area of involvement, thickness of areas of psoriasis, redness and scaling; it can be used to monitor response to treatment, and may help guide treatment choices.

After you are dressed, the dermatologist will talk about your psoriasis and discuss treatment options. These will vary from prescribing different creams to use, offering a course of ultraviolet light treatment, or, for more severe cases, discussing tablet or injection treatments.

Ultraviolet B treatment is one of the commonest hospital-based treatments for psoriasis, and involves attending three times a week for a whole-body exposure to UVB, each treatment taking only a matter of minutes. This is very effective, getting psoriasis clear in around 75% of patients with an average of 24 treatments. If the psoriasis returns at some stage in the future, then repeat courses are often used. The treatment is considered safe, and is offered to children and adults.

For patients with more severe psoriasis, or in those whose rash does not clear with UVB, or returns quickly after treatment, then there are tablet or injection type treatments that are very effective. These all have potential side-effects and always require careful discussion between the patient and dermatologist, together with provision of information leaflets or booklets before a decision is made regarding their use. You should be fully involved in the discussion about treatment options, as choice of treatment depends on a lot more than just how your psoriasis looks.

Finally, you will have an opportunity to ask questions. You may wish to write a list of questions before the consultation so you don’t forget to ask them on the day. They may be about the psoriasis itself, or to do with expected response to treatment. There are some things that are hard to answer, such as why you developed the psoriasis, or how much of a problem it is going to be in the future; but plenty of information is available and websites of organisations such as The Psoriasis Association ( and the British Association of Dermatologists ( may be helpful.


Pr. Peter Farr




Peter Farr is a consultant dermatologist at the Royal Victoria Infirmary, Newcastle upon Tyne and is an honorary professor in clinical photobiology at Newcastle University.




Living with Hair Loss

Living with Hair Loss


By Dr Alia Ahmed


Hair is an important element of our identity1,2. From a young age we are told stories of beautiful maidens letting down their lustrous locks or handsome princes with a shining mane adorning their heads. Hair is seen historically as a symbol of health, wealth and fertility. We use hair to express ourselves and create our own image in society, from bold colours to complicated styles, our hair is linked with our personality. As a style conscious population, we are subjected to media images of models with perfect hair, hair-enhancing products and the new trend of blow dry bars in every city.

So what happens when a person starts to lose their hair? With so much emphasis on how a person looks, inevitably for some people hair loss will be psychologically devastating1. Hair loss is a common condition that presents to dermatology clinics with psychological, emotional and social consequences2. People with hair loss report increased incidence of depression, anxiety, relationship problems, lack of self-confidence, increased self-consciousness and low self-esteem3. Females also seem to be more psychologically affected than males4.

There are several types of hair loss and the reasons behind them include a complex interplay of genetics, hormonal influences, underlying medical conditions, and more often than not, no cause can be found. Some common types of hair loss include:

1.     Alopecia areata – a specific form of hair loss occurring in rounded patches on the scalp, can also involve hair loss from other parts of the face and torso (e.g. eyebrows, eyelashes, beard).

2.     Telogen effluvium – this is a temporary type of hair loss seen after a trigger (e.g. illness, pregnancy, stressful life event).

3.     Androgenetic alopecia – this is the most common type of progressive hair loss that occurs in both sexes. Affected people experience hair thinning over time, males around the temples and back of the scalp, and females around the top and front of the scalp.

4.     Scarring alopecia (or cicatricial alopecia) – this is a type of hair loss caused by damage to the hair follicle (e.g. due to bacterial or fungal infection or an autoimmune process).

If you are worried about hair loss it is a good idea to visit a doctor that has knowledge about this problem. This would ideally be your general practitioner or a dermatologist. You might feel like hair loss is not something your doctor is interested in, but it is important to share your concerns in case there is something that can be done. You may need to have some simple blood tests to rule out other common causes of hair loss (e.g. thyroid problems or iron deficiency).

Hair loss can be challenging to treat and your doctor may need to try a number of options before making any real progress. To get through this difficult time make sure you have realistic expectations from the treatment, discuss the possible outcomes with your doctor, including how long it may take to see results. If possible, discuss your problems with hair loss with people you can trust to provide support (e.g. friends, partners or family).

Prognosis of hair loss is variable and unpredictable, making this is a particularly difficult condition to cope with. The impact of hair loss may continue for several years after the initial diagnosis, this is further complicated by the lack of treatments available3. Feelings of embarrassment, low mood and social anxiety are common. People affected by hair loss might want to hide the condition, this may start by experimenting with different hairstyles, or hats and scarves, which are good options, but may then progress to physically hiding from the world (e.g. avoiding going out or doing activities that can draw attention to your hair). Losing confidence in social situations due to feelings of embarrassment makes people affected by hair loss feel lonely and isolated. As hair has such a physical presence and is linked to images of attractiveness, people can start to feel unattractive, this can impact current and future relationships. Common thoughts can include:

‘Will he/she fancy me?’
‘Does he/she still love me?’
‘Are they looking at my hair?’

Apart from medical therapies for hair loss, it is important to develop skills to deal with living with a diagnosis of hair loss, especially as this has such a psychological impact on people. Hair loss is a physical condition, but it can have consequences for a person’s mental health. The fact that the condition can last a long time and become chronic means that the better equipped you are to deal with the physical signs, the less negative impact it can have on your life. In order to make sure that negative thoughts about hair loss do not take over it may help to be as informed as possible. Try to think outside the box and consider how else you could maintain your quality of life whilst living with hair loss. For example:

1.     Obtain as much information as possible about your type of hair loss (approved patient information leaflets are available from; or look at for information).

2.     Consider all options of treatment that are offered by your doctor. Important questions to ask are:

a.     What is the likelihood of success of this treatment?
b.     What are the side effects of this treatment?
c.     How long do I need to take this treatment?
d.     What if this treatment does not work?
e.     How much will it cost?

3.     It may be important to consider alternative options for disguising hair loss. For example, wigs can be available on the NHS in some cases (ask your doctor if you are eligible) or can be bought privately.

4.     Other products that can be used to disguise hair loss include hair thickening powders (can buy inexpensively from approved sources), hair extensions (prices will vary), or permanent skin tattooing for small areas (e.g. eyebrows).

5.     For some people, hair transplantation may be an option. Research the providers of this service and ensure they are qualified to provide this treatment. It may be expensive and is not always successful, so take your time before making any decisions.

6.     It might be difficult to imagine that ‘talking therapies’ might help hair loss. It might not help hair grow back, but it is possible to develop life skills to deal with this problem. Ways to do this include cognitive behavioural therapy, mindfulness, and acceptance and commitment therapy (to name a few). Ask your doctor if you can be referred to a psychologist who can help teach you techniques on how to cope with any distressing feelings.

7.     Look at alternative options for self-help, the internet is a great source of information (e.g. has a free searchable database of patient support groups and charities; has resources to teach you how to manage negative feelings in your own time). There are also a number of mobile apps that may be suitable (these may have a fee so check the small print).

8.     Consider joining support groups for hair loss, for example Alopecia UK.

Through the internet and social media there is a wealth of information about hair loss in the public domain, including various types of treatments. Hair loss is an individual problem and suitable treatments are dependent on the type of hair loss experienced. Your doctor is the best person to advise you. There are a number of alternative treatments advertised, and some can be very expensive. It is important to obtain as much information as possible before embarking on any treatment courses that require a high financial commitment. Unfortunately there are people who will take advantage of the vulnerability of people with hair loss and offer ‘miracle’ cures, there will be little scientific evidence for this, again always discuss with your doctor.

Increasingly we are defined by how we look. Feeling confident about oneself and creating an image that is acceptable to you is probably the healthiest way of dealing with a chronic condition like hair loss. Apart from seeking medical cures, it can be helpful to looking into how we can strengthen our mind to cope with common physical conditions.

Dr Alia Ahmed, MB BS, BSc, MRCP

Specialist Registrar in Dermatology

me 2

To see more of Dr Alia Ahmed’s research please visit:


  1. Sellami R. The relationship between alopecia areata and alexthymia, anxiety and depression: a case-control study. Indian J Dermatol 2014; 59(4): 421
  2. Chaing YZ et al. The role of beliefs: lessons from a pilot study on illness perception, psychological distress and quality of life in patients with primary cicatricial alopecia. Br J Dermatol 2015; 172: 130-137
  3. Williamson D et al. The effect of hair loss on quality of life. J Eur Acad Dermatol Venereol 2001; 15: 137-139
  4. Cash TF. The psychosocial consequences of androgenetic alopecia: a review of the research literature. Br J Dermatol 1999; 141: 398-405


Each month we will bring you a new article from a leading health practitioner who works in psychodermatology or who has contributed to the field. The aim of these articles is to promote communication and togetherness between patients, academics and all health related practitioners.

Thank you to all our guest writers who contribute with articles. If you are a health practitioner or academic who wishes to contribute with an article please contact us here at:

This month we have Kerry Montgomery’s article “Mindfulness”

What could mindfulness offer to people living with visible skin conditions?

People living with skin conditions have reported experiencing social anxiety, depression and low self-esteem. They may have periods where the condition is well managed and times when it is not. Treatments can be time consuming, and sometimes painful. People living with skin conditions should have access to treatments that can help with the physical and psychological symptoms. Mindfulness is one psychological intervention which could support people living with skin conditions. Whilst mindfulness has been around for many years and has roots in Buddhism, it is a relatively new approach to managing distress and long term health conditions.

Kabat-Zinn (1994) defines mindfulness as “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally to the unfolding experience.” Mindfulness interventions offer people a new perspective. Consider the following example:

You are living with eczema which is visible on your face and hands. On a night out with friends you notice someone is staring at you. Suddenly you start to have thoughts ‘they’re staring at my skin’, which leads to thoughts like ‘they think I’m horrible!’ This might remind you of unpleasant experiences in your past, and before you know it you’re turning it over and over in your mind, feeling anxious and low.

Back in the present a friend might say ‘hey, you seem miles away’, and you are. In your mind you are very far from present. Mindfulness techniques can help you to identify when thoughts have drifted away from the present and help you intentionally redirect attention. Viewing thoughts non-judgmentally can help people to disengage from negative thinking patterns.

There are a number of mindfulness exercises which can help refocus the attention to the present moment. These include mindfulness of breathing, which involves consciously drawing attention to the breath and body scan exercises which involve bringing the attention to sensations within the body. Studies using mindfulness interventions have found that it can support people experiencing symptoms of anxiety and depression, which are associated with physical health problems.

Here is another example, you have been living with psoriasis for ten years. Today you are traveling to a job interview and you start to think: ‘they’ll look at my skin and think I’m contagious’ and ‘they won’t want me around customers looking like this’. These thoughts lead on to other thoughts: ‘I’m unattractive…they won’t hire me’. It is natural thoughts like this leave you feeling anxious and low. You decide you are not going to the job interview. You give up an opportunity because you’re worried about what the interview panel might be thinking.

If we break this down, the first thought was analysed and interpreted, and set off a chain of secondary thoughts and actions. What if you acknowledged the thought ‘they’ll look at my skin and think I’m contagious’, and rather than thinking over it you used mindfulness techniques to bring your attention back to the present moment?

What about if when you had the first negative thought ‘they’ll look at my skin and think I’m contagious’ you notice this and purposely focus your attention to what is going on around you? You might use a mindfulness of breathing exercise to do this. This would reduce the likelihood of you experiencing further negative thoughts. You then feel more confident to attend your job interview.

Mindfulness can be learned in a number of ways, there are various self-help interventions available. These can take the form of booklets with guided audio meditations as well as structured mindfulness programmes. These are delivered by experienced mindfulness practitioners in a group setting and involve guided meditations.

Mindfulness interventions can offer a helpful way to reduce distress however; it should be acknowledged that many people still experience stigma and negative reactions due to their appearance. It is therefore important that we continue to address social perceptions of skin conditions.


Kerry Montgomery is a PhD student at Sheffield University. Kerry’s PhD examines psychosocial distress in people living with visible skin conditions and looks at how mindfulness based interventions can support those living with skin conditions. Kerry is a psychological wellbeing practitioner within Sheffield improving access to psychological therapies service and has experience of working with people experiencing common mental health problems and long term health conditions.

For more information on this article please contact:


Managing ‘Imperfections’


Managing ‘Imperfection’


It is human nature to want to look good and experiment with our appearance. It is also human nature to make immediate judgements about others based on how they look. Social psychologists call this the ‘cognitive miser’ effect. We have so much information to process on a daily basis that we need to take shortcuts. One of these shortcuts is making judgements based on superficial information or stereotypes. Dating apps prioritise physical appearance in finding a partner and, as a result, reinforce making snap judgements about other people based on their appearance. Magazines and billboards portray narrow ideas about what women and men should look like. Typically, these images represent young and attractive people who have sculpted bodies wearing fashionable clothes and, notably, who have flawless skin (albeit achieved by cosmetics and image editing techniques). Em Ford’s video is a powerful demonstration of negative and hurtful views about those who do not have a flawless appearance (which is most of us) and also how those same critical views are expressed when people understandably use concealer to hide these societally-defined ‘imperfections’. It is a hurtful double jeopardy.

E. Tory Higgins proposed that people having several different ways of seeing themselves. Higgins suggested that we each have an ‘actual’, ‘ought’ and ‘ideal’ self view. The actual self is how we currently perceive ourselves to be. The ought self is what we think we should be like. And the ideal self is what we aspire to be. It is possible to see how other people’s views and popular culture influence our ought and ideal selves. As a result of images in the media and magazines, I might think I ought to have flawless skin or that I should aspire to look perfect. If I then think that my actual self does not match either the ought or ideal selves then there will be negative effects. Psychologists have found in a number of research studies that a mismatch between actual-ought selves or actual-ideal selves results in feelings of low self-esteem, shame, depression and anxiety. We feel shame when we perceive that we are fundamentally flawed in some way and that, because of this, we should hide ourselves away from others. This tendency is likely to result in social isolation and anxiety about being with other people both of which are likely to make us feel sad or depressed. Also, avoiding situations makes both depression and anxiety worse. When we are depressed we become less motivated and energetic and are likely to avoid others. This results in a decrease in positive experiences and, as a result, it becomes harder to gain an improvement in mood. When considering anxiety, avoidance makes people become even more sensitive to potential negative judgement from others. Whilst in the short term avoidance can feel good (we avoid anxiety and situations that we find difficult or upsetting) in the longer term avoidance can be harmful because it does not allow us to challenge negative beliefs, (e.g. that we will be rejected), possibly resulting in greater social isolation. Avoidance can take many forms. It isn’t just avoiding meeting new people or going out but also covering up with concealing products or clothing. It can also be filling time with other activities to provide an excuse for not meeting others. Most of us learn to manage new situations through trial and error and through this we develop confidence. But, this becomes harder when we feel anxious or depressed because we fear getting things wrong or lack the energy to keep trying.

Everyone with a skin condition has challenges to overcome but the issues of ‘looking different’ are particularly acute for young people because they are in the process of developing their own identity, relationships, and aspirations. At this time, peer and intimate relationships become increasingly important. Avoidance is therefore not a good coping strategy because it affects making relationships with others and trying new experiences. In effect, we don’t experiment and learn who we want to be. Psychologically, depression is underpinned by low self-esteem. Self-esteem can be thought of as how a person subjectively evaluates his or her own worth. Our self-esteem is partly based on the experiences we have had in our early lives and how well these have equipped us to deal with the negative views of others. If our early experiences or interactions with others are negative it is likely that we will have developed a negative view of ourselves and this will make us more susceptible to needing to meet society’s expectations about appearance. People with low self-esteem and who are anxious or depressed tend to think in biased ways and will look for evidence to support their negative self-view. Imagine a person walks into a room and nobody talks to them immediately. This could be interpreted negatively leading to the individual to escape and not really check out what this meant because they assume this is evidence of people not being interested. As another example, someone says you look nice and you infer that they must have thought you looked bad on other occasions because they had not said this before. These biases keep your negative views of self in place and mean that you come to expect that all situations will turn out badly. They also prevent you finding out that your beliefs may not come true.

If you want some further help, this is a resource you can download to help overcome low self-esteem:

And this is the book from which the web resource was developed:

Overcoming Low Self-Esteem, 1st Edition: A Self-Help Guide Using Cognitive Behavioral Techniques: Self-help Guide Using Cognitive Behavioural Techniques (Overcoming Books).

Mary John is a consultant clinical psychologist and Laura Simonds is a university lecturer. They both do research on mental health issues in young people and on the psychological effects of long term physical health conditions.