Research: Skin disorders can affect mental health

Skin disorders can have a devastating impact on the physical and mental health of children and young people and although effective treatments are available, they are scarce, researchers have said.

The Medical Research Foundation has funded research for advanced scientific understanding of these conditions, which could ultimately lead to improved support and treatment for children and young people living with skin disorders.

Skin disorders can have a negative impact on all aspects of life, from schooling and relationships to career and lifestyle choices. Adolescence in particular is a time of self-consciousness, self-doubt and exaggerated concern with appearance and physical attractiveness. It represents a critical period in physical and psychological development, which is why skin disorders - which are very common in this age group - can have such an enduring impact.

According to a 2020 survey by the All Parliamentary Group on Skin, 98 percent of patients with a skin disorder report that their condition affects their emotional and psychological wellbeing, yet only 18 percent have received some form of psychological support.

New research, led by scientists from King's College London and Newcastle University, will investigate two skin disorders in particular - eczema and ichthyosis - which are both known to have a profound impact on quality of life.

Understanding the link between severe itching, sleep disturbance and brain function in eczema - Professor Carsten Flohr, Chair in Dermatology and Population Health Sciences at King's College London and Honorary Consultant in Dermatology at St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust

Eczema is an inflammatory skin disease affecting 20 percent of children and eight per cent of adults. It is strongly linked to severe impacts on quality of life, as well as psychological and psychiatric illness such as anxiety, depression and attention-deficit hyperactivity disorder (ADHD).

Eczema often starts before the age of two, and affected babies may develop poor sleep habits early. Eczema persists into adolescence or adulthood in around 30 per cent of cases, meaning that people with eczema can suffer with itchy skin and disturbed sleep for large parts of their lives.

Poor quality sleep affects memory, concentration and mood, and in healthy children and young people, poor quality sleep has been associated with poorer educational outcomes.

Crucially, in children and young people with eczema, those without sleep disturbance do not have a significantly higher risk of ADHD than the general population, whereas for children and young people with eczema and sleep disturbance, the chance of having ADHD is 40-50 per cent higher than those without eczema. This suggests that sleep disturbance itself can be associated with psychological and cognitive difficulties.

However, researchers do not fully understand the links between eczema, itching and mental health issues. Professor Flohr and colleagues propose that chronic inflammation in the skin and blood, leading to sleep disturbance and inflammation in the brain, are likely to be important drivers of these mental health issues.

To test this theory, Professor Flohr will study patients aged 12-18 from the Paediatrics Severe Eczema Clinic at St Thomas' Hospital and King's College London, comparing adolescents with eczema to healthy adolescents, and to children and young people with ADHD.

The researchers will investigate whether brain structure and function, and thought processes, are affected by sleep disturbance and inflammation. This includes assessments using sleep diaries and gadgets, measurements of brain activity, and blood tests to measure changes in circadian rhythm (the natural body clock). Professor Flohr and colleagues will also examine the lived experience of sleep disturbances related to eczema, as well as its cognitive and psychosocial impact.

Professor Flohr said: "We think the mental health issues seen in children and young people with eczema could in part be explained by chronic inflammation in the skin and blood, leading to sleep disturbance and inflammation in the brain. Thanks to funding from the Foundation, we will be able to address this theory, with the long-term aim of developing strategies to help manage sleep disturbance better. Potentially, this could prevent the knock-on psychological effects we see in children and young people with eczema."

Investigating severe forms of the genetic condition 'ichthyosis' - Dr Neil Rajan, Senior Lecturer and Honorary Consultant Dermatologist, Newcastle University

There are many different types of ichthyosis, but they all feature the development of inflamed, scaly skin.

Ichthyosis can be inherited (genetic) or acquired during life. The inherited forms are rare, generally present from infancy, and are usually lifelong conditions. Acquired ichthyosis can develop at any age due to a number of medical problems, such as kidney disease.

Unlike skin conditions such as eczema, which tends to be patchy and come and go with time, in ichthyosis the scaling is present throughout life and usually affects the whole body. Ichthyosis sufferers can face harassment, discrimination and uncomfortable symptoms that are often only relieved by time-consuming treatments - all of which can have a marked impact on mental health.

Researchers know that genetic ichthyosis can be caused by changes in DNA that affect skin cells, but little is known about how such DNA changes cause the skin to become scaly and inflamed. In some cases, skin cells are formed at a faster rate than they are needed, and they pile up on the skin surface, thickening the skin. In other forms, the cells are produced at the normal rate but instead of brushing off when they reach the surface, they cannot become detached from the cells beneath them and so they build up in layers (https://www.ichthyosis.org.uk/).

Working with Professor Muzlifah Haniffa from Newcastle University and the Wellcome Sanger Institute, and Professor Edel O'Toole from Queen Mary University of London, Dr Rajan will study how skin cells in patients with severe types of ichthyosis are different from normal skin cells, and why the protective barrier in the skin is weakened. He wants to study how the immune system reacts to this weakness in the skin barrier, looking at these differences across different layers of the skin.

The researchers hope that by doing this, they will be able to find changes in the skin of patients with ichthyosis that could potentially be improved by new treatments. To test potential treatments, they will grow skin cells in the lab, which will allow them to see if such drugs are able to 'treat' ichthyosis in the lab.

Dr Rajan said: "Adolescence is a time of self-consciousness, self-doubt and exaggerated concern with appearance and physical attractiveness - all of which can make ichthyosis an especially painful experience for teenagers. By studying skin samples taken from ichthyosis patients, we're hoping to reveal more about the genetics underpinning the condition, which is needed in order to develop much-needed new treatments for adolescents with ichthyosis."

Co-investigator, Professor Edel O'Toole from Queen Mary University of London, is an expert on ichthyosis and is Chair of the Medical Advisory Board of the Ichthyosis Support Group. Professor O'Toole said: "Young people with severe ichthyosis really suffer and I hope this research will provide new insights which will lead to advances in treatment."