Dr Roger Henderson
1. Overview
2. Learning objectives
3. Clinical learning
– 3.1 Introduction to mental health and skin conditions
– 3.2 Dry skin
– 3.3 The impact on mental health in adults and children
– 3.4 The hidden cost of dry skin conditions
– 3.5 Treatment
4. The impact of Covid-19 on skin
5. Consultation hints and tips
6. Aide memoir
7. Criteria for referral
8. Summary of learning
9. Further reading
10. References
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Dry skin (xerosis) is a common condition characterised by rough, flaky or scaly skin and is triggered by lack of water in the upper skin layer known as the stratum corneum. It is a very common symptom in a number of skin problems including eczema, psoriasis, and dermatitis and can also represent a condition in itself. There is a growing need for specialist mental health support for people with skin disease and this need is especially important following the Covid-19 pandemic.
This module is aimed at primary care healthcare professionals (HCPs) who regularly manage patients with dry skin conditions. The learning objectives for this module are to;
Chronic skin disease is known to be linked to psychological distress and psychiatric co- morbidities. Dry skin conditions such as atopic dermatitis are strongly associated with anxiety and depression – a reminder that skin disease is not just a physical issue. Skin problems can impact on every area of life including education, relationships, work and leisure activities. The long-term psychological impact of chronic skin disease includes feelings of shame and isolation, embarrassment, depression and anxiety.
Approximately 25% of the UK population consult a GP every year for a skin-related problem but the level of expertise among HCPs in both dermatology and psychodermatology (the multi- disciplinary interplay between dermatology, psychiatry and psychology) varies considerably. This can lead to signs of psychological distress in such patients being missed, including in children. Children with eczema have more emotional conduct and hyperactivity problems compared to children who do not have eczema. Children with skin disease are not usually offered support services, which can subsequently impact significantly on their wellbeing and mental health in adulthood.
The psychosocial impact of skin disease is typically underestimated by HCPs and there is increasing evidence that managing patients with skin disease holistically from the start of their condition reduces the physical and psychosocial impact on them in the long-term.
Dry skin (xerosis) can occur year-round and affects people of all ages but is often worse in winter months because of low humidity. There are many possible causes of dry skin including ageing, dry climate, genetics, health conditions such as diabetes and kidney disease, and occupations where hand washing occurs frequently. Older people are more likely to develop dry skin because the skin thins with age and loses its elasticity, and moisture-producing oil and sweat glands tend to dry up.
If dry skin is severe, it causes inflammation, leading to itching and rashes called dermatitis. There are a number of types of dermatitis including;
Other skin conditions such as psoriasis can also cause significant drying of the skin.
There are four general categories that most patients with a mental health component of their skin condition fall into;iv v
1. Patients with chronic skin diseases such as psoriasis or eczema that are exacerbated by stress, low mood or anxiety
2. Patients with a primary skin disease that is accompanied by psychological distress
3. Patients with a skin condition that causes a change in appearance and may have a psychosocial impact
4. Patients with psychiatric or psychological conditions who present to HCPs
It is also important to recognise that a skin condition with physical symptoms classified as
‘mild’ can result in severe mental health issuesvi and so the severity of the skin problem is not necessarily correlated to the level of mental health problem experienced. Mental health distress impacts on treatment adherence and outcome as well as exacerbating the course of skin disease.vii Examples include atopic dermatitis and chronic urticaria that are strongly associated with depressive and anxiety symptomsviii and up to 20% of patients with psoriasis have clinically significant depression with almost the same number reporting suicidal thoughts and having a greater risk of suicide. There is a direct and significant association between skin conditions and mental health with one recent survey finding that 98% of people with skin problems believing their condition impacted on their emotional and psychological well-being and 5% reporting thoughts of hopelessness and suicidal ideation linked to this, yet only 18% had received some form of psychological support.
The same APPG study found that all the children who responded said their skin condition affected their psychological wellbeing, and 85% said they had low self-esteem as a consequence. During school-age years, peers may avoid playing with children with skin disease due to the belief that they may be infectious, and this social exclusion has been linked to low self-esteem.xii This is further exacerbated by children with severe dermatitis being less likely to participate in sport and outdoor activities and older children with this condition have fewer friends, participate less frequently in social events and miss more classes than unaffected classmates.xiii
Children with skin problems persisting into adulthood can have their work productivity and psychological well-being negatively impacted as a consequence.xiv
There is a significant cost to the UK economy from lost working days due to skin disease.
In 2013 the UK Government paid £61 million in work benefits where the main condition was skin-relatedxv and this did not reflect the economic impact of the depression, anxiety or mental health distress of people affected by long-term skin conditions. HCPs can spend significant amounts of time attempting to help patients with skin conditions and mental health distress in primary care but many studies suggest it is significantly more cost effective to see such patients in a specialist psychodermatology setting.
Atopic eczema-related out-of-pocket costs (such as emollients, clothing and cleaning costs) pose a substantial burden for affected individuals and are higher than in other chronic diseases. Some patients with chronic dry skin conditions may ‘doctor shop’ by having multiple attendances in both primary and secondary care settings, with each attendance having a financial cost to the NHS.xviii The prescribing of emollients to treat dry skin and eczema is associated with fewer primary care visits, reduced healthcare utilisation and reduced costs, and using emollients – especially those containing colloidal oatmeal – is associated with fewer topical corticosteroid and antimicrobial prescriptions.xix
Emollients are the cornerstone of treatment for all dry skin conditions. These soften, smooth and rehydrate the skin, helping to reduce the signs and symptoms of dry skin as well as making the skin less itchy, moister and more flexible, preventing skin cracking. When used in the right quantity and frequency, they often reduce the need for topical steroids.xxi
There are several different types of emollients, in the form of gels, lotions, creams, ointments, bath and shower oils, and soap substitutes. Simple emollients put a fine moisture-retaining layer of non-physiologic lipid or oil, such as petrolatum or mineral oil, over the skin surface and thereby reduce water loss from the stratum corneum (the upper skin layer). More advanced emollient products contain additional ingredients, including humectants such as urea and glycerol, which attract and hold water in the stratum corneum.xxii
In 2018, the NHS Clinical Commissioners (an independent collective voice of CCGs) recommended that treatment should not normally be offered or prescribed in primary care for mildly dry skin.xxiii Further guidance to CCGs from them was published in 2019 including a short section on the use of bath additives and shower preparations for dry skin and pruritic skin conditions.xxiv As a consequence, many CCGs unfortunately (and incorrectly) took this as guidance to discourage emollient prescribing generally, with the result that many patients with dry skin conditions have found it increasingly difficult to access emollient treatment on prescription, causing their skin condition and its psychological impact to deteriorate.
There is no good evidence from controlled trials to support the use of one emollient over another and prescribing emollients should never be based purely on cost alone. Patient preference is crucial along with clinical assessment, but other factors to be consideredxxv include;
Patients should be instructed on how to apply their emollient correctly, putting it onto the
skin and rubbing it in following the same direction as the skin hair. The best time to apply it is after washing, bathing or showering when the skin is warm and moist allowing moisture to be trapped in the skin. Compliance with regular emollient use is far more likely if a patient fully understands the benefits of emollients and has been shown how to apply them properly.xxviiii As a result, always take time to demonstrate to your patient how to apply emollients correctly.
The 2020 APPGS report found that counselling and cognitive behavioural therapy (CBT) were the most common psychological therapies provided to inquiry respondents with skin conditions, and approximately a fifth received medications, such as anti-depressants.
When assessing a person with a suspected common mental health disorder, consider using a validated measure relevant to the disorder or problem being assessed, for example, the 9-item Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression Scale (HADS) or the 7-item Generalized Anxiety Disorder scale (GAD-7) to inform the assessment and support the evaluation of any intervention.
When offering treatment for a common mental health disorder or making a referral, follow a stepped-care approach, usually offering or referring for the least intrusive, most effective intervention first such as cognitive behavioural therapy.
If a person with a skin condition presents with symptoms of anxiety and depression, assess the nature and extent of the symptoms, and if they have depression accompanied by symptoms of anxiety, the first priority should usually be to treat the depressive disorder, in line with the NICE guideline on depression. If they have an anxiety disorder and comorbid depression or depressive symptoms, consult the NICE guidelines for the relevant anxiety disorder and consider treating the anxiety disorder first. If both anxiety and depressive symptoms are present (with no formal diagnosis) and these are associated with functional impairment, discuss with the person the symptoms to treat first and the choice of intervention.xxix
People with chronic skin disease are at higher risk for mental health disease and many (especially those on immunosuppressant medications) have had to shield and self-isolate. A significant number of these patients have experienced higher rates of anxiety, low mood and social isolation as a result as well as reduced physical attendance at medical services. The psychosocial stress of the pandemic may itself act as a trigger for inflammatory skin conditions including an increased risk of subsequently developing autoimmune diseases such as psoriasis.xxxii
The sensible advice about regular handwashing during the pandemic has itself caused problems with the National Eczema Society reporting in August 2020 that one in four children was suffering from hand eczema due to increased handwashing. In addition 38 per cent of children reported dry skin, 17 per cent reported cracked skin and 6 per cent experienced hand bleeding.
Using PPE and following increased hygiene habits appears to have a mild to moderate impact on the majority of health care workers’ dermatologic quality of life, which are worse in females and in those with previous skin disease.xxxiii
There is little specific literature on the long-term impact of Covid-19 infected individuals with existing skin disorders but European Academy of Dermatology have stated that parents of school children with skin disease are generally less stressed, tired and exhausted than parents of preschool children with skin disease, and that parents of small children with skin diseases and children infected by Covid-19 with skin manifestations will have the highest quality of life impairment. Patients with existing psychodermatology issues declared they were less anxious due to diminished work pressure and time spent commuting, and those who had disfiguring facial lesions felt less stigmatised due to the mandatory wearing of masks.
Skin conditions, including psoriasis and atopic dermatitis, can increase the risk of COVID-19 and many skin conditions have dysregulated immune responses, potentially increasing Covid-19 risks due to a number of shared components between skin conditions and the immune response to Covid-19.xxxv
As one of the most Covid-19 vulnerable groups of patients, the elderly population must adhere to specific guidelines to reduce their chance of contracting it. Older patients who implement measures such as frequent handwashing benefit most from the perspective of viral infectivity but paradoxically this group is also the most vulnerable to dermatologic consequences associated with these preventative measures. Barrier function and recovery in aged skin (aged >80 years) is more readily disrupted than in young skin (aged 20–30 years) with increased trans-epidermal water loss and altered permeability to chemical substances. Increased handwashing can then further exacerbate this problem, leading to xerosis – the most common cause of pruritus in the elderly.
Time with patients is short, so make sure you cover the following;
1. Explain the importance of skin barrier repair and why emollients are necessary to achieve it. Emollients are first-line therapy for all dry skin conditions, including eczema, psoriasis and ichthyosis.
2. Make sure the patient understands how emollients should be used. Give clear advice as to how to use them for washing, showering and bathing. Emollients can be used as a soap substitute by applying before getting into the shower or bath and washing off.
3. Always ensure sufficient emollient is prescribed as many patients are prescribed insufficient quantities. This reduces the need for frequent pharmacy visits, and any emollient(s) should be added to their repeat prescription. If the patient pays prescription charges, it is more cost effective to have a prescription prepayment certificate (PPC). For more information on PPCs, visit: www.nhs.uk
4. Never concentrate on the skin alone of a patient presenting with a dermatological problem. Always treat them holistically, enquiring as to their general medical health and emotional well-being. Ask open questions such as ‘How are you feeling generally?’ and ‘What can I help you with today?’
5. If you suspect psychological issues may be present, try to address those initially in that consultation if possible rather than at a future date. Let the patient know you take their mental health concerns seriously and that they are as important to you as their skin problems.
6. If local psychodermatology services are available, refer the patient to them if appropriate. Studies have repeatedly demonstrated the benefits of psychodermatology – one study showed that amongst patients who completed psychodermatology therapies, 94% reported reduced stress, 92% reported increased confidence, and 90% reported that they understood their skin condition better.xxxv1
The most common locations affected by dry skin conditions are the hands, legs, arms and face/ cheeks.
Itching and cracking/splitting of the skin is one of the most troubling physical aspects of living with a dry skin condition. More than three fifths find itching one of the most difficult physical aspects of their dry skin condition(s) to live with.xxxvii
Reducing itching and skin cracking makes people with dry skin more confident, less stressed, more hopeful and empowered to take control of their skin health.
The majority of people with dry skin conditions see an improvement in their skin from using an emollient at least once a day.
Asking about both emollient use and psychological well-being are crucial in any consultations about dry skin conditions.
If emollient treatment in combination with other topical treatments is not controlling your patient’s skin condition, or it is becoming more severe and you are confident that they are adhering to your treatment guidelines, then referral to a dermatology specialist should be considered.
If you have concerns about the mental health of your patient or if treatment is not improving their symptoms, seek advice from your local mental health team or consider referral to a psychiatric specialist if appropriate.
1. Dry skin conditions are very common and all HCPs should be aware of the place of emollient therapy in managing mild-to-moderate skin conditions.
2. Chronic skin disease is linked to psychological distress and psychiatric comorbidities, which significantly increase disability in these patients.
3. Atopic dermatitis and chronic urticarial are strongly associated with anxiety and depressive symptoms.
4. Every patient with a skin condition should be treated holistically, with assessment of their emotional well-being as well as their skin occurring at each consultation.
5. The Covid-19 pandemic has worsened the psychological distress felt by many patients with skin problems.
This clinical learning booklet has been endorsed by the CPD Certification Scheme and can be used as a CPD resource. If you are a GP, you can use it towards your CPD accreditation scheme and as part of your Personal Development Plan (PDP). If you are a nurse, you can use it towards NMC revalidation for both individual and participatory learning.
Individual learning may involve you reflecting on your learning, and identifying points to improve practice in caring for patients with skin problems – see questions below to help with this reflection.
Recall a patient case where skin symptoms or dry skin conditions were present:
1. What were the skin symptoms identified?
2. Did you enquire about their psychological well-being as well as their skin condition?
3. If so, did you explore any concerns raised by them in the consultation?
4. What can you do in the future to improve patient outcomes?
i. Moncrieff G, Cork M et al. Use of emollients in dry skin conditions: consensus statement. Clin Exp Dermatol. 2013; 38: 231-238.
ii. Mental health and dermatology practice in the COVID-19 pandemic. G. Lada et al. Clinical and Experimental Dermatology 2020.
iii. Hammer-Helmich L, et al. BMJ Open 2016;6:e012637.
iv. Aguilar-Duran S, Ahmed A, Taylor R and Bewley AP (2014) How to set up a psychodermatology clinic. Clinical and experimental dermatology, 39(5), pp.577-582.
v. Marshall C, Taylor R and Bewley AP (2016) Psychodermatology in clinical practice: main principles. Acta dermato-venereologica, 96(217), pp.30-34.
iv. Augustin M (2013) Cumulative life course impairment: identifying patients at risk. In Dermatological Diseases and Cumulative Life Course Impairment. Karger Publishers. 44, pp.74-81.
vii. Fortune DG, Richards HL, Kirby B, McElhone K, Markham T, Rogers S, Main CJ, Griffiths CEM (2003) Psychological distress impairs clearance of psoriasis in patients treated with photochemotherapy. Arch Dermatol 139(6): 752-756
vii. Mental health and dermatology practice in the COVID-19 pandemic. Clinical and Experimental Dermatology. G. Lada, P. S. Talbot, A. Bewley, C. E. Kleyn. First published: 06 July 2020 https://doi.org/10.1111/ced.14330
ix. Suicide risk and prevention during the COVID-19 pandemic. Gunnell D et al. Lancet Psychiatry. 2020 Jun;7(6):468-471. doi: 10.1016/S2215-0366(20)30171-1.
x. The All Party Parliamentary Group on Skin. Mental Health and Skin Disease report (2020)
xi. The impact of paediatric skin disease on self-esteem. K.L. Vivar and L. Kruse. Int J Womens Dermatol. 2018 Mar; 4(1): 27–31.
xii. Paller A.S., McAlister R.O., Doyle J.J., Jackson A. Perceptions of physicians and pediatric patients about atopic dermatitis, its impact, and its treatment. Clin Pediatr (Phila) 2002;41:323–332
xiii. Brenninkmeijer E.E., Legierse C.M., Sillevis Smitt J.H., Last B.F., Grootenhuis M.A., Bos J.D. The course of life of patients with childhood atopic dermatitis. Pediatr Dermatol. 2009;26:14–22.
xiv. Eckert L., Gupta S., Amand C., Gadkari A., Mahajan P., Gelfand J.M. Impact of atopic dermatitis on health-related quality of life and productivity in adults in the United States: An analysis using the National Health and Wellness Survey. J Am Acad Dermatol. 2017;77:274–279
xv. The Work Foundation (2016) The impact of long term conditions on employment and the wider UK economy.
xvi. Ablett K and Thompson AR (2016) Parental, child, and adolescent experience of chronic skin conditions: A meta-ethnography and review of the qualitative literature. Body image, 19, pp.175-185.
xvii. Out-of-pocket Costs for Individuals with Atopic Eczema: A Cross-sectional Study in Nine European Countries. Zink A et al. Acta Derm Venereol 2019; 99E-published Dec 6, 2018.
xviii. Bewley AP, Affleck A, Bundy C, Higgins E and McBride S (2013) Psychodermatology services guidance: the report of the British Association of Dermatologists’ Psychodermatology Working Party. British Journal of Dermatology, 168(6), pp.1149-1150
xix. Cost and effectiveness of prescribing emollient therapy for atopic eczema in UK primary care in children and adults: a large retrospective analysis of the Clinical Practice Research Datalink. Moncrieff G et al. BMC Dermatol. 2018;18:9 Published online 2018 Oct 29.
xx. Loden M. Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders. American Journal of Clinical Dermatology. 2003; 4(11):771-788
xxi. Primary Care Dermatology Society and British Association of Dermatologists. Guidelines for the management of atopic eczema. 2006; 28
xxii. Moncrieff G, Cork M, Lawton S, et al. Use of emollients in dry-skin conditions: consensus statement. Clin Exp Dermatol 2013;38:231-8
xxiv. Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCGs. NHS Clinical Commissioners; 2018. Available from: https://www.england.nhs.uk/wp-content/uploads/2018/03/otc-guidance-for-ccgs.pdf
xxiv. NHS England. Items which should not be routinely prescribed in primary care, 2019. Available from: https://www.england.nhs.uk/medicines/items-which- should-not-be-routinely-prescribed/
xxv. Cost and effectiveness of prescribing emollient therapy for atopic eczema in UK primary care in children and adults: a large retrospective analysis of the Clinical Practice Research Datalink. Moncrieff G et al. BMC Dermatol. 2018;18:9 Published online 2018 Oct 29;
xxvi. NICE. CG57 Atopic eczema in under 12s: diagnosis and management, London, NICE, 2007
xxvii. Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients, 2018. MHRA. Available from: https://www.gov.uk/drug-safety-update/emollients-new-information-about-risk-of-severe-and-fatal-burns-with-paraffin-containing-and-paraffin-free- emollients
xxviii. Penzer R. Best Practice In Emollient Therapy: A Statement for Healthcare Professionals December 2012; 11(4):60-79
xxix. NICE. Common mental health problems: identification and pathways to care. Clinical guideline [CG123]Published: 25 May 2011
xxx. The All Party Parliamentary Group on Skin. Mental Health and Skin Disease report (2020)
xxxi. Mental health and dermatology practice in the COVID-19 pandemic. G. Lada et al Clinical and Experimental Dermatology July 2020
xxxii. Song H, Fang F, Tomasson G et al. Association of stress-related disorders with subsequent autoimmune disease. JAMA 2018; 319: 2388–400.
xxxiii. Daye M et al. Evaluation of Skin Problems and Dermatology Life Quality Index in Health Care Workers Who Use Personal Protection Measures during COVID-19 Pandemic. Dermatol Ther. 2020 Sep 28 : e14346.
xxxiv. Recommendation from the EADV QoL and Patient Outcomes Task Force; Summary of the Position Statement of the EADV Task Force on Quality of Life and Patient Oriented Outcomes on quality of life issues in dermatologic patients during the COVID-19 pandemic. June 2020. Journal of the European Academy of Dermatology and Venereology 34(8) DOI:10.1111/jdv.16720
xxxv. Associations between COVID-19 and skin conditions identified through epidemiology and genomic studies. Patrick M et al. J Allergy Clin Immunol. 2021 Mar; 147(3): 857–869.e7.
xxxvi. A retrospective review of a dedicated psychology-based psychodermatology service, A. Mizara, K. Badsha, M. Griffiths and S. McBride, The British Association of Dermatologists Annual Conference 2014.
xxxvii. Cetraben and BSF Survey| October 2020
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