10.5826/dpc.1301a29
Introduction: Skin diseases have negative psychological and social consequences, especially when they are chronic and affect a visible area of the body, such as the face.
Objectives: &nbsp;The purpose of this study is to investigate and compare the psychosocial impact of three common chronic dermatoses of the face: acne, rosacea, and seborrheic dermatitis.
Methods: The Dermatology Life Quality Index (DLQI), Hospital Anxiety and Depression Scale (HADS), and Social Appearance Anxiety Scale (SAAS) were used to compare acne, rosacea, and seborrheic dermatitis patients and healthy controls. The relationships between DLQI, HADS, and SAAS results were investigated, as well as their associations with disease duration and severity.
Results: The study included 164 acne patients, 134 rosacea patients, 120 seborrheic dermatitis patients, and 124 controls. The patient groups had significantly higher DLQI, HADS, and SAAS scores than the control group. Rosacea patients had the highest DLQI and SAAS scores, as well as the highest anxiety prevalence. Patients with seborrheic dermatitis had the highest rate of depression. The DLQI, HADS, and SAAS results were moderately correlated with each other, but their relationship with disease duration and severity was insignificant or weak at best.
Conclusions: Chronic facial dermatoses have a detrimental impact on mood and quality of life. Although patients with acne, rosacea, and seborrheic dermatitis have distinct lesions, the outcomes in terms of quality of life, anxiety, and depression are largely similar. Furthermore, these patients have a higher prevalence of social anxiety as a result of their overall appearance rather than just their faces.
text/xml
2160-9381
2438
en
Emin Özlü
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
seborrheic dermatitis
The Psychosocial Impact of Chronic Facial Dermatoses in Adults
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-03-03
2023-01-31
2023-02-27
e2023029
Dermatol Pract Concept
Introduction: Skin diseases have negative psychological and social consequences, especially when they are chronic and affect a visible area of the body, such as the face.
Objectives: &nbsp;The purpose of this study is to investigate and compare the psychosocial impact of three common chronic dermatoses of the face: acne, rosacea, and seborrheic dermatitis.
Methods: The Dermatology Life Quality Index (DLQI), Hospital Anxiety and Depression Scale (HADS), and Social Appearance Anxiety Scale (SAAS) were used to compare acne, rosacea, and seborrheic dermatitis patients and healthy controls. The relationships between DLQI, HADS, and SAAS results were investigated, as well as their associations with disease duration and severity.
Results: The study included 164 acne patients, 134 rosacea patients, 120 seborrheic dermatitis patients, and 124 controls. The patient groups had significantly higher DLQI, HADS, and SAAS scores than the control group. Rosacea patients had the highest DLQI and SAAS scores, as well as the highest anxiety prevalence. Patients with seborrheic dermatitis had the highest rate of depression. The DLQI, HADS, and SAAS results were moderately correlated with each other, but their relationship with disease duration and severity was insignificant or weak at best.
Conclusions: Chronic facial dermatoses have a detrimental impact on mood and quality of life. Although patients with acne, rosacea, and seborrheic dermatitis have distinct lesions, the outcomes in terms of quality of life, anxiety, and depression are largely similar. Furthermore, these patients have a higher prevalence of social anxiety as a result of their overall appearance rather than just their faces.
Emin Özlü
2023/01/31
10.5826/dpc.1301a29
e2023029
Associate Professor of Dermatology, Private Practice, Duzce, Turkey 
2160-9381
seborrheic dermatitis
en
e2023029
Misery L, Touboul S, Vinçot C, et al. [Stress and seborrheic dermatitis]. Ann Dermatol Venereol. 2007;134(11):833-837. doi:10.1016/s0151-9638(07)92826-4
The Psychosocial Impact of Chronic Facial Dermatoses in Adults
https://dpcj.org/index.php/dpc/article/download/2438/1934
              The Psychosocial Impact of Chronic Facial
                       Dermatoses in Adults
     Yunus Ozcan1, Mehmet Ali Sungur2, Begum Yaman Ozcan3, Yavuz Eyup4, Emin Ozlu5


1 Department of Dermatology, Duzce Ataturk State Hospital, Duzce, Turkey
2 Department of Biostatistics, Duzce University Faculty of Medicine, Duzce, Turkey
3 Department of Psychiatry, Duzce University Faculty of Medicine, Duzce, Turkey
4 Department of Dermatology, Unye State Hospital, Unye/Ordu, Turkey
5 Associate Professor of Dermatology, Private Practice, Duzce, Turkey



Key words: acne, anxiety, depression, rosacea, seborrheic dermatitis
Citation: Ozcan Y, Sungur MA, Yaman Ozcan B, Eyup Y, Ozlu E. The Psychosocial Impact of Chronic Facial Dermatoses in Adults.
Dermatol Pract Concept. 2023;13(1):e2023029. DOI: https://doi.org/10.5826/dpc.1301a29
Accepted: April 16, 2022; Published: January 2023
Copyright: ©2023 Ozcan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Yunus Ozcan, Department of Dermatology, Duzce Ataturk State Hospital, Duzce, Turkey.
E-mail: yunusozcan18@gmail.com




  ABSTRACT             Introduction: Skin diseases have negative psychological and social consequences, especially when they
                       are chronic and affect a visible area of the body, such as the face.
                       Objectives: The purpose of this study is to investigate and compare the psychosocial impact of three
                       common chronic dermatoses of the face: acne, rosacea, and seborrheic dermatitis.
                       Methods: The Dermatology Life Quality Index (DLQI), Hospital Anxiety and Depression Scale
                       (HADS), and Social Appearance Anxiety Scale (SAAS) were used to compare acne, rosacea, and seb-
                       orrheic dermatitis patients and healthy controls. The relationships between DLQI, HADS, and SAAS
                       results were investigated, as well as their associations with disease duration and severity.
                       Results: The study included 166 acne patients, 134 rosacea patients, 120 seborrheic dermatitis
                       ­patients, and 124 controls. The patient groups had significantly higher DLQI, HADS, and SAAS scores
                        than the control group. Rosacea patients had the highest DLQI and SAAS scores, as well as the highest
                        anxiety prevalence. Patients with seborrheic dermatitis had the highest rate of depression. The DLQI,
                        HADS, and SAAS results were moderately correlated with each other, but their relationship with
                        ­disease duration and severity was insignificant or weak at best.
                       Conclusions: Chronic facial dermatoses have a detrimental impact on mood and quality of life.
                       ­Although patients with acne, rosacea, and seborrheic dermatitis have distinct lesions, the outcomes in
                        terms of quality of life, anxiety, and depression are largely similar. Furthermore, these patients report
                        similar levels of social anxiety as a result of their overall appearance.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023029                                                                      1
Introduction                                                       Sociodemographic and Clinical Characteristics
                                                                   All participants’ ages, genders, and BMIs, as well as the se-
Healthy skin shields the organism from the outside. How-           verity and duration of illness for patient groups, were re-
ever, in its absence, a person becomes not only vulnerable to      corded. Global acne grading system[1] for acne patients,
the physical environment but also suffers from psychological       rosacea clinical scorecard[2] for rosacea patients, and sebor-
and social problems. While it is easier to conceal patholo-        rheic dermatitis area severity index[3] for seborrheic derma-
gies in certain areas, concealing the face is often more diffi-    titis patients were used to assess the severity of illness, and
cult. One’s social, economic, and romantic opportunities are       only the scores obtained from the facial area were used.
shaped by one’s face. Thus, facial dermatoses may be more
likely to have negative consequences.                              The Dermatology Quality of Life Index (DQLI)
    Acne, rosacea, and seborrheic dermatitis are chronic skin
                                                                   This scale, created by Finlay[4] and adapted by Ozturk-
diseases that primarily affect the face. Although each of these
                                                                   can[5], aims to measure and compare data across all skin
diseases is well known to be associated with poor quality of
                                                                   diseases. Questions are answered based on the previous
life, anxiety, and depression, no study has been conducted to
                                                                   week. The higher the final score, the greater the decrease in
compare the psychosocial burden of these diseases.
                                                                   quality of life. The outcomes are graded as follows:
    In this study, we examined acne, rosacea, or seborrheic
dermatitis patients who presented to a dermatology out-
                                                                      0 – 1 no effect at all on patient’s life
patient clinic with facial complaints. We hoped to use the
                                                                      2 – 5 small effect on patient’s life
findings to better identify patients who might benefit from
                                                                      6 – 10 moderate effect on patient’s life
psychosocial support in addition to dermatological care, as
                                                                      11 – 20 very large effect on patient’s life
well as to strengthen patient compliance. The patients’ qual-
                                                                      21 – 30 extremely large effect on patient’s life
ity of life as well as the frequency and severity of anxiety and
depression were compared. Also, the social anxiety caused
                                                                      It is further divided into six subscales to determine the
by patients’ overall appearances—which extended beyond
                                                                   focus of the impact on quality of life:
their facial appearance—was compared.

                                                                      Questions 1&2: Symptoms, feelings
Objectives                                                            Questions 3&4: Daily activities
                                                                      Questions 5&6: Leisure
The purpose of this study was to compare the quality of life,
                                                                      Question 7: Work/school
anxiety, and depression levels in adult acne, rosacea, and
                                                                      Questions 8&9: Personal relationships
seborrheic dermatitis patients and healthy controls. We also
                                                                      Question 10: Treatment
compared the social anxiety caused by overall appearance
(rather than just the face) between these groups.
                                                                   The Hospital Anxiety and Depression
                                                                   Scale (HADS)
Methods
                                                                   The hospital anxiety and depression scale was created to screen
Study Design, Participants and Ethics                              for the presence of anxiety and depression in patients with
This cross-sectional study included patients between the ages      physical illnesses who presented to non-psychiatric clinics[6].
of 18 and 65 who presented to the Duzce University Hospital        Half of the 14-question scale investigates anxiety, while the
Dermatology Clinic with acne, rosacea, or seborrheic dermatitis    other half investigates depression. It is answered based on the
between October 2020 and July 2021. Patients who presented         previous week. In 1993, Aydemir et al. adapted it, and cut-off
with more than one of these diagnoses, as well as patients with    scores indicating the presence of anxiety and depression were
other facial dermatoses, scarring, or dysmorphia, were excluded    determined[7]. An anxiety subscale score of 11 or higher in-
from the study. Patients who were pregnant or breastfeeding,       dicates the presence of anxiety, whereas a depression subscale
patients with comorbidities that could cause neurological or       score of 8 or higher indicates the presence of depression[7]. The
psychiatric symptoms, and those who had used central nervous       results also reflect the severity of anxiety and depression, al-
system-influencing medications in the previous 6 months (in-       lowing them to be used in comparisons or patient follow-up[6].
cluding systemic isotretinoin) were all excluded from the study.
Hospital employees were chosen as healthy controls.                The Social Appearance Anxiety Scale (SAAS)
    The study protocol was reviewed and approved by the            The social appearance anxiety scale was developed by Hart
Duzce University Ethics Committee (07.09.2020–2020/199).           et al. in 2008[8] and later adapted by Dogan et al. in 2010[9].
All participants in the study provided written consent.            It was created to assess fear in situations where the person’s



2                                                                      Original Article | Dermatol Pract Concept. 2023;13(1):e2023029
overall external appearance can be evaluated. The appear-                  Scheffe’s method was employed as a post-hoc test. Categori-
ance is assessed in a broader context, rather than focusing                cal variables were evaluated using Pearson’s chi-square, Fish-
on a specific feature such as hair, nose, or chest size. Its pri-          er’s exact test, or Fisher-Freeman-Halton test, depending on
mary purpose is to assess the components of social anxiety.                the expected value principle. Pearson or Spearman correla-
The scale consists of 16 questions with no cut-off point. As               tion analysis was used to examine correlations between con-
the score rises, so does the person’s anxiety about his or her             tinuous variables, depending on the distribution of the data.
appearance.                                                                   An ordinal logistic regression model was designed to
                                                                           analyze the relationship between acne, rosacea, seborrheic
Statistics                                                                 dermatitis, control groups, and DLQI outcomes using the
Baseline demographic and clinical characteristics in acne,                 previously described five outcome grades of the scale. For
rosacea, seborrheic dermatitis, and control groups were                    SAAS, an ordinal logistic regression model was also cre-
described using mean (standard deviation), median (inter-                  ated, and the final scale score was employed as the response
quartile range), frequencies, and percentages. The Pearson                 variable. The binary logistic regression models for anxiety
chi-square test was used to compare the categorical variable               and depression subscales were created using the previously
(sex). The continuous variables (age, BMI, and duration of ill-            defined cut-off values. The healthy controls served as the
ness) were initially evaluated using the Kolmogorov-Smirnov                reference group. Age, gender, and BMI were included as
test, and then compared using the Kruskal-Wallis test be-                  covariates in all regression models, and the results were re-
cause they did not have a normal distribution. Pairwise com-               ported as adjusted odds ratios with 95% confidence inter-
parisons were analyzed using the Mann-Whitney U test with                  vals. The SPSS 26.00 package program was used to analyze
Bonferroni correction.                                                     the data. Statistical significance was defined as .05 or less.
    The distribution of the DLQI, HADS, and SAAS re-
sults in the acne, rosacea, seborrheic dermatitis, and con-                Results
trol groups was analyzed using the Kolmogorov-Smirnov
test. Because the data did not have a normal distribution,                 Participants
the Kruskal-Wallis test was performed to compare the re-                   The study enrolled 166 acne, 134 rosacea, and 120 sebor-
sults. Pairwise comparisons were analyzed using the Mann-­                 rheic dermatitis patients, along with 124 healthy volunteers.
Whitney U test, with Bonferroni correction applied in cases                Rosacea patients had the highest mean age, BMI, and longest
where the difference was found to be significant. Further-                 duration of illness. Acne patients had the lowest mean age
more, Quade’s non-parametric analysis of covariance (AN-                   and BMI of any group. The majority of patients with acne
COVA) was employed to account for differences in baseline                  and rosacea were female, while the majority of patients with
demographic factors, including age, gender, and BMI.                       seborrheic dermatitis were male (Table 1).


                 Table 1. The baseline demographic and clinical features of the participants.
                                           Acne              Rosacea             Seborrheic Dermatitis           Control            p
 n (%)                                  166 (30.5)          134 (24.6)                  120 (22.1)              124 (22.8)          —
 Age1             Mean (SD)             22.8 (5.3)          37.9 (12.9)                31.9 (12.2)             31.7 (11.1)       < .001*
                  Median (IQR)           21.5 (6)                36 (22)                  28 (13)                27.5 (15)
                  [Min.–Max.]            [18 – 55]           [18 – 65]                   [18 – 65]               [20 – 65]
 Sex, n (%)       Male                   51 (30.7)           29 (21.6)                  89 (74.2)                64 (51.6)          <
                  Female                115 (69.3)          105 (78.4)                  31 (25.8)                60 (48.4)       .001**
       1
 BMI              Mean (SD)             22.3 (3.4)           28.8 (6.1)                 25.3 (4.7)              24.8 (4.5)       < .001*
                  Median (IQR)           21.6 (4)             28 (7.5)                  24.6 (6.1)              24.4 (6.6)
                  [Min.–Max.]           [16 – 40.4]        [17.5 – 53.1]              [15.4 – 39.4]           [16.4 – 41.5]
 Duration of Illness2, Years
 Mean (SD)                               4.7 (4.1)           8.4 (9.5)                   4.9 (6.5)                   0            .003*
 Median (IQR)                             4 (4.5)             5 (10)                       3 (5)                     0
 [Min. – Max.]                           [0 – 20]            [0 – 40]                    [0 – 50]                    0

*Kruskal-Wallis test
**Pearson Chi-square
Pairwise comparisons are significant at p <.05 for:
1
  Acne vs. Rosacea, Seborrheic dermatitis, Control; Rosacea vs. Seborrheic dermatitis, Control
2
  Acne vs. Rosacea; Rosacea vs. Seborrheic dermatitis



Original Article | Dermatol Pract Concept. 2023;13(1):e2023029                                                                              3
The Dermatology Life Quality Index                                        134.513, p <.001]. The adjusted odds ratio for acne patients
Acne, rosacea, and seborrheic dermatitis patients (p <.001)               was 8.78 (95% CI 5.24–14.72, p <.001), for rosacea patients
had a significantly lower quality of life than the control                was 13.04 (95% CI 7.44–22.86, p <.001), and for the seb-
group when the results were interpreted as grades (Figure 1).             orrheic dermatitis patients was 8.17 (95% CI 4.80–13.88,
The negative impact on quality of life was similar across                 p <.001).
acne, rosacea and seborrheic dermatitis patients.
    Acne patients had a higher mean and median score than                 The Hospital Anxiety and Depression Scale
seborrheic dermatitis patients and a lower mean and me-                   HADS results suggested the presence of anxiety in
dian score than rosacea patients [DLQI, mean (SD) = acne:                 30 (18.1%) acne patients, 50 (37.3%) rosacea patients,
5.5 (5.1); rosacea: 6.3 (5.8); seborrheic dermatitis: 4.3 (4);            31 (25.8%) seborrheic dermatitis patients, and 10 (8.1%)
control: 1.3 (1.8)]. The only statistically significant differ-           subjects from the control group (Table 3). Using the previ-
ence after adjusting for age, gender, and BMI was found in                ously reported cut-off points in the HADS, a binary logistic
pairwise comparisons between the patient groups and the                   regression model was used to investigate the relationship be-
healthy controls (Table 2).                                               tween the acne, rosacea, seborrheic dermatitis, and control
    Acne patients had higher average scores on the “symp-                 groups, and the presence of anxiety. Age, gender, and BMI
toms and feelings” and “treatment” subscales, whereas ro-                 were identified as confounders and were adjusted for. The
sacea patients had higher impairment in “daily activities,”               healthy controls served as the reference group. The logistic
“leisure,” “work and school,” and “personal relationships.”               regression model was statistically significant [χ2(6) = 37.542,
But the only significant result was obtained when comparing               p <.001]. The presence of anxiety was associated with an
patients with rosacea and seborrheic dermatitis on the sub-               adjusted odds ratio of 2.59 (95% CI 1.18–5.69, p =.017) in
scale concerning daily activities (mean (SD): rosacea: 1.13               acne patients, 5.90 (95% CI 2.73–12.73, p <.001) in rosacea
(1.6) – seborrheic dermatitis: .48 (.92); p = .002).                      patients, and 4.01 (95% CI 1.84–8.73, p <.001) in sebor-
    Ordinal logistic regression was performed to evaluate                 rheic dermatitis patients.
the likelihood of being in a higher DLQI grade in acne, ro-                  In terms of anxiety severity, patients with rosacea scored
sacea, and seborrheic dermatitis patients, with healthy con-              the highest, with a mean of 8.49 (4.7). Seborrheic dermatitis
trols serving as the reference group. Age, gender, and BMI                patients had a mean of 7.92 (4.19), acne patients had a mean of
were identified as confounders and were adjusted for. The                 7.32 (3.99), and the control group had a mean of 5.73 (3.52).
                                                              2
logistic regression model was statistically significant [χ (6) =          After controlling for age, gender, and BMI, we discovered that



        100%                               1,8%                           2,2%                                            3,2%
                                                                                      10%
          90%                13,3%                       17,9%
                                                                                                                24,2%
          80%                                                                         17,5%

          70%                26,5%                       23,1%
          60%

          50%
                                                                                      47,5%
          40%                36,7%                       34,3%                                                  72,6%
          30%

          20%

          10%                21,7%                       22,4%                        25%

           0%
                             Acne                       Rosacea                   Seborrheic                   Control
                                                                                  Dermatitis

            No Effect        Small Effect         Moderate Effect            Very Large Effect         Extremely Large Effect


      Figure 1. The negative impact of skin disease on quality of life.



4                                                                             Original Article | Dermatol Pract Concept. 2023;13(1):e2023029
               Table 2. Comparison of dermatology life quality index (DLQI) scores by group.
                                  Acne                        Rosacea              Seborrheic Dermatitis               Control
 Median (IQR)                     4 (5)                          5 (7)                           3 (5)                   1 (2)
 [Min.-Max.]                     [0-26]                          [0-27]                       [0-16]                    [0-10]
 Mean (SD)                      5.5 (5.1)                     6.3 (5.8)                      4.3 (4)                   1.3 (1.8)
 SEM                              .399                           .501                            .372                    .165
 p*                              < .001                         < .001                        < .001                     Ref.

p value for Kruskal-Wallis test < .001
* Mann-Whitney U test.
After controlling for age, gender, and BMI, pairwise comparisons are significant (p <.05) for:
Acne vs. Control; Rosacea vs. Control; Seborrheic dermatitis vs. Control.




          Table 3. Comparison of the frequency and severity of anxiety and depression by group.
                                  Acne                 Rosacea            Seborrheic Dermatitis           Control               p
 Participants, n (%)           166 (30.5)             134 (24.6)                 120 (22.1)              124 (22.8)
 Anxiety
      Yes, n (%)               30 (18.1)               50 (37.3)                 31 (25.8)                10 (8.1)        < .001*
      Median (IQR)                7 (5)                  9 (7)                      7 (6)                   6 (4)        < .001**
      [Min.- Max.]               [0-19]                 [0-19]                     [0-19]                  [0-20]
      Mean (SD)               7.32 (3.99)             8.49 (4.7)                7.92 (4.19)              5.73 (3.52)
      SEM                          .31                   .407                       .382                    .317
 Depression
      Yes, n (%)               46 (27.7)               51 (39.5)                 49 (41.5)               19 (16.1)        < .001*
      Median (IQR)                5 (5)                  6 (5)                      6 (6)                   4 (4)        < .001**
      [Min.- Max.]              [1 – 18]               [0 – 19]                   [0 – 14]                [0 – 14]
      Mean (SD)               5.66 (3.54)            6.51 (3.73)                6.31 (3.62)              4.59 (2.89)
      SEM                         .275                   .323                       .331                    .260

* Pearson Chi-square
** Kruskal-Wallis test
After controlling for age, gender, and BMI, pairwise comparisons are significant (p <.05) for:
Anxiety: Acne vs. Control; Rosacea vs. Control; Seborrheic dermatitis vs. Control.
Depression: Acne vs. Control; Rosacea vs. Control; Seborrheic dermatitis vs. Control



patients with acne, rosacea, and seborrheic dermatitis experi-            in rosacea patients, and 3.53 (95% CI 1.89–6.59, p <.001)
enced more severe anxiety than healthy controls, but there was            in seborrheic dermatitis patients.
no significant difference across the patient groups (Table 3).               In terms of depression severity, rosacea patients received
    The depression subscale suggested the presence of de-                 the highest scores, with a mean of 6.51 (3.73). This was fol-
pression in 46 (27.7%) of the acne patients, 51 (39.5%) of                lowed by seborrheic dermatitis with a mean of 6.31 (3.62),
the rosacea patients, 49 (41.5%) of the seborrheic dermati-               acne with a mean of 5.66 (3.54), and the control group with
tis patients, and 19 (16.1%) of the control group (Table 3).              a mean of 4.59 (2.89). After controlling for age, gender,
To examine the association between the acne, rosacea, seb-                and BMI, it was found that acne, rosacea, and seborrheic
orrheic dermatitis, and control groups and the presence of                dermatitis patients experienced more severe depression than
depression, a binary logistic regression model was created                healthy controls, but there was no significant difference be-
using the depression cut-off points in the HADS. Age, gender,             tween the patient groups (Table 3).
and BMI were identified as confounders and were adjusted
for. The healthy controls served as the reference group. The              The Social Appearance Anxiety Scale
                                                                 2
logistic regression model was statistically significant [χ (6)            According to the results of the SAAS, rosacea patients had
= 25.227, p <.001]. The presence of depression was associ-                the highest mean score of 38.51 (16.37). Acne patients had a
ated with an adjusted odds ratio of 2.16 (95% CI 1.15–4.04,               mean of 36.86 (14.24), seborrheic dermatitis patients had a
p =.016) in acne patients, 3.35 (95% CI 1.76–6.37, p <.001)               mean of 33.83 (13.67), and the control group had a mean of



Original Article | Dermatol Pract Concept. 2023;13(1):e2023029                                                                       5
26.37 (8.4). In paired comparisons, acne, rosacea, and seb-                with seborrheic dermatitis. These associations were found to
orrheic dermatitis patients’ scores were significantly higher              be significant but weak, with the strongest link being found
than the control group after controlling for age, gender, and              between the severity of seborrheic dermatitis and the DLQI
BMI. The pairwise comparisons of the patient groups re-                    results [r (120) =.446, p =.000]. There was no significant
vealed no significant differences (Table 4).                               relationship between illness duration and DLQI, HADS, or
     An ordinal logistic regression model was created to ex-               SAAS outcomes in the patient groups (Table 5).
plore the relationship between the acne, rosacea, seborrheic                  In all patient groups, the DLQI, HADS, and SAAS out-
dermatitis, and control groups and the SAAS results. Age,                  comes had significant and positive correlations with each
gender, and BMI were identified as confounders and were                    other (Table 6). The strongest correlation was seen between
adjusted for. The healthy controls served as the reference                 the HADS anxiety and depression subscales, which were
group. The logistic regression model was statistically signif-             moderately correlated with each other. There was also a
icant [χ2(6) = 54.586, p <.001]. The adjusted odds ratio for               moderate association between the DLQI and the SAAS out-
receiving a higher score on the scale was 3.14 (95% CI 2.05–               comes in acne patients [r (166) =.659, p =.000].
4.81, p <.001) for acne patients, 4.05 (95% CI 2.54–6.48, p
<.001) for rosacea patients, and 2.46 (95% CI 1.57–3.83, p
                                                                           Discussion
<.001) for seborrheic dermatitis patients.
                                                                           Acne, rosacea, and seborrheic dermatitis patients’ quality of
Correlations                                                               life was found to be significantly lower when compared to
There was a positive relationship between disease severity                 healthy people. These patients reported having more negative
and the DLQI, HADS, and SAAS scores in acne and rosacea                    feelings about themselves as a result of their skin illnesses,
patients. Similarly, a positive relationship was found between             and they had more difficulty with their daily and leisure time
disease severity and the DLQI and SAAS scores in patients                  activities, work and school lives, and personal relationships.


          Table 4. Comparison of social appearance anxiety scale (SAAS) scores between groups.
                                    Acne                       Rosacea               Seborrheic Dermatitis                Control
 Median (IQR)                      35 (22)                      35 (26)                       32 (23)                     24 (12)
 [Min.-Max.]                     [16 – 75]                     [16 – 79]                     [16 – 67]                   [16 – 50]
 Mean (SD)                     36.86 (14.24)                38.51 (16.37)                 33.83 (13.67)                 26.37 (8.4)
 SEM                               1.106                         1.414                           1.249                      .754
 p*                                < .001                       < .001                           < .001                     Ref.

p value for Kruskal-Wallis test < .001
* Mann-Whitney U test.
After controlling for age, gender, and BMI, pairwise comparisons are significant (p <.05) for:
Acne vs. Control; Rosacea vs. Control; Seborrheic dermatitis vs. Control.



     Table 5. The correlations between severity and duration of illness with the dermatology quality of
    life index, anxiety and depression scores, and the social appearance anxiety scale in patient groups.
                                        DLQI                 Anxiety Subscale          Depression Subscale                 SAAS
                                            r                          r                             r                        r
 Severity of Illness
 Acne                                  .271**                       .172*                         .206*                     .241*
 Rosacea                               .354**                      .290**                         .272*                    .308**
 Seborrheic Dermatitis                 .446**                        .173                          .198                     .262*
 Duration of Illness
 Acne                                   -.022                        .071                          -.002                    -.007
 Rosacea                                -.144                       -.108                          -.122                    .003
 Seborrheic Dermatitis                  -.053                        .018                          -.036                    .070

DLQI: Dermatology Life Quality Index, SAAS: Social Appearance Anxiety Scale, r: Correlation coefficient.
* significant at p < .05
** significant at p < .001



6                                                                              Original Article | Dermatol Pract Concept. 2023;13(1):e2023029
     Table 6. Correlations of the dermatology quality of life index, anxiety and depression scores,
                          and the social appearance anxiety scale by groups.
                     DLQI and            DLQI and                                Anxiety and          Anxiety           Depression
                     Anxiety            Depression           DLQI and            Depression         Subscale and       Subscale and
                     Subscale            Subscale             SAAS                Subscales            SAAS               SAAS
                          r                   r                      r                 r                   r                 r
 Acne                  .468**              .473**                .659**             .564**             .413**             .339**
 Rosacea               .354**              .338**                .487**             .671**             .400**             .437**
 Seborrheic            .275*                .182*                .401**             .593**             .304**             .374**
 Dermatitis
 Control               .255*                .204*                 .154              .330**             .333**               .039

DLQI: Dermatology Life Quality Index, SAAS: Social Appearance Anxiety Scale, r: Correlation coefficient.
* significant at p < .05
** significant at p < .001




Furthermore, anxiety and depression were both more com-                  triggers such as the sun, weather, stress, emotional state, and
mon and severe in these individuals. They experienced more               various foods may cause patients to develop an avoidance
intense social anxiety as a result of their beliefs that their ap-       behavior, either consciously or unconsciously. Patients may
pearance would be judged negatively, and the source of this              refrain from participating in outdoor activities to avoid be-
anxiety extended beyond the facial area to overall negative              ing exposed to triggers such as the sun, hot or cold air, wind,
body image thoughts (not being attractive, being overweight,             and social gatherings to avoid emotional triggers. This can
hair color, nose shape, body shape).                                     result in introversion, social isolation, depression, and anx-
    Rosacea patients had the most negative impact on their               iety. A lack of sunlight is linked to an increased risk of de-
quality of life, followed by acne and seborrheic dermatitis              pression[12,13]. Anxiety and other psychological stressors
patients, respectively. There was also a statistically signifi-          contribute to this cycle by exacerbating rosacea symptoms
cant difference between rosacea and seborrheic dermatitis                through the release of proinflammatory cytokines[14].
patients. This difference, however, was eliminated after con-               Another intriguing finding is the high rate of depression
trolling for age, sex, and BMI. Similarly, the severity of social        in seborrheic dermatitis patients. Seborrheic dermatitis is
anxiety caused by overall appearance was highest in rosa-                frequently linked to neurological conditions such as Parkin-
cea patients, second in acne patients, and third in seborrheic           son’s disease[15,16], tardive dyskinesia[17], or spinal dam-
dermatitis patients, but the differences were not statistically          age[18]. There is also a link between seborrheic dermatitis
significant.                                                             and psychiatric illnesses. According to the literature, those
    A study comparing acne and seborrheic dermatitis found               with mood disorders are more likely to develop seborrheic
that acne patients had a higher rate and severity of anxiety             dermatitis[19], and those with seborrheic dermatitis are
and depression[10]. A study in Lithuania comparing acne                  more likely to develop depression[20]. Parkinson’s disease
and rosacea patients aged 18-70 found that acne patients                 is characterized by a decrease in dopamine, and dopamine
had higher anxiety and rosacea patients had higher depres-               receptor blockage results in tardive dyskinesia. Recently, the
sion[11]. The fact that these studies were completed with                importance of dopamine has been emphasized in addition
a smaller number of patients is a limitation. Our study in-              to serotonin and noradrenaline in the pathophysiology of
cluded a larger number of participants, comparing patients               depression[21]. Although our study was observational in
with acne, rosacea, and seborrheic dermatitis simultaneously.            nature and was not intended to establish a cause-effect rela-
According to our data, anxiety rates were highest in rosacea             tionship, it is worth noting that seborrheic dermatitis is fre-
patients, followed by seborrheic dermatitis and acne patients,           quently seen in conjunction with diseases in which dopamine
respectively. Depression rates were highest in patients with             plays a prominent role in the pathophysiology.
seborrheic dermatitis, followed by rosacea and acne patients,               Our findings show that the severity of psychosocial im-
respectively. The severity of anxiety and depression, on the             pact in patients with acne, rosacea, and seborrheic derma-
other hand, was comparable in acne, rosacea, and seborrheic              titis is unrelated to the duration or severity of symptoms.
dermatitis patients after controlling for age, sex, and BMI.             The literature shows that even when different measurement
    Rosacea patients’ physical symptoms, such as burning,                methods are used, the results are similar. Acne[22,23], rosa-
stinging, redness, and flushing, may explain why the nega-               cea[24,25], and seborrheic dermatitis[26] severity and dura-
tive impact on quality of life is greater. Common rosacea                tion have been reported to be insignificant or significant but



Original Article | Dermatol Pract Concept. 2023;13(1):e2023029                                                                        7
weakly related to psychosocial outcomes. This suggests that       is not only a symptom of illness; it is also one of its causes,
patients with a new-onset or mild disease may be severely         and it can lead to suicidal ideation during vulnerable times
impacted. On the other hand, despite having a severe or           in one’s life. Identifying vulnerable patients and breaking the
long-term disease, some patients can maintain their mental        disease-stress cycle in both steps might improve patient com-
health. This implies that what matters is not the biological      pliance and treatment efficacy.
process itself, but the meaning ascribed to one’s own illness.
    Another intriguing aspect is the correlation between
the DLQI, HAD, and SAAS results. The negative effects ob-
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Original Article | Dermatol Pract Concept. 2023;13(1):e2023029                                                                                    9
