Internalized Skin Bias Linked to Adverse Psychopathology in HS Patients

Melissa Butt, DrPH

A new investigation from Penn State College of Medicine found that internalized skin bias was associated with adverse psychopathology and impaired health-related quality of life (HRQOL) in patients with hidradenitis suppurativa (HS).

Additionally, internalized skin bias appeared to moderate the associations of depression and anxiety related to HRQOL. Previous data suggests that patients with HS were twice as likely to have depression or anxiety.

Recent research has continued the exploration of skin diseases and other psychological constructs contributing to negative affectivity and cognitions, with 1 of those constructs being internalized skin bias.

Investigators led by Melissa Butt, DrPH, Department of Public Health Sciences at Penn State, evaluated the associations of internalized skin bias with additional core outcomes in HS while determining if these biases mediated the associations between adverse psychopathological outcomes and impaired HRQOL.

The Methods

Investigators recruited participants from a group of patients with HS who had volunteered for research studies at Penn State Health Milton S. Hershey Medical Center. Additional participants were recruited virtually through ResearchMatch StudyFinder at Penn State Health.

Eligible participants were 18 years of age or older, able to consent, and had a positive result on a 2-item HS screening instrument or had active HS within the past 2 years.

Butt and colleagues used 4 instruments in their analysis including the Internalized

Skin Bias Questionnaire (ISBQ), the Hidradenitis Suppurativa Quality of Life (HiSQOL) instrument,the Beck Depression Inventory−II (BDI−II),21 and the Burns Anxiety Inventory (BAI).

After responding to these instruments, participants were tasked with providing demographic and health history including age, sex, race, ethnicity, level of education, employment status, duration of HS disease, self-staging of HS severity, smoking status, and history of mental health concerns.

Butt and investigators hypothesized that a negative association between internalized skin bias and HRQOL would emerge, and a positive correlation would be seen between skin bias internalization and depression and anxiety.

The Findings

A total of 279 participants were considered for the study, with a total of 230 being selected in the end. Among then, the mean age was 39.2 years, and nearly all of study participants (90.9%) were women.

Participants identified with the following race and ethnicity groups: 3 (1.3%) Asian/Pacific Islander, 27 (11.8%) Black/African-American, 3 (1.3%) Native American/Alaska Native, and 178 (77.7%) White/Caucasian, 19 (8.3%) Hispanic, and 203 (88.7%) as non-Hispanic.

Based on this sample, depression and anxiety were considered to be a substantial burden, with 56.5% of participants’ scores qualifying for moderate or greater anxiety and 45.7% moderate or greater depression.

Meanwhile, the mean HRQOL scores were moderately high at 34.5 (16.7), which indicated strong levels of impairment. A moderate correlation between ISBQ score and depression (r=0.67) and fair correlations with HRQOL (r=0.52) and anxiety (r=0.56) were also observed.

Given the data, internalized skin bias appeared to positively mediate the associations between depression and anxiety, with the estimated proportions of the total effect being 38.7% and 24.9%, respectively.

Controlling for age, disease severity, and disease duration, both anxiety and internalized skin bias were positive predictors of impaired HRQOL.

As such, investigators called for additional clinical trials to evaluate the effectiveness of adjuvant psychotherapy on patient-centered and mental health outcomes for patients with HS.

“Systemically, advocacy initiatives to educate, raise awareness of, and eliminate social stigma in the general population as well as among health care can help counter the effects ISB can have on patients,” the team wrote.

The study, "Associations of Internalized Skin Bias with Age, Adverse Psychopathology, and Health-Related Quality of Life Among Patients With Hidradenitis SuppurativaA Cross-sectional Analysis," was published online in JAMA Dermatology.