Does Perceived Stigmatization Differ Across Skin Diseases, and What Factors Predict It?

🔍 Key Finding Perceived stigmatization is common in patients with skin diseases, particularly psoriasis, atopic dermatitis, alopecia, and bullous disorders, and is associated with younger age, male sex, being single, higher body mass index, lower overall health, higher disease severity, presence of itch, longer disease duration, greater distress, suicidal ideation, body dysmorphic concerns, and lower appearance satisfaction. These findings can help clinicians and policymakers identify and support vulnerable patient groups.

🔬 Methodology Overview

• Design: Observational, cross-sectional, multicenter study.
• Setting: 22 secondary or tertiary dermatological outpatient clinics in 17 European countries.
• Participants: 5,487 dermatological outpatients and 2,808 skin-healthy controls.
• Data Collection: Self-report questionnaires (Perceived Stigmatization Questionnaire (PSQ), demographic information, health status, psychological measures) and clinician-assessed dermatological diagnoses and disease severity.
• Statistical Analysis: Independent samples t-tests, multivariate hierarchical regression analyses. Square root transformation applied to PSQ scores due to skewness. Sensitivity analyses excluding outliers performed.
• Outcome Measure: Perceived stigmatization as measured by the PSQ.
• Predictor Variables: Sociodemographic characteristics, general health, disease-related factors (severity, itch, duration, visibility), and psychological variables (mood and appearance-related).

📊 Results

• Higher perceived stigmatization in patients: Dermatological patients (n=5,487) experienced significantly higher levels of perceived stigmatization compared to skin-healthy controls (n=2,808) (p<0.001, Cohen’s d = 0.26). This difference was most pronounced on the “confused/staring behavior” subscale (p<0.001, d=0.40).
• Specific conditions with highest stigma: Patients with psoriasis, atopic dermatitis, alopecia (areata and other types), and bullous disorders reported the highest levels of perceived stigmatization.
• Psychological factors as strongest predictors: Body dysmorphic concerns and distress were the strongest predictors of perceived stigmatization.
• Other significant predictors: Lower age, male sex, being single, higher disease severity, presence of itch, longer disease duration, higher BMI, lower overall health, and suicidal ideation were also significant predictors of perceived stigmatization.
• Variance explained: The final model, including all significant predictors, explained 32.6% of the variance in perceived stigmatization scores.
• “Confused/staring” key to perceived stigma: Between-group differences in stigmatization were primarily driven by the “confused/staring behavior” subscale, suggesting this behavior is central to the experience of perceived stigma in skin conditions.

💡 Clinical Impact Perceived stigmatization is common in patients with skin diseases, particularly psoriasis, atopic dermatitis, alopecia, and bullous disorders, and is associated with several sociodemographic, health-related, disease-related, and psychological factors. Clinicians should be aware of these vulnerable patient groups and screen for psychological distress and suicidal ideation, potentially referring to multidisciplinary management when patients report a psychological burden due to perceived stigma.

🤔 Limitations

• The generic perceived stigmatization measure may have underestimated the extent of perceived stigmatization and yielded results less comparable with previous research using disease-related instruments.
• Lack of a minimal clinically important difference threshold precluded evaluation of the clinical relevance of differences in perceived stigmatization.
• Inability to evaluate whether patients screening positive on the PHQ-2 met clinical criteria for depressive disorder.
• Analyses comparing patients with controls included psychological confounders, which are also consequences of stigmatization, requiring cautious interpretation of results.
• Small sample sizes for individual diagnoses limited power and external validity.
• Certain patient groups may be under-represented in tertiary centers, potentially affecting results.

✨ What It Means For You Healthcare providers should be aware of the increased risk of perceived stigmatization and its psychological impact, particularly among younger, male, single, overweight patients with longstanding disease, appearance concerns, and itch. Additional psychological assessment and multidisciplinary management are recommended for patients reporting a psychological burden due to perceived stigma, given its association with suicidal ideation and distress.

Reference van Beugen S, Schut C, Kupfer J, Bewley AP, Finlay AY, Gieler U, Thompson AR, Gracia-Cazaña T, Balieva F, Ferreira BR, Jemec GB, Lien L, Misery L, Marron SE, Ständer S, Zeidler C, Szabó C, Szepietowski JC, Reich A, Elyas A, Altunay IK, Legat FJ, Grivcheva-Panovska V, Romanov DV, Lvov AN, Titeca G, Sampogna F, Vulink NC, Tomás-Aragones L, Evers AWM, Dalgard FJ; and the European Society for Dermatology and Psychiatry (ESDAP) Study collaborators. Perceived Stigmatization among Dermatological Outpatients Compared with Controls: An Observational Multicentre Study in 17 European Countries. Acta Derm Venereol. 2023;103:adv6485. https://doi.org/10.2340/actadv.v103.6485