Chronic skin conditions linked to bullying, depression, and suicide risk in children, adolescents

Pediatric patients with chronic skin diseases—including acne, atopic dermatitis (AD), and psoriasis—face significant and frequently underappreciated risks to their mental health and social well-being, according to findings from several recent studies examining quality of life, stigmatization, and psychiatric comorbidities in this population.^1-5

Skin disease is among the most common medical problems seen in childhood and adolescence. Acne affects approximately 80% of adolescents aged 12 to 18 years.¹ AD affects up to 25% of children, with 85% of cases presenting in patients younger than 5 years.¹ Psoriasis, although less common in pediatric patients, has been reported to begin in patients younger than 20 years in approximately 37% of adult cases.¹ Despite the prevalence of these diagnoses, their psychosocial consequences have historically received limited clinical attention.

A 2021 review published in Children examined the effects of acne, AD, and psoriasis on quality of life, bullying, stigmatization, and suicide risk in patients 18 years and younger.¹ A 2024 cross-sectional study published in JAMA Dermatology, involving 1671 children aged 8 to 17 years at 32 pediatric dermatology centers across the US and Canada, used validated instruments to measure the extent of stigma and its correlations with depression, anxiety, and peer relationships across a range of chronic skin conditions.² These findings are further supported by more recent work documenting the breadth of mental health comorbidities—including attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD)—in youth with AD,³ and by a 2023 review advocating for routine psychological screening in pediatric patients with psoriasis.⁴

Quality of life and self-esteem

Among children with chronic skin diseases, quality of life is substantially impaired. Using the Children's Dermatology Life Quality Index (CDLQI), psoriasis was found to decrease health-related quality of life by 30.5% (P < .001) among children aged 5 to 16 years—a greater reduction than that observed with epilepsy, enuresis, and diabetes.¹ AD and psoriasis had a greater impact on health-related quality of life compared with other chronic dermatologic conditions, such as vitiligo.¹

The visible nature of these conditions plays a central role in their psychological impact. Among adolescents with chronic skin disease, such as acne, self-image tends to be worse than in those with congenital facial differences.¹ Importantly, this negative self-perception does not reliably correlate with physician-assessed disease severity. Research on acne has shown that patients’ perceptions of how severe their condition is are often shaped more by anxiety, depression, and low self-esteem than by objective clinical assessments.¹ In a cross-sectional study conducted among adolescents in Greece, the lowest self-esteem scores were observed in participants who perceived their acne as more severe, independent of clinician evaluation.¹

Caregivers are also affected. Mothers of infants with AD have been found to more frequently describe themselves as depressed and anxious and to characterize their infants more negatively compared with mothers of unaffected children.¹ In families of children with psoriasis, the Dermatitis Family Impact score was positively correlated with both the CDLQI score (r = 0.554; P < .001) and disease severity scores (r = 0.350; P < .001), indicating that as the child's disease burden grows, so does the family's.¹

Stigma, bullying, and social exclusion

The 2024 JAMA Dermatology study found that only 27% of children with chronic skin diseases reported minimal or no stigma, meaning 73% experienced some degree of stigmatization.² Among all participants, 43.8% had at least moderate stigma scores, and 8.2% had high stigma scores.² Conditions associated with the highest stigma burden included hyperhidrosis, ichthyosis, epidermolysis bullosa, and hidradenitis suppurativa—the latter notable for involving lesions in areas typically concealed by clothing, illustrating that perceived stigma can occur even when disease is not visually apparent.²

Girls reported more stigma than boys (Cohen d = 0.26), and a history of bullying, as reported by parents, was strongly associated with worse stigma scores (Cohen d = −0.79).² Approximately 29.4% of parents reported awareness that their child had been bullied, primarily at school.² Bullying was also significantly associated with poor peer relationships, depression, and anxiety.²

Identity formation is especially relevant to this discussion given its developmental timing. As one study noted, identity formation is most malleable during childhood and adolescence: When children are attempting to understand who they are, they are being shaped by self-esteem and social perceptions, which can cause significant distress when compounded by a visible skin condition.⁴ Older pediatric patients with AD reported having fewer friends, participating in fewer social events and sports teams, and missing more school than their peers without AD.¹ Children with psoriasis similarly avoided physical activities and extracurricular sports, which may compound other comorbidities associated with psoriasis, including obesity, hypertension, and psychiatric disorders.¹

Psychiatric comorbidities: Depression, anxiety, and neurodevelopmental conditions

Mental health consequences in this population extend well beyond depression and suicidal ideation. A 2023 narrative review published in Pediatric Dermatology found that youth with AD are at increased risk not only for anxiety and depression but also for ADHD and ASD.³ The review identified sleep disturbance as the most consistently characterized mediating factor in the relationship between AD and psychological symptoms, with findings generally supporting sleep problems as a pathway through which AD contributes to mental health difficulties.³ There is also substantial evidence that child AD negatively affects parental mental health, and that parental mental health in turn influences child psychological functioning.³

In the 2024 JAMA Dermatology study, stigma correlated strongly with child-reported depression (Spearman ρ = 0.61) and moderately with anxiety (ρ = 0.54) and peer relationships (ρ = −0.49).² Stigma was also the strongest predictor of reduced quality of life across mental health domains (B = 1.05; 95% CI, 0.96-1.13) in a mixed-model regression analysis.² Children with hyperhidrosis and hidradenitis suppurativa had the highest percentages of moderate-to-severe depression scores (40.9% and 44.4%, respectively).²

For pediatric patients with psoriasis specifically, both anxiety and depression have been found at elevated rates, although the evidence base for this age group has lagged adult data. A 2023 review in Pediatric Dermatology called for routine psychological screening and intervention in dermatology practice, noting that children diagnosed at a younger age appear especially vulnerable due to less robust coping skills.⁴ A 2023 meta-analysis also found an increased risk for suicidal ideation specifically in the pediatric subgroup of patients with psoriasis (HR, 1.50; 95% CI, 1.12-2.03), a finding not seen when the analysis included all ages.⁵

Suicidal ideation and suicide risk

Suicidal ideation has been reported more frequently across all 3 conditions. A Norwegian study that included 3775 adolescents found that about one-quarter of participants with severe acne reported suicidal thoughts.¹ Investigators also observed that suicidal ideation occurred at rates more than twice as high among girls and 3 times as high among boys with severe acne compared with adolescents who had mild to moderate acne. A New Zealand survey of 9567 students aged 12 to 18 years found that reporting a serious acne problem was independently associated with both severe depressive and anxiety symptoms and a higher risk of suicide attempts—associations that persisted after controlling for depression and anxiety.¹

Among adolescents with AD, research involving 788,411 participants in South Korea showed that 19% reported suicidal thoughts, while 4.5% reported suicide attempts.¹ The analysis also identified female adolescents with AD who had distorted perceptions of their weight as being at the greatest risk for suicidal ideation, suicide planning, and suicide attempts (P < .001). Researchers proposed that elevated proinflammatory cytokine levels associated with AD—which may affect serotonin metabolism and neurotransmitter balance—may contribute biologically to suicidality beyond the effects of psychological distress alone.¹

Patients with severe psoriasis also face elevated risks. In one observational study, approximately 7% of patients with severe psoriasis had active suicidal ideation compared with 4% in the general population.¹ A retrospective cohort study in the United Kingdom found an increase in completed suicides among patients with psoriasis compared with controls (relative risk, 1.3; 95% CI, 1.0-1.8).¹ Proinflammatory cytokines involved in psoriasis may further worsen depression by overactivating the hypothalamic-pituitary-adrenal axis and disrupting serotonergic neurotransmitter levels.¹

Clinical implications and management

Despite the well-documented burden of disease, a significant gap remains between patient need and physician response. One review found that nearly 84% of patients with AD and their caregivers were unaware that support groups for these skin conditions existed, and 74% reported that their provider had never discussed the psychological impact of their disease.¹ Over 50% of patients with AD reported not discussing their quality of life with their physician and feeling unsupported by their provider.¹

The 2024 JAMA Dermatology study authors noted that physician assessment of disease severity and visibility alone is insufficient to capture the full disease burden: "Identifying stigmatization, including bullying, and tracking improvement through medical and psychosocial interventions may be a key role for practitioners."² The study's authors also emphasized that children as young as 8 years should self-report stigma, rather than having physicians rely solely on parental assessments, given that child- and proxy-reported stigma scores only moderately correlated with one another (ρ = 0.51).²

Validated tools are available to support screening. The Patient-Reported Outcomes Measurement Instrumentation System Pediatric Stigma-Skin tool, validated for children 8 years and older, can be completed in minutes during a routine clinical visit.² The CDLQI, the Infant Dermatitis Quality of Life Index, the Dermatitis Family Impact questionnaire, and the Childhood Atopic Dermatitis Impact Scale each assess different aspects of disease burden for patients and families, although none has yet been established as a gold-standard measure of long-term quality of life.¹

Recommended management strategies span clinical and psychosocial domains. Effective treatment of the underlying skin condition may reduce visibility-related stigmatization, although evidence is mixed on whether symptom improvement alone reduces bullying.¹ Physician-mediated interventions may include connecting patients with peer support groups or condition-specific online communities, referring patients to specialized camps for children with skin disorders, and employing shared decision-making approaches to increase treatment adherence and patient engagement.¹

Education-based interventions targeting teachers and school staff have also been proposed. School programs that train teachers to recognize the vulnerabilities of students with chronic skin conditions and teach others in the classroom about these diseases may help reduce stigmatizing environments.¹ For children with at least moderate stigma scores, the 2024 study's authors recommended active psychosocial interventions, which may include referral to psychiatry or psychology, discussions with school personnel, and structured group or family sessions to strengthen coping strategies, social relationships, and resilience.²

The authors of the reviewed studies uniformly note that no clear clinical guidelines currently exist for managing the long-term psychosocial comorbidities of pediatric dermatologic conditions. Multifaceted treatment focused on controlling physical symptoms alongside interventions to build resilience and positive self-perception may be the most effective approach to maintaining quality of life for this population over the long term.^1-4

References

1. Kelly KA, Balogh EA, Kaplan SG, Feldman SR. Skin disease in children: effects on quality of life, stigmatization, bullying, and suicide risk in pediatric acne, atopic dermatitis, and psoriasis patients. Children (Basel). 2021;8(11):1057. doi:10.3390/children8111057
2. Paller AS, Rangel SM, Chamlin SL, et al; Pediatric Dermatology Research Alliance. Stigmatization and mental health impact of chronic pediatric skin disorders. JAMA Dermatol. 2024;160(6):621-630. doi:10.1001/jamadermatol.2024.0594
3. Radtke S, Grossberg AL, Wan J. Mental health comorbidity in youth with atopic dermatitis: a narrative review of possible mechanisms. Pediatr Dermatol. 2023;40(6):977-982. doi:10.1111/pde.15410
4. Strouphauer E, Stolar A, Tollefson M. Manifestation of anxiety and depression among pediatric patients with psoriasis: a review. Pediatr Dermatol. 2023;40(1):11-18. doi:10.1111/pde.15185
5. Hung WK, Tung TH, Wang TY, Liao SC, Chi CC. Risk for incident suicidality among psoriasis patients: a systematic review and meta-analysis. Arch Dermatol Res. 2023;315(3):455-465. doi:10.1007/s00403-022-02377-5