Pediatric Patients With Psoriasis: Mental Health Insights

In this feature interview, The Dermatologist met with Emily Renee Strouphauer to discuss her recent study, “Manifestation of Anxiety and Depression Among Pediatric Patients With Psoriasis: A Review.”¹

Emily Renee Strouphauer is a student associated with the school of medicine at Baylor College of Medicine in Houston, TX.

What are the associations between psoriasis and mental health disorders in pediatric patients and how do these compare with adults with psoriasis?

Psoriasis is a highly visible, chronic skin disease that has clear correlations with anxiety and depression for both adult and pediatric populations. In children and adolescents, research is limited, but current studies generally support a positive relationship between pediatric psoriasis and the onset of anxiety and depression. There have been large scale commercial claims database studies that have looked at the rates of anxiety and depression in children with and without psoriasis, although there's clear limitations to them, such as we can't measure causality and not everybody has health insurance. So, these studies leave several patients unrepresented, but they still show us that children with psoriasis are significantly more likely to have anxiety and depression compared with those without psoriasis. This is similar to what's seen in adults with psoriasis. Studies generally endorse that adults with psoriasis are 2 to 3 times more likely to develop depression compared with the general population.

The important distinction here is in the timing in which psoriasis presents alongside psychosocial development. So children and adolescents are particularly vulnerable to mental health consequences because they're in the midst of something called identity formation. And this is a longitudinal event, of course, but it's most malleable in childhood and adolescence. Identity formation basically has to do with how we establish a unique view of ourselves, and this is dependent on self-esteem, social perceptions, and negative evaluations from either ourselves or other people. Especially now, kids are constantly being exposed to ideal images in the media at a time when they're trying to discover who they are and what defines them. Psoriasis can certainly have a role in how a child perceives themselves or their outlook on life, which can manifest as anxiety and depression. And these judgements and perceptions are being formed at such a critical time and development that they can be harder to break.

How can physicians implement psychological screenings and interventions in their practice for pediatric patients with psoriasis?

There are several validated measurement tools with psychometric properties for pediatric patients. The Children’s Dermatology Quality of Life Index is useful for kids aged 4 to 16 roughly. There's also a cartoon version, which is fun, that can be given to kids on the younger age of that spectrum. It can be easily handed to patients during the visit to fill out, so it isn’t clinician administered. It's better than not addressing mental health, but the questions may not particularly resonate with every child. An even better idea would be allocating time during visits to talk to patients about how psoriasis is impacting their life. Especially with this being such a chronic condition, there's a great opportunity for providers to gain trust with their patients over time and be able to open these conversations more naturally.

There's no best way to have these conversations with kids. There's going to be some kids who are just an open book and will be very forthcoming with how they're feeling. Then there's going to be kids who are shyer. Tailor your approach based on your experiences with each patient. If you do identify a child or adolescent who you think has symptoms of anxiety or depression, it's important to thank them for being vulnerable. Remind them that psoriasis is not their fault. I think just that statement alone coming from a medical professional can take some of the guilt and shame away. You can also mention that many other kids with psoriasis feel frustrated, insecure, or sad. Validate those emotions and let them know you're on their team. Depending on your clinical judgment, you can always refer them to counseling, psychiatry, or other resources as necessary.

How can physicians work with caregivers in managing pediatric patients with mental health disorders associated with psoriasis?

Caregivers are a great resource for helping detect and manage mental health issues, especially in kids who are at a younger age and can’t really express or understand their emotions around psoriasis yet. Caregivers are the ones who are noticing changes in behaviors and mood, even if the child themselves isn't. The American Academy of Child and Adolescent Psychiatry webpage has so many great resources for parents of children who are struggling with anxiety, depression, bullying, or anything that has to do with a manifestation of having a skin disorder. There are discussions such as, how do I know what depression looks like in a child? What do I say to my child when they're feeling anxious? Clinicians can direct parents to these resources and then check in with the parents during each psoriasis visit to see how their child has been doing since the last visit. It can be hard for parents to see their child having to take on not only psoriasis, but also experiencing anxiety and depression because of it. Encouraging the parents as much as possible is important, too.

Are there any other insights you would like to share with your colleagues regarding anxiety and depression among pediatric patients with psoriasis?

Something I find incredibly special about dermatology is the fact that clinicians can change a child's life from the outside in. By managing and treating psoriasis the best you can, along with validating and supporting mental health, you can make such an impact on their quality of life, confidence, and well-being.

Reference
Strouphauer E, Stolar A, Tollefson M. Manifestation of anxiety and depression among pediatric patients with psoriasis: a review. Pediatr Dermatol. Published online November 13, 2022. doi:10.1111/pde.15185