Why skin shame matters more than symptoms in chronic skin conditions

By Hugo Francisco de SouzaReviewed by Susha Cheriyedath, M.Sc.Apr 22 2025

Shame about visible skin conditions may matter more than the condition itself. A major new study shows that skin shame is a top driver of poor mental health and low quality of life in people with eczema and psoriasis, more than anxiety or depression.

Study: Facets of shame and their impact on quality of life in patients with atopic dermatitis and psoriasis. Image Credit: sruilk / Shutterstock

In a recent study in the journal Scientific Reports, researchers investigated the associations between shame (skin and general) and psychopathological outcomes in patients with atopic dermatitis (AD) and psoriasis. The study comprised a cross-sectional online survey conducted on German-speaking patients (AD = 162 individuals, psoriasis = 251) and included several patient-reported metrics of shame, anxiety, depression, and quality of life (QoL).

Study findings

Study findings revealed that female patients and those with depression, anxiety, or lower self-reported QoL experience stronger sensations of shame than those without. Furthermore, while differences between AD and psoriasis patients were negligible, disease severity was found to be strongly correlated with adverse psychopathological outcomes. Self-assessed disease severity and skin shame were demonstrated to be the most important determinants of patient QoL, with skin shame contributing more strongly than depression or anxiety in regression models, though depression approached significance in psoriasis patients.

Background

Shame is a multifaceted, complex emotion wherein an individual desires to be ‘unseen’ due to self-perceptions of being inferior, worthless, or flawed. Shame can be studied through any of its several facets, which include cognitive shame (violation of personal or moral values), body shame (inadequacies in achieving perceived body ideals), or general shame (distress and psychopathology). “(Shame) is considered 'one of the most powerful, painful, and potentially destructive experiences known to humans' because it concerns the entire self. Shame is elicited during real or imagined social interactions, and plays a crucial role in psychosocial functioning.”

‘Skin shame’ is a subtype of body shame characterized by an individual considering their skin as flawed or unattractive. It is, hence, intrinsically associated with skin diseases, particularly those that cause visible defects or lesions in areas visible during social interactions. Unfortunately, research exploring the associations between shame and dermatological factors remains in its infancy, with prior study results remaining inconclusive, mainly due to insufficient sample sizes. Furthermore, correlations between skin shame and psychopathological outcomes such as depression and anxiety have yet to be formally investigated.

About the Study

The present study aims to address these gaps in the literature by explicitly evaluating: 1. Potential differences in how AD and psoriasis patients experience shame, 2. The relationship between skin shame and psychopathological outcomes (depression, general shame, and anxiety), and 3. The associations between shame and patients’ QoL.

Study participants were recruited through online surveys publicized on German support groups, offices, and self-help resources, as well as in involved departments. German-speaking adults who agreed to share their sociodemographic and skin-associated medical histories were included in the subsequent analyses.

Data collection was primarily questionnaire (survey) based and included the Shame Assessment for Multifarious Expressions of Shame (SHAME) questionnaire for the assessment of participants’ shame response to several scenarios, the Skin Shame Scale (SSS-24) questionnaire for evaluating participants’ skin-related shame experiences during the preceding week, and the Patient Health Questionnaire-4 (PHQ-4) for investigating participants’ depression and anxiety metrics.

Additionally, the Dermatology Life Quality Index (DLQI) questionnaire, the Patient-Oriented Eczema Measure (POEM), and the Psoriasis Symptoms and Signs Diary (PSSD) were used to evaluate patients’ self-assessed QoL and disease severity, respectively. To reduce potential bias, the study also calculated a modified DLQI score excluding an item explicitly referencing shame. Statistical analyses included χ²-tests for between-group categorical variable comparisons, Student’s t-test for continuous variables, Pearson’s correlation coefficients, and hierarchical linear regressions for assessing the degree of correlations between variables of interest and their impacts on outcomes of interest.

Study Findings

Of the 467 survey respondents, 54 were excluded due to insufficient data, leaving a final sample cohort of 413 participants (64.6% women, mean age = 43.0 yrs, 39.2% AD, 60.8% psoriasis). Study findings surprisingly revealed no statistical differences between AD and psoriasis patients across skin shame, depression, anxiety, or SHAME total scores.

Younger individuals and female patients were found to experience shame (particularly skin shame) more strongly than their older or male counterparts. Notably, existential shame (a facet of general shame) showed no association with age or sex, unlike other shame facets. Correlation analyses revealed strong correlations between skin shame and psychopathological outcomes (depression and anxiety). Notably, depression and anxiety were, in turn, strongly related to patient-reported QoL.

In AD patients, disease severity was found to strongly impact patients’ skin shame, anxiety, and depression scores, but the duration of the disease did not have any bearing on these outcomes. For psoriasis patients, disease duration showed a negative correlation with bodily shame, anxiety, and depression—longer durations were linked to lower levels of these outcomes, though this association was not significant in regression models.

Hierarchical linear regression models identified patient-reported skin disease severity and skin shame as the first and second most significant predictors of quality of life (QoL) in patients with atopic dermatitis (AD) and psoriasis, respectively. Skin shame’s explanatory power exceeded that of depression and anxiety, which were not significant predictors in most models. Disease duration, however, was not a significant predictor in either group when accounting for other variables.

“Pending replication, our findings hold important clinical implications. Assuming that skin shame is at least as relevant as depression and anxiety in both AD and psoriasis patients and substantially impacts their QoL, addressing this painful emotion through systematic screening within routine assessment might be beneficial. Moreover, psychosocial interventions to reduce shame may help to increase QoL.”

Conclusions

The present study finds strong associations between AD and psoriasis patients’ perceptions of disease severity and their psychopathological states (degree of anxiety and depression), with the latter, in turn, determining their overall QoL. These findings highlight the role of disease-caused skin shame as the second-most critical determinant of QoL, outpacing the effects of depression and anxiety in most cases.

“…adequately addressing shame might help to alleviate AD and psoriasis patients’ disease burden.”