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"Chronic cutaneous lupus erythematosus is prone to cause substantial disfigurement on visible skin, negatively impacting patients’ mental health and social life."
Stigmatization and social isolation may be associated with the development of depressive symptoms in patients with chronic cutaneous lupus erythematosus (CCLE). Early identification of isolation, coupled with public education, may reduce these symptoms, according to a study published in Lupus Science and Medicine.1
“CCLE is the largest subgroup, with conditions prone to cause substantial disfigurement on visible skin, negatively impacting patients’ mental health and social life,” investigators stated. “In patients with SLE, both cutaneous involvement and stigma were found to be associated with depression, and stigma has contributed to low self-esteem and isolation from social activities in this population.”
A cross-sectional assessment of patients with clinically diagnosed CCLE was performed using Patient-Reported Outcomes Measurement Information System (PROMIS) short-forms evaluating levels of depression, emotional support, physical health, and social isolation. The Neuro-QoL system assessed disease-related stigma. The Georgians Organized Against Lupus (GOAL) group recruited eligible patients from the Georgia Lupus Registry (GLR). Linear regression analyses determined the relationship between stigma and depression and the effect of isolation and emotional support on that association.
In total, 121 patients participated in the analysis, of which 87.6% were female, 85.1% were Black, the mean age was 54.1 years, and mean disease duration was 14.2 years. Of these patients, 30.6% (n = 37) reported moderate to severe depression (PROMIS Depression T-score ≥60).
Feelings of stigma were significantly associated with depression (b=0.77; 95% CI0.65 to 0.90) and social isolation was associated with both stigma (b=0.85; 95% CI 0.72 to 0.97) and depression (b=0.70; 95% CI0.58 to 0.92). After controlling for confounders, stigma continued to be associated with depression (b=0.44; 95% CI0.23 to 0.66). However, it lost significance when social isolation was added (b=0.40; 95% CI 0.19 to 0.62). The social isolation factor impacted 72% of the total effect of stigma on depression. Age, sex, race, and marital status did not differ significantly in patients with and without depression. Emotional support was inversely associated with depression in the univariate analysis.
The study was strengthened by extending the literature to focus on patients with CCLE and utilizing a largely Black cohort of patients, as previous studies involved mostly White patients. This is especially important as Black patients have a higher susceptibility to CCLE and present more noticeable ear and scalp dyspigmentation and scarring alopecia, which may lead to greater psychological impact. Investigators were able to perform a “real-world” assessment as patients were recruited from multiple sources. Additionally, this was the first study to provide evidence for psychosocial pathways to depression in this specific patient population.
However, the cross-sectional study design limited casual interpretation and the study relied on self-reported measures, which may have led to bias. Investigators were not able to clinically assess participants for skin activity and damage, which may impact depressive symptoms. Additionally, as patients where predominantly Black and from the Southeastern United States, results cannot be generalized to other populations. Future studies can help to provide context for understanding psychosocial pathways and mental health in this patient population.
“Our findings underscore the importance of increased clinical attention to diagnosis and management of depression among patients with CCLE as well as suggesting additional intervention points that might prevent depression from occurring,” investigators concluded. “Early identification of patients experiencing social isolation and social stigma, combined with effective interventions to address these factors could potentially prevent these patients from deeper social withdrawal and development of depression. Additionally, public health campaigns that raise awareness about these potentially disfiguring conditions may help to reduce the social stigma and mitigate the psychosocial impact of CCLE on affected individuals.”
Drenkard C, Theis KA, Daugherty TT, et al. Depression, stigma and social isolation: the psychosocial trifecta of primary chronic cutaneous lupus erythematosus, a cross-sectional and path analysis. Lupus Sci Med. 2022;9(1):e000697. doi:10.1136/lupus-2022-000697