Skin is the largest and most visible organ in the body. Just as clear, glowing and unblemished skin elicits praise and attention, skin problems can provoke the reverse, with sufferers feeling shunned or judged by their appearance. No wonder conditions such as acne and psoriasis have been linked with depression and anxiety.
There's no denying that skin diseases can be ugly, itchy and confronting and the social stigma surrounding flawed skin still seems only just a step away from during the Middle Ages, when lepers were shunned and forced to don bells to warn of their approach.
The burden of having a skin condition remains heavy, regardless of age, gender or social status and, collectively, skin disease is the fourth greatest cause of the non-fatal global health burden.
Experts say it's time society realised the enormity of living with a skin problem and helped alleviate the physical and emotional toll by extending the afflicted and their carers a helping hand.
Three skin conditions - acne, fungal skin diseases, other skin and subcutaneous diseases - were in the top 10 most prevalent diseases worldwide in 2010, according to an analysis of their prevalence and impact, published in the Journal of Investigative Dermatology.
''Using more data than has been used previously, the burden due to these diseases is enormous in both high and low-income countries,'' say the study's authors.
''These results argue strongly to include skin disease prevention and treatment in future global health strategies as a matter of urgency.''
There are measures people can take to prevent sun damage, burns, cuts and rashes, but despite our best efforts to try to protect the body's largest organ, some damaging, life-changing skin conditions can't be cured.
Dermatologists say the stress on patients and their families of managing some skin conditions and the associated physical, psychological and social impact on their lives is huge.
Psoriasis patients have a 39 per cent increased risk of depression. Those with it in severe form have a 77 per cent increased risk and are at increased risk of anxiety and suicide, says the Australian National Psoriasis Foundation.
Irene Prantalos, 39, has psoriasis. She has suffered from the condition for 28 years since the first spot appeared at the age of 11. Her doctor initially gave her cortisone cream, but within five years psoriasis had covered her body and at times left her bedridden and hospitalised.
Prantalos, a Chinese medicine practitioner whose psoriasis is now more manageable, says she spent years wearing baggy clothes for comfort, and hats, trying not to be noticed.
Her family and friends were supportive but many others were bereft of empathy and teased her during her flare-ups. Adults, she says, were the worst.
Her hairdresser mother once ejected a client mid-hairdo from her salon when she made disparaging remarks about Irene's condition. While in high school, an administration staffer demanded she go home to ensure she didn't infect others with her (non-contagious) ailment.
''I have had people edge away from me,'' says Prantalos, who credits a part of her recovery to the Mediterranean diet which prompted her to pen a cookbook with her mother.
Paediatric dermatologist John Su concluded 17 years ago that families of children with moderate or severe eczema, a condition that is becoming more common, needed much more support given the profound social, personal, emotional and financial costs to families of coping with the common disease.
There are also other less prevalent skin conditions that cause some children to retreat from society. Some children require more than two hours a day of intense skin care before they are ready to leave the house.
Su says people with eczema could also be predisposed to other health problems, such as asthma and hay fever later in life as part of ''the atopic march''.
The burden of a skin condition such as eczema can also affect the choice of profession for some people, such as those with grass allergies, complicating outdoor careers and sporting activities.
Su is concerned about the increasingly unhelpful way young people in particular can feel judged and can judge others by the appearance of their skin.
''Some teachers don't understand skin conditions that well.
''I've had children with eczema, where, although their skin gets irritated by certain clothing, they have not been allowed to wear other clothes that would irritate their skin less. Or they haven't been given any time allowance to rinse off after swimming in a chlorinated pool, because it's considered that they should be just like all the other kids,'' Su says.
Many people spend more time choosing skin creams than using them, he says.
''Some children or parents become concerned with certain 'blemishes', but often whether it's a blemish or a beauty spot can depend a lot on the eye of the beholder.''
Dermatologist Dr Andrew Ming, of the Australasian College of Dermatologists, says patients still report being ostracised: one of his psoriasis patients recently asked for help so she could look good for summer because of the strong reaction she had when strangers spotted her skin.
''She said, 'When I get into the pool with my daughter to have lessons, people get out of the pool because they don't understand what it is and they think it must be something contagious','' says Ming.
''They think, 'Oh, skin rashes - gosh it must be contagious'.
''So not only does it look and feel bad, but people are shunned by their community, and the embarrassment and the social stigma attached to these are quite overwhelming for patients.''
Ming says he has teenage acne patients who are depressed by their appearance. Parents need to recognise the importance of seeking help early with their teenagers' acne to enable more time to control the condition, which is often simply viewed as a rite of passage of adolescence.
''[Some parents think] 'You've just got to suck it up with your pimples and deal with it as I did when I was a kid'.
''But you look at the parents and many of them are scarred,'' Ming says.
''We do know that there are good studies supporting that people with scarring and things like that have difficulties progressing in the workplace or achieving success in that crucial job interview.''
The condition vitiligo, or depigmented skin, is particularly troublesome for many of Ming's patients with darker skin. There is a significant social, cultural, emotional and psychological impact, particularly because the skin abnormality is more obvious, he says. ''How we perceive our own skin is often how we think others perceive our skin.''
It's vital for anyone with a skin condition to seek help early, just as they would with any other illness.
''There are a lot of conditions which, if treated early, can be controlled to a greater degree than when it's left too late.''
- Daily Life
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