Facets of shame are differently expressed in dermatological disease: a prospective observational study.

Dear Editor, Recent years have witnessed a growing interest in clinical research on the experience of shame and its associations with psychological functioning and well‐being.1 Shame is a self‐regulatory function of the body in adapting to the social environment, as well as maintaining and restoring self‐esteem and self‐acceptance.2 Feelings of shame have been reported to cause psychosocial restriction in patients with various dermatological diseases such as infection, or diseases with visible skin lesions like psoriasis or acne.3, 4 These have a significant impact on the individual's social interaction and well‐being.4

In a prospective single‐centre observational study, approved by the ethics committee of the Medical University Graz (30‐241 ex 17/18), we examined consecutive dermatological outpatients with a variety of diagnoses: psoriasis, tumours, inflammatory diseases, infections, allergic diseases and eczema. In total 296 individuals participated; 238 questionnaires were returned and the data from 201 were eligible for analysis. The mean ± SD age was 43·6 ± 17·7 years (range 23–80) and 113 were women (56·2%). The subjective burden of disease was assessed on a 10‐point scale.

The patients completed two questionnaires. (i) Skin Shame Scale (SSS‐24). This psychodermatological assessment captures an individual's burden of skin shame. It consists of 24 items, which have to be answered on a Likert scale (1–5 points).5, 6 (ii) SHAME (Shame Assessment scale for Multifarious Expression of shame). This questionnaire includes three subscales based on 21 items (bodily shame and cognitive shame as adaptive, and existential shame as pathological–dysfunctional shame), and a summary score. Answers are given on a six‐point Likert scale.2 For controls we used data from 488 individuals (of 597 participants eligible for analysis) without skin disease, mean ± SD age 38 ± 15·2 years (range 18–86), with 325 women (66·6%). These controls were recruited via an online survey at the Medical University Graz, or were hospital residents or related persons. The only difference between controls and dermatological patients was the higher educational level of the former.5

anovas and χ2‐tests, and ancovas (age as the control variable) were used for group comparisons. Tukey's honestly significant difference test was used for post hoc comparisons.

Patients with psoriasis, infection or eczema exhibited the highest skin shame levels (P < 0·001) (Table 1). However, there were no differences between the patients in regard to all other shame aspects. Skin shame was more pronounced in patients with visible skin lesions (P < 0·01) and a longer duration of disease (P < 0·05). Compared with controls without skin disease, dermatological patients had a higher level of skin shame (P < 0·001). Disease burden was highest for eczema and infection (eczema = infection > allergic = tumours; F = 3·55, P = 0·004, η2 = 0·09).

Table 1

Differences between various diseases regarding the aspects of shame, visibility of skin disease and duration of disease

Variable	Disease duration ≥ 5 years, n (%)b	Age (years)	SSS‐24 (score)	SHAME bodily	SHAME cognitive	SHAME existential	SHAME summary score
Total	61 (50)	43·5 ± 17·8	57·8 ± 18·0	2·60 ± 1·07	4·00 ± 1·18	1·84 ± 0·92	2·81 ± 0·81
P	30 (77)	47·9 ± 14·6	65·3 ± 17·6	2·42 ± 0·99	3·98 ± 1·19	1·69 ± 0·74	2·69 ± 0·76
T	7 (39)	51·7 ± 20·1	48·5 ± 15·1	2·47 ± 1·06	3·79 ± 1·37	1·90 ± 0·97	2·72 ± 0·83
ID	8 (36)	40·7 ± 18·5	65·1 ± 15·6	2·60 ± 1·09	4·09 ± 1·20	1·78 ± 0·93	2·83 ± 0·82
I	5 (29)	33·7 ± 14·7	53·6 ± 18·2	2·88 ± 1·13	4·24 ± 0·92	2·05 ± 1·09	3·05 ± 0·76
A	5 (45)	43·4 ± 15·1	48·9 ± 15·6	2·62 ± 0·98	3·96 ± 1·14	1·83 ± 0·81	2·81 ± 0·79
E	6 (38)	34·7 ± 15·6	62·6 ± 17·5	2·86 ± 1·20	4·04 ± 1·11	1·92 ± 1·14	2·94 ± 0·95
	χ2 = 17·8** , c	F = 5·88***	F = 8·29***	F = 0·43	F = 0·15	F = 0·71	F = 0·39
	P = 0·003	P = 0·001	P < 0·001	P > 0·05	P > 0·05	P > 0·05	P > 0·05
		η2 = 0·13d	η2 = 0·18e
Visible			61·6 ± 17·3	2·68 ± 1·10	4·06 ± 1·15	1·90 ± 1·01	2·88 ± 0·82
Invisible			53·1 ± 17·5	2·47 ± 0·99	3·92 ± 1·25	1·77± 0·75	2·72 ± 0·78
			F = 9·88**	F = 1·56	F = 0·59	F = 0·84	F = 1·64
			P = 0·002	P > 0·05	P > 0·05	P > 0·05	P > 0·05
			η2 = 0·05
< 5 yearsa			58·9 ± 17·8	2·64 ± 1·00	4·06 ± 1·11	1·86 ± 0·81	2·85 ± 0·72
≥ 5 yearsa			65·4 ± 16·4	2·50 ± 1·00	4·15 ± 1·18	1·68 ± 0·82	2·78 ± 0·77
			F = 4·42*	F = 0·55	F = 0·17	F = 1·53	F = 0·56
			P = 0·038	P > 0·05	P > 0·05	P > 0·05	P > 0·05
			η2 = 0·04
Patients			57·8 ± 18·0	2·60 ± 1·07	4·00 ± 1·18	1·84 ± 0·92	2·81 ± 0·82
Controls			44·6 ± 13·7	2·79 ± 1·03	4·24 ± 0·95	1·59 ± 0·68	2·87 ± 0·71
			F = 108·02***	F = 4·96	F = 7·94**	F = 15·94***	F = 0·97
			P < 0·001	P > 0·05	P = 0·003	P < 0·001	P > 0·05
			η2 = 0·14		η2 = 0·01	η2 = 0·02

The data are presented as the mean ± SD unless stated otherwise. SSS‐24, Skin Shame Scale; SHAME, Shame Assessment scale for Multifarious Expression of shame; A, allergic diseases (n = 27); E, eczema (n = 22), ID; inflammatory diseases (n = 35); I, infection (n = 27); P, psoriasis (n = 49); T, tumours (n = 41). aDisease duration. bMissing data for 78 individuals. c,d,ePost hoc (significant differences): cP > T = ID = E = I = A; dP = T > I = E; eP = E = ID > T = A. *P < 0·05, **P < 0·01, ***P < 0·001. The exact P‐value is stated for all significant comparisons (except for P < 0.001).

In summary, patients with psoriasis, inflammatory skin disease or eczema had especially high levels of skin shame, but the patient groups did not differ in other aspects of shame. Dermatological patients had a higher level of existential shame (P < 0·001), but lower cognitive shame (P < 0·01) compared with controls. This can be explained by the fact that patients develop denial and cognitive avoidance strategies, as described in those with acne.4 This aspect may also have played a role in patients with psoriasis, who had the highest skin shame score but the lowest SHAME summary score compared with the other patient groups. Furthermore, patients with psoriasis seem to develop a coping mechanism to protect themselves from stressful emotional responses by blocking the processing of disgusted facial expressions encountered in others.7

Disease persisting for > 5 years was associated with higher skin shame. Therefore, the prolonged burden of a disease, as well as visible skin lesions, may result in a fear of negative evaluation and feelings of disgust.7, 8 Rzepa et al. mentioned that, on a self‐reported questionnaire, genital lesions in sexually transmitted diseases, including HIV infection, produce more shame than lesions in patients with psoriasis.3 This questionnaire cannot be compared with the very specific skin shame questionnaire that was used in our study. We suggest that a variety of shame aspects may be involved, namely skin shame on visible areas and general shame in infections including sexually transmitted diseases. The number of patients was too small to draw final conclusions in this respect.

Shame may be regarded as an important aspect of the psychosocial burden of skin disease, and should be given special attention in the future. The results of these investigations will have further implications on future treatment strategies and are likely to improve health outcomes in dermatology patients.