Predictors and mechanisms of self-stigma in five chronic skin diseases: A systematic review

BackgroundPeople with skin disease suffer due to disease-related physical symptoms, as well as due to significant psychosocial burden. A major contributor of this burden is the experience of stigmatization. Research indicates that people with visible skin diseases deal with both social stigma and self-stigma.ObjectiveThis systematic literature review aimed to aggregate existing research on correlates and mechanisms that contribute to self-stigmatization among people with atopic dermatitis, psoriasis, vitiligo, alopecia areata or hidradenitis suppurativa and to, ultimately, identify targets for psychosocial interventions.MethodsThe review followed PRISMA guidelines. Four databases, PubMed, OVID, Web of Science and PsycINFO were searched for peer-reviewed articles. Studies were identified by two independent researchers and were eligible if they (1) assessed adults with one of five chronic skin diseases-atopic dermatitis, psoriasis, vitiligo, alopecia areata or hidradenitis suppurativa, (2) measured self-stigma or relevant synonyms, (3) evaluated psychosocial correlates, predictors or explanatory mechanisms of self-stigma and (4) were published in German or English in a peer-reviewed journal. The Johanna Briggs Institute Checklist for Analytical Cross Sectional Studies was used to evaluate the quality of studies.ResultsTwenty-seven studies were included with a mean quality rating of 7.04 (out of 8). Social stigma, coping strategies (such as lack of acceptance) and lack of social support were identified as main predictors of self-stigma. Although study quality was good, all but one study had a cross-sectional design that does not allow examining causal relationships among the determinants of self-stigma.ConclusionsFindings from the present review revealed several psychosocial variables that are malleable and potentially suitable as intervention targets. Those variables such as acceptance should be targeted in evidence-based interventions specifically developed to reduce self-stigma to, ultimately, improve mental health of people affected. Along with experiencing stigmatization in social contexts, individuals with visible chronic skin disease often deal with self-stigma. The graphical abstract depicts an adapted model from Germain and colleagues (2021) and highlights correlates, predictors and outcomes associated with self-stigma for people with atopic dermatitis, psoriasis, vitiligo, alopecia areata or hidradenitis suppurativa according to the present systematic literature review of 27 included studies. Study quality ratings were good although majority of the reviewed studies were cross-sectional and causal inferences could not be made. Psychosocial correlates to self-stigmatization with supporting evidence in both Germain and colleagues' (2021) model and the current review were noted with an asterisk (*), whereas additional correlates found in our review were emphasized in red text. Several psychosocial correlates were considered modifiable, such as social stigma, coping strategies and social support, and therefore potential targets for psychosocial interventions (highlighted in green and pathways depicted with solid green lines), while others were not (depicted with dashed grey lines). The figure also identifies measurable outcomes (highlighted in blue) for future interventions.image