gms | German Medical Science

Background and status of international research: Experiences of stigma and social rejection have been well-documented for people with visible skin disease, with misconceptions of being contagious or unhygienic. This social stigma (SS) can become internalized stigma (IS), where people adopt biases about their condition. Both stigma types have the potential to influence self-esteem, threaten individual and group identity, and have long-lasting effects on psychosocial functioning and health.

Research question and objective: A systematic review and meta-analysis was conducted to examine current evidence on the relationship of SS and IS with multiple adjustment indicators: psychological well-being, quality of life, physical health, social relationships, sexual functioning, and preventive health behaviors among adults with visible skin disease.

Method: Databases were searched for peer-reviewed articles that measured stigma and any indicator of adjustment. Native-speaking reviewers independently conducted screening and data extraction. Bivariate association between stigma and at least one indicator of psychological health (depression, anxiety, quality of life) were transformed to Fisher's Z values. Meta-analysis used a random effects model to examine these relationships. Narrative synthesis was conducted to evaluate connections between stigma with physical health, social and sexual well-being, and health behaviors, and to identify potential moderators.

Results: Search and screening yielded a final sample of 32 studies. Most were cross-sectional (97%), conducted in Europe (69%), with 31 articles written in English and 1 in German. Skin diseases included psoriasis (66%), vitiligo (19%), dermatitis/eczema (8%), acne vulgaris (3%), and rosacea (2%). Measures blended multiple types of stigma (59%), with no studies solely addressing internalized stigma. Narrative synthesis found that stigma was associated with greater psychological distress and lower perceived health; relationships with the other outcomes were more variable. Meta-analysis: Pooled effect sizes revealed that stigma was positively associated with depression (Fisher’s Z = 0.52) and anxiety (Fisher’s Z = 0.42), and negatively with quality of life (Fisher’s Z = -0.63, p’s < 0.01). Worse disease severity was linked with greater stigma, suggesting a contributing role.

Discussion: This is the first meta-analysis on the relation between skin disease stigma and psychological health outcomes. Greater stigma was associated with poorer psychological adjustment. Cross-sectional relationships were largely in the expected directions and would be strengthened with longitudinal studies.

Practical implications: Gaps in existing literature provides direction for future studies, suggesting that researchers explore social, sexual, or health behavior outcomes using improved stigma measurement to detect nuances in how SS or IS influence adjustment and health outcomes.

Appeal for practice: Current evidence presents insight into the extent to which the patient’s experience with skin disease stigma can lower functioning in domains beyond just that of mental health, suggesting stigma as a vital intervention target for providers.

Funding: Sonstige Förderung