More to Skin Than Meets the Eye: Bullying and Childhood Skin Conditions

Childhood bullying is a common occurrence and can have serious consequences on a child’s physical and mental health. Nearly 20% of students experience bullying at school, and an estimated 15% of high school students report being electronically bullied through texting and social media such as Instagram and Facebook.^1,2 Unfortunately, common skin conditions such as acne and atopic dermatitis (AD) leave children highly vulnerable to bullying. The visibility of skin lesions may place them at an increased risk of bullying as compared with children with other chronic childhood diseases. This was illustrated by a study that found that highly visible lesions on the face and arms of patients with vitiligo were associated with teasing and bullying, while body sites that are easily covered by clothing (eg, chest, abdomen) were not.³ Chronic illnesses, including skin conditions, are just one risk factor putting children at an increased risk for becoming a target of bullying. Other risk factors are listed in Table 1.⁴ An observational cross-sectional study of bullying in pediatric dermatology patients found that nearly half of patients had a positive bullying history, with acne, eczema, nevi, and alopecia areata being the most commonly identified skin diseases associated with bullying.⁵ Through personal interviews with patients, Magin et al⁶ found teasing and bullying to be common among patients with acne, AD, and psoriasis. These patients reported a number of negative psychological consequences, such as decreased self-esteem, secondary to these hurtful behaviors.⁶ Dermatologists must be able to recognize the potential for bullying in children with skin disease in order to provide holistic patient care. 

Types of Bullying
According to the Centers for Disease Control and Prevention, bullying is any unwanted, aggressive behavior by an individual child or adolescent or group of youth that is not comprised of siblings or current dating partners. The behavior must involve power imbalance and be repeated multiple times or be highly likely to be repeated.⁷ Bullying can be categorized into several types: physical (eg, hitting, kicking), verbal (eg, teasing, taunting, name calling), and indirect or relational (eg, rumor spreading, social exclusion).⁸ With the increased access to cell phones, computers, and tablets, cyberbullying is another type of bullying that has emerged in recent years. 

Bullying Due to Skin Conditions
Bullying and teasing have been associated with many medical conditions, but literature on bullying in children with skin conditions is limited. Skin conditions that have been associated with bullying include AD, psoriasis, alopecia areata, acne, scleroderma, congenital nevi, vitiligo, and vascular anomalies.^3,6,9-19 Although little data exists on the prevalence of bullying in children with skin conditions, a few disease-specific organizations have attempted to measure the scope of the problem. According to the National Eczema Association (NEA), one in five school-aged children experience bullying secondary to their skin condition.²⁰ A National Psoriasis Foundation (NPF) survey found that 44% of children have been bullied by their peers, and 38% of children reported that the abuse was a direct result of their skin disease.²¹ 

In general, verbal bullying is the most common type of bullying experienced by children.²² This also appears to be true regarding bullying related to skin disorders. In a study that looked at the quality of life in children with various skin conditions, verbal bullying was the most common type of bullying experienced by children overall.¹² In a qualitative study on children with AD, most children reported bullying in school and shared with the investigators that peers often laughed at their skin and used hurtful words such as virus, dirtiness, infectious diseases, garbage, waste, and ugliness.⁹ Verbal bullying is not limited to these types of deliberately negative comments. Magin et al⁶ found that even seemingly playful teasing experienced by patients with acne, psoriasis, and atopic eczema was hurtful and led to significant psychological and emotional sequelae.

The Importance of Early Screening
Bullying can have short-term and long-lasting effects on the physical and mental well-being of children. Bullied children are at an increased risk of psychosomatic problems such as headaches, abdominal pain, back pain, sleeping difficulties, appetite issues, bedwetting, skin problems, and vomiting.²³ Children who experience bullying are also at an increased risk of psychological sequelae including depression and anxiety disorders that may extend into adulthood. Copeland et al²⁴ showed that bullying during childhood was associated with an increased prevalence of agoraphobia, generalized anxiety, and panic disorder in adulthood. While having a skin condition may put children at an increased risk of bullying, it is important to acknowledge that having a chronic skin condition also inherently increases the risk of psychological sequelae. In a large observational study, pediatric patients with psoriasis were shown to have an approximately 25% to 30% greater risk of developing depression and/or anxiety compared with children without psoriasis.²⁵ Children in the United States with AD were also found to have an increased risk of depression and anxiety in a large cross-sectional study.²⁶ 

Early screening and identification of children who have experienced bullying are necessary in order to reduce its harmful consequences. In one study, only about 10% of pediatric dermatology patients with a positive bullying history had been asked about bullying by a medical professional in the past.⁵ While there are no evidence-based screening tools to identify bullying, simply starting the conversation may be the first step in screening a patient.²⁷ It is important for the clinician to address this topic as children will often not disclose this information on their own. A list of questions to help start the conversation is listed in Table 2.^4,27 In addition, parents of younger children can be asked if they have discussed bullying with their child or if they have observed that their child has been made fun of or picked on. They can also be asked about other red flags that may suggest that their child has been bullied such as physical symptoms as discussed above and changes in the child’s mood or behavior (eg, school avoidance). 

Tips on Management 
Once bullying has been identified, it is important for clinicians to take the time to listen to the family and to discuss the impact that it has had on the child. Some children may only need routine follow up at the dermatologist’s office, while others may need more frequent visits and regular care by their pediatrician. Other children may benefit from a referral to a pediatric psychologist or another mental health provider who can provide additional expertise and support. An interdisciplinary approach may optimize a child’s care by working with other clinicians, as well as school officials, counselors, and social workers.  

It is important for dermatologists to be aware of resources that may help their patients cope with bullying. A list of selected resources, including helpful websites and antibullying apps, is available in Tables 3 and 4. Providers can empower patients by educating children and their families on their skin disorder and by providing educational materials for schools.²⁸

One such resource is the Tools for School Kit created by the NEA, which was designed for teachers, parents, and students to learn more about AD.²⁹ A similar kit was created by the NPF for children with psoriasis.³⁰ Clinicians can also help patients by connecting them with other children who are dealing with the same condition. Such strategies can help children realize that they are not alone. A number of disease-specific face-to-face or online support groups exist that can help children connect with peers. A list of support organizations for childhood skin conditions is found in Table 5.³¹ Dermatologists may also refer patients to specialized summer camps for children with skin disorders. One such camp is Camp Discovery, which is sponsored by the American Academy of Dermatology and is offered in multiple locations throughout the summer.³²

Childhood bullying is common, and visible skin differences make children even more susceptible to this harmful behavior and its sequelae. Dermatologists can help limit these adverse effects by detecting bullying early, implementing effective interventions, and working closely with families, other clinicians including pediatricians and mental health providers, school officials, counselors, and social workers.

Dr Leszczynska is trained in pediatrics and is the current dermatology research fellow at Dell Medical School at the University of Texas in Austin. Dr Jaquez is a pediatric psychologist, director of the Psychosocial Program for the Children’s Blood and Cancer Center at Dell Children’s Medical Center of Central Texas in Austin, assistant professor of psychiatry at Dell Medical School at the University of Texas at Austin, and assistant clinical professor in the educational psychology department at the University of Texas at Austin. Dr Diaz is chief of pediatric dermatology at Dell Children’s Medical Center in Austin. She is also assistant professor of pediatrics and medicine (dermatology) and dermatology residency associate program director at Dell Medical School at the University of Texas in Austin.

Disclosure: The authors report no relevant financial relationships.

References
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