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. 2025 Aug 26;20(8):e0331030. doi: 10.1371/journal.pone.0331030

The psychosocial dimensions of seborrheic dermatitis: A cross-sectional study on anxiety, personality, and quality of life

Gamze Taş Aygar 1,*, Hanife Karataş 1, Elif Kaya 1, Nur Şeyma Borazan 1, Selda Pelin Kartal 1
Editor: Ahmad Khalid Aalemi2
PMCID: PMC12380286  PMID: 40857256

Abstract

Background

Seborrheic dermatitis (SD) is a chronic inflammatory skin disorder that predominantly affects sebaceous gland-rich areas, such as the scalp, face, and chest. It is clinically characterized by erythematous plaques and scaling. Although its pathogenesis is multifactorial, involving genetic predisposition, microbial colonization, and environmental triggers, the psychosocial dimensions of SD remain insufficiently explored. Given the chronic and visible nature of the disease, psychological factors like anxiety and personality traits may shape patients’ perception of disease burden and their quality of life (QoL).

Objectives

This study aimed to assess the relationship between anxiety levels, personality traits, and the clinical severity and quality of life in patients with seborrheic dermatitis. By evaluating these dimensions together, the study seeks to better understand the psychosocial impact of SD.

Materials and methods

A cross-sectional study was conducted with 210 adult South Dakota patients. Disease severity was assessed using the Seborrheic Dermatitis Area and Severity Index (SDASI), while QoL was measured using the Dermatology Life Quality Index (DLQI). Anxiety was evaluated using the Beck Anxiety Inventory (BAI), and personality traits via the Bortner Personality Scale. Correlation analyses and regression models were employed.

Results

SDASI demonstrated a strong positive correlation with Physician Global Assessment (Rho = 0.815, p < 0.001), confirming its validity as a clinical severity tool. DLQI exhibited moderate positive correlations with both BAI and anxiety severity (Rho = 0.465 and Rho = 0.365, p < 0.001), indicating that anxiety substantially contributes to patient-perceived disease burden. In contrast, SDASI showed no significant associations with anxiety levels or personality traits (all p > 0.05), highlighting a dissociation between physician-rated severity and patient-reported quality of life. Weak correlations were observed between DLQI and female gender (Rho = 0.159, p = 0.011) as well as seasonality (Rho = 0.145, p = 0.018).

Conclusion

Seborrheic dermatitis imposes a significant psychosocial burden that is more strongly linked to anxiety than to objective clinical severity. Our findings underscore the importance of integrating routine psychological screening—such as BAI assessment—into SD management to identify patients at risk of diminished quality of life. This study contributes novel evidence by concurrently evaluating clinical, psychological, and personality dimensions, reinforcing the need for a multidimensional, patient-centered approach to chronic inflammatory skin disorders.

Introduction

Seborrheic dermatitis (SD) is a chronic, relapsing skin disorder affecting sebaceous-rich areas such as the scalp, face, and chest. It affects approximately 1–3% of immunocompetent individuals and is associated with various risk factors including genetic predisposition, seasonal changes, and the proliferation of Malassezia species. Patients frequently report flares triggered by environmental and psychological factors, especially stress [1,2].

The pathogenesis of SD involves epidermal barrier dysfunction and sebaceous gland activity, which facilitate Malassezia overgrowth and skin inflammation. These mechanisms, in combination with psychological stressors, can contribute to disease onset and exacerbation [1,3,4].

Recent research has highlighted the role of stress-related neuroendocrine responses in skin disorders. In SD, stress may alter sebaceous gland activity and immune responses, aggravating clinical symptoms [5–8]. However, the psychological burden of SD, including anxiety and the influence of personality traits, remains underexplored despite the condition’s visibility and chronic course.

Personality structure, particularly the distinction between Type A and Type B traits, may influence how individuals perceive and cope with chronic illnesses. Type A individuals, who are more competitive and stress-prone, might be more vulnerable to anxiety, whereas Type B individuals tend to be more relaxed and resilient [9,10].

This study aims to investigate the relationship between SD severity, anxiety, personality traits, and quality of life. By examining these psychosocial dimensions together—using the Seborrheic Dermatitis Area and Severity Index (SDASI), the Beck Anxiety Inventory (BAI), the Bortner Personality Scale, and the Dermatology Life Quality Index (DLQI)—the study provides a more integrated understanding of SD’s impact. Unlike previous research, it uniquely incorporates personality assessment via the Bortner Scale to better inform holistic, patient-centered management approaches.

Materials and methods

This cross-sectional study comprised a total of 210 adult patients aged between 18 and 65 years who presented to the dermatology outpatient clinics of Ankara Etlik City Hospital between April 2024 and October 2024. Patients were included if they were 18 years or older and had a confirmed diagnosis of seborrheic dermatitis affecting the scalp, face, auricular and postauricular regions, chest, or back. Exclusion criteria included patients under the age of 18, pregnant women, and individuals with a history of psychiatric disorders. The study received ethical approval from the Ethics Committee for Scientific Research Evaluation at Ankara Etlik City Hospital (Reference number: AESH-BADEK-2024–218). All participants were informed about the study purpose and procedures, and provided written informed consent prior to participation. The study did not include minors. All procedures were conducted in accordance with the Declaration of Helsinki.

Assessment tools

Seborrheic Dermatitis Area and Severity Index (SDASI):

SDASI was used to objectively evaluate the severity and extent of seborrheic dermatitis. The tool assesses disease severity based on erythema, scaling, and infiltration, scored on a scale of 0 (none) to 4 (very severe). Additionally, the percentage of the affected area was scored from 1 to 6, based on the extent of skin involvement. The total SDASI score is calculated by summing the severity and area scores, with scores categorized as mild (0–4.2), moderate (4.3–8.4), and severe (8.5–12.6).

Beck ANXIETY INVENTORY (BAI)

Anxiety levels were assessed using the Turkish version of the BAI, a validated self-report questionnaire [11]. The inventory consists of 21 items measuring physical and emotional manifestations of anxiety. Scores were categorized as mild (8–15), moderate (16–25), and severe (26–63). This tool provided valuable insights into the intensity and nature of anxiety symptoms in patients.

Bortner personality scale

Personality traits were evaluated using the Turkish version of the Bortner Personality Scale, which assesses Type A and Type B personality patterns [12]. The scale uses bipolar statements to measure behavioral tendencies related to stress, urgency, and competitiveness. A total score below 100 indicated a Type B personality, while scores above 100 reflected a Type A personality. The total score for each participant ranged from 21 to 168.

Statistical methods

All recorded data were analyzed using the Statistical Package for Social Sciences, version 27.0 (SPSS Inc., Armonk, NY, USA). The normality of numerical data distributions was assessed using the Kolmogorov–Smirnov and Shapiro–Wilk tests. Continuous variables with normal distribution were presented as mean ± standard deviation, while non-normally distributed variables were presented as median (interquartile range). Categorical variables were expressed as frequencies and percentages. The Mann–Whitney U test was used to compare two independent groups when the data did not follow a normal distribution. Pearson chi-square tests were employed to compare categorical variables (e.g., gender vs. SD severity). Due to the non-normal distribution of SDASI, DLQI, and other relevant psychometric scores (BAI, Bortner), Spearman’s rank correlation coefficient (Spearman’s rho) was used to assess the strength and direction of associations among these variables. Correlation strength was interpreted as follows: 0.00–0.19 = very weak; 0.20–0.39 = weak; 0.40–0.59 = moderate; 0.60–0.79 = strong; 0.80–1.00 = very strong. All statistical tests were two-tailed, and significance was set at p < 0.05.

Results

1. Demographics and lifestyle factors

The demographic characteristics of the study participants are presented in Table 1. The Type A and Type B personality groups did not differ significantly in terms of age, gender, marital status, education level, occupation, BMI, smoking habits, or alcohol use (all p > 0.05).

Table 1. Demographic features of the patient groups n = 210).

Type A personality (n = 128) Type B personality (n = 82) P
Age (median: IQR) 28.5 (14.0) 27.5 (18.0) 0.578
Gender (n/%) 0.451
 Female 63 (49.2) 36 (43.9)
 Male 65 (50.8) 46 (56.1)
Marital status (n/%) 0.339
 Single 65 (50.8) 47 (57.3)
 Married 61 (47.7) 32 (39.0)
 Widow 2 (1.6) 3 (3.7)
Education (n/%) 0.461
 Primary School 6 (4.7) 7 (8.5)
 Secondary School 30 (23.4) 16 (19.5)
 Bachelor’s Degree 92 (71.9) 59 (72.0)
Occupation (n/%) 0.839
 Non-working 4 (3.1) 2 (2.4)
 Officer 39 (30.5) 27 (32.9)
 Student 32 (25.0) 26 (31.7)
 Others 21 (16.4) 13 (15.9)
 Housewife 14 (10.9) 6 (7.3)
 Worker 9 (7.0) 5 (6.1)
 Retired 9 (7.0) 3 (3.7)
 BMI (median: IQR) 24.4 (5.0) 24.6 (5.1) 0.955
Weight status NA
 Normal weight 67 (52.3) 42 (51.2)
 Underweight 3 (2.3) 3 (3.7)
 Overweight 40 (31.3) 27 (32.9)
 Grade 1 obesity 13 (10.2) 7 (8.5)
 Grade 2 obesity 3 (2.3) 2 (2.4)
 Grade 3 obesity 2 (1.6) 1 (1.2)
Smoking (n/%) 0.161
 Non-smoker 74 (57.8) 58 (70.7)
 Smoker 46 (35.9) 21 (25.6)
 Gave-up smoking 8 (6.3) 3 (3.7)
Alcohol (n/%) 0.421
 Non-user 96 (75.0) 67 (81.7)
 User 31 (24.2) 15 (18.3)
 Gave-up alcohol 1 (0.8) –
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IQR: Interquartile range.

2. Clinical characteristics

Table 2 summarizes the clinical features of seborrheic dermatitis in both personality groups. There were no statistically significant differences between Type A and Type B groups in terms of systemic comorbidities, symptom type, location of lesions, trigger factors, or seasonal pattern of the disease (p > 0.05).

Table 2. Clinical features of the patient groups.

Type A personality (n = 128) Type B personality (n = 82) P
Systemic diseases (n/%) NA
 None 99 (77.3) 67 (81.7)
 Hypertension 2 (1.6) 4 (4.9)
 Hypo/hyperthyroidism 6 (4.7) 4 (4.9)
 Diabetes Mellitus 4 (3.1) –
 Inflammatory diseases 4 (3.1) 2 (2.4)
 Others 13 (10.2) 5 (6.1)
Erythema (n/%) 0.564
 Absent 28 (21.9) 13 (15.9)
 Mild 58 (45.3) 36 (43.9)
 Moderate 35 (27.3) 29 (35.4)
 Severe 7 (5.5) 4 (4.9)
 Very severe 0 (0.0) 0 (0.0)
Squamation (n/%) 0.344
 Absent 1 (0.8) 3 (3.7)
 Mild 54 (42.2) 31 (37.8)
 Moderate 57 (44.5) 34 (41.5)
 Severe 16 (12.5) 13 (15.9)
 Very severe 0 (0.0) 1 (1.2)
Infiltration (n/%) 0.207
 Absent 65 (50.8) 31 (37.8)
 Mild 39 (30.5) 36 (43.9)
 Moderate 16 (12.5) 11 (13.4)
 Severe 8 (6.3) 4 (4.9)
 Very severe 0 (0.0) 0 (0.0)
Symptoms 0.378
 Asymptomatic 11 (8.6) 8 (9.8)
 Itching 97 (75.8) 55 (67.1)
 Burning and stabbing pain 2 (1.6) 4 (4.9)
 Itching with burning and stabbing Pain 18 (14.1) 15 (18.3)
Location (n/%) NA
 Scalp 109 (85.2) 79 (96.3)
 Face 13 (10.2) 11 (13.4)
 Chest 0 (0.0) 4 (4.9)
 Ear 59 (46.1) 36 (43.9)
 Back 44 (34.4) 25 (30.5)
Triggers (n/%) NA
 None 4 (3.1) 7 (8.5)
 Menstruation 14 (10.9) 4 (4.9)
 Food 13 (10.2) 5 (6.1)
 Stress 116 (90.6) 65 (79.3)
 Humidity 13 (10.2) 7 (8.5)
 Cosmetics 16 (12.5) 16 (19.5)
 Sun 15 (11.7) 7 (8.5)
 Infection 4 (3.1) 4 (4.9)
Seasonal character 0.279
 None 50 (39.1) 26 (31.7)
 Spring 13 (10.2) 15 (18.3)
 Summer 40 (31.3) 26 (31.7)
 Autumn 17 (13.3) 12 (14.6)
 Winter 20 (15.6) 17 (20.7)
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As shown in Table 3, disease duration, continuous vs. episodic course, number of flare-ups per year, duration of flare-ups, SDASI score and severity categories, Physician Global Assessment scores, DLQI, BAI scores, and anxiety status distribution also did not differ significantly between personality groups (p > 0.05). Notably, 30.9% of our patients exhibited moderate-to-severe anxiety, highlighting a substantial psychological burden in the overall cohort.

Table 3. Clinical features of the patient groups on seborrheic dermatitis.

Type A personality (n = 128) Type B personality (n = 82) P
Duration of disease (years; median: IQR) 5.0 (8.0) 4.0 (4.3) 0.096
Continuous/Episodic 0.5
 Continuous 48 (37.5) 27 (32.9)
 With episodes 80 (62.5) 55 (67.1)
Number of episodes per year (median: IQR) 5.0 (6.0) 5.0 (6.0) 0.944
Dıration of attacks (days; median: IQR) 14.0 (23.0) 10.0 (23.0) 0.12
SDASI (median: IQR) 5.2(3.0) 5.4 (4.0) 0.735
SDASI groups (n/%) 0.94
 Mild 48 (37.5) 32 (39.0)
 Moderate 64 (50.0) 39 (47.6)
 Severe 16 (12.5) 11 (13.4)
Physician global assessment 0.646
 1 35 (27.3) 28 (34.1)
 2 66 (51.6) 34 (41.5)
 3 17 (13.3) 14 (17.1)
 4 9 (7.0) 5 (6.1)
 5 1 (0.8) 1 (1.2)
DLQI (median:IQR) 9.0 (8.0) 9.0 (8.0) 0.518
BAI (median:IQR) 9.0 (17.0) 9.0 (14.0) 0.281
Anxiety status (n/%) 0.204
 Mild 85 (66.4) 60 (73.2)
 Moderate 23 (18.0) 16 (19.5)
 Severe 20 (15.6) 6 (7.3)
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IQR: Interquartile range, SDASI: Seborrheic Dermatitis Area and Severity Index, DLQI: Dermatology Life Quality Index, BAI: Beck anxiety index.

3. Correlations between variables

A strong positive correlation was observed between SDASI and Physician Global Assessment (Rho = 0.815, p < 0.001), supporting the validity of SDASI in assessing disease severity. SDASI was weakly positively correlated with scalp involvement (Rho = 0.149, p = 0.031), duration of disease (Rho = 0.160, p = 0.010), continuous course of SD (Rho = 0.238, p < 0.001), and number of flare-ups per year (Rho = 0.235, p < 0.01).

DLQI was weakly positively correlated with Physician Global Assessment (Rho = 0.157, p = 0.011), female gender (Rho = 0.159, p = 0.011), and seasonal pattern (Rho = 0.145, p = 0.018).

4. Associations with SDASI and DLQI severity

There were no significant differences in anxiety level, BAI score, personality type, or Bortner score according to SDASI severity categories (p > 0.05). Similarly, DLQI scores did not differ significantly based on number or location of involved skin areas.

5. Anxiety and personality traits

Moderate positive correlations were found between DLQI and both BAI (Rho = 0.465, p < 0.001) and degree of anxiety (Rho = 0.365, p < 0.001), indicating that greater anxiety was associated with worse quality of life. However, SDASI was not significantly correlated with BAI, anxiety severity, or personality traits (all p > 0.05). Personality type also did not show a significant correlation with either SDASI or DLQI.

Discussion

This study investigated the relationship between psychological and personality factors, clinical severity, and perceived burden in SD, emphasizing the divergence between clinician-rated severity and patient-reported outcomes. Our findings support the multifactorial nature of SD, showing that objective clinical severity (SDASI) was not significantly associated with anxiety or personality traits, whereas perceived burden (DLQI) was moderately correlated with anxiety levels. This dissociation highlights the relevance of incorporating psychosocial parameters in the assessment of SD, as emotional distress may not be reflected in clinical evaluation alone.

The absence of significant associations between SDASI and psychological variables suggests that clinical severity in SD is likely driven by biological mechanisms such as sebaceous gland hyperactivity, immune dysregulation, and epidermal barrier impairment [1,7,13]. In contrast, the observed impact of anxiety on quality of life—independent of visible disease severity—is consistent with prior research indicating that patients’ psychological state substantially influences their perception of disease burden [14–16].

Our findings are also consistent with previous literature emphasizing the psychological impact of SD. Baş et al. (2015) reported elevated anxiety and depression levels and impaired emotional and social quality of life in SD patients, though they did not assess associations with disease severity [17]. Cömert et al., including a control group, found significantly higher anxiety prevalence in SD patients (32.5%) compared to healthy controls (12.6%), but no correlation with disease severity. Our results reflect this pattern, revealing no relationship between anxiety and SDASI, but a moderate correlation with DLQI, reinforcing the distinction between clinical observation and subjective burden.

Further supporting these observations, a recent meta-analysis reported clinically significant anxiety in 19% of SD patients—comparable to atopic dermatitis (21%) and acne vulgaris (30%) [18]. In our cohort, 30.9% of participants exhibited moderate-to-severe anxiety (BAI ≥ 16), exceeding the meta-analytic prevalence and closely paralleling the rate reported by Cömert et al [14]. Although our study did not include a control group, these comparisons underscore the substantial psychological burden associated with SD. By simultaneously evaluating clinical severity, psychological distress, and personality traits in a relatively large sample, our study contributes to a more comprehensive understanding of SD and reinforces the need for integrated psychosocial assessment in dermatological care.

In addition to anxiety, we examined personality traits, focusing on Type A vs. Type B behavioral patterns. No significant associations were found between personality and disease severity or quality of life. However, prior studies have indicated that certain Type A traits—especially hostility and urgency—may be linked to systemic inflammation and stress-related pathophysiology [19–21]. In contrast, non-hostile traits such as conscientiousness may offer protective effects [22,23]. Although no direct relationship was observed in our sample, the influence of personality on stress perception and coping strategies warrants further study in SD.

Our results also provide insights into environmental and temporal disease patterns. Most patients reported episodic rather than continuous disease courses, with 63.9% citing seasonal triggers, particularly during summer. This aligns with literature suggesting more frequent flare-ups in warm, humid climates [24]. While studies in tropical settings have described chronic-recurrent patterns [24,25], our findings suggest that environmental variability in continental climates may influence intermittent disease activity. Stress was identified as the most frequent exacerbating factor, emphasizing its dual role as both a psychological and physiological trigger.

The significant correlation between Physician Global Assessment and SDASI supports SDASI’s utility as a reliable measure of clinical severity. However, the weak correlation between SDASI and DLQI highlights the discrepancy between clinical evaluation and patient-perceived burden. Our findings support incorporating patient-reported outcomes such as the DLQI into routine dermatological assessment to ensure holistic and patient-centered care. Additionally, modest correlations of DLQI with female gender and seasonal sensitivity suggest that demographic and contextual factors may further modulate quality of life in SD.

This study has several limitations. First, its cross-sectional design prevents conclusions about causality between psychological factors and disease severity. Second, the sample was drawn from a single outpatient center, potentially limiting generalizability. Third, reliance on self-reported questionnaires may introduce response bias. While patients with diagnosed psychiatric disorders were excluded, unmeasured factors—such as socioeconomic status, lifestyle, and broader psychosocial context—were not assessed. Lastly, the absence of a control group limits direct comparison to the general population.

Conclusion

This study elucidates the multifactorial nature of seborrheic dermatitis, revealing that the condition is shaped by biological, psychological, and environmental influences. While clinical severity (SDASI) showed no significant associations with anxiety or personality traits, patient-perceived burden (DLQI) was moderately correlated with anxiety severity (Rho = 0.465, p < 0.001), highlighting the dissociation between physician-rated disease and patient experience. These findings underscore the importance of incorporating systematic psychosocial screening into SD management. Routine use of anxiety screening tools (e.g., BAI) alongside conventional clinical assessments may help identify patients in need of psychosocial support, improving patient-centered care. By concurrently evaluating clinical, psychological, and personality dimensions in a single SD cohort, this study contributes novel insights to the dermatological literature and reinforces the value of a multidimensional, biopsychosocial approach in managing chronic inflammatory skin conditions.

Supporting information

S1 File. Data.

(XLSX)

pone.0331030.s001.xlsx (75.1KB, xlsx)

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Ahmad Khalid Aalemi

15 Jul 2025

Dear Dr. taş aygar,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: N/A

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

Reviewer #1: Hello

The article has an interesting topic and various questionnaire tools have been used.

Just one important point is that in many cases there are other intervening factors that can be effective in the relationship between variables. Various factors such as gender, age, race, lifestyle conditions and other mental and social diseases.

Good luck.

Reviewer #2: Presented manuscript looks like an extension of the paper “Depression, Anxiety Levels and Quality of Life in Patients with Seborrheic Dermatitis. Turk J Dermatol 2015;9(4):181-185.” but with the use of alternative instruments and a higher number of involved patients.

The title of the present manuscript (The Psychosocial Dimensions of Seborrheic Dermatitis: Implications for Multidimensional Disease Management) should be changed as there is nothing about management in it.

Anxiety and QoL in patients with seborrheic dermatitis were well studied in multiple published articles and it is therefore especially important to underline what is new in the results of the presented manuscript.

Reviewer #3: The Abstract

• Include numerical data, such as correlation coefficients and p-values, in the abstract's results section.

• Recognize study limitations, such as cross-sectional design, lack of causation, and possible self-report bias.

• Consider clinical implications, such as routine anxiety screening in SD management.

The Introduction

• The introduction presents a comprehensive summary of seborrheic dermatitis, including biological, immunological, and psychological aspects, and clearly states the research goal.

• However, improvements are required in terms of language correctness, conciseness, and structural organization.

• The introduction contains instances of excessive detail. For example, the initial statement, "Seborrheic dermatitis (SD) is a chronic and recurrent skin disease that is widely prevalent…" is immediately followed by, "Seborrheic dermatitis (SD) is hypothesized to result from…," which unnecessarily introduces the same term in consecutive paragraphs.

• Define “EPB” once, then use the abbreviation consistently. Ensure all terms like DLQI, SDASI, BAI are introduced properly if appearing.

Materials and Methods

• Specify the categorical comparisons done using the "Pearson chi-square test," such as gender vs. severity.

• Explain why Spearman correlation (non-parametric) was chosen, such as "due to non-normal distribution of SDASI/DLQI scores."

Results

• Incorporate essential findings from tables into the narrative rather than depending solely on tables. The writers cite "Table 1," "Table 2," and so on, but there is no concise synopsis of what each table contains other than a sentence.

• Effect sizes are not interpreted. For example: "Rho =.365" It would help readers interpret the phrase "a moderate correlation." Consider using parentheses to provide uniform interpretation (e.g., mild, moderate, strong).

• Divide the section into subheadings and paragraphs, like:

Demographics and Lifestyle Factors

Clinical Characteristics

Correlations Between Variables

Associations with SDASI and DLQI Severity

Anxiety and Personality Traits

• There were no significant differences for these variables regarding SDASI (p > 0.05). Which variables exactly? Repeat them or summarize.

Discussion

• Divide the discussion into clear theme sections, such as:

Summary of key findings

Interpretation of psychosocial vs. clinical outcomes

Role of personality and anxiety

Seasonal and gender-related effects

Clinical implications

Limitations and future research

• Recommendation: Soften causal wording. Change "stress as the major cause" to "stress was frequently reported as a flare trigger."

• Some in-text references (e.g., "Cömert et al.") are not linked to a citation number or reference list.

Conclusion

• The multidimensional method is valid, but a brief example (e.g., psychological screening + clinical assessment) would improve comprehension.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

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PLoS One. 2025 Aug 26;20(8):e0331030. doi: 10.1371/journal.pone.0331030.r002

Author response to Decision Letter 1

21 Jul 2025

Response to Reviewers

We thank the reviewers and the editor for their careful reading and valuable feedback, which helped us improve the quality and clarity of the manuscript. Below, we provide point-by-point responses to each comment

Reviewer #1

We sincerely thank the reviewer for their valuable insights. To address the concerns raised, we have taken the following steps:

Comment 1:

The article has an interesting topic and various questionnaire tools have been used. Just one important point is that in many cases there are other intervening factors that can be effective in the relationship between variables. Various factors such as gender, age, race, lifestyle conditions and other mental and social diseases.

Response:

We sincerely thank the reviewer for their valuable insights. In response:

1. Demographic and environmental variables: We have revised the Discussion section (paragraph 6) to explicitly acknowledge that gender and seasonal variation were weakly but positively correlated with DLQI scores, suggesting they may independently affect perceived quality of life.

2. Confounding variables: We now highlight that, although psychiatric comorbidities were excluded, other psychosocial and lifestyle factors may influence results and should be explored in future research.

3. Study limitations: These considerations have been added to the final paragraph of the Discussion as study limitations, and we recommend that future studies use multivariate models and broader sampling to further clarify these relationships.

Reviewer #2

Comment 1:

“Presented manuscript looks like an extension of the paper ‘Depression, Anxiety Levels and Quality of Life in Patients with Seborrheic Dermatitis. Turk J Dermatol 2015;9(4):181–185.’ but with the use of alternative instruments and a higher number of involved patients.”

Response 1:

We thank the reviewer for this observation and for bringing attention to the 2015 study by Baş et al. While there are thematic overlaps regarding anxiety and quality of life in seborrheic dermatitis (SD), our study introduces several important distinctions that contribute novel insights:

• Psychological Focus: We utilized the Beck Anxiety Inventory (BAI) rather than HADS, providing a more detailed and widely used tool for anxiety measurement in dermatology.

• Personality Trait Analysis: The inclusion of the Bortner Personality Scale allowed us to examine Type A/B personality characteristics, which have not been previously studied in SD.

• Objective Clinical Severity: We included SDASI (Seborrheic Dermatitis Area and Severity Index) to assess physician-rated disease severity and analyze its association with patient-reported outcomes—a novel addition compared to prior research.

• Sample Size and Diversity: Our sample size was more than double that of the 2015 study, improving the robustness of correlation analyses and enabling exploration of demographic and environmental modifiers (e.g., seasonal variation).

• Conceptual Contribution: A key contribution of our study is the analysis of discordance between objective severity (SDASI) and perceived burden (DLQI), which is central to developing multidimensional care strategies.

We have clarified these contributions in the revised Introduction and Discussion sections to emphasize the novelty and added value of our research.

Comment 2:

“The title of the present manuscript (The Psychosocial Dimensions of Seborrheic Dermatitis: Implications for Multidimensional Disease Management) should be changed as there is nothing about management in it.”

Response 2:

We appreciate the reviewer’s suggestion regarding the manuscript title. To better reflect the content and focus of the study, we have revised the title to:

“The psychosocial dimensions of seborrheic dermatitis: A cross-sectional study on anxiety, personality, and quality of life”

This revised title avoids implying clinical management content while maintaining a clear summary of the study’s psychosocial scope.

Comment 3:

“Anxiety and QoL in patients with seborrheic dermatitis were well studied in multiple published articles and it is therefore especially important to underline what is new in the results of the presented manuscript.”

Response 3:

We thank the reviewer for this insightful comment. We fully acknowledge that anxiety and quality of life (QoL) in seborrheic dermatitis (SD) have been addressed in previous research, frequently using instruments such as the Hospital Anxiety and Depression Scale (HADS) or the Beck Anxiety Inventory (BAI). While our study also utilized the BAI, it differs in several key aspects.

First, to our knowledge, this is the first study to apply the Bortner Personality Scale in an SD population, allowing us to explore how Type A/B behavioral patterns relate to perceived disease burden. Second, our comparatively larger sample size strengthens statistical power and generalizability.

Furthermore, we employed both physician-rated severity (SDASI) and patient-reported impact (DLQI) to examine the divergence between clinical and subjective disease burden—an approach that enables a more multidimensional understanding. Additionally, we analyzed the influence of demographic and contextual variables (such as gender and seasonal variation), which have often been overlooked or only briefly mentioned in prior work.

For example, Baş et al. (2015) reported elevated anxiety and reduced QoL in SD patients, but their study did not evaluate disease severity or personality dimensions. By contrast, our study extends the literature by incorporating intersecting clinical, psychological, and environmental factors, offering a more integrative perspective on the psychosocial burden of SD.

Reviewer #3

Abstract

Comment 1:

Include numerical data, such as correlation coefficients and p-values, in the abstract's results section.

Response 1:

Done. We have added key correlation coefficients and p-values to the Results section of the Abstract. For example: “SDASI showed a strong positive correlation with Physician Global Assessment (Rho = 0.815, p < 0.001)… DLQI moderately correlated with BAI and anxiety severity (Rho = 0.465 and Rho = 0.365, both p < 0.001)

Comment 2:

Recognize study limitations, such as cross-sectional design, lack of causation, and possible self-report bias.

Response 2:

A sentence recognizing the study’s limitations, including its cross-sectional design and reliance on self-reported instruments, has been added to the end of the Abstract.

Comment 3:

Consider clinical implications, such as routine anxiety screening in SD management.

Response 3:

We revised the abstract's final sentence to emphasize the potential utility of routine anxiety screening in SD management.

Introduction

Comment 1:

The introduction presents a comprehensive summary of seborrheic dermatitis… However, improvements are required in terms of language correctness, conciseness, and structural organization.

Response 1:

1. We removed excessive anatomical/biological detail and redundant phrases.

2. Repetitions such as reintroducing SD across paragraphs were eliminated.

3. The structure has been revised to improve clarity and focus on the psychosocial framework.

Comment 2:

The introduction contains instances of excessive detail. For example… "Seborrheic dermatitis (SD) is..." repeated across paragraphs.

Response 2:

The repetition of the term "seborrheic dermatitis (SD)" across consecutive paragraphs has been eliminated.

Comment 3:

Define “EPB” once, then use the abbreviation consistently. Ensure all terms like DLQI, SDASI, BAI are introduced properly if appearing.

Response 3:

The reference to “EPB” was removed during simplification of the Introduction, as it was not essential for the study’s psychosocial focus. We added the following clarifying sentence at the end of the Introduction:

“This study aims to investigate the relationship between SD severity, anxiety, personality traits, and quality of life. By examining these psychosocial dimensions together—using the Seborrheic Dermatitis Area and Severity Index (SDASI), the Beck Anxiety Inventory (BAI), the Bortner Personality Scale, and the Dermatology Life Quality Index (DLQI)—the study provides a more integrated understanding of SD’s impact. Unlike previous research, it uniquely incorporates personality assessment via the Bortner Scale to better inform holistic, patient-centered management approaches.

Materials and Methods

Comment 1:

Specify the categorical comparisons done using the "Pearson chi-square test," such as gender vs. severity. Explain why Spearman correlation (non-parametric) was chosen, such as "due to non-normal distribution of SDASI/DLQI scores.

Response 1:

1. We now specify where the Pearson chi-square test was applied (e.g., gender vs. SD severity).

2. We explained the use of Spearman correlations due to the non-normal distribution of the continuous variables.

These changes appear in the revised “Statistical Methods” section.

Results

Comment 1:

Incorporate essential findings from tables into the narrative rather than depending solely on tables. The writers cite "Table 1," "Table 2," and so on, but there is no concise synopsis of what each table contains other than a sentence.

Response 1:

The Results section has been rewritten to integrate findings directly from the tables into the text, including values and statistical significance.

Comment 2:

Effect sizes are not interpreted. For example: "Rho =.365" It would help readers interpret the phrase "a moderate correlation." Consider using parentheses to provide uniform interpretation (e.g., mild, moderate, strong).

Response 2:

Correlation values now include interpretation descriptors (e.g., “moderate positive correlation”).

Comment 3:

Divide the section into subheadings and paragraphs, like:

Demographics and Lifestyle Factors

Clinical Characteristics

Correlations Between Variables

Associations with SDASI and DLQI Severity

Anxiety and Personality Traits

Response 3:

The Results section has been restructured under thematic subheadings:

1. Demographics and Lifestyle Factors

2. Clinical Characteristics

3. Correlations Between Variables

4. Associations with SDASI and DLQI Severity

5. Anxiety and Personality Traits

Comment 4:

There were no significant differences for these variables regarding SDASI (p > 0.05). Which variables exactly? Repeat them or summarize.

Response 4:

The Results section now specifies all tested variables and clearly states when no statistically significant differences were found.

Discussion

Comment 1:

Divide the discussion into clear theme sections, such as:

Summary of key findings

Interpretation of psychosocial vs. clinical outcomes

Role of personality and anxiety

Seasonal and gender-related effects

Clinical implications

Limitations and future research

Response 1:

We thoroughly revised the Discussion to include the following improvements:

1. Organized into clear thematic subtopics (e.g., main findings, psychosocial-clinical contrast, personality/anxiety, demographic effects, limitations).

2. Emphasized the divergence between objective disease severity (SDASI) and subjective burden (DLQI).

3. Discussed personality traits in the context of chronic inflammatory disorders with added references [17–21].

4. Replaced causal language with association-based interpretations.

5. Limitations such as cross-sectional design, lack of control group, and self-reported instruments were clearly stated.

6. Compared results with previous studies, particularly Cömert et al. [14] and Baş et al. [17], to emphasize novelty.

Comment 2:

Soften causal wording. Change "stress as the major cause" to "stress was frequently reported as a flare trigger.

Response 2:

All causal language has been replaced with association-based phrasing.

Comment 3:

Some in-text references are not linked to citation numbers.

Response 3:

All references now include corresponding numbered citations in the reference list.

Conclusion

Comment 1:

The multidimensional method is valid, but a brief example (e.g., psychological screening + clinical assessment) would improve comprehension.

Response 1:

The final sentence of the Conclusion has been revised to include a concrete example:

“…such as combining BAI-based anxiety evaluation with SDASI assessment in routine visits.”

Attachment

Submitted filename: Response to reviewers.docx

pone.0331030.s003.docx (32.3KB, docx)

Decision Letter 1

Ahmad Khalid Aalemi

31 Jul 2025

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Sep 14 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Ahmad Khalid Aalemi, M.D., M.Sc., Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Partly

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

Reviewer #3: Yes

**********

Reviewer #2: Conclusions should be rewritten. Conclusions of the abstract in its present form may be written without any study. Conclusions should be based on study results.

Authors mentioned in the Discussion section elevated levels of anxiety in SD patients from two other studies but did not compare their own results with the general population. It can be especially important to support authors' conclusions.

Finally, it is important to reflect the scientific novelty of the study in conclusions.

Reviewer #3: (No Response)

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #2: No

Reviewer #3: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org

PLoS One. 2025 Aug 26;20(8):e0331030. doi: 10.1371/journal.pone.0331030.r004

Author response to Decision Letter 2

1 Aug 2025

We thank the Academic Editor and the reviewers for their thoughtful and constructive feedback on our manuscript titled "The psychosocial dimensions of seborrheic dermatitis: A cross-sectional study on anxiety, personality, and quality of life" (Manuscript ID: PONE-D-25-15883R1). We have carefully addressed all comments and revised the manuscript accordingly. In particular, we have:

• Rewritten the Conclusions in both the Abstract and the main text to ensure they are directly grounded in our study results and reflect the scientific novelty of our work;

• Integrated comparative data from previous studies, including control group findings, to contextualize our results with respect to the general population;

• Added a reference to a recent meta-analysis (Chen et al., 2025) to further support the interpretation of our findings;

• Revised the Discussion section to improve clarity, flow, and emphasis on our study's contributions;

• Updated the reference list and re-numbered citations as needed.

Below, we provide a point-by-point response to each reviewer comment, including detailed explanations of all modifications made in the manuscript. We hope that the revised version meets the journal’s standards for publication.

Reviewer comment:

Conclusions should be rewritten. Conclusions of the abstract in its present form may be written without any study. Conclusions should be based on study results. Finally, it is important to reflect the scientific novelty of the study in conclusions.

Author response:

We thank the reviewer for this valuable comment. In accordance with the recommendation, we have completely rewritten the Conclusion sections in both the main text and the Abstract to ensure that they are clearly grounded in the results of our study and reflect the scientific novelty of our work.

Specifically:

1. Generic statements were removed and replaced with data-driven conclusions (e.g., the lack of correlation between SDASI and anxiety, and the moderate correlation between DLQI and anxiety; Rho = 0.465, p < 0.001).

2. We emphasized the dissociation between clinician-rated disease severity and patient-reported burden.

3. We highlighted the novelty of the study, noting that it is among the few to concurrently evaluate clinical, psychological, and personality factors in SD patients.

4. The implications for clinical practice were also clearly stated, including the potential utility of routine psychological screening.

The revised Conclusion (in manuscript) now reads as follows:

This study elucidates the multifactorial nature of seborrheic dermatitis, revealing that the condition is shaped by biological, psychological, and environmental influences. While clinical severity (SDASI) showed no significant associations with anxiety or personality traits, patient-perceived burden (DLQI) was moderately correlated with anxiety severity (Rho = 0.465, p < 0.001), highlighting the dissociation between physician-rated disease and patient experience. These findings underscore the importance of incorporating systematic psychosocial screening into SD management. Routine use of anxiety screening tools (e.g., BAI) alongside conventional clinical assessments may help identify patients in need of psychosocial support, improving patient-centered care. By concurrently evaluating clinical, psychological, and personality dimensions in a single SD cohort, this study contributes novel insights to the dermatological literature and reinforces the value of a multidimensional, biopsychosocial approach in managing chronic inflammatory skin conditions.

The Abstract results and conclusion was also rewritten as follows:

Results

SDASI demonstrated a strong positive correlation with Physician Global Assessment (Rho = 0.815, p < 0.001), confirming its validity as a clinical severity tool. DLQI exhibited moderate positive correlations with both BAI and anxiety severity (Rho = 0.465 and Rho = 0.365, p < 0.001), indicating that anxiety substantially contributes to patient-perceived disease burden. In contrast, SDASI showed no significant associations with anxiety levels or personality traits (all p > 0.05), highlighting a dissociation between physician-rated severity and patient-reported quality of life. Weak correlations were observed between DLQI and female gender (Rho = 0.159, p = 0.011) as well as seasonality (Rho = 0.145, p = 0.018).

Conclusion:

Seborrheic dermatitis imposes a significant psychosocial burden that is more strongly linked to anxiety than to objective clinical severity. Our findings underscore the importance of integrating routine psychological screening—such as BAI assessment—into SD management to identify patients at risk of diminished quality of life. This study contributes novel evidence by concurrently evaluating clinical, psychological, and personality dimensions, reinforcing the need for a multidimensional, patient-centered approach to chronic inflammatory skin disorders.

Reviewer comment:

Authors mentioned in the Discussion section elevated levels of anxiety in SD patients from two other studies but did not compare their own results with the general population. It can be especially important to support authors' conclusions.

Author response:

Thank you for this insightful comment. In response, we have revised the Discussion section to better contextualize our findings in relation to the general population. Specifically, we now reference the study by Cömert et al., which utilized a comparable methodology and reported an anxiety prevalence of 12.6% among healthy controls. In contrast, our cohort exhibited a markedly higher anxiety rate of 30.9%, reinforcing the notion that seborrheic dermatitis is associated with a disproportionate psychological burden.

Additionally, we incorporated the recent systematic review and meta-analysis by Chen et al. (2025), which reported a pooled anxiety prevalence of 19% and depressive symptoms in 21% of SD patients. This further strengthens the argument that the psychological impact of SD exceeds that observed in general or dermatological populations.

To improve overall clarity and cohesion, we also reorganized and edited several sentences in the Discussion. These changes help to better emphasize the novel aspects of our study—namely, the simultaneous evaluation of clinical severity, psychological symptoms, and personality traits.

We note that due to these additions, the reference list has been updated and re-numbered accordingly.

Relevant revision in Discussion section:

Cömert et al., including a control group, found significantly higher anxiety prevalence in SD patients (32.5%) compared to healthy controls (12.6%), but no correlation with disease severity. Our results reflect this pattern, revealing no relationship between anxiety and SDASI, but a moderate correlation with DLQI, reinforcing the distinction between clinical observation and subjective burden. Further supporting these observations, a recent meta-analysis reported clinically significant anxiety in 19% of SD patients—comparable to atopic dermatitis (21%) and acne vulgaris (30%) (18). In our cohort, 30.9% of participants exhibited moderate-to-severe anxiety (BAI ≥16), exceeding the meta-analytic prevalence and closely paralleling the rate reported by Cömert et al. (14). Although our study did not include a control group, these comparisons underscore the substantial psychological burden associated with SD. By simultaneously evaluating clinical severity, psychological distress, and personality traits in a relatively large sample, our study contributes to a more comprehensive understanding of SD and reinforces the need for integrated psychosocial assessment in dermatological care.

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Decision Letter 2

Ahmad Khalid Aalemi

11 Aug 2025

The psychosocial dimensions of seborrheic dermatitis: A cross-sectional study on anxiety, personality, and quality of life

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