Mass quarantine measures in the time of COVID‐19 pandemic: psychosocial implications for chronic skin conditions and a call for qualitative studies

Dear Editor,

During the ongoing COVID‐19 pandemic, almost all European countries are adopting mass quarantine or isolation measures as a public health strategy to limit the spread of the contagion. Italy, as the first European country to be deeply affected by such pandemic, is currently approaching the fourth week of total lockdown, with restrictive measures on the population and profound challenge for the national health‐care system. Mass quarantine measures have been employed in the history of medicine to prevent the country‐wise spread of communicable diseases, including the severe acute respiratory syndromes and old plagues with cutaneous manifestations such as smallpox. ¹

The current quarantine/isolation condition represents a novel experience for the majority of the involved people, and it can contribute to cause relevant adverse psychological effects: quarantine/isolation measures have been associated with a range of psychopathological conditions including emotional exhaustion, irritability, anxiety, increased anger, and symptoms related to depression and post‐traumatic stress disorder (PTSD). ² Studies have suggested that health‐care workers represent an especially at‐risk population as they are exposed to highly sustained and intense emotional efforts during the pandemic. ² Notably, negative psychological sequelae of quarantine/isolation have been reported to occur for months after the events. ² , ³

The ongoing restrictive measures and emotional suffering related to COVID‐19 pandemic will potentially lead thousands of people to experience a decrease in socio‐economic status as well as to perceive increased levels of psychological stress. Notably, (i) the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM5) mentions psychosocial stressors among the risk factors for a range of conditions including depressive episodes, panic disorder and adjustment disorders, ⁴ (ii) severe symptoms caused by COVID‐19 infection may represent a life‐threatening condition potentially contributing to the development of PTSD or related disturbances, and (iii) psychological stress, PTSD, depressive and anxious disorders have been associated with the onset or worsening of several dermatologic disturbances, this being partially mediated by complex neuroendocrine modulations of inflammatory and related systems. ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰

Increased psychosocial stress, in fact, may have an impact on the course of many common ‘stress‐responsive’ skin conditions, such as psoriasis, atopic eczema, urticaria and chronic pruritus, as well as on healthy skin, as suggested by previous studies and by common dermatological wisdom. Stressful events have been long considered relevant triggers for the onset or recurrence of psoriasis, and stress can play a role in itch perception and in chronic pruritic conditions. ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ Inflammatory skin conditions have been associated with PTSD, and cutaneous symptoms have been reported to be predictors of the severity of such condition. ⁵ The importance of the brain–skin axis has been consistently underlined. ⁹ , ¹⁰

Such evidence raises the possibility that the sustained psychosocial stress induced by the current pandemic can potentially lead to exacerbations or onset of common inflammatory skin conditions (e.g. psoriasis, atopic eczema, urticaria and pruritic conditions) at the population level, both in the short term and after the resolution of the pandemic. National health‐care systems are currently undergoing major efforts to face the COVID‐19 outbreak, thus possibly resulting in a reduction of routine dermatological care for chronic conditions in the upcoming months. Increased use of teledermatology programs and of patient empowerment strategies should be encouraged to support the care of individuals with chronic inflammatory skin conditions.

As clinicians, we will soon have to deal with short‐term and long‐term psychosocial effects related to the COVID‐19 pandemic on patients with dermatological disorders. We support an ‘holistic’ management of skin diseases, and we encourage a comprehensive study of the complex implications of this pandemic for such patients.