Stigmatizing attitudes towards facial psoriasis, atopic dermatitis, vitiligo and alopecia areata

Chronic skin diseases such as psoriasis, atopic dermatitis, alopecia areata and vitiligo are associated with significant psychological burden, especially when lesions affect visible areas.1 Social stigma may be internalized by patients as perceived stigma,2 impairing quality of life and predicting depressive symptoms. While 58.7%–90% of affected individuals report stigma,3 few studies have investigated the emotional and social responses of the general population. We conducted a 12-month prospective observational study. Adults without professional knowledge or personal/familial history of psoriasis, atopic dermatitis, vitiligo or alopecia areata, were consecutively enrolled. Participants viewed AI-generated facial images, representing the four diseases (Figure 1) and indicated which face (or none) elicited the strongest emotional response: compassion/pity, disgust, blame/disapproval/contempt and curiosity.4 Subsequently, participants completed a questionnaire pertaining to one randomly assigned condition, with items adapted from the Desire for Social Distance and Stereotype Endorsement Scales.5 Responses were recorded on a 5-point Likert scale, with lower scores reflecting greater stigma. The study was approved by the local ethics committee (Protocol 7261). A total of 598 participants were included (mean age 39.6 years, 58.4% female): 148 completed the questionnaire on psoriasis, 150 on vitiligo, 151 on alopecia areata and 149 on atopic dermatitis (Table 1). Compassion and curiosity were most frequently elicited by vitiligo (27.8% and 32.0%; p < 0.01 for both), aligning with reports that up to 90% of affected individuals are questioned about their appearance.6 Alopecia areata ranked second for compassion, possibly due to its association with chemotherapy-induced hair loss, which may trigger empathetic responses. Disgust and blame/disapproval/contempt were elicited mainly by psoriasis (22.3% and 17.9%; p < 0.01 for both), likely because scaling and erythema may be misinterpreted as signs of neglect. Social distance and stereotype endorsement scores indicated moderate acceptance (3.8 ± 1.2), while perceived attractiveness was low (2.7 ± 1.1). Atopic dermatitis scored lowest for willingness to live in close contact, while vitiligo scored highest (p = 0.033). Atopic dermatitis and psoriasis were perceived as more contagious and less hygienic (p = 0.009 and p = 0.051 respectively), fostering fear and avoidance behaviours. Overall, 15.9% expressed a desire for social distance (Likert 1–2), and 14.0% endorsed stigmatizing stereotypes. Using vitiligo as reference, multivariate analyses showed that psoriasis was rated more positively for friendship (p = 0.044), dating (p = 0.050), employment (p = 0.015) and social media presence (p = 0.017), but was rated more contagious (p = 0.034) and less mature (p = 0.045). Alopecia areata was more accepted in social media (p = 0.021) and dating (p = 0.029), likely reflecting its increased visibility online, contributing to greater familiarity and normalization. Atopic dermatitis was perceived as more employable (p = 0.044), yet less hygienic (p = 0.002) and more contagious (p = 0.003). Vitiligo was linked to stronger social and occupational stigma, consistent with reports that 35.9%–56.1% of people are unwilling to marry someone affected.7 Stereotypes concerning intelligence, maturity and trustworthiness appear to contribute to workplace stigma, as reflected in our study and previous reports.8 Older age among respondents was associated with higher stigma, consistent with previous literature,9 while younger generations, possibly due to social media exposure, were more likely to adopt inclusive attitudes. Male sex was associated with greater stigma, while higher education predicted increased social distancing, particularly regarding friendships and relationships (p < 0.009 and <0.006, respectively), in line with previous studies.4 Limitations include the single-centre design, potential influence of AI-generated images and possible response bias. Stigmatization is often fuelled by misinformation, highlighting the need for public health campaigns aimed at correcting misconceptions and promoting social inclusion for people living with chronic skin conditions. None. All the authors declare that they have no conflicts of interest relevant to this manuscript. The study was approved by the Local Ethical Committee (Protocol No.: 7261) and was conducted in accordance with the principles of the Declaration of Helsinki. Not applicable. The data that support the findings of this study are available from the corresponding author upon reasonable request.