Scars from eczema and vitiligo run more than skin deep

I sighed as Mary walked out of the consultation room. Her sense of disappointment and low self-esteem were palpable in the silence of the room. Thirteen-year-old Mary (I am changing the names of my patients to protect their privacy) has been struggling with vitiligo for the last two years. She has gone through phototherapy, applied topical medications and taken oral supplements to treat her vitiligo.

Mary’s condition had improved but recently became active again, and she was feeling upset with the spreading patches. Her mother, who had accompanied her to the appointment, shared that Mary has been finding it difficult to adjust to secondary school life, as she is conscious about the white patches on her skin, especially on her face and hands. As a result, she has become more withdrawn and has also restricted her choice of co-curricular activity to an indoor option as she wants to avoid sun exposure.

This reminded me of another patient I had seen earlier in the day – nine-year-old John, who has severe atopic dermatitis (commonly known as eczema). He has just started treatment with a medication currently approved to treat moderate to severe eczema. When John came to see me a month ago, he was feeling extremely down due to his extensive weepy, red and itchy skin. Dark eye circles revealed that his sleep had been adversely affected by the eczema. John’s parents said he had not gone to school for the last three weeks as he could not concentrate in class, did not want rude stares from classmates and unkind comments from strangers on the bus.

As a dermatologist who has been seeing children and adults with skin conditions for over a decade, I often come across patients like Mary and John. Although afflicted with different skin conditions, both Mary’s and John’s mental health and well-being have suffered because of their highly visible skin disease.

In an era dominated by perfectly filtered social media feeds and sometimes excessive consumption of highly engaging influencer content, children and adolescents face unprecedented pressure regarding their appearance and body image. While this environment is challenging for any young person, it creates a compounded, invisible struggle for those living with visible skin conditions. These struggles are far from rare and chances are that most readers would know a child who is quietly dealing with them.

Skin conditions affect mental health

Eczema, one of the most common childhood skin conditions in Singapore, currently stands as the single most frequent diagnosis at KK Women’s and Children’s Hospital’s (KKH) paediatric dermatology clinic – a stark indicator of a growing public health issue. The overall prevalence of eczema in Singapore stands at 13.1 per cent. Many patients are diagnosed in infancy or in childhood, with the prevalence in Singapore school-going children aged seven to 12 years reported at 20.8 per cent. The condition is more prevalent in children (20.6 per cent) compared with adults (11.1 per cent).

Patients with eczema suffer from red, itchy, dry skin, which can affect any part of the body surface. Flare-ups can be triggered by dust, sweating, hot and humid weather, co-existing illnesses and stress. Eczema patients are three times more likely than others to develop depression and anxiety, driven by a never-ending cycle of persistent itch, poor sleep quality, limitations on daily activities and the stress of having to deal with visible skin conditions.

Vitiligo is an autoimmune condition where the body produces antibodies to attack the melanocytes (pigment cells) within the skin. It falls under a group of conditions known as pigmentary disorders – conditions that affect the colour of the skin. It is less common compared with eczema, with estimates suggesting that it affects 7.4 people per 1,000 population in Singapore. Crucially, half of all vitiligo cases begin before the age of 20, striking precisely during a young person’s most formative and vulnerable years.

In vitiligo, the patient develops white patches of skin, which may affect any body surface. The disease can be particularly noticeable in individuals with darker skin. Research consistently links vitiligo to severe mental health burdens. The condition can trigger psychosocial distress, depression, anxiety and social phobia, particularly among younger patients.

An under-recognised burden

For the young people suffering from such conditions, the mirror reflects not just a medical diagnosis, but a daily battleground for self-esteem. From a dermatologist’s perspective, treating the skin is only part of the management plan. In fact, visible skin conditions may be a significantly under-recognised contributor to youth mental health struggles – a matter that is already a growing national concern in Singapore. It has been reported that 30 per cent of chronic skin conditions are influenced by psychiatric disturbances. Many adolescents with visible skin disease also suffer from depression, anxiety and even suicidal tendencies.

In treating patients with such skin conditions, their mental health issues also need to be addressed. At KKH, patients with both skin issues and associated mental health concerns can be seen in a combined dermatology-psychology clinic.

The medical goal must shift from reactive to proactive. Treating skin conditions early and effectively is not just about aesthetics; it is also about improving the quality of life and about reducing the risk of severe mental health consequences later. Recognising how deeply a patient’s psychological state is being affected must be factored into the clinical urgency of the treatment plan.

A group of global experts in vitiligo recently signed a consensus statement recognising that a patient’s psychological distress must be factored into any assessment of the severity of the disease. This highlights the importance of not just treating the skin disease, but also the underlying psychosocial factors.

Breaking down the barriers to care

Several barriers hinder patients and their families from seeking treatment early. These include myths and misinformation accessed on websites with unfiltered content.

There is also the issue of social stigma, where shame and a lack of public understanding often cause families to hide or delay seeking treatment for conditions like vitiligo. We need more open and judgment-free conversations as well as public education to overcome these hurdles. Fortunately, in Singapore there is now a vitiligo patient support group as well as eczema patient support groups to help members journey safely together.

Lastly, there may be a lack of awareness on the advances in medicine, which have significantly altered the treatment landscape and meaningfully shifted treatment outcomes for eczema and vitiligo in the last few years.

Some of these medications are suitable even for very young patients. Dupilumab is approved to treat eczema in patients as young as six months old. Abrocitinib can be given from the age of 12 and eligible patients may be considered for government subsidies. Meanwhile, Ruxolitinib cream can be used on patients 12 years and older with generalised vitiligo. While it still requires special medical approval in Singapore for prescription, my team and I have seen promising results treating both adult and paediatric patients with it at KKH and Singapore General Hospital (SGH).

Importantly, care does not stop when a child grows up. The same specialist sees patients across the pigmentary disorders clinics at KKH and at SGH, ensuring that the relationship, history, and trust built over years carry forward seamlessly into adulthood – a continuity that matters deeply for conditions that are lifelong and deeply personal.

When it comes to intervention, waiting is not a neutral choice. Delaying treatment allows the condition to take a deeper, sometimes permanent toll on a child or adolescent’s confidence and psychological development. By understanding that help is available, acknowledging that these conditions are more than just skin deep, and responding to visible differences with compassion rather than judgment, we can reduce the mental burden of such visible skin conditions.

Mary and John have a tough battle to face. But I am confident we can make it easier for them to lead a better life.