Consistent with previous studies, we identified an increased risk of AUD with dermatologic disease mediated by depression and anxiety. We add to the literature by highlighting the additive effect of comorbid dermatologic and psychiatric disease on prevalence of AUD. Dermatologic disease is highly visible and patients often face societal stigma, discrimination, and prejudice.8 This stress is compounded by false beliefs and harmful stereotypes of personal attributes, such as poor hygiene, as reasons for developing dermatologic disease.9 For many patients, this psychosocial stress alone may confer a higher absolute risk for AUD.10 Our results demonstrated that this stress may be exacerbated in patients living with both dermatologic disease and comorbid depression and anxiety, as their odds of AUD were significantly higher than patients with just depression and anxiety alone.
The association between AUD and almost all of the studied dermatologic diseases was strongly mediated by depression and anxiety, except in HS. Despite this, patients with HS had the highest absolute risk for AUD and the lowest number needed to screen to identify AUD. One possible explanation is that HS is a disease that is not only psychosocially and visually burdensome, but physically burdensome, with patients reporting symptoms such as severe pain, malodour, and suppuration.11 As such, the pain associated with HS may play a larger role in the observed increased prevalence of AUD than psychological sequelae. In contrast to more visibly disfiguring diseases, such as acne or vitiligo, whose risk for AUD is greatly mediated by PD, the physical burden and pain associated with HS may play a larger role in in the observed increased prevalence of AUD.
Limitations and Future Directions
These findings must be interpreted in the context of the study design. First, objective EHR diagnostic coding was used to define AUD, rather than self-reported survey data, which is only available for a subset of AoURP participants. While there are limited studies that validate classification accuracy of ICD-9 and 10 coding for AUD,12,13 using ICD codes for case identification remains best practice. Next, this cross-sectional database does not include information on the temporality, severity, or treatment of the diagnoses investigated in this study. As such, we could not examine the sequence of dermatologic disease, depression and anxiety, and AUD, raising the potential for reverse causality. Lastly, only comorbid depression and anxiety were examined in this study. Data suggests that dermatologic disease may be associated with other psychiatric disorders, including post-traumatic stress symptoms and obsessive compulsive disorder, even after treatment success.14 Future studies should examine the role that other comorbid psychiatric conditions may play in the prevalence of AUD and other substance use disorders.