Mental health has emerged as one of the major unresolved challenges in 21st-century medicine. According to the annual report of the Spanish National Health System published on August 5th, 2024, 34.3% of the general population presents some type of mental disorder, a figure that rises to 40% among individuals older than 50 years and up to 50% among those >85 years.1

This high prevalence becomes even more dramatic if we consider that 90% of completed suicides are associated with mental disorders. Even more so for dermatologists, when we know that dermatologic patients have a higher rate of such disorders.

Thus, a U.S. study2 showed that outpatients with skin diseases presented, during the last year of the study, a prevalence of emotional disorders 20% higher than the average population, while hospitalized patients showed rates 20–30% higher.

A similar Spanish study found that 23% of outpatients and 15% of hospitalized patients in dermatology departments presented greater psychiatric comorbidity than the rest of the population.3

Skin diseases, by directly affecting body image, constitute a privileged field from which to observe the relationship between the somatic and the psychic. During adolescence, visible diseases may shape withdrawn personalities or, at the opposite extreme, aggressive and antisocial behaviors. In adulthood, anxiety and depression are common. In all these cases, suicidality—a concept encompassing thoughts and ideas as well as suicidal plans and attempts—is present.

Completed suicide, the leading cause of death during adolescence and youth, should no longer be considered a field unrelated to our specialty. On the contrary, in this context, it is essential for dermatologists to recognize and address emotional suffering as an inherent part of clinical practice.

When faced with a nearby completed suicide, it is common to wonder why and for what purpose such a tragic act occurred. It is difficult to understand the motivation behind desiring and carrying out one's own voluntary death. Yet behind suicide there is always intense emotional suffering that the individual is unable to cope with, along with the desire to stop suffering.4 That is also the implicit plea of the patient who comes to consultation with a disease that causes shame, isolation, and social definition.

We believe that the skin diseases most frequently associated with suicidality are primary skin diseases—especially visible, chronic, or stigmatizing ones—systemic diseases with cutaneous signs, and psychiatric disorders with dermatologic signs. As an example of the first group, we can mention patients with psoriasis, who still today show suicidal ideation in 14% of cases.5 Regarding completed suicide in dermatology, according to a recently published meta-analysis,6 the leading cause is hidradenitis suppurativa.

Furthermore, drugs may have depression- and suicidal ideation – inducing effects. This role has long been recognized in glucocorticoids. Other drugs have gradually been added to the list, although in many cases with considerable uncertainty. The best-known controversy concerns isotretinoin. For years, debate has persisted regarding whether this drug may induce depression or suicidal ideation. The most recent evidence suggests that the relationship is stronger between acne itself and mood disorders than with the treatment per se.7 This is also our experience and conviction.

A similar situation occurs with 5-alpha-reductase inhibitors, mainly finasteride. The Agencia Española de Medicamentos y Productos Sanitarios reported in this regard that “cases of suicidal ideation have been reported in patients with androgenetic alopecia treated with finasteride.” However, it neither confirms nor denies causality in this relationship. Although some studies suggest that the disease per se—and not the drug—is the true risk factor, uncertainty persists and obliges dermatologists to maintain a delicate balance between therapeutic benefit and emotional safety. In our experience, and that of many dermatologists, this relationship has not been observed despite treating numerous patients with this profile. Nevertheless, as specialists, we must act prudently, without alarmism but also without denialism. We must inform honestly, assess antecedents, and properly document every conversation.

Recognizing warning signs through meticulous anamnesis is the first step: emotional symptoms such as persistent sadness, anhedonia, or feelings of guilt; physiologic symptoms such as insomnia and changes in eating habits; cognitive symptoms such as rumination, poor concentration, and decreased performance; and behavioral symptoms such as seeking solitude, substance use, or impulsive behavior must all be investigated and assessed.

When any of these signs are present, should we openly ask about suicidal ideation? Or would we be giving the patient ideas about carrying it out? Would this increase the nocebo effect? Our opinion, as well as that of many psychiatrists, is that we should ask about possible suicidal ideation. A subtle question may be preferable to a direct one. For example: “Some patients in situations like yours have had suicidal thoughts. Has this happened to you?” And if the answer is affirmative, action must be taken and, when appropriate, referral to the corresponding psychiatric unit should follow.

Furthermore, we must study the patient as a whole. Not only the disease, but the person: biography, environment, personal and family history, searching for evidence of anorexia, bulimia, body dysmorphic disorder, alcoholism, drug addiction, borderline personality disorder, gender dysphoria, bullying, sexual abuse, bipolar disorder, schizophrenia… and naturally, the presence of suicidality.

As Durkheim8 pointed out, suicide is inversely related to social integration. Thus, a disease that isolates the patient may become the trigger for their deepest suffering. The question we should ask ourselves is not only “What is happening to their skin?” but also “How does the patient feel living with this?” and “Who accompanies them?”

Nor can we ignore the fact that we practice within a strained health care system, where excessive workload limits consultation time. We know that 31.4% of physicians present burnout syndrome,9 which diminishes listening capacity, reduces empathy, and erodes the quality of care.

Given the importance of these figures, prevention is not an option but an ethical imperative that must begin by breaking the silence. “The greatest ally of suicide is silence,” accurately stated a report by the Fundación Española para la Prevención del Suicidio. However, when talking about “what we would rather not talk about,” it must be done with respect and fairness: we cannot turn the suicidal individual into a hero, because that makes them a model to follow, nor can we demean them, since the suffering of a suicidal individual is immense and cannot be trivialized or judged.

Prevention must be multifactorial and requires a collective effort. Collaboration with psychiatrists, pharmacists, nurses, social workers, and psychologists is essential.

Dermatologists must make this issue visible in our consultations, congresses, social media, and scientific publications. We must disseminate, inform, and accompany. This implies not only providing help-line numbers such as 024 or 112, but also offering rigorous and empathetic information about skin diseases. Scientific societies, accredited experts, and communication channels must be our allies in this task. Especially in a hyperconnected world, where social media may both generate harm and offer refuge, we must promote positive content, dismantle myths, and present real role models.10

An example in this regard is the Conscious Self-Compassion Program,11 consisting of mindfulness-based training that uses a combination of personal development and psychotherapy, delivered through an online platform in a sample of adults with chronic skin conditions and risk factors, with satisfactory results observed.

From an educational perspective, there is an urgent need to incorporate mental health and psychodermatology content into under- and postgraduate curricula. We need to train health care professionals in psychodermatology, provide emotional screening tools, and integrate mental health into medical student curricula. We also need to create safe spaces for healthcare professionals themselves, in which doubts, experiences, and strategies may be shared. We must not forget that we too are vulnerable.

Finally, values-based education, social equity, and inclusion are fundamental pillars for preventing emotional suffering and its tragic consequences. Perhaps we do not have all the answers, but we do have a clear responsibility: to look beyond the skin. As Viktor Frankl12—neurologist, psychiatrist, and Holocaust survivor—wrote: “He who finds meaning in life does not think about death.” Our mission, as dermatologists, is also to accompany the patient in that search.