Introduction

Seborrheic dermatitis (SD) is a chronic, relapsing skin disorder affecting sebaceous-rich areas such as the scalp, face, and chest. It affects approximately 1–3% of immunocompetent individuals and is associated with various risk factors including genetic predisposition, seasonal changes, and the proliferation of Malassezia species. Patients frequently report flares triggered by environmental and psychological factors, especially stress [1,2].

The pathogenesis of SD involves epidermal barrier dysfunction and sebaceous gland activity, which facilitate Malassezia overgrowth and skin inflammation. These mechanisms, in combination with psychological stressors, can contribute to disease onset and exacerbation [1,3,4].

Recent research has highlighted the role of stress-related neuroendocrine responses in skin disorders. In SD, stress may alter sebaceous gland activity and immune responses, aggravating clinical symptoms [5–8]. However, the psychological burden of SD, including anxiety and the influence of personality traits, remains underexplored despite the condition’s visibility and chronic course.

Personality structure, particularly the distinction between Type A and Type B traits, may influence how individuals perceive and cope with chronic illnesses. Type A individuals, who are more competitive and stress-prone, might be more vulnerable to anxiety, whereas Type B individuals tend to be more relaxed and resilient [9,10].

This study aims to investigate the relationship between SD severity, anxiety, personality traits, and quality of life. By examining these psychosocial dimensions together—using the Seborrheic Dermatitis Area and Severity Index (SDASI), the Beck Anxiety Inventory (BAI), the Bortner Personality Scale, and the Dermatology Life Quality Index (DLQI)—the study provides a more integrated understanding of SD’s impact. Unlike previous research, it uniquely incorporates personality assessment via the Bortner Scale to better inform holistic, patient-centered management approaches.

Materials and methods

This cross-sectional study comprised a total of 210 adult patients aged between 18 and 65 years who presented to the dermatology outpatient clinics of Ankara Etlik City Hospital between April 2024 and October 2024. Patients were included if they were 18 years or older and had a confirmed diagnosis of seborrheic dermatitis affecting the scalp, face, auricular and postauricular regions, chest, or back. Exclusion criteria included patients under the age of 18, pregnant women, and individuals with a history of psychiatric disorders. The study received ethical approval from the Ethics Committee for Scientific Research Evaluation at Ankara Etlik City Hospital (Reference number: AESH-BADEK-2024–218). All participants were informed about the study purpose and procedures, and provided written informed consent prior to participation. The study did not include minors. All procedures were conducted in accordance with the Declaration of Helsinki.

Results

1. Demographics and lifestyle factors

The demographic characteristics of the study participants are presented in Table 1. The Type A and Type B personality groups did not differ significantly in terms of age, gender, marital status, education level, occupation, BMI, smoking habits, or alcohol use (all p > 0.05).

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Table 1. Demographic features of the patient groups n = 210).

https://doi.org/10.1371/journal.pone.0331030.t001

2. Clinical characteristics

Table 2 summarizes the clinical features of seborrheic dermatitis in both personality groups. There were no statistically significant differences between Type A and Type B groups in terms of systemic comorbidities, symptom type, location of lesions, trigger factors, or seasonal pattern of the disease (p > 0.05).

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Table 2. Clinical features of the patient groups.

https://doi.org/10.1371/journal.pone.0331030.t002

As shown in Table 3, disease duration, continuous vs. episodic course, number of flare-ups per year, duration of flare-ups, SDASI score and severity categories, Physician Global Assessment scores, DLQI, BAI scores, and anxiety status distribution also did not differ significantly between personality groups (p > 0.05). Notably, 30.9% of our patients exhibited moderate-to-severe anxiety, highlighting a substantial psychological burden in the overall cohort.

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Table 3. Clinical features of the patient groups on seborrheic dermatitis.

https://doi.org/10.1371/journal.pone.0331030.t003

Discussion

This study investigated the relationship between psychological and personality factors, clinical severity, and perceived burden in SD, emphasizing the divergence between clinician-rated severity and patient-reported outcomes. Our findings support the multifactorial nature of SD, showing that objective clinical severity (SDASI) was not significantly associated with anxiety or personality traits, whereas perceived burden (DLQI) was moderately correlated with anxiety levels. This dissociation highlights the relevance of incorporating psychosocial parameters in the assessment of SD, as emotional distress may not be reflected in clinical evaluation alone.

The absence of significant associations between SDASI and psychological variables suggests that clinical severity in SD is likely driven by biological mechanisms such as sebaceous gland hyperactivity, immune dysregulation, and epidermal barrier impairment [1,7,13]. In contrast, the observed impact of anxiety on quality of life—independent of visible disease severity—is consistent with prior research indicating that patients’ psychological state substantially influences their perception of disease burden [14–16].

Our findings are also consistent with previous literature emphasizing the psychological impact of SD. Baş et al. (2015) reported elevated anxiety and depression levels and impaired emotional and social quality of life in SD patients, though they did not assess associations with disease severity [17]. Cömert et al., including a control group, found significantly higher anxiety prevalence in SD patients (32.5%) compared to healthy controls (12.6%), but no correlation with disease severity. Our results reflect this pattern, revealing no relationship between anxiety and SDASI, but a moderate correlation with DLQI, reinforcing the distinction between clinical observation and subjective burden.

Further supporting these observations, a recent meta-analysis reported clinically significant anxiety in 19% of SD patients—comparable to atopic dermatitis (21%) and acne vulgaris (30%) [18]. In our cohort, 30.9% of participants exhibited moderate-to-severe anxiety (BAI ≥ 16), exceeding the meta-analytic prevalence and closely paralleling the rate reported by Cömert et al [14]. Although our study did not include a control group, these comparisons underscore the substantial psychological burden associated with SD. By simultaneously evaluating clinical severity, psychological distress, and personality traits in a relatively large sample, our study contributes to a more comprehensive understanding of SD and reinforces the need for integrated psychosocial assessment in dermatological care.

In addition to anxiety, we examined personality traits, focusing on Type A vs. Type B behavioral patterns. No significant associations were found between personality and disease severity or quality of life. However, prior studies have indicated that certain Type A traits—especially hostility and urgency—may be linked to systemic inflammation and stress-related pathophysiology [19–21]. In contrast, non-hostile traits such as conscientiousness may offer protective effects [22,23]. Although no direct relationship was observed in our sample, the influence of personality on stress perception and coping strategies warrants further study in SD.

Our results also provide insights into environmental and temporal disease patterns. Most patients reported episodic rather than continuous disease courses, with 63.9% citing seasonal triggers, particularly during summer. This aligns with literature suggesting more frequent flare-ups in warm, humid climates [24]. While studies in tropical settings have described chronic-recurrent patterns [24,25], our findings suggest that environmental variability in continental climates may influence intermittent disease activity. Stress was identified as the most frequent exacerbating factor, emphasizing its dual role as both a psychological and physiological trigger.

The significant correlation between Physician Global Assessment and SDASI supports SDASI’s utility as a reliable measure of clinical severity. However, the weak correlation between SDASI and DLQI highlights the discrepancy between clinical evaluation and patient-perceived burden. Our findings support incorporating patient-reported outcomes such as the DLQI into routine dermatological assessment to ensure holistic and patient-centered care. Additionally, modest correlations of DLQI with female gender and seasonal sensitivity suggest that demographic and contextual factors may further modulate quality of life in SD.

This study has several limitations. First, its cross-sectional design prevents conclusions about causality between psychological factors and disease severity. Second, the sample was drawn from a single outpatient center, potentially limiting generalizability. Third, reliance on self-reported questionnaires may introduce response bias. While patients with diagnosed psychiatric disorders were excluded, unmeasured factors—such as socioeconomic status, lifestyle, and broader psychosocial context—were not assessed. Lastly, the absence of a control group limits direct comparison to the general population.

Conclusion

This study elucidates the multifactorial nature of seborrheic dermatitis, revealing that the condition is shaped by biological, psychological, and environmental influences. While clinical severity (SDASI) showed no significant associations with anxiety or personality traits, patient-perceived burden (DLQI) was moderately correlated with anxiety severity (Rho = 0.465, p < 0.001), highlighting the dissociation between physician-rated disease and patient experience. These findings underscore the importance of incorporating systematic psychosocial screening into SD management. Routine use of anxiety screening tools (e.g., BAI) alongside conventional clinical assessments may help identify patients in need of psychosocial support, improving patient-centered care. By concurrently evaluating clinical, psychological, and personality dimensions in a single SD cohort, this study contributes novel insights to the dermatological literature and reinforces the value of a multidimensional, biopsychosocial approach in managing chronic inflammatory skin conditions.

Supporting information