Lesion visibility and localization as predictors of social appearance anxiety in Pemphigus vulgaris: a case–control study

Pemphigus vulgaris (PV), a chronic autoimmune blistering disorder, frequently affects highly visible regions such as the face, scalp, and upper body, potentially altering body image and increasing social appearance anxiety (SAA). The psychosocial pathways linking lesion visibility and localization to SAA, however, remain insufficiently examined. This analytical cross-sectional case�control study compared SAA levels between 150 PV patients with visible lesions and 150 age- and sex-matched controls, and explored associations between SAA and illness perception, anxiety, depression, self-esteem, and dermatology-specific quality of life. Participants completed the Social Appearance Anxiety Scale (SAAS), Hospital Anxiety and Depression Scale (HADS), Dermatology Life Quality Index (DLQI), Brief Illness Perception Questionnaire (B-IPQ), Rosenberg Self-Esteem Scale (RSES), and a Visual Analog Scale (VAS) for perceived severity. Group comparisons, Pearson correlations, one-way ANOVA by lesion visibility and location, and moderation analysis (PROCESS Model 1: HADS-A � VAS ? SAAS) were performed. PV patients demonstrated significantly higher SAA than controls (55.8?�?10.2 vs. 21.3?�?8.8; p?0.001). Within patients, SAA correlated positively with HADS-A, DLQI, and B-IPQ, and negatively with self-esteem. General anxiety moderated the relationship between perceived severity and SAA (interaction 0.18, p=0.006), indicating greater distress among highly anxious individuals. Lesion visibility showed a clear gradient, with face, scalp, and neck lesions producing the highest SAA (ANOVA F(3,146) = 8.02, p?0.001). Findings highlight lesion visibility and localization as key determinants of SAA in PV and suggest that integrating psychological screening into dermatologic care may help address elevated appearance-related distress.