Twenty-five years ago, a small group of doctors started the Association of Psycho-Cutaneous Medicine of North America (APMNA)—“psycho” meaning mind and “cutaneous” meaning skin. “The group was 15 percent mental health professionals and 85 percent dermatologists, and our purpose was to try to legitimize and quantify the link between mind and skin using a holistic approach,” says psychodermatologist Rick Fried, MD, based in Pennsylvania.
The tight-knit group—there are only 10 members in the U.S.—investigates not only the role that psychological issues and stress play in exacerbating skin conditions, but also the anxiety, depression and mental health concerns that can arise when people have those skin issues. “Many dermatologic conditions, such as eczema, acne, alopecia areata, psoriasis, and hyperhidrosis, are aggravated by emotional stressors. These same diseases can have a significant impact on the emotional health and well-being of those affected, and can lead to psychological disorders,” says Washington, D.C. dermatologist Tina Alster, MD, who refers her patients to psychologists or psychodermatologists for further care when necessary.
Former APMNA president Dr. Francisco Tausk, a psychodermatologist and professor at the University of Rochester, says there are very well-defined training courses for psychodermatology in Europe, but not in the United States. “There’s a lot more involvement from the medical community there,” he explains. “Here, we come to the specialty through many different avenues: some of us are psychiatrists, some psychologists, some dermatologists, but nobody has had specific training in psychodermatology.”
That was the case for John Koo, MD, a psychodermatologist and professor at University of California San Francisco, who was doing his psychiatry residency when he was repeatedly called up to the dermatology floor for consults. “Every time, the case was different in nature: someone who was stressed out and their eczema was out of control, or a teenager with psoriasis who was so depressed, they refused to go to school,” he says, expressing his fascination by the intersection of the specialties. And as it turns out, the two converge more than we think: “It’s been published that about 30 percent of patients who see a dermatologist have emotional issues that are related to their skin condition— all the way from mild stress to psychosis,” adds Dr. Tausk.
The Mind-Skin Connection
Though more research in this field is needed, there is undoubtedly a link between mind and skin. “Our skin and our brain come from the same embryological origin—there are nerves that get all the way to the top layers of our skin,” Dr. Tausk explains. “The very obvious example is how our skin flushes when we feel embarrassed.”
Though a blush appears instantaneously, Dr. Fried says that just as often, the mind-skin effects can be more delayed. “We used to think the skin was like Las Vegas: what happens there stays there. The chemicals in inflammatory skin conditions—the things that make acne red and swollen, eczema red and itchy, and psoriasis thick, red and scaly—we thought they stayed there,” he explains. “We now know they cross the bloodbrain barrier and get into the central nervous system where they can lower levels of neurotransmitters serotonin, norepinephrine and dopamine. When these levels get low, people are much more prone to depression and anxiety, and can have difficulty functioning or concentrating. This begs the question: Is living with an inflammatory skin condition associated with depression because living with the skin problem and how it feels and looks is depressing? Or is it because the inflammatory chemicals decrease neurotransmitters centrally? It’s probably both.”
One thing all inflammatory skin issues have in common is stress. “Stress is the biggest factor in the link between mind and skin, as it can increase inflammation and cause many things to become off balance in the body,” says Mara Weinstein Velez, MD, a psychodermatologist and assistant professor at University of Rochester. “Stress also increases cortisol levels, which can lead to increased sebum production, worsening conditions like acne and rosacea. It also triggers our skin’s inflammatory response, leading to flare-ups of skin rashes like psoriasis and eczema.” However, though most of the population suffers from significant stress, our bodies are not designed to deal with chronic stressors, which is why seeking professional help early on is key.
There are three main groups of psychodermatology patients, though the first two often overlap.
01 According to Dr. Weinstein Velez, the first group of patients are the ones who are stressed, which then causes their existing skin condition to worsen or a new skin condition to arise. “For example, stress can cause someone to break out into hives or have a psoriasis flare-up,” she explains.
02 The second group is those who have a skin condition first, like acne or eczema, which ultimately creates stress. “Visible skin issues that others can see may make the patient feel sad or depressed,” says Montclair, NJ dermatologist Jeanine Downie, MD. “Psoriasis, eczema and acne are all part of easily noticed dermatologic issues that can be linked to depression. Some patients who are prone to depression can become very agitated by even a slight breakout; others need to be reassured that they are non-contagious and will do well with proper skin maintenance.”
03 Lastly, there are patients with psychological issues who express their problem by being destructive to their skin or nails (dermatitis artefacta), or pulling out their hair (trichotillomania). “There’s also a condition called Morgellons where patients think they have parasites crawling in their skin, and this is the most difficult one to treat,” says Dr. Koo, who was featured in a Netflix documentary on the subject called Skin Deep.
Many of these conditions require collaborative efforts to treat, such as a combination of these therapies.
Both over-the-counter and prescription-based topicals are considered the entry point of treatment for many people with chronic skin conditions. We’re also seeing a trend of skin-care brands designed to address signs of stress on the skin. Dr. Tausk is a consultant for a newer line of products called LOUM, which, in clinical studies, proved to decrease the irritation and inflammation that is produced by the nerves that transmit the stress response. “There are also studies showing that topicals containing CBD oil can be helpful for certain skin diseases like eczema and acne, and I think it’s a very effective anti-inflammatory,” he says.
Mindfulness Meditation + Exercise
According to Dr. Fried, there is a ton of data showing that those who regularly practice mindfulness meditation have less psoriasis, less often. “We know concretely that it decreases the release of inflammatory chemicals in the body and you’re more likely to feel more comfortable in your skin,” he explains. “Sometimes you can just do square-box breathing for two minutes a day, and it’s amazing how gradually and meaningfully it can change how your skin functions.” Dr. Tausk also recommends MindfulnessBased Stress Reduction (MBSR) programs that combine meditation and yoga. “There are a lot of apps for these things these days—Headspace is a good one— but I still think in-person treatment is most effective,” he adds.
Dr. Tausk was trained in hypnosis during medical school, which is how he became interested in the field of psychodermatology after seeing the unbelievable effects of hypnotherapy on patients with skin conditions. “We published a paper more than 20 years ago on the effects of treating psoriasis with hypnosis and no other medication,” he says. “Those who were highly hypnotizable were clear or almost clear after treatment.” Dr. Fried also thinks hypnosis can be a very useful tool. “Data shows it can be helpful for relieving itch and uncomfortable sensations, hives, the blush-flush of rosacea, and other stress-related skin issues. But, it’s important to go to a licensed professional.”
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is another helpful form of treatment, however psychodermatologists generally aren’t trained in it and often refer their patients out to practicing psychologists. “The whole idea of CBT is very simple: People have certain pattern of thoughts, and those who are depressed, stressed or anxious are full of negative thoughts,” says Dr. Koo. “CBT helps them recognize their negative thoughts, as well as recognize that these thoughts are not necessarily the reality or the truth as they exist in the world.”
Psychodermatologists traditionally maintain a more holistic mindset with oral prescription medication being a last resort. However, Dr. Koo says “some medications are so powerful—the newer biologics like Talz for psoriasis—that they can clear the disease by themselves and then the patient is much less stressed, though that’s not the result for everyone.” Case in point: The wife of one of Dr. Fried’s male psoriasis patients told him she “got her husband back” after a month on Skyrizi medication. “He hadn’t even realized how much he’d withdrawn from his family,” says the doctor. Anxiolytics, antidepressants and antipsychotics are also utilized when necessary, and are often combined with counseling.