As a generation, we’re more aware than ever of the numerous ways that stress can infringe on everything from our mind to our mood.
Again and again, stress is emerging as the inexplicable and (often) unsolvable trigger behind so many of the conditions we suffer from today. Inflammation caused by stress, can play out in our guts (stress is thought to be one of the main causes of IBS), our hair (stress has been pinpointed as a leading reason for hair loss), and our skin, where it’s been shown to be responsible for countless maladies including rashes, swelling and redness alongside established skin conditions like acne, psoriasis, eczema and rosacea.
The wellness industry has risen as an antidote to the uncertain and at times overwhelming world in which we live. But although, for many it can offer some comfort, it’s also been curbed by skepticism since it lacks the evidence-led, scientific and proven approach that modern medicine provides.
But an emerging field is seeking to address this. Psychodermatology has brought together the fields of psychology with dermatology to look at the affect of stress on our skin both holistically and analytically. We spoke to consultant dermatologist, Dr Alia Ahmed, who works as part of the psychodermatology team at the Royal Hospital of London and Dr Anthony Bewley of the British Association of Dermatologists, to help shed some light on how it can help.
What is psychodermatology?
“Psychodermatology is a discipline that combines dermatology, psychology and psychiatry. It specifically deals with people with skin conditions that are caused or made worse by feelings of stress (e.g. eczema, psoriasis, rosacea), as well as those skin problems that may have a psychiatric origin (e.g. skin picking, hair pulling, body dysmorphia) and those associated with psychiatric problems like depression and anxiety (e.g, alopecia areata, vitiligo),” says Dr Alia.
How does it approach skin conditions differently to how they’ve traditionally been treated?
“In psychodermatology the aim is to provide patients with a holistic approach to managing their skin, that takes into account the physical symptoms and also deals with the psychological effects on the individual and/or their loved ones. In practical terms this means that as well as providing treatment for skin problems, a psychodermatologist will spend time working out how much a person’s skin is affecting their quality of life, mood, work and relationships,” says Dr Alia.
“There are many people with chronic skin conditions that feel nobody understands what they are going through, a psychodermatologist can provide valuable support and help identify areas that may require treatment. This can be in the form of psychological support, psychological therapies (e.g. habit reversal therapy for people with eczema that are experiencing debilitating itch), or medication for clinical symptoms of depression and anxiety,” adds Dr Alia.
“We know that from a multidisciplinary approach, skin disease is more quickly and more comprehensively managed and less physical treatment is needed to get the same clinical benefit,” says Dr Andrew, “which means that it is cheaper in the long run.”
What studies have been done to establish a connection between the mind and our skin and what have these studies shown?
“The link between mind and skin is well established and can be explained at a biochemical level via the Hypothalamic Pituitary Adrenal (HPA) axis. Stress activates this system in the brain to release chemicals and hormones that can cause or drive skin disease. Studies have shown that stress can directly impact the skin barrier, increase the likelihood of skin infection and even cause skin dryness or redness, as well as itch and pain. There are a number of skin conditions that are linked with the mind, for example eczema, psoriasis, rosacea, and acne,” says Dr Alia.
Have you noticed more interest in the field of psychodermatology in recent years, if so, why? Is the boom in wellness behind it?
“Yes, definitely – from patients and the public,”says Dr Andrew. “There is a much stronger focus in recent years on psychological well-being, especially in those people that have chronic medical problems,” agrees Dr Alia. “This is a concept welcomed by psychodermatology. Psychological therapies and support are much more accessible (e.g. through apps), this makes managing psychological health more of a priority for both healthcare providers and patients,” she adds.
“The idea of ‘healthy mind, healthy body’ can be extended to include the skin. Psychodermatology supports evidence-based suggestions for lifestyle changes that can promote healthy skin. As people are more interested in their own bodies and the effect that their mind is having on their health, it is only natural that the most visible organ (i.e. the skin) should get more focus,” says Dr Alia.
Why is it an important field in skin health right now?
“Psychodermatology has always been important but there is a growing voice from patients about the importance of psychological wellbeing as well as the importance of skin wellbeing. The skin and the brain are closely linked through the nerves in the skin. Patients are often told that it is ‘only your skin’ and ‘just a skin disease’ and can feel very disempowered by those kind of statements,” explains Dr Andrew.
“Patients want to find ways of making sure their skin disease is taken seriously and not dismissed,” he adds. “There is a body of research showing that patients tell us that living with skin disease (for them) is as bad as living with cancer or heart disease. I have a patient with breast cancer and psoriasis and she says that she would rather live with cancer than live with psoriasis,” he explains.
“So, patients are increasingly demanding to have holistic patient-centric skin and general health management and that is why psychodermatology is so important.”
For those who are skeptical of mindfulness and mentions of “energy” and “chakras”, how is this field grounded in medicine and in proven efficacy?
“As with any medical treatment, the psychological treatments suggested by doctors should be grounded in evidence. There are studies that look at the effect of mindfulness-based stress reduction techniques in dermatology, and although some of the results are positive, more robust evidence and well-designed studies are required. The techniques of mindfulness that are offered by widely available apps (e.g. HeadSpace) may be useful for some individuals and I do advise their use if I feel it will benefit. There is no ‘one size fits all’ and some psychological therapies are more suited to one individual compared to another. It can take time to find the best approach,” explains Dr Alia.”
“All dermatologists will see inflammatory skin diseases such as eczema and dry skin. We know dermatologists are aware that any stress can lead to exacerbation of skin disease. Stress can be psychological in nature (such as relationship or work issues or moving house or bereavement), or can be physically related (such as sleeplessness, tiredness, overworking), or can be related to lifestyle (such as over use of alcohol or recreational drugs). We know that stress causes skin disease but also living with a skin disease can be very stressful,” says Dr Andrew.
What is the relationship between our mind and itching?
“We know that because the brain and the skin are very closely connected through the nerves in the skin, that itching is very debilitating. People who are itchy are very aware of the relentless irritation of the itch they experience. Also we know that stress can lead to increased itch. But we do know also that relaxation and mindfulness and medication can really help reduce itch (usually together with physical treatments such as medication aimed at switching off the cause of the itch),” explains Dr Andrew.
Does exercise make it better or worse?
“Certainly moderate exercise will really help with psychological wellbeing and also improves the function of the skin. Exercise will also help with the immune system within the skin and so moderate exercise is always a great way of helping with both skin and psychological distress,” says Dr Andrew.
What sort of treatments are recommended in psychodermatology and what would an appointment with a psychodermatologist roughly look like?
“When seeing a psychodermatologist, a person’s skin condition will be diagnosed by taking a thorough history and conducting investigations. In addition to this, time will be spent asking patients about how they are coping, including questions about mood, appetite, sleep, study, work and relationships. If it is felt that psychological distress is being expressed then this can be managed using a number of strategies,” says Dr Alia.
“The treatment for the skin disease can be creams, tablets, phototherapy or even injections. The treatment for the psychological distress can be relaxation techniques, mindfulness, meditation, seeking support from Counsellors or even medication for anxiety and depression,” explains Dr Andrew. “It is important as well to remember that patients are in control of their bodies and can use other techniques such as exercise and a good balanced diet with lots of fresh fruit and vegetables.”
“Sometimes it is enough for patients to be able to talk about how they are feeling to lead to a positive difference in their skin condition,” adds Dr Alia.
Can you get it on the NHS?
“Yes, although the availability of psychodermatology services across the UK is sporadic,” says Dr Andrew. “For example there are no psychodermatology clinics in Wales as far as we know, and if you are a child or an adolescent with need for psychodermatology provision there are very few clinics indeed where you can be seen.”
Where else can you seek help?
The Skin Support website was developed by the British Association of Dermatologists and set up to help people who are in emotional distress due to a skin condition. It provides a hub of information on various skin conditions as well as supplying self-help materials and support services.
Here are Dr Andrew’s top tips for a holistic approach to caring for your skin
- Do not suffer in silence. Always seek the help of the healthcare professionals.
- Do not be afraid to ask for what treatments are available including what treatments are available for psychological distress.
- Take time to look after yourself. Give yourself time for chilling out, relaxing or using mindfulness.
- Take moderate exercise.
- Make sure you allow yourself plenty of time to “come down” from a stressful day and get a good night’s sleep.
- Eat well with lots of fresh fruit and vegetables.
- Avoid not-so-helpful coping strategies such as alcohol.
- Talk about it to somebody else – that can be a family member or a trained Counsellor.