What Is Psychodermatology, and Is it the Key to Stressed Skin?Well+Good

Ever notice that pimples often pop up during especially busy times at work? Or that you sometimes break out in a rash before a first date?  Or that when you’re super-stressed (like, say, during a global pandemic), your skin looks dull and discolored? Well, none of these things are coincidences. In the past 20 years, researchers in a young field of science called psychodermatology have found evidence to suggest that your skin is having a perfectly normal reaction, given the conditions it is under.

Psychodermatology lives at the intersection of psychiatry and dermatology, studying how one’s mental and emotional health relates to their skin, and vice versa. With only a handful of established clinics across the U.S., psychodermatology is still a fairly new concept in American skin care, which makes sense: When most people have skin issues, they make an appointment with a dermatologist, and when they have mental health concerns, they make an appointment with a licensed mental health practitioner—it’s rare that the two are working together.

But over the past few years, as the conversation around mental health has shifted to the forefront, so too has our awareness of its impact on our complexions—and psychodermatology has emerged to help us keep them clear. Keep reading for what you need to know.

Unpacking the connection between the brain and the skin

The brain-skin connection starts before we’re born. Our skin and central nervous system are created from the same cells in-utero, and remain physically connected with nerves and blood vessels throughout our lives, explains Amy Wechsler, MD, a board-certified psychiatrist and dermatologist and author of The Mind-Beauty Connection.

“We know there is a very complex interplay between the skin and the neuroendocrine systems,” echoes Evan Rieder, MD, a board-certified dermatologist and psychiatrist based in New York City. “But we are still working out the details on all of that.”

While there’s still a lot to learn about how these systems work together, one of the most well-studied areas of psychodermatology to date relates to stress, which is known to exacerbate certain skin conditions. When you’re stressed out, it pushes your body into fight or flight mode and triggers a burst of cortisol (aka the stress hormone), which sharpens your mind and boosts your energy so that you can better navigate the stressful situation. While a quick cortisol spike is okay, chronic stress can throw your baseline levels out of whack. When this happens and your cortisol is spiked for long periods of time, it can trigger a whole host of stress-related skin concerns.

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“The same hormones that prepare our bodies for stressful situations are also known to stimulate our oil glands. This leads to an increase in sebum production and inflammation, which translates to stress breakouts,” says Joshua Zeichner, MD, a board-certified dermatologist based in New York City.  “We know that stress has a significant impact on the skin, impairing skin barrier function, slowing wound healing, and worsening a variety of skin conditions, including acne and rosacea. Stress can also lead to facial flushing and rosacea, flares along with worsening of atopic dermatitis, including red, scaly, rashes and itching of the skin.”

From there, it becomes a vicious cycle. Your stress affects your skin, which affects your self-esteem (acne and eczema, for example, have been linked to increased instances of anxiety and depression), which in turn creates more stress.  “For better or worse, your skin can influence the way you feel about yourself and how you are willing to show up in the world,” says Jeshana Avent-Johnson, Psy.D, a licensed psychologist and advisor for Selfmade, a psychodermatology-based skin-care brand. “Not wanting to be seen physically can result in not wanting to be emotionally seen as well.”

Where psychodermatology comes in

Psychodermatologic conditions typically fall into one of three categories: psychophysiological, primary psychiatric, and secondary psychiatric. Psychophysiologic disorders are skin conditions that are worsened by stress (like eczema or acne, which respond to that cortisol spike mentioned above). Primary psychiatric disorders are skin conditions that are fundamentally psychological but have skin manifestations like trichotillomania, an hair-pulling disorder that falls under the obsessive compulsive umbrella. And secondary psychiatric disorders are skin conditions that start with the skin, but have profound psychological effects (like cystic acne and vitiligo). Though these conditions can have varying degrees of severity, it’s worth noting that making an appointment with a psychodermatologist isn’t incumbent on having a particularly difficult skin condition—even something as common as acne can benefit from this type of specialized treatment.

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So what does this “specialized treatment” look like in practice? Because skin and mental health are so closely connected, psychodermatology takes a two-pronged approach to address them both for optimal results. Unlike visiting a traditional dermatologist, a psychodermatology appointment will likely include an in-depth line of questioning about your lifestyle in addition to a skin check.

“If you come to see me about a rash, I am not just going to ask you about your skin,” says Dr. Wechsler. With every new patient, she makes sure to inquire about their sleep schedule, mood, relationships, and much more.

Making an appointment with a psychodermatologist isn’t incumbent on having a particularly difficult skin condition—even something as common as acne can benefit from this type of specialized approach.

As far as treatments go, Robert Tausk, MD, a board-certified dermatologist who specializes in psychodermatology and serves as an advisor for LOUM Beauty, describes the process as threefold. The first pillar includes comprehensive dermatological medical treatment, the second is all about stress reduction and lifestyle changes, and the third focuses on topical treatments to address the skin effects of stress. This means that standard care can include a mixture of traditional dermatological practices, like oral and topical medications, combined with psychological interventions, like talk therapy, meditations, support groups, and in some cases, hypnosis.

Should you see a psychodermatologist?

“If you are at a point where you’ve exhausted all medical options and your skin is still flaring, or maybe you’re having depression associated with the skin condition and it is affecting your quality of life, it’s time to think about what else is going on there and look at alternative treatments,” says Dr. Rieder.

For many patients, addressing skin conditions with a psychodermatological approach can be life-changing. “Patients who have a psychological component to their skin condition respond more quickly, more robustly, and in a more sustained way to a combination of dermatological treatment along with psychotherapy and possibly psychiatric medications that address the whole person,” says Josie Howard, MD, a San Francisco-based psychiatrist with expertise in psychodermatology,

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However, for the average patient, seeking out psychodermatologic care can be challenging. With only a few providers in the U.S. coupled with insurance difficulties, receiving this type of treatment is time-consuming and expensive.

“There are very few practitioners and limited training opportunities for physicians who are interested in the field,” said Dr. Howard. “Not to mention, there is also so much stigma around seeking mental health care.”

On top of that, “a lot of insurance companies do not pay for this type of treatment,” says Dr. Rieder, “It could be billed as a psychiatry or dermatology visit but with the amount of work required, a lot of people do not accept insurance in this field. If they did, they couldn’t afford to keep their business open.”

In the future, as the line between skin and mental health becomes increasingly central to the beauty conversation, there’s potential for psychodermatology treatments to become more accessible. “[Hopefully] there will be more mental health care providers working in dermatology offices for easy access to patients and better coordination of care between providers,” says Dr. Howard.

Until then, brands like Selfmade and Loum—which were founded with psychodermatologic principles at their center—are doing their part to give people the products and resources they need to deal with their stressed skin concerns at home. Although a serum or moisturizer can’t replace meeting with a professional, for those without access to psychodermatological care, they can help mitigate some of the impact of stress on the skin. Self-care practices that lower your stress levels can also help improve the condition of your complexion.

All’s to say, if you’re dealing with any of the above, know that you’re not alone, and that there are resources out there that can help.

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