SELF recently posted an article about the hidden mental health effects of eczema. How should dermatology clinicians approach their eczema patients about the mental impacts of this skin condition? When should a dermatologist refer to a mental health professional?
For expert advice, I reached out to dermatologist and clinical psychologist Richard Fried, MD, PhD, clinical director of Yardley Dermatology Associates and Yardley Clinical Research Associates in Yardley, PA.
What mental health symptoms do you commonly see in your eczema patients?
I commonly see anxiety, depression and obsession where thinking about their eczema is consuming a great deal of patients’ emotional and physical time. In the extreme, I sometimes see confusion or even suspicions of infestation. One of the most common trigger events for eczema is stress. Eczema can be stressful itself and it can worsen or have its onset because of stress. Eczema has a self-perpetuating cycle that’s important to recognize. The better we can minimize itch and decrease visible eczema, the less stress the person has. And, as the stress reduces, whatever treatment we are working with will likely work better.
Are these symptoms related to or independent from the physical effects of eczema?
Both. We can have people who look pretty good — all you see is a minimal amount of red — but the psychological impact can be devastating. We can also see people with severe disease who aren’t happy but their psychological impact can be minimal. Just because you have a low EASI (Eczema Area and Severity Index) doesn’t tell you diddly squat about how they are feeling about it. When it comes to psychological impact, there is only one opinion that matters and it’s the owner. If I have eczema and I’m doing OK, that doesn’t tell us anything about how I will feel tonight or tomorrow because eczema is a fluid state.
Do mental health struggles, in turn, impact eczema flares?
Yes, but not always in a predictable way. Sometimes people can be under enormous stress and it does not seem to worsen their eczema. Sometimes they are feeling better and the eczema can flare. We know when under stress we are more likely to release pro-inflammatory cytokines that can make the skin look and feel worse. Statistically speaking, the better the person can manage their stress and the less stressful their environment is, the more likely their eczema will be better. For eczema, psoriasis and acne, there is a tendency for blame, which is hurtful to the patient and also increases stress so the patient doesn’t have the energy to care for their skin condition.
How do you approach mental health concerns with your eczema patients? What questions do you ask to determine to what extent, if any, eczema is impacting a patient’s mental health?
I like to first validate a sense of reality and understanding that living with eczema can be very difficult. I often say, “I take eczema seriously. It is a difficult and capricious or unpredictable condition to live with. There is always a sense of impending doom. You can’t predict how you will feel. Skin will often flare the time we can least afford it to flare.”
I then ask my eczema patients, “How much of your time, energy and happiness do you think eczema is claiming now and in the past? Is it stopping you from doing what you need or want to do?” If they say, “I hate it,” then it’s easy to begin a conversation about mental health and eczema.
I always make this statement, “I have to do my job and my job is to make your eczema better as quickly and easily as possible so you can have your life back.”
If they stare at me oddly, then I ask if eczema is impacting work, school, friends or family. If they say no, then I say, “That sounds pretty good. If something comes to mind today or in the future, I would be happy to hear what it is.”
What I will ask of almost everyone with inflammatory skin disease is if they do anything to relieve stress and frustration in life in general. “Do you meditate? Run? Lift weights? Yoga? Tai-chi?” A lot of people say yes, but if the answer is no or vague then I explain that the vast majority of performing artists or athletes are asked to do some stress, distress and anxiety reducing activities like meditation or square box breathing because the body responds to those things in a favorable manner. The body’s blood sugar and heart rate lowers, and you can’t be good or bad at these activities. Often you get the same benefits no matter how well you do them.
If you can feel how sad, depressed or agitated they are, sometimes I will say, “I can feel and see that you seem very sad or upset. Is this just a bad day or is there a lot going on?” If they say they are having a tough time then we talk about a referral to a mental health professional. I tell them there are very straightforward techniques and medications that can help them feel better.
It is important to ask the tough questions when needed:
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- Are you having any thoughts of hurting yourself or anyone else?
- Do you think you will act on these thoughts?
- Do you have a plan for acting out these thoughts?
- In the past have you attempted to hurt yourself in anyway?
Most skin professionals would not want to ask these questions, but I think we have to ask ourselves this question: What happens if, God forbid, that person takes their own life? As humans, we have a good ability to sense frustration and sadness. It’s the rare patient who is in trouble, but we took the Hippocratic oath for that rare patient.
As a board-certified dermatologist and clinical psychologist, what do you recommend to your patients who are looking for help addressing mental health and eczema?
The National Eczema Association has resources on eczema and mental health. There are also a number of support groups.
Research has shown Cognitive Behavioral Therapy (CBT) can help, too. What I recommend to clinicians to find a mental health professional or a couple who have an interest in skin problems and specifically inflammatory skin conditions. These can be some of the most gratifying patients to treat. One of the CBT tenets is dealing with self-talk so you can address the catastrophizing that occurs with eczema. In addition, progressive muscle relaxation helps with eczema and itch.
Many young people today do not think of a mental health referral as insulting. The stigma of referral is diminishing. Some will ask if I think eczema is all in their head. I tell them, “Eczema didn’t begin in your head, but living with eczema can get in your head.” Living with chronic symptoms sucks neurotransmitters in the brain. It jangles the whole system. You’re more prone to be stressed and irritable. In the real world, anyone with a skin problem should be doing something to decrease stress. Meditative breathing alone for five minutes can increase vagal tone, which lowers blood sugar and blood pressure.
Hope itself is also a psychological intervention. I tell them that there has never been a better time to have eczema on this planet because of the medications. The understanding of what causes eczema has never been clearer than what it is now. Thinking this will never get better throws logs on the fire. However, giving people a sense of control and that the itch can be made better gives hope, and with hope comes the decreased release of pro-inflammatory chemicals and pruritogens. And, as soon as they begin to have hope they are more likely to adhere to their medications.
Sometimes patients are skeptical. I tell them we have a deep tool bag and I love the challenge.
What else should dermatology clinicians know about mental health and eczema?
Dermatology clinicians should know that eczema patients – like everyone else – are allowed the full spectrum of emotions every day of their lives. When living with eczema you are allowed to be angry and miserable as long as you don’t wreck relationships and hurt yourself.
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