Stylecaster recently posted an online article about psychodermatology. How do the mind and skin influence each other? What do we now know and what questions are still unanswered? How can dermatology clinicians best counsel their patients when the mind-skin connection is at work?
For expert advice, I reached out to Steven Daveluy, MD, FAAD, associate professor and program director at Wayne State Dermatology.
What does psychodermatology entail?
Psychodermatology is the overlap between psychology and dermatology. It pertains to any patient where psychological factors play a role in their skin disease.
There are four categories of psychocutaneous disease. The first two categories involve psychiatric disease causing skin problems.
- Primary psychiatric condition: In this case, the patient has psychiatric disease that is impacting their skin. One that commonly presents in dermatology is delusional infestation (delusional parasitosis), where a delusion causes patients to believe they have a parasite in their skin where none exists. It’s an incredibly stressful problem that can ruin someone’s life. Trichotillomania and skin picking disorders are other examples.
- Psychogenic pruritus: Patients have itching all over secondary to anxiety, depression or psychosis.
In the remaining two categories, patients have a primary skin disorder.
- Secondary psychiatric disorders: Patients have a skin disease that leads to psychiatric disease. We all understand the impact that skin disease can have on quality of life and emotional wellbeing. Many skin diseases can lead to anxiety or depression, including psoriasis, atopic dermatitis, hidradenitis suppurativa, vitiligo, skin cancer and others.
- Psychophysiologic disorders: Situations where the primary skin disease flares with emotional stress. Stress is well documented to flare atopic dermatitis, psoriasis, urticaria and hidradenitis suppurativa, among others.
How do the mind and skin influence each other? What are some of the outcomes that dermatology clinicians can experience in their clinical practice?
There is a strong connection between the mind and the skin, going all the way back to embryology where both the skin and central nervous system develop from the ectodermal layer. As mentioned above, we know that skin disease can impact mental health. Pruritus and pain can increase stress and impair sleep, which further compound problems. The mind can also exert a strong influence on the function of the skin. When someone is nervous, their face may flush and their palms may start sweating, demonstrating just two of the ways that our emotions can impact our skin. I’m sure we’ve all experienced the sensation of skin crawling after seeing a patient with a severe scabies infestation, caused by our mind worrying that we may have picked up the infestation.
Considering the mind-skin connection is crucial to achieve the best outcomes with your patients. In primary psychiatric conditions, skin-directed therapy won’t help since it’s not a skin problem. Treatment has to be directed at the underlying psychiatric condition. When the patient has a primary skin disorder, it’s really important that we’re having discussions about their mental health. Patients may not think to discuss these problems with their dermatologist, and we have an opportunity to help them understand and get help so they don’t have to suffer alone.
How has the perception of the mind-skin connection among dermatology clinicians changed over time?
We’ve developed a much greater appreciation of the mind-skin connection and how it impacts skin disease. Research has proven the connection for so many skin diseases, especially when it comes to comorbid psychiatric disease. This has helped us demonstrate the impact that skin disease has on our patients, which helps us advocate for access to highly effective treatments. It’s like the old cliche, “It’s more than skin deep.”
What do we now know about the mind-skin connection and what questions are still unanswered?
We have a lot of evidence supporting the mind-body connection, including the neural pathways, neurotransmitters and cytokines involved, in many cases. The more difficult questions to answer are regarding the “why”? Using delusional parasitosis as an example, why does a patient suddenly develop a belief that they are infected with a parasite? The rest of their thinking is unclouded, so why did they develop this one belief that their brain just can’t apply logic to? Maybe someday we’ll gain a better understanding of these questions. They aren’t unique to psychodermatology. We don’t know why some people develop psoriasis or eczema either.
How can a dermatology clinician recognize when the mind-skin connection is at work in a patient’s skin condition?
We’re well-trained to recognize the mind-skin connection in most cases. We are well accustomed to the history and exam (including the baggie of samples) for patients with delusional infestation. We recognize when a patient has only excoriations with no primary skin lesions, and we also pick up on their mood from their affect, helping us recognize underlying anxiety or depression.
There are many more opportunities to recognize and appreciate the connection in clinic. I find it very helpful to open the door for patients to discuss the psychological impact of their skin disease by asking their permission. For example, “We know that hidradenitis suppurativa can have an impact on patients’ mental health. Would it be alright if we talked about your mental health?” It’s a great way to breach the topic without stigma.
What advice do you have for dermatology clinicians in counseling their patients in these situations?
As I mentioned above, it’s important for us to start the conversation with our patients. We want to take care of every aspect of their skin disease, including the emotional impact. Work with mental health professionals in your area, so you can refer patients who need their services. Many patients feel better just having someone show interest in their mental health.
When it comes to primary psychiatric diseases, I advise dermatologists to get comfortable using some psychiatric medications. For many of us, it wasn’t part of our training, but there are many medications that weren’t part of our training and we’ve learned to use. We use serious medications, like biologics, JAK inhibitors, methotrexate, etc. We have the skills to safely and appropriately prescribe medications for mood disorders. As you gain experience, your comfort level will grow. You’ll also be inspired by the positive impact for your patients. These patients often won’t see a mental health professional since they can’t understand that they don’t have a primary skin disease. That’s why it’s so important that we provide treatment. I encourage you to gain some experience with medications like doxepin, SSRIs, pimozide and olanzapine. If not, make sure you have someone who treats psychocutaneous disease to whom you can refer your patients.
What else should dermatology clinicians know about psychodermatology and the mind-skin connection?
I know that the encounter with a patient with psychocutaneous disease can have a bigger emotional burden on the dermatologist. Please remember that you can have an enormous impact on the quality of life for these patients. They truly need us desperately. Imagine if one of your loved ones was afflicted with one of these problems and the care you would want for them.
If you dread these encounters, here are a few tips to help your mental health. Before entering the room, take a few deep breaths and put up your “emotional armor.” Picture a forcefield around you that will protect you. You will be able to help the patient, but nothing that happens will be able to affect your emotions. It may sound silly, but it really works. If an encounter does cause you stress, afterward take a few deep breaths to engage your parasympathetic nervous system and calm you down before the next patient. You can do this while washing your hands and picture the stress washing away. I know these encounters can put you behind in a busy clinic. Consider asking the patient to come back when you will have time to fully explore their issues and help them. Then schedule them back in a longer appointment or an appointment at the end of a clinic session when you can see them without other patients waiting.
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