Nonstop itching. Swelling and peeling you can’t soothe. And where did those rashes or flakes come from? When problems like these won’t go away, the harm can run more than skin deep.
People with chronic skin diseases face a higher risk of developing mental health conditions, says Ladan Mostaghimi, MD. Trained in both psychiatry and dermatology, Mostaghimi is part of a niche field of specialists known as psychodermatologists, who focus on patients’ mental and skin health.
“When you have a chronic skin condition that lasts for months or years, you have to constantly maintain the treatment,” Mostaghimi says. Not only is it expensive, she notes, but patients face long-term episodes of stress and embarrassment because of their affected areas. That can fuel mental health conditions such as depression and social anxiety.
Through her practice, the Wisconsin Psychocutaneous Clinic, Mostaghimi trains dermatologists to be more aware of how their patients’ physical condition may be affecting their mental health.
That’s something dermatologist Jeffrey Cohen, MD, is also tuned into. As director of the Psoriasis Treatment Program at the Yale School of Medicine, Cohen researches the links between psychiatric conditions and inflammatory skin diseases. It’s an overlap he also sees regularly in his patients.
“It happens all the time,” he says. “Someone comes in with really severe psoriasis, for example, and they might say, ‘Because of this, I don't feel like I can go out. I don't feel like I can interact with my friends. I just want to stay home and sleep.’ This person is describing the signs and symptoms of depression.”
Mental health conditions and stress can also affect the skin. For instance, stress is a well-known trigger for psoriasis flare-ups, and anxiety is one for hives. In addition, Mostaghimi’s research shows that people with inflammatory skin diseases tend to experience more insomnia, which she says can in turn increase stress and impact mental health.
If you have a chronic skin condition, you may have never considered talking to your dermatologist about your mental health. But both Mostaghimi and Cohen say you absolutely should — and that dermatologists, in turn, should ask patients questions to draw out that information so they can help.
The following interviews have been edited for length and clarity.
What’s the connection between skin and mental health?
Jeffrey Cohen, MD: We have come to learn over time that diseases that we used to think were solely skin diseases truly are not that because there's a degree of systemic inflammation that goes along with these skin diseases.
For example, someone who has psoriasis or someone has eczema — yes, they have inflammation in their skin, and that's what leads to the clinical presentation of the psoriasis or eczema in the skin. But also, they have inflammation in other parts of the body. And so that can lead to what we call comorbidities, or other medical conditions that run along with the skin diseases and extend to mental health disorders.
At the same time, it’s important to point out that just because there's an increased risk of developing mental health conditions in people, for example, with psoriasis or eczema, does not mean that they are common occurrences or that everyone with a skin condition will also develop a mental health condition.
Ladan Mostaghimi, MD: One way that the brain connects to our body is through the hypothalamus pituitary adrenal, or HPA, axis for a stress response that can affect the organs, including the skin. The relationship is bidirectional: so when we are stressed, our body gets the signal, and when the body is distressed, it sends the signal back to the brain.
What specific skin conditions seem to overlap with mental health conditions?
Cohen: We’ve looked at a lot. Psoriasis is a big one for depression, anxiety, and obsessive-compulsive disorder (OCD).
Eczema has also had a lot of attention in this area, with an increased risk for depression, anxiety, OCD, and schizophrenia. Eating disorders and eczema are linked.
There are also a number of less common skin diseases that are associated with depression and anxiety.
The research doesn’t point to the “why” behind the associations. But the unifying factor of all of these are that they're highly impactful on your life and they have a high degree of systemic inflammation that is associated with them.
If a patient is struggling with their mental health, should they talk to their dermatologist about it? And what might that conversation look like?
Cohen: Absolutely. Like I said, it happens all the time. They might say, “I'm feeling anxious all the time. I'm not sure when my psoriasis is going to flare up. I can't stop thinking about it. I want to go exercise tomorrow, am I going to feel comfortable doing that, or are my joints going to hurt too much? Am I going to have too much discomfort in my skin to do what I want to do normally,” whatever it is?
That person might be describing anxiety to you. As their dermatologist, you don't necessarily have the time or skill set to unpack that yourself.
But you can, and should, start that conversation and validate that this is having a really important impact on their life. You can then recommend that they talk to their primary care physician about it.
Mostaghimi: If people feel that their skin disease is making them depressed, anxious — it’s affecting their motivation, energy level, social interactions — they should talk to their dermatologist. … Even if there’s no psychodermatologist in the area, dermatologists can still refer patients to appropriate therapists.
The other thing that we are realizing is that some patients with skin problems do have some suicidal thoughts, and that is not normal. So I want to emphasize that if people have suicidal thoughts, they do need to talk immediately to their providers. And if the thoughts are strong, call 988. They have trained operators that can help them.
(Editor’s note: The 988 Suicide & Crisis Lifeline is available 24-7. You can call, text, or chat 988 if you’re thinking about suicide or have any other kind of mental or emotional distress. It’s confidential. Read more about what to expect if you contact 988.)
How might an appointment with a psychodermatologist differ from a traditional dermatologist?
Mostaghimi: In psychodermatology, we do a biopsychosocial assessment of the patient, so the appointments are longer. Sometimes we ask people to fill out different questionnaires so we can find out which areas of life the skin disease is affecting. Based on that, we come up with a holistic plan to take care of the skin disease as well as the mental health issues and the social issues.
Depending on the problem, we may recommend that they get specific therapies, like cognitive behavioral therapy or acceptance and commitment therapy, or medication if the problem is more severe.
What do you wish more people, including doctors, knew about the connection between dermatology and mental health?
Mostaghimi: When I lead education workshops and teach people how to take care of patients with psychodermatology problems, my main message is … to take a look at the patients holistically and see that a disease is not something that's just standing by itself. It's something that is affecting someone, affecting their relationships, affecting how they work. So asking patients about how their skin problem is affecting their life is the most important question.
