Psychodermatology Synopsis: The Connection Between Psychology & Skin

Psychodermatology is a branch of therapeutic care based on the interactions between the neurological, immunological, cutaneous, and endocrine systems, known as the NICE network. It recognizes the complex interrelationships between skin and the neuroimmune cutaneous system and integrates psychological therapies along with dermatological intervention. A great deal of scientific discovery has been realized regarding the connection between the brain and skin as they share an intricate, complex relationship influenced by several body systems. Research has confirmed that skin functions as a primary stress receiver and is capable of stress-initiated responses. The increasing prevalence of external and emotional stress has contributed to a rise in inflammatory related skin conditions and in particular, those connected to neuro-dermatological origins. This has perpetuated an increasing awareness of relationships involving dermatology and psychology that have previously remained somewhat obscure.

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THE ORIGINS OF PSYCHODERMATOLOGY

Psychodermatology was first documented in 1886 by an Italian psychopathologist, Enrique Morselli, under the name dysmorphophobia. Sigmund Freud also described a case involving a patient with body dysmorphia.² Since the beginning of time, mankind has been concerned with the balance between the mind and body. Hippocrates acknowledged the relationship between stress and its effects on skin, citing cases of individuals exhibiting emotional distress by pulling their hair out. Aristotle and Hippocrates both believed that the mind and body were not two separate entities but complementary and inseparable. Indeed, the principals of healing in natural health and naturopathy involve the concept of holism. Homeostasis of the human body resides within all body systems; it is not separated into parts in the naturopathic philosophy.

The interactions between the mind and skin diseases have been the study focus of many researchers worldwide. The Association for Psychoneurocutaneous Medicine of North America was formed in 1991 as a platform to educate physicians, clinicians, and patients about psychodermatology, psychosomatic dermatology, and psychoneuroimmunology. Similar organizations include The European Society for Dermatology and Psychiatry and The Japanese Society of Psychosomatic Dermatology. Though sufficient data has been published supporting the links between psychology and dermatology, there is both a lack of statistical evidence and widespread medical community support that presents incredulity. During the 1980s, only a small number of physicians, psychiatrists, and dermatologists in the United States were interested in psychodermatology. Since the European acceptance of psychodermatology as a valid part of dermatologic science, it has gained wider recognition and is taught as part of the curriculum in many countries.^1,3

The exact prevalence of psychological factors that affect skin disease is not known; however, it has been estimated to be 25% to 33% in various studies. According to an article featured in Psychiatric Times, research has shown that the stimuli received in skin can influence the immune, endocrine, and nervous systems at both the local and central levels. In several skin diseases, such as atopic dermatitis, the tissue levels of nerve growth factors and neuropeptides, such as substance P (a neurotransmitter), have been associated with the pathogenesis of disease and markers of disease activity.⁴ Careful consideration should be given to the correlation between skin and inflammatory skin pathologies. Psychodynamics reveal that the affected skin often represents the expression or suppression of negative emotions which may be difficult for the individual to articulate or process. However, unlike many other organs in the body, the epidermis has an immediate reaction with emotions, thereby supporting the concepts of the brain-skin connection.⁵

 

CLASSIFICATIONS OF PSYCHODERMATOLOGY

Psychophysiological disorders include and identify skin conditions that are precipitated by psychological stress. These disorders exhibit an association between stress and exacerbation.

Acne vulgaris

Acne excoriee

Atopic dermatitis

Lichen simplex

Psoriasis

Pruritis

Rosacea

Seborrheic dermatitis

Urticaria

Herpes simplex virus

Hyperhidrosis

Alopecia areata

 

Primary psychiatric disorders are associated with underlying psychopathology and are known as stereotypes of psychodermatological diseases. These individuals may exhibit potentially self-induced skin lesions, and their conditions are connected to underlying physiological behaviors.

Body dysmorphic disorder

Dermatitis artifact

Eating disorders

Factitial dermatitis

Obsessive-compulsive disorders

Parasitosis (delusions of parasitosis)

Phobic states

Trichotillomania (obsessive hair pulling – scalp, brows, lashes)

 

Secondary psychiatric disorders are psychological problems that develop secondarily to the negative impact of a skin disease because the disfigurement has an impact on the individual’s self-esteem and psyche.

Alopecia areata

Albinism

Chronic eczema

Hemangiomas

Ichthyosis

Psoriasis

Rhinophyma

Vitiligo

 

Cutaneous sensory disorders are conditions where the individual experiences abnormal sensations on skin that include itching, stinging, crawling, and burning.

Neurodermatitis

Burning mouth syndrome

Psychogenic itch

Sensitive skin

Nummular eczema

Lichen Simplex

Atopic dermatitis

 

CLASSIFICATIONS OF STRESS

The effects of stress are characterized in three main ways – physiologically, psychologically, and adaptive behaviors. Psychological stress can greatly affect the immune system through the sympathetic nervous system (SNS), hypothalamic-pituitary-adrenal axis (HPA), parasympathetic nervous system (PNS).

The sympathetic-adrenal-medullary and hypothalamic-pituitary-adrenal axes possess direct and indirect connections with the immune system. The dynamics of stress impact each person differently and the coping mechanisms determine the extent of the stressful events.

 It is important to understand that the nervous system, endocrine system, and cutaneous immune system work synergistically to maintain homeostasis of the body and skin. Stress reduces one’s ability to repair damaged cells. Research has shown that skin is not only a target of psychological stress but also an active participant in the stress response, through the production of local HPA axis components, peripheral nerve endings, and resident skin cells. There are bidirectional communication pathways between the brain and skin, which play key roles in integrating these interactions. During a stressful event, physiological mechanisms respond by initiating a catabolic fight-or-flight response fueled by the hypothalamus. Through a combination of nerve and hormonal signals, the adrenal glands release a surge of hormones including adrenaline and cortisol.

Skin receives sensory input from external stressors through the receptors – nociceptors, thermoreceptors, and mechanoreceptors which are responsible for transmitting these signals to the spinal cord and then to the brain. The central nervous system (CNS) processes and responds to these signals, which in turn coordinates stress responses in skin. Skin and its appendages are targets of stress mediators and a local source of these factors, which engineer various immune and inflammatory responses. The central role in cellular skin reactivity to various stressors may be attributed to dermal mast cells, as they show close connections with sensory nerve endings and release numbers of proinflammatory mediators such as histamines, serotonin, bradykinin, eicosanoids, thromboxanes, leukotrienes, prostaglandins, cytokines, interleukin, and tissue necrosis factor (TNF).

Stressed skin is a biochemically driven response to physical or emotional stressors that impact the immune system. Hallmarks include discoloration, flushing, blanching, heightened sensitivity, skin flaking, loss of elasticity, and aggravated skin diseases. Stressed skin (no matter the age) may also encounter delta opioid receptor activation, which are keratinocyte membrane receptors involved in translating stress messages from the environment including free radicals, chemicals, and cigarette smoke. These are considered “inflammaging” factors.⁸ Sensitive skin’s primary characteristic displays an intact barrier facilitating compromised barrier function. During periods of psychological stress, the barrier can be disturbed by both the integral and protective function of the stratum corneum. An impaired stratum corneum permits allergens to permeate skin, reacting with cells in the epidermis that initiate the inflammation cascade, thereby impacting a nerve response. A large number of skin diseases including atopic dermatitis and psoriasis appear to be precipitated or exacerbated by psychological stress. The disruption of barrier function also increases epidermal cell proliferation, DNA synthesis, synthesis of keratins associated with hyperproliferation, and increases local secretion of tissue necrosis factor as well as a rise in keratinocyte proliferation which may result in epidermal hyperplasia.

 

MANAGEMENT OF PSYCHODERMATOLOGIC DISORDERS

The allopathic medical approach for the management of psychodermatologic disorders generally includes the reduction of stress, emotions, and behavioral habits that damage skin, hair, or nails and other therapies that can enhance a response to treatment. Physicians often utilize the Griesemer index chart, developed by R.D. Griesemer, MD (dermatologist and psychiatrist), which categorizes the effect of emotions on various skin disorders for physicians and clinicians. Using this chart, stress may be measured with subjective units of distress on a scale of zero to 10. Other therapies that may be used include antidepressants, antipsychotics, sedatives, psychologic and behavior modifications, hypnosis, self-hypnosis, biofeedback, and cognitive-behavioral methods.

Alternative approaches may include somatic psychotherapy. Somatic psychotherapy is a holistic therapeutic approach that incorporates a person’s mind, body, spirit, and emotions in the healing process. Treatment therapies may include meditation, acupuncture, tai chi, relaxation training, reiki, and yoga. The use of herbs, botanical products, and supplements have become increasingly popular as treatment options.

Aromatic psychodermatology may be described as the interaction between essential oils, the mind, and the relationship between olfaction, emotions, and psychodermatology. Essential oils have been used for depression, anxiety, and general psychophysiological disorders. The volatile organic compounds that essential oils possess exert a pharmacological effect once applied to the body dermally or olfactorily (inhalation). The olfactory system is capable of reducing the impact of stress because of its connection to the limbic region of the brain.¹¹

Topical products represent an important part of adjunct treatment regarding skin symptomology whether from the dermatological or aesthetic perspective. Dermatological, topical medicaments address infection, pruritus, sensitivity, inflammation, and hydration.

 

The cumulative effects of stress and how it may impact health are not always apparent. Knowing what triggers stress should be an important part of daily care. Clients are the primary participants in charge of managing their stress inventory. Taking an objective look at time management, exercise, behavioral tendencies, sleep, and nutrition will create balance. As part of the health and wellness industry, practitioners have access to a plethora of tools and resources to support themselves and their clients.

 

References

1. APMNA – Association for Psychoneurocutaneous Medicine of North America. http://www.psychodermatology.us/.
2. França, Katlein, Anna Chacon, Jennifer Ledon, Jessica Savas, and Keyvan Nouri. “Pyschodermatology: a Trip through History.” Anais brasileiros de dermatologia. Sociedade Brasileira de Dermatologia, 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3798372/.
3. “Psychodermatology.” Wikipedia. Wikimedia Foundation, May 3, 2021. https://en.wikipedia.org/wiki/Psychodermatology#cite_note-evidence-1.
4. “Psychodermatology: When the Mind and Skin Interact.” Psychiatric Times, n.d. https://www.psychiatrictimes.com/view/psychodermatology-when-mind-and-skin-interact.
5. Jafferany, Mohammad. “Psychodermatology: a Guide to Understanding Common Psychocutaneous Disorders.” Primary care companion to the Journal of clinical psychiatry. Physicians Postgraduate Press, Inc., 2007. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1911167/#.
6. “Psychodermatology: A Review.” Practical Dermatology. Bryn Mawr Communications, n.d. https://practicaldermatology.com/articles/2015-may/psychodermatology-a-review.
7. Mento, Carmela, Amelia Rizzo, Maria Rosaria Anna Muscatello, Rocco Antonio Zoccali, and Antonio Bruno. “Negative Emotions in Skin Disorders: A Systematic Review.” International journal of psychological research. Facultad de Psicología. Universidad de San Buenaventura, Medellín, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7498125/.
8. Chajra, H., B. Amstutz, K. Schweikert, D. Auriol, G. Redziniak, and F. Lefèvre. “Opioid Receptor Delta as a Global Modulator of Skin Differentiation and Barrier Function Repair.” Wiley Online Library. John Wiley & Sons, Ltd, March 9, 2015. https://onlinelibrary.wiley.com/doi/abs/10.1111/ics.12207.
9. “Management of Psychodermatologic Disorders.” Medscape, October 15, 2010. https://www.medscape.com/viewarticle/730033_2.
10. Satyapal Singh, J.S. Tripathi, N.P. Rai, An overview of Ayurvedic & contemporary approaches to Psychodermatology. The Journal of Phytopharmacology 2014. http://www.phytopharmajournal.com/Vol3_Issue4_10.pdf.
11. Shutes, Jade. “Aromatic Psychodermatology.” The School of Aromatic Studies, May 10, 2020. https://aromaticstudies.com/aromatic-psychodermatology/.

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Dr. Erin Madigan-Fleck is a naturopathic medical doctor, licensed master cosmetologist, aesthetician, and licensed aesthetics instructor. She received her naturopathic doctoral degree from the University of Science, Arts & Technology College of Medicine and her naturopathic clinical studies at Progressive Medical Center in Atlanta, Georgia. Madigan-Fleck is a member of The American Society for Nutrition, International Association for Applied Corneotherapy and The Society of Dermatological Skin Care Specialists. She is also the CEO and owner of Naturophoria, a naturopathic skin care clinic in Atlanta, Georgia.