The Connection Between Mental Health and Skin Disorders: Strategies for Comprehensive Care

Our skin is on display for the world to see, making it one of the most important contributors to our self-image, confidence, and interpersonal interactions. Blemishes, rashes, wounds, and the like can have a profound impact on our self-esteem and quality of life, placing those of us with skin disorders at particularly high risk of mental health conditions. 

In this article, we’ll dive into the emerging field of psychodermatology—a discipline that recognizes the bidirectional relationship between the mind and the skin and adopts a holistic approach to treating skin conditions.

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Understanding the Mental Health-Skin Disorder Connection

Historically, the mind and the skin have been treated as separate entities—islands unto themselves. But we now recognize the complex interplay between the mind and the rest of the body, which includes the two-way relationship between psychological well-being and skin conditions. 

Patients living with chronic skin diseases like psoriasis, acne, rosacea, and eczema often find themselves in a continuous feedback loop. Stress, anxiety, depression, and trauma significantly influence their skin symptoms, but the daily struggle of living with the skin disease also places a huge burden on their mental health, contributing to more stress, anxiety, and depression. One survey found up to 85% of patients with skin diseases report mental health issues that stem from living with the condition, and there’s a higher risk of suicide in this population.

Mental Health Impact on Skin Disorders

Prolonged psychological stress can contribute to and exacerbate skin conditions in several ways.

The epidermis (outermost layer of skin) is instrumental in keeping us safe from the outside world, but it also interacts with the central nervous system. Chronic stress has been found to disrupt epidermal permeability, contributing to inflammatory skin disorders like eczema and psoriasis. Likewise, chronic stress can disrupt normal gastrointestinal tract function, leading to a leaky gut. When gut barrier function is compromised, toxins, food particles, and other outsiders can enter the systemic circulation, leading to inflammation and an uptick in skin symptoms. Uncontrolled stress also contributes to HPA-axis dysfunction. The inflammatory cascade that follows can contribute to and exacerbate skin disease symptoms. 

Skin Disorders Impact on Mental Health

Living with a chronic skin condition significantly increases the risk of mental health symptoms. For example, it’s estimated that up to 84% of patients with psoriasis have comorbid mental health conditions. Skin diseases can be painful and difficult to manage, increasing the likelihood of depression and even suicide. Patients with skin lesions may also experience poor quality of life, anxiety, work-related issues, social phobias, low self-esteem, and poor body image.

Classification of Psychocutaneous Disorders

Generally, psychocutaneous disorders can be classified into three main categories:

Skin disorders arise from a complex interplay between unique environmental and lifestyle experiences, immune system dysfunction, hormonal imbalances, and genetics. While it’s unclear if poor gut health is a factor in all skin diseases, it is a constant theme in the literature:

• Patients with rosacea tend to have higher rates of small intestinal bacterial overgrowth (SIBO). One trial found rosacea patients who eradicated SIBO experienced almost complete resolution of their skin symptoms.
• Patients with psoriasis who have altered GI barrier function experience higher levels of inflammation and worse skin symptoms.
• Patients with acne have higher rates of increased intestinal permeability and possibly SIBO, which can alter skin homeostasis.
• Gut dysbiosis plays a pivotal role in the development of atopic dermatitis.

Assessment Strategies for Integrated Care

Helping patients improve the skin-mind connection requires a comprehensive assessment and an uncovering of root causes. Providers should take a deep dive into their patient’s specific skin disease antecedents, triggers, and mediators (ATMs). ATMs can include unmanaged stress, infections, food-related allergies or sensitivities, nutritional deficiencies, and toxin exposures. 

Having patients fill out an extensive symptom and history questionnaire before their appointment can provide valuable insight into ATMs. During the visit, allow patients time to elaborate on the information in their questionnaire to create a safe space for sharing. In addition, providers can employ a nutrition-focused physical exam to uncover potential nutrient deficiencies contributing to both skin and mental health symptoms. Based on the information gleaned from the patient’s written and oral history and the physical exam, providers may order various blood, saliva, stool, and urine tests to aid in the development of the personalized care plan.

Comprehensive Treatment Approaches

Many skin disorders are relapsing and remitting—symptoms will flare for a time and then go back to baseline. Some patients require the continuous use of strong medications, and others use prescription treatments only when needed. Either way, this back and forth can have a significant impact on quality of life and mental well-being. Providers can assist patients in breaking this cycle by targeting root causes with a comprehensive treatment approach.

While various pharmaceuticals like selective serotonin-reuptake inhibitors and other antidepressants, antipsychotics, biologics, corticosteroids, and anti-inflammatories are often used to treat skin and mental health symptoms, they can come with dermatologic and mental health consequences. Natural solutions offer significant healing benefits with little to no side effects and may significantly reduce the need for medication. 

Mental Health Treatments 

Since stress is a major player in various skin disorders, mind-body therapies may offer meaningful skin and mental health symptom relief. 

Mind-body therapies like meditation, mindfulness-based stress reduction, biofeedback, hypnotherapy, and guided imagery offer a multipronged approach—they alleviate the physiologic changes that are caused by stress (i.e., leaky gut and epidermal barrier disruption), help patients eliminate harmful behaviors that exacerbate skin symptoms (i.e., skin picking, eating disorder behavior, and hair pulling), and improve overall mental well-being. 

Incorporating mind-body therapies can reduce the amount of medication needed by patients with eczema and psoriasis. Meta-analyses have also shown that mind-body techniques can improve itching, scratching, psychosocial outcomes, and skin symptom severity. 

Behavioral therapies like habit reversal and cognitive behavioral therapy offer benefits as well. Habit reversal is very promising for eczema, skin picking, and hair pulling. Cognitive behavioral therapy has been found to improve symptom severity, reduce anxiety and depression, and significantly improve skin conditions in patients with eczema and psoriasis.

Dietary Treatment

Chronic inflammation may be a contributing factor in many skin conditions, including eczema, psoriasis, acne, and rosacea. Inflammation may also influence mental health symptoms.

The dietary pattern can be harnessed to combat root causes like inflammation and poor gut health. While dietary approaches need to be personalized to the patient, an anti-inflammatory diet may improve skin and mental health symptoms by reducing inflammation, keeping the gut barrier intact, and maintaining healthy immune system function. 

An anti-inflammatory diet is built around fruits, vegetables, unsaturated fats, whole grains, legumes, fermented foods, tea, coffee, herbs, spices, and oily fish. This dietary pattern also limits or excludes foods and beverages that contribute to inflammation, like processed meats, ultra-processed foods, refined grains, sugar-sweetened beverages, candies, cakes, cookies, and excessive amounts of alcohol.

Dietary and Herbal Supplements

Dietary supplements also hold promise for skin and mental health conditions:

• Vitamin D deficiency may be an underlying factor in skin diseases. Vitamin D supplementation may improve eczema, psoriasis, and acne. One note of caution for patients with rosacea—elevated vitamin D levels may contribute to rosacea development and disease course.
• Omega-3 fatty acids (>1800 mg/day) have been found to improve psoriasis symptom scores, erythema, and scaling. And omega-3 supplements may improve symptoms in patients with atopic dermatitis, acne, and skin ulcers. 
• Probiotics may improve skin barrier function and reduce skin sensitivity, as well as help to improve gut microbiome balance. Probiotics may lead to symptom improvement in psoriasis patients, and a combination of probiotics and prebiotics may significantly improve eczema severity. 
• Chinese herbal medicine may significantly improve quality of life and symptom severity in patients with psoriasis and atopic dermatitis. 
• Herbal treatments, taken internally or applied topically, like vitex, essential oils, garlic, arnica, capsaicin, aloe vera, and gingko, have much anecdotal evidence but lack strong research at this time.

Lifestyle Treatments

In addition to stress management techniques and dietary modifications, lifestyle therapies can be very effective for managing skin conditions and their associated mental health effects.

• Acupuncture has been used in Traditional Chinese Medicine (TCM) for the treatment of many skin disorders from urticaria and acne to herpes zoster and vitiligo. Systematic reviews have concluded that acupuncture is likely effective as an adjunct to treatment for acne, psoriasis, and eczema.
• Smoking cessation (and avoidance of being around cigarette smoke) should be encouraged as smoking can disrupt blood flow to the skin, increase inflammatory cytokines, trigger the immune system, and disrupt hair follicle function. Smoking may especially contribute to psoriasis, contact dermatitis, alopecia, and possibly acne symptoms.
• Restful sleep should be prioritized. Skin diseases and mental health conditions can disrupt sleep, but poor sleep can also upregulate inflammation, leading to further skin exacerbation and mental health symptoms. 
• Time in nature may help patients better manage mental health symptoms. A systematic review found people who spend time in nature tend to have less anxiety and depression afterward. Another study found improvements in cortisol and blood pressure levels and a calmer autonomic nervous system after time in nature. 

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Key Takeaways

• Skin-related conditions place a huge burden on mental well-being.
• There’s a bidirectional relationship between the skin and the mind where poor skin health impacts mental health, and mental health impacts the health of the skin. Rather than one root cause, skin diseases result from the complex interplay between personalized emotional and environmental experiences, genetics, and hormonal and immune system imbalances. 
• Pharmaceuticals offer relief for both skin diseases and the mental health conditions they cause but often come with skin and mental health side effects.
• Identifying the root causes of both skin and mental health symptoms in a specific person and addressing them with holistic approaches like mind-body therapies, nutrition, dietary supplements, and lifestyle modification can have an immense impact on patient outcomes.