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Do you need a skin shrink?

Do you suffer from problem skin, yet nothing seems to make a difference? We reveal how psychodermatology might be the cure you never knew you needed...

Skin problems are extremely common. In the UK, around one in four people consult a GP about a skin condition every year. But while there are many treatments available for common complaints such as acne, eczema, psoriasis and rosacea, what do you do when you’ve tried everything and nothing seems to help?  

Could it be that your problem goes beyond the physical and that there are also psychological issues you may need to address?  If so, it may be time to see a psychodermatologist or ‘skin shrink,’ who will treat your skin condition on both a physical and psychological level.

What is psychodermatology?

"We already know that problem skin can have a major impact on someone’s daily life, affecting confidence and self-esteem," says Professor Anthony Bewley, Consultant Dermatologist at Barts Health NHS Trust, London. "But, what’s increasingly being recognised is that certain emotional and psychological issues can trigger, or make existing skin problems worse.

"This is where psychodermatology can help–it involves the holistic management of the patient rather than the ‘label’ (eg: adult acne), and combines physical, psychological and, or psychiatric techniques when treating someone. The idea is that we not only look at the skin condition, but also what’s going on for someone on a psychological level."

The brain/skin link

Professor Bewley says that the skin and brain is closely linked through various mechanisms. "Firstly, the cutaneous nerves (supplying nerve supply to the skin) connect directly to the brain. There is direct ‘wiring’ from the skin to the brain (and vice versa) through the nerves. So, if there is inflammation of the skin, these messages get through to the brain and trigger neuroinflammation (in the brain).  

"Secondly, there is a connection between the skin and brain via the hormonal system. We call this the hypothalamic-pituitary-adrenal axis, or HPA axis, which represents the interaction between the hypothalamus, pituitary gland and adrenal glands. This plays an important role in the body’s response to stress. If you’re stressed, your body produces an excess of stress hormones (eg: cortisol, adrenalin) and this can exacerbate skin conditions such as acne, rashes, eczema and psoriasis."  

Finally, says Professor Bewley, there is communication between the immune system, the skin and the brain. "The skin has immune cells that help to protect against infection and inflammation, and are involved in the healing process. So, if there is inflammation of the skin, these messages get through to the brain and may trigger neuroinflammation (which can lead to anxiety and depression)." This process also works in reverse: in a US study (Molecular Psychiatry, 2020) it was shown that chronic stress can cause neuroinflammation.

Beauty brands are also latching onto the concept with products and ingredients designed to actively help tackle stress–according to a survey by Japanese skincare brand Tatcha, 74 per cent of people sense their mental state and their skin are connected.

How psychodermatology can help

So, when should you see a psychodermatologist?  "If, despite treatment your skin condition doesn’t improve or, it’s getting more severe, ask your GP or dermatologist to refer you to a psychodermatologist," says Professor Bewley.  

Mental health and skin is a growing area and more NHS psychodermatologists/clinics are dealing with this area. You can also refer yourself to a private psychodermatologist if you can find a suitable one, however, Professor Bewley says going via the NHS is better as they have bigger teams.

"At the initial consultation you will be seen by a dermatologist and psychologist, or psychiatrist at the same time. The golden rule of psychodermatology is to treat the skin and the psychological issue at the same time."

Alongside physical treatment, you will also be advised on psychological therapies. Professor Bewley says this may include talking therapies, cognitive behavioural therapy (CBT), mindfulness or relaxation techniques, dietary and, or wellbeing advice.

During follow up treatments you will see the dermatologist, psychologist, or other healthcare professionals separately. Or, you might be referred on the (national) Improving Access to Psychological Therapies programme (IAPT). Research shows when people are treated holistically, in terms of managing their skin and the psychological impact, they get better more quickly and there is less recurrence.

Common skin problems & the mind/body connection

Eczema is an inflammatory dry skin condition where skin gets incredibly itchy, dry, cracked and sore. It most commonly affects hands, insides of the elbows, backs of the knees, face and scalp. Food intolerance, fragrances, chemicals and stress can trigger outbreaks. Treatment to manage symptoms may include emollients creams and topical steroids.  

How psychodermatology can help

"People with eczema frequently feel anxious, frustrated and self-conscious about the appearance of their skin," say Professor Bewley. "But, lack of sleep, also plays a big part. When there is severe itching this interferes with sleep, and makes anxiety worse. Talking therapies can help to tackle anxiety or depression. A technique called habit reversal method can to control scratching. This involves becoming more aware of the triggers that lead to scratching (eg: anxiety) and learning to resist scratching for longer." Physical treatments may include emollients and topical steroids.

Psoriasis is a common, chronic, non-infectious skin disease. Plaque psoriasis is the most common type. This causes red, flaky, crusty patches of skin covered in silvery scales which tends to affect elbows, knees, scalp and lower back. Psoriasis causes shedding skin which can be very distressing.  

How psychodermatology can help

"Anxiety and depression can be big issues with psoriasis," says Professor Bewley. "Sufferers often become very withdrawn and avoid socialising or having relationships. It’s a vicious cycle, as low mood and depression can lead to inflammation and make outbreaks more frequent and severe." A psychodermatologist can offer psychological support alongside physical therapies (eg: topical creams and ointments, oral and injected medications, and phototherapy).

Acne is caused when the pores become blocked with excess sebum. This causes bacteria to thrive. Non inflammatory acne includes blackheads and whiteheads. Inflammatory acne includes papules, pustules, nodules and cysts.

How psychodermatology can help

"Adult acne is often associated with loss of confidence about self-image," says professor Bewley. "This can lead to body dysmorphic disorder. Many people feel so impacted by changes in their skin that they want to hide away. Acne can also massively affect self confidence and cause anxiety and depression. It can make people feel out of control. Psychological therapies that help to reduce negative emotions can help to break the mind/body link that is making symptoms worse."

Rosacea causes redness and flushing across the nose, cheeks, forehead and chin. There may also be tiny, broken blood vessels and small red bumps filled with pus. Other symptoms may include swelling around the eyes and sore eyelids if ocular rosacea is present.

How psychodermatology can help

"Rosacea, like acne, can have a profound effect on someone’s confidence," says Professor Bewley. "They may try and avoid social situations, which causes them to feel more anxious and even depressed. So, it’s important to address these issues and also look for any other underlying psychological causes." Physical treatments include prescription gels and creams, antibiotics, or intense pulsed light treatment (IPL) to alleviate inflammation, redness and spots.

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