English version | Under the skin

Under the mind. A dermatologist explains how mental health affects the skin – and vice-versa.

Model Lisa Fonssagrives photographed by Horst P. Horst for Vogue, 1941 ©Getty Images
Model Lisa Fonssagrives photographed by Horst P. Horst for Vogue, 1941 ©Getty Images

Right now, it’s possible that you’re tired of hearing about, reading about and speaking about chaos. From the exhausted “these are uncertain times” to the overly used “the new normal”, phone calls with friends, conversations with families, shares on Instagram and the endless news cycle are constant reminders that the world really is upside down. What does this all mean? It’s possible that you may be feeling a little more anxious and stressed out than ever – and it’s also possible that your skin is feeling it too. “Mental health and skin conditions are clearly associated,” says dermatologist Judite Pereira, explaining that the connection between skin and mind is found in the common biological origin between the nervous system and the skin. “We can say that the skin is like a sensor, that establishes a full connection with the external world and the internal world, reacting in a more or less intense way to the emotions that are evoked by different stimulus.” Deeply connected, mind and skin are capable of influencing each other mutually – and the bond that they share is more complex and profound than we can begin to imagine. “In today’s society, the level of demands, be it with work or personal life, can lead to certain levels of stress and anxiety, with a serious impact when it comes to internal conflicts, fears, dreads and anguishes, that alter our reason and make us victims of our own situations,” says Judite Pereira, referring the importance of understanding why stress and anxiety can affect us. “Considering that the skin is a visible organ, with a communication and social integration function, different skin conditions have serious effects on our self-image, with stigmatizing repercussions, which can by itself cause anxiety, depression, and consequently alter our quality of life,” the dermatologist says. “It’s like a vicious circle. It increases the individual vulnerability, which acts as a precipitant factor for mental health disorder, aggravating or triggering some skin conditions like acne, rosacea, psoriasis, atopic dermatitis, alopecia, and even pruritus.” Referring to what happens to our skin when we’re stressed or anxious, the dermatologist begings by explaining that “sometimes, and immediately, stress and anxiety can trigger well known individual skin reactions such as redness, paleness, pruritus, a sense of discomfort, burning and sweating.” As Judite explains, this happens “because there is an exaggerated response of our cutaneous vessels to the release of certain substances, the stress substances, let’s say.” On the other hand, the dermatologist says, “circumstances of emotional stress, anxiety and depression can aggravate the skin condition that the patient already had, or precipitate its appearance, even though it’s not the cause,” referring to examples like acne, psoriasis, atopic dermatitis, vitiligo and herpes. “Considering that the range of skin conditions bounded to psychodermatoses is broad, it’s convenient to essentially differentiate two types: first, we have the mental health disorders with dermatological repercussions and, secondly, skin conditions with mental health repercussions.” 

“Mental health and skin conditions are clearly associated.”

When it comes to mental health disorders with dermatological repercussions, as Judite Pereira explains, “one of the main ones, that is very common in today’s society, is obsessive-compulsive disorder, that is characterized by excoriations and trichotillomania.” Also frequent today, the dermatologist says, is body dysmorphic disorder. “In this case, the person looks at herself in the mirror and always sees something that she can’t accept, body wise,” the specialist explains, referring that those who live with body dysmorphic disorder show signs of what is called “cutaneous hypochondria; a lot of symptoms, a lot of complaints, but few signs of an organic disease.” Usually, says Judite, what they do show is benign skin injuries, with the areas of concern being the face, the hairy areas and the genitals. “When it comes to the face, normally, there are multiple complains: redness, dilated pores, scars, tiny skin pigmentations, little visible vases. Sometimes we have to ask the patient to show us in the mirror where these injuries are, because we don’t see them. It’s very common.” In this field that is “a world”, as the dermatologist puts it, it’s also possible to observe some cases of phobia, where “the patient has an irrational fear of contracting or suffering from certain diseases, or because they had a condition they got cured from, or because a friend or family member suffered from it.” “The fear of these infections leads to excessive hand washing, which can cause irritative dermatitis. We are talking about people who are constantly worried, and cleaning functions as an escape,” the dermatologist explains. “Sometimes, these patients also present what we call cancerphobia, they are scared of suffering a malignancy of any sign they have on the skin. The patient becomes obsessed, and for that reason consults a dermatologist several times during the year. On one hand it’s good, but on the other we have the reason why they do it. We also have the so called tanorexia, which is an obsessive desire of being tanned. The patients don’t accept being pale.” Besides that, as the dermatologist refers, eating disorders such as nervous anorexia or bulimia can also have repercussions on the skin. “It’s common for those short and thin hairs to appear. Alopecia, eczema and stretch marks are also frequent in such cases. There’s a nutritional deficient that is reflected on the skin.” 

“Different skin conditions have serious effects on our self-image, with stigmatizing repercussions, which can by itself cause anxiety, depression, and consequently alter our quality of life.”

As for the skin conditions with mental health repercussions, Judite starts by saying that this group entails “dermatology conditions with consequences on a psychic level, and/or aggravated by emotional factors, stress and anxiety. We have a condition, that condition disfigures us, in a way, and creates stress, which worsens the conditions.” Here, the dermatologist says, “we can frame acne, psoriasis, rosacea, atopic dermatitis, vitiligo and increases sweating,” and in these cases “stress, anxiety and depression are not the cause, but can aggravate, modify the evolution or precipitate some skin condition outbreaks, and in different proportions.” Starting with acne, the dermatologist explains that “anxiety, stress and depression can increase the outbreaks and at the same time, the fact that someone has acne can already be the cause of such situations, especially with women, who even excoriate the acne injuries.” “Normally, this is associated with body image disorders. Everything is connected. They have a low self-esteem, with anxiety and depression,” says Judite. “A lot of times, these excoriates are signs of an obsessive-compulsive disorder and immature personality. The person looks in the mirror, sees acne and starts excoriating, which has no benefits for the acne in question.” As for rosacea, “that is characterized by red skin ion the face, which worsens with sun exposure, oscillations in temperature, nutrition and emotional chocks”, Judite explains that “there is a local vascular imbalance, on the face, and an increased sensibility, responsible for the redness.” On the other hand, she says, such manifestations have psychic consequences. “When rosacea comes, it usually comes to stay, and that has a number of consequences when it comes to depression and anxiety, which aggravates the cycle.” In the case of psoriasis, also very common, one can observe “a big implication in psychosocial and work life, since it’s a chronic disease that evolves through outbreaks, and that can manifest itself through extensive injuries, even distorted ones, which alter body image.” 

“Psychodermatology appears with the need of considering a mixed approach to dermatological conditions. We can say that it’s an intermediate discipline between dermatology, psychiatry and psychology.” 

From the problem to the solution, Judite starts by mentioning that “in order to obtain good dermatological results, even cosmetic, we should always proceed with a global treatment”, in an approach that is echoed by psychodermatology. “Psychodermatology appears with the need of considering a mixed approach to dermatological conditions. We can say that it’s an intermediate discipline between dermatology, psychiatry and psychology,” she says. “This discipline allows dermatologists to have a broader knowledge of the relationship between skin conditions and mental health conditions, in order to give a better therapeutic response, more specific, that goes beyond the dermatological treatment.” When it comes to psychodermatoses, and even though there is no one way answer – the treatment always depends on “the type of patient and the intensity of the problem presented” –, Judite says that, in general terms, “the skin of these patients is sensitive.” “It’s really important to reinforce daily hydration, in order to restore and maintain the physiological balance of the skin’s barrier,” she recommends. “One should use gentle cleansing products, with a pH between 4,5 to 5,5, and cosmetic products that are easy to apply, and that are not too thick. Patients usually reject these kinds of creams. When we give a cream that is not fluid, the patient may complain that it’s too sticky. The cosmetic aspect and the fluidity to the touch is also very important. Products should be easy to apply, they should be non-irritant, and at the same time have an emollient, regenerating, calming, anti-inflammatory and decongesting action.” Besides that, the dermatologist recommends products that are hypoallergenic, non-comedogenic, with no alcohol and fragrance. Judite also refers those with a biological action, which inhibit neurogenic inflammation. “When we control that inflammation, we are able to suppress sensations of discomfort, redness and burning,” she says. “These types of products increase the level of tolerance for a those with reactive skin, allowing for short- and long-term comfort, and a better quality of life.” And if aging is a concern – as Judite Pereira says, “in such a demanding society, the appearance of wrinkles can also influence anxiety and stress, and the indulgence that we can give to ourselves is applying a certain cosmetic product – the dermatologist also recommends using sensitive skin products, and paying a special attention to active ingredients such as gluconolactone, retinaldehyde (a pre-cursor to retinoic acid), vitamin C, DMAE (a biostimulator with a lifting and firming action) and alpha lipoic acid (an antioxidant). 

“Mind and body form an integrated unit, and that’s why health is not only physical, organic, but also mental.”

In a time when we look at wellbeing in a more holistic way, it’s important to not forget the influence that mental health has on our skin, and the influence that our skin conditions have on our mental health. “When we don’t see an evolutive response, favorable to the correct treatment in place, we should weigh the possibility of existential psychic, social or work-related factors, which normally affect the evolution of the condition, and the patient has no idea why,” the dermatologist says. “There’s a whole surrounding that we sometimes miss. We don’t see it, but it’s there and it takes its toll on our everyday life. If the therapeutic response is positive, sometimes stress becomes a secondary, and when we start seeing a certain therapeutic response, this emotional part and this stress become secondary.” As Judite explains, dermatology is aware of the different aspects of skin conditions, that make up a whole in an integrated human being. “Mind and body form an integrated unit, and that’s why health is not only physical, organic, but also mental. With that being said, we shouldn’t leave emotional and psychological factors behind, since skin conditions can be precipitated or influences by them. We should always give an integrated treatment,” the dermatologist believes. “This model has been around since the 70s; in a general sense, looking at a human being, we should consider the interaction of biological, psychological and social aspects. Any change in one of these will always have repercussions on our health.” 

*Originally published on Vogue Portugal's The Madness Issue.