How many times has a new or established patient presented to you with a new onset skin rash that was acute and angry in nature? As you are digging deeper with your patient interview, you find that a large stress (or stressors) has occurred in that person’s life. Sources of stress may include unemployment, divorce, a new baby, etc.
Like me, you probably have suspected that the patient’s dermatitis is no small coincidence given the stress in the patient’s life. Also, perhaps you have shared my reality of waking up with a gigantic acne pustule (that should have its own zip code and mayor) on the face after having a trying day or week at work. Stress and skin are related, and practitioners should keep this link in mind when assessing the patient.
I will preface this by saying I have no formal background in psychology. However, I want to share with you the insights I learned after hearing a lecture by the dermatologist Richard G. Fried, MD.1
Patients can fall into a vicious cycle. A stressful event causes an onset or worsening of skin disease, which causes more stress and the skin disease becomes worse. That same cascade can start at the beginning of skin disease, which then causes more stress and so on and so on.
From a physiologic perspective, Urpe and colleagues say it best: “The skin can be seen as the juncture of the simultaneous and connected activity of brain, immune system, and the skin itself. Neuropeptides, interleukins and immune system messengers are the means through which communication among the three entities takes place.“2
That said, we know it is a complex cascade of cytokines being produced that enhance the inflammatory response in these patients in times of great stress. Due to all of the factors that can contribute to disease progression, we have yet to account specifically for the relationship between stress and conditions such as psoriasis or atopic dermatitis.
A study by Parker and co-workers hits home.3 Mice underwent the stress of smelling fox urine (with the fox being their natural predator) and being restrained for 14 days. Researchers then subjected the mice to ultraviolet B exposure. The stressed mice developed squamous cell carcinoma-like tumors by week eight in comparison with week 21 for the control group.
The study authors concluded, “Although we cannot extrapolate that stress in mice and in humans is identical, the significant acceleration of tumor formation by stress exposure found in this study provides the background support to study the role of stressors in facilitating human cutaneous neoplasms. Further insight in the underlying mechanisms that mediate the accelerating effects of stress on UV mediated carcinogenesis may allow us to design translational psychosocial and pharmacological interventions that can be applied to protect against the development of skin cancers in humans.”3
Keys To Identifying Stress-Related Skin Problems
All right, we have somewhat established a link here. When faced with these patients, what do we do?
First, ask the patient questions that further our understanding of the impact of stress on the skin disease in his or her life. Gupta and colleagues suggest some questions:4
• What does your condition stop you from doing?
• Is your skin disorder affecting your social life?
• Are you frequently worried about the reaction of others to your skin disorder?
• Are you regularly anticipating negative comments about your skin condition from strangers?
• Does your skin disorder affect how you feel about yourself?
• Do you feel anxious or depressed as a result of your skin disorder?
• Is your skin condition affecting your functioning at school or work?
• Does your skin condition interfere with your sleep on a regular basis?
• Is the pain or itching caused by your skin condition very distressing for you?
• Does psychological stress cause your skin disorder to flare up? If yes, have you been experiencing a lot of stress lately?
• Due to your skin condition, do you feel you have to deal with a lot of daily hassles that others do not have?
Second, really listen and be empathetic to the patient’s situation. You will only alienate the patient if you tell him or her the skin rash is in his or her head, and there is nothing you can do. Unfortunately, I have heard that story from my patients one too many times.
Although we as podiatric physicians will not be able to provide for the psychological needs of the patient, we can get a better view of the situation and make the proper referral to a dermatologist or clinical psychologist. Beyond the standard topical or oral dermatological therapy that we could prescribe, the consulting physician might offer the patient talk therapy, antidepressants, biofeedback, hypnosis or meditation techniques for further intervention.
1. Fried RG. The fifth dimension of the skin: psychodermatololgy. Presented at the 7th Annual Orlando Dermatology Aesthetic and Clinical Conference, Orlando, Fla. January 2010.
2. Urpe M, Buggiani G, Lotti T. Stress and psychoneuroimmunologic factors in dermatology. Dermatol Clin 2005;23(4):609-17.
3. Parker J, Klein SL, McClintock MK, et al. Chronic stress accelerates ultraviolet-induced cutaneous carcinogenesis. J Am Acad Dermatol 2004;51(6):919-22.
4. Gupta MA, Gupta AK, Ellis CN, Koblenzer CS. et al. Psychiatric evaluation of the dermatology patient. Dermatol Clin 2005;23(4):591-9.