More Than Skin Deep
The relationship between skin health and mental health:
Skin issues have long been brushed off as superficial and more an issue of cosmetic appearance than medical necessity. However, research has shown the clear impact of skin disease on mental health.
Recently, Shields et al. analyzed stigma towards individuals with acne, and some key findings are (1):
Individuals with severe acne had greater reluctance in socializing, hiring, physical contact, dating, and sharing social media photos.
Individuals with severe acne were more likely to be perceived negatively, and associated with poor hygiene, unattractiveness, lower intelligence, likability, maturity, and trustworthiness.
The stigma was more pronounced for images depicting individuals with darker skin. This raises concerns regarding already existing health disparities and racial biases.
Study participants with a personal history of acne displayed less stigmatizing attitudes.
Having visual skin lesions affects self-esteem, which can cause self-isolation and poor quality of life, manifesting as anxiety, depression, and suicidal ideation. (2) What is unique about the association of dermatology and mental health is that there is no clear delineation of how a particular disorder will affect an individual. Some can have diffuse cystic acne with minimal stress, while others can have major worry over a minor breakout; it is entirely individual.
While skin conditions like acne and eczema (atopic dermatitis) do not have high mortality, they are often compared to fatal illnesses and are therefore neglected. Studies have shown that atopic dermatitis has the highest disability-adjusted life-year (DALY) burden among all skin diseases, and its burden is ranked in the top 15 among all nonfatal diseases. (3) (Sidebar: DALY evaluates the psychosocial effects and humanistic burdens of disease to quantify which diseases affect not only our quantity of life but also our quality of life.) The concept of “itch” is often regarded as a “minor” symptom, but it can cause stress, anxiety, and other mood disorders. Furthermore, diminishing “itch” in clinical settings can lead to detrimental psychosocial outcomes. (4)
What skin conditions do people commonly experience?
The American Academy of Dermatology (AAD) defines the most common skin conditions affecting Americans to be acne, atopic dermatitis, rosacea, psoriasis, and skin cancer. Of those, acne is the most common, with up to 50 million Americans being affected each year. Additionally, 85% of those aged 12-24 years old have experience with acne in some capacity. (5)
What is acne?
Medically: Acne vulgaris is defined as a chronic inflammatory disease of the pilosebaceous unit with a multitude of triggers. Bacterial colonization, hormonal-induced sebum production, and diet have been proposed as etiology, but there is no one determined cause. This makes treatment anything but uniform. Besides active breakouts, acne can lead to scarring and hyperpigmentation leading to a lifetime of its effects. (6)
Translation: Acne is caused by inflammation of the hair follicle, hair shaft, and little glands that make oil on our face. What causes this inflammation? Bacteria, hormones, diet, and more may all play a role, which is why treatment is so individualized. The reason acne can leave scars is because any inflammation in our body can overwhelm normal function, and usually leaves behind some disorganization in its wake. In the case of acne and skin, it usually leaves behind toughness (called “fibrosis”) and greater pigmentation, leading to scars.
What is eczema?
Medically: Eczema, or atopic dermatitis, is a chronic skin condition that causes dry, itchy skin that is prone to infection. Research indicates that genetic mutations in genes such as filaggrin likely play a significant role. Filaggrin is essential for skin cell maturation, and mutations can lead to a dysfunctional skin barrier. This dysfunction results in a “leaky” barrier allowing water loss and skin dehydration, as well as penetration of irritants and allergens, triggering inflammatory responses. Additionally, people with eczema exhibit alterations in their immune responses, predisposing them to infections and heightened sensitivity to various triggers like fragrances and allergens. (7)
Translation: Eczema (also called atopic dermatitis) is a chronic condition that causes dry, itchy skin that is prone to infection. Eczema is thought to be caused by mutations in a protein in the skin. Since the skin acts as your body’s barrier to the outside, mutations in this protein make your barrier “leaky,” allowing water to exit and other things (like bacteria and chemicals) to get in more easily. This makes people with eczema more prone to dry and easily irritated skin, leading to itchiness and redness.
Here’s what people who live with acne or other skin conditions want you to know:
“My skin does not heal easily – do not comment or offer advice/solution for scars!”
- Trisha T. (Georgia Tech)
“Eczema is out of my control and it’s an ongoing struggle to find treatment that works”
- Vera M. (Chapman University)
“Acne has led me to isolate in the past, most severely in college. It made me insecure and honestly I didn’t like to be photographed or seen by my peers. I’ve mostly gotten over it, but I feel too old to have acne at 25.”
- Sel S. (Gainesville)
“Acne, eczema or psoriasis are not an indication of poor hygiene!”
- Ariana A. (West Palm Beach)
“I’ve had eczema my whole life and I don’t wish it on my worst enemy. People constantly give me unsolicited advice but I feel like I have tried it all.”
- Carolina V. (Miami)
“Dealing with adult acne affected my self-esteem to the point where it made me avoid eye contact with people on days when I had severe breakouts because I didn’t want them to look at my face. Looking at my skin in the mornings, I was self-conscious that others would think I was unprofessional or unhygienic. If your colleague or peer is dealing with acne, question your assumptions about why they’re dealing with acne (surprise: a lot of acne is hormonal and difficult to control) and avoid staring at the spots on their face. Allowing others to forget about their skin condition and live without self-conscious thoughts, especially at work or school, goes a long way for their mood, confidence, and productivity.”
- Anonymous (Florida)
How can I be a better peer or friend to someone who might be struggling with their skin?
Refrain from commenting on skin's appearance. Anyone with acne is well aware they have a spot no matter how small and do not need anyone else to bring a comment to it.
Do not make product recommendations without being prompted. While this may seem helpful, those with acne may have tried multiple products and be frustrated by their skin’s lack of response to what seems to work for most people. Remember: there is no one-size-fits-all treatment for acne!
Be a good listener. Empathize with your friend when they are venting about their skin. Avoid diminishing their complaints by brushing off their acne as minor; this can do more harm than help. Acknowledge that is frustrating for them and you are here to listen.
Challenge negative self-talk by encouraging your friend to frame themselves in a more positive light. Again, we are not diminishing their struggles but encouraging a more positive self-reflection.
What are some steps I can take to improve my skin health and prevent acne (if I want to)?
Wash your face every evening. If you wear makeup, use a dedicated makeup removing cleanser to wipe it away. Follow that with a skin cleanser, either gentle (think Vanicream or Cerave) or an acne-targeting wash (salicylic acid or benzoyl peroxide are power ingredients for treating oily skin). Experiment with what works best; if your skin becomes too dry or irritated, steer clear of the active ingredients.
Do not pick! This is tempting and instinctual but imperative for healing for minimal scarring. Use a hydrocolloid patch from brands such as Starface and Mighty Patch. Hydrocolloid helps draw the inflammation up from the pimple but these patches additionally act as a physical barrier to prevent wandering fingers from picking.
Wear your daily SPF. Aside from the benefits of preventing skin cancer, wearing sunscreen can prevent active acne from persisting as hyperpigmentation and keep sensitive skin protected from sun rays.
Maintain a healthy and low-sugar diet to minimize acne flares. While there is not a lot of concrete research supporting the link between acne and diet, studies show that there may be a connection between acne and the food you eat. Adopting a low glycemic (aka low sugar) diet consisting of mostly fresh vegetables, fruits, beans, and steel-cut oats may help. Avoid fried food, white bread, sugary beverages, and over-indulgence of sweets. Studies also suggest cow’s milk contributes to acne even though it is considered low-glycemic. A.k.a. try limiting dairy and see how your skin responds! (8)
When should I go to the doctor for my skin?
There is no definite timeline for when you should see a dermatologist (a doctor specializing in the skin); it’s dependent on your knowledge of what you are treating and how comfortable you feel with assessing products that work for you. This tool by the AAD can help determine if it would be helpful:
Bottom line: If you have been dealing with acne for a day, a week, or even a year, seeing a dermatologist would benefit you in determining the cause of your acne, providing prescriptions to treat it, and providing crucial support. Acne is not unanimous in its etiology so neither is treatment. A dermatologist can provide you with a custom routine.
What kind of doctor or provider do I go to for help with my skin?
You can see a dermatologist, dermatology PA, or dermatology NP. What’s the difference?
A dermatologist is a physician (aka a doctor) who completed four years of medical school (a doctorate degree), one year of residency training in internal medicine or surgery, and three years of residency training in dermatology. These doctors have the credentials MD or DO after their name.
A dermatology PA (physician assistant) is a provider who completed two years of a physician assistant program (a master's degree) and dermatology training from their supervisors and/or employers. These providers have the credentials PA-C after their name.
A dermatology NP (nurse practitioner) is a provider who completed two years of a nurse practitioner program (a master's degree) after nursing school and dermatology training from their supervisors and/or employers. These providers have the credentials ARNP, CRNP, CNP, or LNP after their name.
To find out which providers specialize in the specific area you’re concerned about, visit their practice website to learn more about their expertise and experience.
Fun Fact: Psychodermatology explores skin problems affected by stress and conversely, psychological problems caused by disfiguring skin disorders. (9)
How do I find a dermatologist or other provider?
Visit your insurance provider’s website to determine which providers are covered under your insurance.
Additionally, you can use find-a-derm.aad.org for providers as determined by the AAD.
This resource can guide you through finding what provider is the best for you.
Some dermatology visits may require a referral from your primary care provider for your insurance to help pay for them. Getting a referral from your primary care physician might be as simple as a telephone or video consultation. If you’re unsure if you’ll require a referral, call your insurance provider to ask.
Dermatology has long wait times to get established with a provider, so patience may be key! Many dermatologists employ highly skilled physician assistants and nurse practitioners that you can see sooner and initiate care.
Mobile Dermatology clinics are becoming more popular and accept most insurances. For example, On Spot Dermatology in Florida pops up in local communities and neighborhoods, and takes both appointments and walk-ins while providing comprehensive dermatologic services.
Where Can I Learn More?
Practical Dermatology, Perspective: Mental Health is Skin Health
American Psychological Association, The Link Between Skin and Psychology
Disclaimer: The information above is intended to provide education and advocacy regarding dermatologic conditions. It is not medical advice and should not be used for medical diagnosis. For questions regarding diagnosis, treatment, and more regarding any medical conditions, contact your healthcare professional.
Published: February 5, 2024.
Written by Emily Woolhiser (Medical Student) and Alexandra Lawlor (Medical Student).
References
Shields, A., Nock, M. R., Ly, S., Manjaly, P., Mostaghimi, A., & Barbieri, J. S. (2024). Evaluation of Stigma Toward Individuals With Acne. JAMA dermatology, 160(1), 93–98. https://doi-org.proxy.kansascity.edu/10.1001/jamadermatol.2023.4487
Cortés H, Rojas-Márquez M, Del Prado-Audelo ML, Reyes-Hernández OD, González-Del Carmen M, Leyva-Gómez G. Alterations in mental health and quality of life in patients with skin disorders: a narrative review. Int J Dermatol. 2022;61(7):783-791. doi:10.1111/ijd.15852
Fasseeh AN, Elezbawy B, Korra N, Tannira M, Dalle H, Aderian S, Abaza S, Kaló Z. Burden of Atopic Dermatitis in Adults and Adolescents: a Systematic Literature Review. Dermatol Ther (Heidelb). 2022 Dec;12(12):2653-2668. doi: 10.1007/s13555-022-00819-6. Epub 2022 Oct 5. PMID: 36197589; PMCID: PMC9674816.
Sanders KM, Akiyama T. The vicious cycle of itch and anxiety. Neurosci Biobehav Rev. 2018 Apr;87:17-26. doi: 10.1016/j.neubiorev.2018.01.009. Epub 2018 Jan 31. PMID: 29374516; PMCID: PMC5845794.
Skin conditions by the numbers. Accessed January 21, 2024. https://www.aad.org/media/stats-numbers
Williams HC, Dellavalle RP, Garner S. Acne vulgaris. Lancet Lond Engl. 2012;379(9813):361-372. doi:10.1016/S0140-6736(11)60321-8
Nemeth V, Evans J. (2022). Eczema. In: StatPearls. StatPearls Publishing. PMID: 30855797.
Can the right diet get rid of acne? Accessed January 22, 2024. https://www.aad.org/public/diseases/acne/causes/diet
The link between skin and psychology. https://www.apa.org. Accessed January 21, 2024. https://www.apa.org/monitor/2015/02/cover-skin
