Psychodermatology at a Glance

Psychodermatology is a relatively new field of study that dives deeper into the interplay of mental health and skin disorders. The skin and brain originate from the same embryonic tissue, the ectoderm, and remain intricately linked throughout life through neural, hormonal, and immune pathways.¹ Therefore, the mind can influence a multitude of conditions, including eczema, psoriasis, alopecia, and acne. The simplest way of psychology manifesting into physical results is the worsened mental health that these conditions bring. For example, alopecia, which results in the loss of hair, worsens confidence and, consequently, mental health. This leads to a cruel cycle of negative psychology, directly resulting in worsening conditions.²  Since the early days, prominent scientists such as Hippocrates and Freud have hypothesized that stress can directly affect mental health. Though their understandings were only fundamental, they have paved the way toward our modern insight. The contemporary understanding is that, due to the embryological link between the brain and skin (ectoderm), there are multiple mechanisms of connection. The most well-understood of these is the neuroendocrine pathway, through which psychological stress triggers a cascade of hormonal, immune, and neurogenic responses that directly compromise the health of skin and hair.³ 

Stress and emotion are seen as being intangible, but they manifest biologically through hormones, immune responses, and inflammation that can fundamentally alter the health of our skin and hair

The neuroendocrine pathway is essentially there to say that when a person is experiencing stress, the hypothalamic-pituitary-adrenal (HPA) axis releases corticotropin-releasing factor (CRF), ACTH, and cortisol.⁴ These elevated levels of cortisol disrupt the skin barrier, delay wound healing, and can even prematurely shift hair follicles from the growth (anagen) phase to the resting (telogen) phase. Stress also alters immune balance, increasing pro-inflammatory cytokines, including interleukin-6 (IL-6), interleukin-1β (IL-1β), and tumour necrosis factor-alpha (TNF-α).⁵ Not only can this worsen inflammatory skin diseases, but it can also trigger autoimmune reactions such as alopecia areata. In hair follicles, stress-related inflammation damages the hair follicles, leading to shedding and delayed hair regrowth. Further research also shows that stress generates reactive oxygen species that damage DNA and proteins in hair and skin cells.⁶ With cortisol also reducing protective molecules like hyaluronan and proteoglycans, it promotes a weakened follicle structure and early regression of the hair cycle. Finally, with neurogenic and sensory signaling, it is evident that the skin, rich in sensory nerves that release neuropeptides (such as substance P, CGRP, and VIP) during stress, can cause inflammation, increase blood vessel permeability, and stimulate immune cells, all of which negatively affect the hair follicle.⁷ This process, as previously mentioned, creates the cycle where stress sensations worsen inflammation, and so as visible symptoms increase, so does stress perception. 

One of psychodermatology’s biggest challenges is objectively measuring stress. However, this invites opportunities for further research to be done, focusing not only on biochemical markers but also on understanding how personal perception of stress shapes physical outcomes. Currently, researchers measure it with both subjective and biological indicators. Subjectively, scales such as the Perceived Stress Scale⁸ and Hospital Anxiety and Depression Scale⁹ assess stress levels. Biologically, stress is measured by looking at HPA-axis markers, such as cortisol and inflammatory cytokines, which show that the neuroendocrine and immune pathways are on.¹⁰ Other scales further note heart rate variability and behavioral observations in an attempt to fully measure a person's stress. 

https://video.wixstatic.com/video/4fbae2_8aeb0a1810d84f76aa1ec99e48f34c5f/480p/mp4/file.mp4

To fulfill a holistic assessment, psychodermatology is forced to take on a unique approach compared to traditional dermatology treatments. Instead of creams or medication, therapy and stress reducers come into play. Therapy for stress management, for example, has been shown to reduce flare-ups in conditions like acne and psoriasis.¹¹ The psychiatric and psychosocial burden within dermatological populations is substantial: approximately 30% of patients presenting to dermatology services exhibit comorbid psychiatric or psychosocial disorders, which meaningfully compound the disability associated with their skin condition.¹²  Of particular concern are elevated rates of suicidal ideation, reported in approximately 8.6% of dermatology outpatients—a figure that underscores the importance of routine psychological screening within dermatological practice.¹³

Psychodermatology reveals how deeply connected the mind and body truly are. Stress and emotion are seen as being intangible, but they manifest biologically through hormones, immune responses, and inflammation that can fundamentally alter the health of our skin and hair. Still, as much as science explains the mechanisms, the field also challenges medicine to look beyond the physical, emphasizing the importance of treating patients as whole beings. 

---

 1. Arck, P.C., & Paus, R. (2006). From the brain–skin connection: The neuroendocrine–immune misalliance of stress and itch. Neuroimmunomodulation, 13(5–6), 347–356.

 2. Slominski, A., & Wortsman, J. (2000). Neuroendocrinology of the skin. Endocrine Reviews, 21(5), 457–487.

 3. Arck, P.C., Slominski, A., Theoharides, T.C., Peters, E.M.J., & Paus, R. (2006). Neuroimmunology of stress: Skin takes center stage. Journal of Investigative Dermatology, 126(8), 1697–1704.

 4. Chrousos, G.P. (2009). Stress and disorders of the stress system. Nature Reviews Endocrinology, 5(7), 374–381.

 5. Roosterman, D., et al. (2006). Neuronal control of skin function: The skin as a neuroimmunoendocrine organ. Physiological Reviews, 86(4), 1309–1379.

 6. Paus, R., et al. (2006). The skin–brain axis: New insights into the complexity of the skin–nervous system relationship. Annals of the New York Academy of Sciences, 1088, 311–326.

 7. Liu, J., et al. (2018). Neurogenic inflammation in the skin: Mechanisms and clinical implications. International Journal of Molecular Sciences, 19(3), 742.

 8. Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385–396.

 9. Zigmond, A.S., & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67(6), 361–370.

 10. Theoharides, T.C., et al. (2012). Atopic dermatitis: A skin–brain axis disorder? Journal of Clinical Psychopharmacology, 32(5), 589–591.

 11. Picardi, A., & Abeni, D. (2001). Stressful life events and skin diseases: Disentangling evidence from myth. Psychotherapy and Psychosomatics, 70(3), 118–136.

 12. Dalgard, F.J., et al. (2015). The psychological burden of skin diseases: A cross-sectional multicentre study among dermatological out-patients in 13 European countries. Journal of Investigative Dermatology, 135(4), 984–991.

 13. Gupta, M.A., & Gupta, A.K. (1998). Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. British Journal of Dermatology, 139(5), 846–850.