The connection between stress, anxiety and your skin

Skin conditions can impact how you interact with others, and might cause anxiety and shame

Most of us would’ve experienced—and been exasperated by—the stray pimple that pops up on the face right before an important event. Even more commonplace, when worried or stressed out, many start sweating profusely. “When your brain is stressing, your skin starts stressing, too,” says Dr Jyoti Kapoor, founder-director and senior psychiatrist, Manasthali, Gurugram, explaining how our mental health often “pops up” on our skin. 

Our skin isn't just a surface; it's our body's biggest organ, a shield between us and the outside world. Psychoanalyst Didier Anzieu called it our “psychological shell” and coined the term “Skin Ego” to explain how kids develop a sense of self from their own skin. Skin reacts to both physical (like rashes from irritants) and emotional (like blushing when embarrassed) triggers. Skin conditions don't just affect your body, but can also impact how you interact with others, cause anxiety, shame, and even raise sexual concerns.

Understanding the mind-skin association

This intrinsic connection between the mind and skin is what the field of psychodermatology addresses. Kapoor explains it succinctly: “When the embryo is forming, it has three layers: ectodermal, mesodermal, and endodermal. The ectodermal layer of the embryo forms the nervous system, brain, and the skin. The cells that we have in our skin are shared in our brain, which means that our brain and skin are very closely connected.” Kapoor further explained psychodermatology through its three classifications—psychiatric disorders with dermatological concerns; dermatological disorders with psychiatric concerns; and psychophysiologic disorders, or a mix of the former two. According to a study, nearly 30 per cent of dermatology patients have psychiatric and psychosocial comorbidities.

Dermatitis Artefacta (self-inflicted cutaneous lesions that the patient denies having induced), Delusion of Parasitosis (a belief that organisms infect their bodies), Trichotillomania (the recurrent pulling out of one's hair resulting in noticeable hair loss), Neurodermatitis (chronic itching or scaling), and Psychogenic Pruritus (cycles of stress leading to itching and vice versa) are some of the more well-known conditions that belong to the first psychodermatological classification wherein the dermatological concern has a psychiatric underpinning. “Most of these disorders occur in the context of somatoform disorder, anxiety disorder, factitious disorder, impulse-control disorder, or eating disorder,” stated a study.

Psychophysiologic disorders like Psoriasis (44 per cent and 80 per cent patients report being stressed prior to the initial flare and recurrent flares respectively), Rosacea (psychological factors contribute to its genesis and course), Atopic Dermatitis (70 per cent patients report stressful life events preceding its onset), Acne Excoriee (habitual act of picking at skin lesions, driven by psychological factors regardless of acne severity), and Hyperhidrosis (persistent sweating brought on by emotional stimuli) occur when the skin disease may not be caused by stress but appears to be precipitated or exacerbated by stress.

Finally, patients who have dermatological disorders with psychiatric concerns like Alopecia Areata (non-scarring hair loss), Vitiligo (depigmentation of the epidermis associated with more psychosocial embarrassment than any other skin condition), and even severe eczema or acne typically have emotional problems as a result of having skin disease. The skin problems these patients face may not be not life-threatening, but can cause considerable social and interpersonal disturbances. The patients often deal with depression, anxiety, struggle at work, and find it hard to connect with others. “I had a vitiligo patient in her early 20s who had developed one patch in her abdomen and came to me after six months of noticing it. And during these six months, she hadn’t stepped out of the home at all, worrying it might spread. Her social life suffered, she was withdrawn, and depressed,” shares Dr Bishurul Hafi, a dermatologist, cosmetologist, and psychodermatologist based out of Kozhikode. 

Identifying stressors 

For patients with long-term, recurring dermatological concerns that manifested later in their life (like vitiligo), psychological intervention works to help them accept the disease, states Nilanajana Chatterjee Chakraborty, founder-director of Anusharan Mental Health Wellness and Research Center, Kolkata. “When they get the diagnosis, patients become very agitated. It takes them time to come into full-throttle acceptance that it may not be reduced or even cured. So we take different approaches in therapy to help them navigate through it.” 

Hafi says that for psychodermatologists, the evaluation of whether a dermatological concern requires psychiatric intervention starts from a patient’s demeanour itself: “The way they interact with us, if they are overly concerned about the issue, their sleep patterns, relationships, hobbies, general mood as well as eating habits.”

Dr Kiran Sethi, medical director of Isya Aesthetics, New Delhi, agrees, adding that she always checks her patients’ mental status and history in every consultation “so I get a sense of their emotional landscape. Most of the time I find my patients’ dermatological concerns have some application in mental health. If they have acne, they're really stressed about it, and so they're worsening it. Or they're very anxious about hair fall which ends up causing even more hair fall. It becomes a self-fulfilling prophecy.” 

Mental health practitioners, too, emphasise on the role stress plays when it comes to dermatological concerns, be it short term or long term. “Our system is responding to stressors in our environment in the worst ways possible, because the stressors are simply too many. So much so that the stressor is actually mimicking a real pathogen in the blood. The peptides that are released in the blood are giving the brain the indicators that there is a pathogen in the blood, and the brain immediately brings out all its systems in order to defend it. And for some people, the defence is a skin disorder,” elaborates Chatterjee Chakraborty. 

Vasudha Rai, wellness advocate and author, believes that “stress is hugely normalised” and isn’t talked about enough in skincare. “It's perfectly normal—it’s part of life and work. But it can kill our health, our peace of mind, which destroys our hormones, hence creating havoc on our skin.” 

Both Hafi and Chatterjee Chakraborty believe that a shift in the stereotypical image of “good skin” needs to take place, which will aid in a change in mindset, further reducing stress and eventually, the skin concerns. “We have to actually divert the thought process from beauty towards stronger words not related to beauty. It takes a lot of time to increase one’s self esteem, identifying what they're good at, identifying how beauty has no benchmark and is defined by cultural and social standards. We then try to help them navigate their thoughts,” says Chatterjee Chakraborty.

Approaching mental health concerns through skincare

However, the journey from the dermatologist’s clinic to that of a psychiatrist/psychologist is one that many patients are hesitant to chart. In a country where voicing and addressing mental health concerns continues to be taboo, getting patients to consider seeking mental health support for a dermatological concern poses one of the greatest barriers in the practice of psychodermatology, especially when it comes to psychiatric disorders with dermatological concerns.

“I was once sent to a patient whose primary condition was trichotillomania, but she refused to take psychiatric treatment even though the dermatologist explained to her that the problem isn’t with hair growth but with compulsive hair pulling which needs to be treated by a psychiatrist. However, she chose not to get it treated by the psychiatrist and kept going back to the dermatologist to simply treat the patches,” recalls Kapoor. She suggests that in order to help their patients approach mental health care from a space of medical logic as opposed to shame, dermatologists can give their patients evidence in the form of a biological understanding of how mental health concerns affect skin cells—the embryological connection, the effect of cortisol (the stress hormone) on the skin, and so on.

This is why Malvika Jain—founder of Sereko, a psychodermatology-based, research-backed skincare brand—strategised a way to sneak in mental health care through the more familiar and routine practice of skincare. “During the COVID-19 pandemic, one of my cousins was experiencing extreme acne on her face. She was knocking the doors of several dermatologists until one finally referred her to a psychiatrist as she was also suffering from extreme anxiety at the time. Her acne was, in fact, a mental health concern flaring up as a skin issue. After months of psychiatric treatment for anxiety, her mental health improved, and so did her acne. It made me think, why is nobody talking about this?” 

Explaining her brand’s objective further, Jain says, “While anxiety pills are available, there is still a reservation in the mind of the consumer to proactively reach out for medication for stress. That’s why I was sure that I wanted to introduce functional and user-friendly formats that don't intimidate the consumer. It’s something that they'll use every day, and can even be discreet about it. They're just using a serum, which happens to be reducing their stress, too.” Sereko, along with psychodermatologist Dr Mohammad Jafferany, has developed a to-be-patented formula called Neurocalm, “a revolutionary complex that turns stress into serotonin. Its ingredients help improve mental well-being, targeting skin issues caused by mental distress and reversing its effects. It helps reverse the effects of mental stress on the skin,” as stated on the brand’s official website.  

For Aman Mohunta and Prachi Bhandari—co-founders of skincare brand Aminu—too, skincare is more than just skin deep. “Taking the time to care for your skin can be a calming and meditative practice, allowing you to slow down and focus on yourself. When you take the time to nourish your skin, you're also nurturing a positive relationship with yourself, which can have a ripple effect on your overall well-being,” shares Bhandari.

While the evident popularisation of wellness approach amongst skincare brands is undeniably a green flag, psychodermatological issues require sustained and long-term psychiatric and/or dermatological support, along with continued emphasis on a healthy and nurturing lifestyle by the patient, something Rai believes can’t be solved by quick fixes of topical application of products that most people experiencing dermatological concerns seek. “I used to have severe rosacea. Since I started practising yoga and meditation, my rosacea has almost gone. That’s why I see pranayam, meditation, and yoga, too, as skincare. I have seen firsthand the benefits,” she shares, adding that “skincare is an indicator of improving mental health.” 

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