Dr. Alia Ahmed Explains Psychodermtology, The Skin’s Impact on Mental Health

How would you define pyschodermatology? Is it the physical connection between the skin and the mind?

Dr. Alia:  Yes, I do define it like that. So, when I was getting my BSc in psychology, I learned about psychoneuroimmunology or PNI. PNI is basically how thought affects the brain’s neurological functions, and in turn, how the brain affects the immune system. Then finally, how the immune system affects everything else.

There is an abundance of evidence that confirms the link between the mind and skin. We know it exists. For instance, the stress axis is one of those massive areas of evidence to support that. More simply, stress and cortisol can affect the immune system and make it less able to defend itself. Stress drives allergic responses, it can delay healing, change the skin barrier, and predispose your skin to redness, dryness, itchiness, and early signs of aging.

Conditions like eczema, psoriasis, hair loss, hives, and acne are all related to the stress axis. So, psychodermatology is the part of dermatology that conjointly examines the mind and skin. Therefore, we're not only offering you a solution for your skin concerns, but we're also saying that it’s just as important for you to tell us how you feel about your skin.

Because if I don't know how you feel about your skin whilst giving you a treatment plan, how do I know that you're going to stick to that? What if the patient hates their skin, and meanwhile, I’m telling them to put a cream on it five times a day. If the patient doesn’t want to wash their skin because they hate it or perhaps they’re so depressed that they’re staying in their room all day or won’t look at it, how can I be sure that they’ll be consistent with the treatment plan without addressing that? People have even told me that they've had to shower in the dark because they don't want to look at their own skin.

So, because the burden of the treatment is mostly on the patient, psychodermatology and asking about their behavior becomes very important. If I don't know how you feel about your skin, I can't guarantee that you're going to stick with a treatment plan. So, it's important for me to explore what happens with the patient when they’re not in the clinic. 

What are a few misconceptions about psychodermatolgoy?

Psychodermatology is not telling a patient,“Oh, go and do some mindfulness, and your acne will go away. Go do hypnosis, and your eczema will get better.” It's definitely not saying that. We know that psychological interventions have a medium-sized effect on skin conditions. We're not just telling you to go and practice relaxation; we're giving you skin-directed treatment that you'll be happy with and be able to use effectively. 

For example, a psychodermatologist might say, “Okay, you seem quite anxious, and you've also mentioned to me that you're not sleeping well. Let’s find some solutions for your sleep.” I acknowledge how things like this drive the stress axis, and likewise, the skin condition. 

Your platform advocates for changing language that pathologizes* skin conditions. Did this intention drive you towards psychodermatology?

*Makes it seem abnormal or unhealthy

Dr. Alia: I think so, yes. I was always interested in why people behave in certain ways. So, when I studied psychology during my BSc, I delved into it whilst also studying health psychology. Health psychology deals a lot with health behaviors and how people look after themselves. 

Behavior and health are inextricably tied together, and that’s why I’m very holistic in my practice. I find it necessary to focus on how the mind physically affects the rest of your body. For example, when you're stressed, your body releases cortisol, and cortisol can affect everything, including your skin, heart, and sleep. 

Once I discovered this, I became more interested. So, when I truly began talking to patients about their skin, I began to see how psychologically impacted they were by it. Likewise, I started to become very conscious of the way I spoke about their skin concerns. I didn’t want them to feel as if their skin was a sin. 

Basically, if you've got acne, it’s not a punishment. If you've got psoriasis, it's not bad. It’s normal. And that's what I’ve always tried to convey to everyone - that it’s normal. 

If your skin or nails bothers you, we can do something about it, but it's not like you’re less than anyone else. So, I think this type of perspective really led me to pursue psychodermatology. 

So would you say that mental health is very linked to skin health?

Dr. Alia:  It’s almost like looking at two sides of the same coin. One of my colleagues says this all the time. Having poor mental health or having a problem that affects your mental health can affect your skin. Concurrently, skin problems can also affect your mental health.

This is where it becomes a vicious cycle. As mentioned before, that’s where psychodermatology comes in. We try to break that cycle. Because without addressing the mental health aspect, then to what extent are we truly treating the patient? A patient’s quality of life is just as important as treatment success numbers. If the patient says,“I'm feeling great. I'm doing everything that I want to do, and I've got my life back on track,”  to me, that’s actually what defines treatment success. 

Would you say that psychodermatology plays a larger role in treatment or prevention?

Dr. Alia: It's very difficult to prevent skin problems. However, if someone with eczema is extremely stressed, the condition can really flare up, and there are plenty of studies to support that. 

Therefore, in psychodermatology, there are primarily two groups of people. We see people who are psychologically distressed because of dermatological conditions, and we see people whose skin concerns are due to psychological conditions. 

These are the conditions like dermatillomania/skin picking and hair-pulling. So, in terms of prevention within psychodermatology, we mostly prevent problems like this. If there’s a patient who has a tendency towards restrictive eating or repetitive behavior patterns like excessive handwashing, we want to prevent those because these habits can lead to other detrimental, repetitive behaviors and likewise detrimental skin concerns. 

When people come in with skin conditions that are driven by stress, we try to address how they manage and deal with the stress. Additionally, we do this to help prevent flares. Again, we also make sure that the patient can maintain the treatment, and this is largely preventative.

Because treatment is largely linked to the individual behaviors of the patient, would you say that addressing the mental state of the patient largely impacts prognosis*?

*The predicted progression or decline of a disease or condition

Dr. Alia:  Definitely. Even if we’ve given patients the highest level of medical treatment for that condition, the patient might still say  “This treatment isn’t working for me” if we haven't solved the mental health issue. Furthermore, they may become discouraged and stop using the treatment completely.

Some patients are so chronically impacted by what their skin has done to their lives, that even when their skin is 100% clear, they still don't feel any better. If the patient is able to attain improved skin, but they still don't feel happy, is that a treatment success or treatment failure? It’s not certain, but given the importance of patient participation during treatment, I would say  yes, prognosis is very linked to mental state. 

Can you give me an example of how you would address excessive behaviors in a psychodermatology patient (i.e obsessive skin picking or restrictive eating)? What are some of the questions that you would ask the patient?

Dr. Alia: Once I’ve identified repetitive behavior like skin picking, hair pulling, or obsessive skin checking, then, I need to work out how bad it is on a scale of 1 to 10. Now, some skin picking is normal, but I'll try to determine where the behavior is on a spectrum. To figure this out, I’ll ask questions like the following: 

What is it that you're doing exactly? 

Are you picking the skin? 

Are you pulling your hair? 

Are you looking in the mirror?

Next, if I find that the patient is doing something physical like skin picking, I’ll ask what they are using and when? 

(Ex: Are you using your fingers? Are you doing it with a tool? Are you using tweezers, and where do you keep them? How often are you doing it?)

Some people don’t realize the severity of their behavior. For instance, if they’ve looked in the mirror 100 times, they may not even realize it. 

But then, their partner might say to me  “She or he is always in the mirror, and in fact, it's so bad that I’ve taken the mirrors down in the house.” 

That's when you know there's a problem. Also, a lot of repetitive behaviors are not done in front of anyone else. They're in isolation. So, I’ll ask if they’re doing it at night, if they’re doing it it the bathroom with the door locked, and if anyone knows.

Because sometimes people can hide these things really well, it’s important for me to ask. For example, a lot of people who pick their skin tell me that they've just got acne. But when I see them, I will tell them,  “This is not acne.” 

And they’ll admit,  “Yes, you're right. It's not. I'm a skin picker…”  

They’re not trying to be dishonest; they just needed me to say it first. 

From that point, I’ll go into deeper questions like these:

Why do you do it? Do you do it when you're upset? Do you do it when you're anxious? Is there a trigger event? Can you tell me? 

Sometimes, there are tools and scales that we can use to look at the severity of these situations. For example, if someone's got body dysmorphia, there are scales that indicate where they are on a spectrum. As a psychodermatologist, we can use these tools to assess and ask questions about how much a patient’s restrictive or obsessive behaviors impact their life. 

(Ex: Are you often unable to go out with friends because nothing falls in your meal plan? Are you apprehensive about them knowing this? Have you picked your skin so much that you don’t go to social events? Do you avoid relationships so you can hide the picking?)

Sometimes people pick in hidden areas. They may not pick on their face. They may be picking on their legs, around their belly button, on their fingers, on their feet, and all sorts of places. 

Moreover, sometimes, people are very ritualistic or perhaps everything has to be very neat. In this case, I would ask the patient,“Do you have to do everything in a certain order before you leave the house? And if the order gets messed up, do you have to start again?”

Patients’ answers never surprise me because certain behaviors tend to happen together. People often have comorbidities.*

*Conditions that often occur together.

Have you seen conditions like melasma have a similar impact to acne on the mental state and behaviors of patients?

Melasma actually can be particularly psychologically devastating issue. A lot of times, melasma patients have had treatment failures, and they want to cover it.

Because the condition has a lot to do with estrogen, it disproportionately happens a lot to women, and it usually happens at a time in life where the woman wasn’t expecting to have a skin problem. And when the patient already has low appearance-related body satisfaction, it can be even more upsetting. So, in terms of self-image, yes, melasma can make women very conscious of themselves. There are definitely studies that show how women are more impacted than men and studies that demonstrate how women are much more self-conscious. Overall, severe skin concerns are more associated with anxiety, depression, and worrying behaviors in women. 

Sometimes these thoughts and behaviors are also compounded by cultural expectations or standards. However, there's usually a good treatment options available. And when they start to get treated, they also start to feel better. 

Nobody can promise 100% the patient won’t have anything left at the end of their treatment. But, when we look at the studies of people that have received treatment, a lot of them are feeling so much better towards the end of treatment. So, there's treatment out there, and rather than let yourself be internally stigmatized or let melasma run your life, don't let it take over, or remember that treatment is an option. Talk to someone about it and also learn how to respond to people’s comments. Because most of the time, it's the comments made like  “What’s on your face?” that affect us. So, be ready to say  “Well, actually I have a condition called melasma. I don’t like to talk about it, and I’m seeing the doctor. Shall we change the subject?” I think these are some of the basic things that I would suggest for melasma  patients.

Do you believe that psychodermatology can help address patient experiences around conditions like alopecia and vitiligo? 

So, given that hair problems, skin problems, and nail problems are usually visible, every dermatology patient that walks in is a psychodermatology patient. Even if they are in hidden areas that the public can’t see, they still really bother patients. So, psychodermatology has a role to play for anyone that comes to see a dermatologist. I do a clinic where I only see hair patients. I don’t see anything else the whole day because people are so significantly and psychologically impacted by hair loss.

Consequently, you have to manage their expectations. Many of them have had a lot of treatment failures. So, you have to build up a trusting relationship with them. You have to reassure them because hair loss treatment normally takes a long time. Often times, we won’t know if it’s working until about six months. So, the conversation has to be very reassuring.

With things like vitiligo, there’s a visible difference, but it’s normal for that person. Vitiligo is a person’s skin journey, but there are so many things like culture and stigmatization. Unlike melasma, vitiligo doesn’t have that many good treatments. I do offer some because there is evidence for some treatments. However, I often talk about acceptance with vitiligo patients because I can’t guarantee that their skin won’t regress upon stopping the treatment. So, instead, I offer a lot of support 

Ultimately, pyschodermatology gives you so much insight into a patient. With that insight, I think you can work with them in a better way and offer the patient experience that they deserve.

Because until I know what is happening to the patient and how they feel, I don’t think I can provide the best level of care. 


Coverphoto cred: Dr. Alia Ahmed