The Mind-Skin Stress Connection

The Skin Cancer Foundation

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Does your state of mind affect your skin health, or does your skin health affect your state of mind? The link works both ways! Our experts explain what you need to know and how to mitigate the damage.

By Jen Singer

As the pandemic began its second year early in 2021, it seemed like an important time to talk about stress and your skin. With more contagious new variants of COVID-19 grabbing headlines, continuing shutdowns and the uncertainty of the vaccine supply, Americans were more on edge than ever. Dermatologists were seeing the evidence.

“You can tell a lot about someone before you even speak with them just by looking at their skin,” says New York City dermatologist Elizabeth K. Hale, MD, a senior vice president of The Skin Cancer Foundation. She says she sees a correlation between her patients’ skin and emotional well-being, “because when your skin looks good, you feel good, and you feel better about yourself.” Unfortunately, the opposite is also true.

Earlier in the pandemic, in April 2020, surveys found that the number of adults reporting symptoms of anxiety, stress and depression was three times higher than in April 2019. Data from the CDC showed that those symptoms increased as the pandemic progressed. By August 2020, people were hitting what a New York Times op-ed called the “pandemic wall,” as a Kaiser Family Foundation survey showed that 53 percent of American adults said their mental health was suffering.

The Skin Cancer Foundation heard from dermatologists at major cancer centers and in private practice who reported that as patients feared exposure to the virus, many avoided or postponed their regular appointments. For people at high risk of skin cancer, putting off an exam for months can increase the risk of diagnosing the disease when it is more difficult to treat. In some cases, it can even become life-threatening. For patients who have skin conditions such as psoriasis, rosacea, eczema, acne and dermatitis, which can be affected by psychological stress, their symptoms often got worse, too.

What Is Psychodermatology?  

“There is indeed a bidirectional association between stress and the skin that can make skin behave badly,” says Richard Fried, MD, a board-certified dermatologist and clinical psychologist in Yardley, Pennsylvania. Even before the pandemic shone a spotlight on these problems, though, the field of psychodermatology was emerging. A 2016 article in the international journal Acta DV defined this “relatively new” field of medicine as encompassing the interaction of mind and skin, with treatments focusing on “improving function, reducing physical distress, diagnosing and treating depression and anxiety associated with skin disease, managing social isolation and improving patients’ self-esteem.” But the concept itself isn’t new, of course. As the article states, “Hippocrates (460-377 BC), in his writings, mentioned the effects of stress on skin. He cited cases of people who tore their hair out in response to emotional stress.”

What Hippocrates didn’t know is that in the earliest stages of an embryo’s development, different tissues and organs develop from three different germ layers (groups of human cells). Turns out, the skin and the nervous system both originate from the same germ layer, which may explain why they interact so intimately.

Only Skin Deep

Unlike other medical conditions, such as diabetes or hypertension, a skin condition is hard to hide. Though studies in other fields of medicine, such as gastroenterology and cardiology, have uncovered an overlap with psychology, dermatology is unique. “The thing that’s different about the skin is that people can see it,” says Evan Rieder, MD, a board-certified dermatologist and psychiatrist at NYU Langone Health. “On social media, you’ll see that people are posting pictures about their skin, inflammatory conditions and their cosmetic procedures more than other types of conditions.”

Another phenomenon is the rise of people staring at their own faces while on video meetings day after day, a trend that seems likely to continue long past the pandemic. “Normally, people get up in the morning and look in the mirror, and they come home from work and look in the mirror before they go to bed,” Dr. Rieder explains. “When people are allowed to gaze at their own image for extended periods of time, they often start to scrutinize details about their faces in ways that are not necessarily healthy.” As people are looking at themselves more often and perhaps in a harsh or revealing light, it’s taking a toll. He reports that patients have asked for more aesthetic procedures to improve their appearance and have asked about treatment for hair loss or thinning hair more than usual, too.

Dermatologists also saw an increase in the effects of long-term mask-wearing, including the rash around the mouth called perioral dermatitis by physicians and “maskne” by many who experienced it.

Some psychological disorders actually take place on the skin, such as body-focused repetitive behaviors (BFRBs). This obsessive-compulsive disorder may include repetitive hair pulling, nail biting or skin picking. BFRB symptoms are linked to anxiety levels — as someone with BFRB gets more stressed, the BFRB symptoms get worse. Unsurprisingly, people with BFRB reported an increase in their BFRB symptoms during the pandemic.

Stress and Skin Cancer

Ultraviolet (UV) light from the sun is the main source of skin damage that can lead to skin cancer. However, stress may also play a role, as it causes the body to produce unstable oxygen molecules called free radicals. Those can increase inflammation and damage your skin’s DNA, leading to mutations and, possibly, skin cancer.

Being diagnosed with skin cancer can lead to psychological distress in a number of ways. It’s the “c” word, for one thing. Patients may worry about the cancer spreading or recurring. They may feel nervous about the treatment, or about surgery causing disfigurement, especially if the cancer is on the face, head or neck — the most common sun-exposed areas. In fact, Dr. Hale reports that some patients resist the removal of skin cancers from cosmetically sensitive areas, fearing the scar more than the disease.

She counsels her patients not to fear treatment. “The face actually heals the best,” she explains. “It has the best blood supply, and it’s the most forgiving.” She says that while it’s important to ensure that all the skin cancer is removed, dermatologists can also deliver the best cosmetic results possible. “The scars can be reasonable and not disfiguring, blending into natural wrinkles and folds. Laser treatment can help minimize scars, too. It’s crucial to get your skin cancers treated as early as possible for your own health and well-being.”

When people are allowed to gaze at their own image for extended periods of time while on video meetings, they often start to scrutinize details about their faces in ways that are not necessarily healthy.

What You Can Do

“Our skin conditions profoundly affect our quality of life, our psyche, our self-confidence and the way that we interact with the world,” Dr. Rieder says. So, it is important to get help and treatment.

Speak up. Don’t be afraid to share how your skin issues are affecting your mental state, or vice versa, so you can get the help you need. Dr. Rieder creates treatment plans that can include dermatologic medications but may also include psychological therapies.
Don’t procrastinate. Dr. Hale tells her patients not to wait to get their skin checked or to treat precancerous and cancerous areas on the skin. “Skin cancer, although it is the most common cancer, is also the most curable when it’s caught early,” she says. Putting off treatment after a diagnosis only increases worry; getting it done can be a great relief.
Develop a good relationship with a dermatologist. Maintaining a regular schedule of visits with your dermatologist can help you prevent skin problems and, if needed, treat skin cancer early. It also helps develop trust and confidence in your doctor. Dr. Hale says that means an annual full-body skin check for most people over age 18, or every six months if you’ve had a precancerous growth or skin cancer removed.
Take an active role. Dr. Fried says that psychological therapies can help heal the skin. “We know that yoga, tai chi, progressive muscle relaxation and mindfulness meditation all improve skin function and enhance the ability of standard treatments to work.” Dr. Hale (who is a runner herself) recommends aerobic exercise to increase blood flow to the skin and reduce feelings of stress.
Avoid sugar and junk food. Eating a healthy diet high in antioxidant-rich, colorful fruits and vegetables can help fight free radicals and inflammation in the skin and make you feel great.

The Ultimate Stress Test: Advice from a Cancer Survivor

Waiting for biopsy results that may lead to a cancer diagnosis is a type of worry that only those of us who’ve gone through it can understand. Tom Petty was right when he sang, “The waiting is the hardest part.” For me, it was stage III non-Hodgkin’s lymphoma, and I had a tumor in my left lung. I would have to face chemo and radiation therapy that would test me in different ways, but even now, after 13 years in remission, I still remember how powerless I felt before hearing that diagnosis.

If you’ve been suspected of having skin cancer, you know all about the waiting. Even if you’ve had more than one, it doesn’t get easier. Because my radiation treatments left the skin on my chest inflamed, it increased my odds of getting skin cancer. In fact, I’ve already been diagnosed with an actinic keratosis (AK), a common kind of precancer that can lead to squamous cell carcinoma. My dermatologist removed the pearly lesion from the base of my neck and gave me a topical chemotherapy ointment fittingly called 5-FU, LOL. (It makes you a little sore and scabby but is nothing like the systemic kind of chemo; trust me.)

I’d thought it was all behind me, but odds are, I’ll have more AKs, so I need to remain diligent about checking my skin and visiting my dermatologist, and I’ll likely have to await more biopsy results. When I do, I will abide by some tips I learned from my previous cancer experience. Maybe they will help you, too.

Ask how you’ll hear. Be sure to ask your doctor how long it will take to get results from the lab (most skin biopsies take about a week) and how you’ll receive your results. Will a nurse or a doctor call, or will it be posted in the online patient portal? Knowing the process can reduce anxiety while you wait.
Get a sense of what to expect. At the time of your biopsy, ask your doctor what happens next if you do receive a diagnosis of skin cancer. What type of treatment might be required, and what might the recovery entail? The more you know, the more you can control your reaction and mitigate the worry.
Be thoughtful about who you tell. People mean well, but some don’t know how to support others in a useful way, because they’re an Eeyore or Tigger type. You remember those characters: Eeyores see the glass as half-empty, and they worry for you and your results. They may share dire statistics and worst-case scenarios that likely don’t even apply to you. Tiggers, on the other hand, believe that your positive attitude will see you through, leaving no room for your very valid fears. You’re better off with a Winnie-the-Pooh, someone who just puts their arm around your shoulder and patiently waits with you. Come to think of it, this is good advice not only while waiting on biopsy results, but also throughout any diagnosis and treatment.
Trust your instincts. Do you prefer to wait in private, distracting yourself with work or fun? Do you like to hash it out with trusted friends, or do research online so that you have as much information as possible when you get your results? There’s no one way to endure the waiting — or what might come afterward — but make sure it’s the one that works for you.

Jen Singer is a health writer based near New York City.

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