The skin and the mind are closely connected: What affects the skin can influence how we feel, and our thoughts and emotions can also show up on the skin. Psychodermatology is a subspecialty of dermatology focused on conditions in which skin and mental health disorders overlap.

“Studies show that patients with skin diseases are 30% more likely to have psychological disorders than patients with diseases affecting other organs. In fact, if we asked any of them whether they believe their condition worsens with stress, 9 out of 10 would say yes,” noted Aurora Guerra-Tapia, MD, PhD, medical director of Dermatólogas Guerra, full professor of dermatology at the Complutense University of Madrid, and former head of the Dermatology Department at University Hospital 12 de Octubre in Madrid, Spain.

Most of the time, patients visit a dermatologist because of a skin lesion they interpret as a skin disease. For example, a patient may present with excoriations in dermatitis artefacta, erosions and burrows in the setting of delusional infestation, alopecia in trichotillomania, or hypertrichosis in anorexia nervosa, along with symptoms such as itching, tingling, and pain. Even when the lesions are self-inflicted, the patient often believes the skin, rather than the mind, is the source of the problem. So an experienced dermatologist is essential to immediately recognize the true origin of the condition. “The difficulty lies not in the diagnosis but in the comprehensive treatment of both the skin and the mind at the same time,” Guerra-Tapia explained to El Médico Interactivo, part of the Medscape’s Professional Network.

Dermatologic conditions have a significant psychological impact on patients. As Guerra-Tapia pointed out, this effect can be attributed primarily to two factors: the visibility of the condition — as seen in diseases such as atopic dermatitis, psoriasis, ichthyosis, vitiligo, or alopecia areata — and the presence of associated symptoms such as itching, pain, or a burning sensation. In both cases, the outcome is often the same: anxiety, depression, suicidal ideation, loss of self-esteem, introversion, and impaired work and social relationships.

The expert explained the criteria used in clinical practice to decide whether to refer a patient: “I begin both dermatological and psychiatric treatment simultaneously, hoping to gain the patient’s trust. Depending on the patient’s progress, I refer them to psychiatry if the condition is severe or requires treatment with antipsychotics. I rarely make an initial referral since the patient — confused and skeptical — will likely disappear and seek out other clinics in search of what they believe they need. In any case, there is no one-size-fits-all approach. Each case varies depending not only on the pathology but also on the patient’s personality and environment.”

Conditions in Psychodermatology

Within the field of psychodermatology, there are several conditions that can be classified into categories, as outlined by María José Torres Baeza in the article “Psychodermatology: The Need to Understand Mind and Body as an Indivisible Unit.”

First, there are primary psychiatric conditions, in which physical symptoms are a direct expression of an underlying mental health disorder such as obsessive-compulsive disorder, anxiety, depression, or psychosis. In these cases, individuals may repeatedly manipulate their skin as a way to cope with intense emotions or when they feel anxious, overwhelmed, or disconnected from what is happening around them. In some patients, this behavior may also be linked to a diminished perception of pain or reduced awareness of their own actions. As a result, self-inflicted skin conditions can develop, often with lesions in different stages of healing or scarring, typically in areas that are easy to reach with the hands or extremities. These conditions include body dysmorphic disorder, in which a person has an excessive preoccupation with perceived physical flaws; neurotic excoriations, or compulsive skin scratching; delusional parasitosis, the false belief that one is infested by parasites; factitious disorder or dermatitis artefacta, in which skin lesions are deliberately self-induced; trichotillomania, or repetitive hair pulling; and onychophagia, or compulsive nail-biting.

Second, there are dermatologic disorders with a secondary psychiatric condition. These arise in response to the emotional distress of living with a disfiguring or symptomatic dermatologic disorder. They have serious effects on psychosocial interaction, self-esteem, and body image, leading to the development of social anxiety and depression symptoms. This group includes psoriasis, acne, vitiligo, alopecia areata, ichthyosis, eczema, albinism, and hemangiomas. 

Third, there are psychophysiologic skin disorders, that is, skin conditions whose severity can worsen or improve depending on the person’s emotional state. Many patients associate the onset or worsening of their symptoms with situations of stress or emotional tension. This category includes conditions such as atopic dermatitis, seborrheic dermatitis, psoriasis, rosacea, alopecia areata, acne, psychogenic urticaria, and psychogenic purpura.

Psychodermatology Units in Hospitals

María José Tribó, MD, head of the Psychodermatology Unit at Hospital del Mar, Barcelona, Spain — established 30 years ago — told El Médico Interactivo that the development of psychodermatology units in hospitals is currently uneven and in the process of consolidation. “Although there is a growing awareness of the importance of the interaction between skin and mental health, the implementation of structured units is not uniform across facilities. In some leading hospitals, such as Hospital del Mar, organized and functional models have been developed, with stable collaboration between dermatology and psychiatry. However, in many others, the approach remains more dependent on ad hoc referrals or the individual initiative of professionals, without formalized pathways,” she stated. According to the expert, one of the main challenges is the lack of established clinical guidelines and standardized protocols, “which leads to uneven development across regions and hospitals.”

Dermatology is often the point of entry for patients because most initially seek care for a skin condition and deny having a psychiatric condition. In the Dermatology Department at Hospital del Mar, when possible psychological or psychiatric involvement is detected during the medical history or clinical course, the patient is referred to the psychodermatology unit. Each patient is approached holistically. Dermatologic assessment, physical examination, and active listening are conducted alongside an evaluation of the patient’s emotional and psychopathologic state. In complex cases, the treatment decisions are discussed by the psychodermatology committee, which meets twice a month, enabling a multidisciplinary approach. “When necessary, psychiatry and/or psychology are involved, integrating the medical and psychological approaches to improve the patient’s prognosis. Based on this joint evaluation, an individualized treatment plan is established, which may include specific dermatological treatment, psychopharmacological intervention, psychotherapy, or a combined approach,” she added.

The Most Effective Care Model in Psychodermatology

The most effective care model is the one based on a truly multidisciplinary and integrated structure, in which dermatology, psychiatry, and clinical psychology work in a coordinated manner within the same care pathway. Tribó explained: “This model must allow for a comprehensive assessment of the patient, taking into account both the skin disease and the associated emotional impact, as well as the possible influence of psychological factors on the onset or progression of the dermatological condition. It is essential that there be fluid communication among the professionals involved and well-defined care pathways that prevent fragmented referrals. In practice, the most effective model combines early detection by general dermatology, specialized evaluation in the psychodermatology unit, and shared follow-up depending on the complexity of the case. For the most complex patients, committee discussions are useful for reaching a consensus on diagnostic and therapeutic strategies.”

Specific Training for Dermatologists

“Specific training for dermatologists in psychodermatology has seen a notable surge in recent years. Although there is still a long way to go,” said Tribó, who noted that with respect to psychiatrists and clinical psychologists, “such training remains limited.” “The groups we collaborate with consist of approximately 90% dermatologists and 10% psychiatrists or psychologists. In Spain, we have the Spanish Research Group of Dermatology and Psychiatry, founded by Guerra-Tapia and Tribó within the Spanish Academy of Dermatology and Venereology, which plays a major role in disseminating knowledge and providing continuing education. At the European level, the European Society for Dermatology and Psychiatry serves as a scientific and educational leader, particularly through its biennial congress, which fosters the exchange of knowledge and experiences among specialists from different disciplines. We also collaborate with the Association for Psychoneurocutaneous Medicine of North America,” Tribó explained.

The Evolution of Dermatology in the Coming Years

“We are observing a gradual increase in mental health-related issues among dermatology patients. This phenomenon is evident among adolescents, where the impact of social media and increased concern about physical appearance can contribute to the development or worsening of certain psychodermatological disorders, such as excoriations,” explained Tribó. She added: In the coming years, dermatology will evolve toward an approach in which mental health will be part of the routine evaluation of many patients. We must not forget that many dermatologic diseases are both chronic and visible.

Unlike other chronic diseases that may go unnoticed by those around them, skin conditions often have a direct impact on the self-esteem, social relationships, and quality of life of those who have them. For this reason, collaboration between dermatologists, psychologists, and psychiatrists will become increasingly necessary.

This story was translated from El Médico Interactivo on Univadis, part of the Medscape Professional Network.