With every bottle of the oral acne medication isotretinoin, commonly known by the brand name Accutane, comes a large warning about the risks of psychiatric effects. “Accutane may cause depression, psychosis and, rarely, suicidal ideation, suicide attempts, suicide, and aggressive and/or violent behaviours,” states the label.
There have been a number of high-profile suicides allegedly related to isotretinoin use, including the death by suicide of Seamus Todd, son of the late Irish actor Richard Todd, in 1997.
While some studies have shown a link between isotretinoin use and suicidal thoughts and depression, it’s not clear whether those mental health effects are caused by the drug itself or the severe acne it’s prescribed to treat — especially since acne can often temporarily get worse at the start of treatment.
Recent research contradicts the earlier expectation that isotretinoin itself could lead to depression or suicidality. Further, there’s increasing — but imperfect — evidence that acne itself can cause depression, a connection that some dermatologists and psychiatrists alike are paying increased attention to.
These questions have coalesced into a burgeoning field known as psychodermatology, which investigates how the mind affects the skin, and how the skin affects the mind.
Unfortunately, the nature of the mind-skin connection is far from clear. The issue? It can be difficult to study potential links between a person’s mental and physical health. Adewole Adamson, a dermatologist at the University of Texas at Austin, told Gizmodo that there are few studies that directly quantify the effects of stress on patients with skin conditions, because in most cases it’s impractical and unethical to put human subjects in stressful, potentially harmful situations just to see what sort of dermatological outcome would arise.
As a result, most of the science about the relationship between stress and inflammatory skin conditions is based on patient recall — that is, asking a patient how stressed they were before a flare-up of their skin condition, said Adamson. And, of course, human memory is imperfect.
Though psychodermatology as its own field of study has emerged in the past two decades, the concept of the skin-mind connection is ancient. Hippocrates, writing in the fourth century BCE, described people who tore out their hair when stressed. But it wasn’t until 1987 when the field was more officially recognised in the form of a convention: the International Congress of Psychosomatic Dermatology in Vienna.
In 1991, the Association for Psychocutaneous Medicine of North America was created, and in 1993, dermatologists and psychiatrists formed the European Society of Dermatology and Psychiatry.
Today, there are few clinics devoted to the practice, and medical school courses dedicated to the subject are rare, according to the American Psychological Association. Not everyone agrees that it’s even especially necessary; on the medical blog Science Based Medicine, Harriet Hall, a family doctor known as “the SkepDoc” has argued that well-practiced medicine already acknowledges a patient’s psychological state during treatment. And while the concept of psychiatry and dermatology being combined into a separate field has yet to see widespread support, there’s increasing research suggesting that the skin and the mind are intimately connected.
Psychodermatology addresses this skin-mind connection from three angles. The first, and perhaps most obvious, looks at what are known as primary psychiatric disorders, in which a psychological condition compels a patient to view their skin as disfigured when it isn’t, and often to self-induce that disfiguration.
Examples include trichotillomania, in which a patient pulls out their hair; delusional parasitosis, when patients think they’re infested with insects or other living creatures; and neurotic excoriations, also known as skin picking. The second is psychophysiologic disorders, when a skin condition is exacerbated by stress — if you’ve ever had an acne breakout during finals week, you’re familiar with this one. Lastly, there are secondary psychiatric disorders, in which an existing skin condition results in psychological distress, namely depression or anxiety.
While few dermatologists will contest that there are connections between skin health and mental health, the extent to which they’re responsible for each other and the mechanisms enabling that connection are still not entirely understood.
Neelam Vashi is a dermatologist at Boston University who has studied the impact of certain skin conditions on patients’ quality of life. She said that skin conditions have a particular “threshold” that can be lowered by stress or environmental factors. When that threshold lowers — say, you’ve just lost your job, or you’ve come down with the flu — that skin condition can flare up or worsen.
Mohammad Jafferany, one of the field’s modern pioneers, explained that some evidence shows this happens because, when a person is stressed, certain hormones, including cortisol, norepinephrine, and epinephrine, are released in the body. This release stimulates an inflammatory response in areas of the body already prone to inflammation — such as the skin, if the patient has an inflammatory skin condition like acne, psoriasis, or atopic dermatitis (also known as eczema).
Mental distress can worsen a skin condition — and it appears that the reverse is true as well.
“If someone has an ongoing mental health problem, the stress of a skin condition could be a trigger for a relapse or worsening of their disorder,” C. Neill Epperson, chair of the psychiatry department at the University of Colorado Medical School, told Gizmodo. A growing body of research supports her assertion.
A 1999 population study out of Japan looked at the impact of an earthquake on the stress levels and eczema symptoms of 1,547 survivors. The study found that 38 per cent of people who endured “severe damage” to their home and environment experienced exacerbated symptoms of eczema, as did 34 per cent of survivors who suffered mild damage to their home. Only 7 per cent of those who experienced no damage saw worsened symptoms of eczema.
In 2003, a small study from Stanford University looked at 22 students’ acne severity during finals. It found that, even after adjusting for confounding variables such as eating badly or not sleeping, the students’ acne worsened as their exams-related stress grew.
With the slowly growing interest in dermatological manifestations of stress, there’s a corresponding rise in interest in how skin conditions can affect a person’s mental health and general quality of life. Vashi, whose research has focused in the past on the effects of hyperpigmentation (spots of skin that become darker than the surrounding skin, often as a result of acne or sun damage) and melasma (dark patches on the skin, often hormonal in nature), conducted a study of her patients with dark spots and found their quality of life was significantly negatively affected.
The impact, she said, was as substantial in patients with dark spots as in people with vitiligo, a disorder in which the skin loses its colour, or psoriasis, both of which can significantly impact a patient’s quality of life.
Some skin conditions can affect patients’ mental health so profoundly that their lives may be risk, Adamson said. “Folks with these conditions, particularly ones that are visible and potentially that are disfiguring — they tend to show higher levels of depression,” he said. “People say dermatologists are pimple poppers, it’s nothing serious that they’re really taking care of, but these inflammatory conditions that aren’t treated can cause a lot of anxiety, depression, and suicide ideality, like with patients with serious psoriasis.”
Indeed, a large British population study looked at medical records from 1987 to 2002 and found that depression, anxiety, and suicidality were significantly heightened among patients with psoriasis, especially younger patients.
Additionally, a 2017 meta-review of the available literature found that psoriasis patients were more likely to attempt—and complete — suicide than those without psoriasis, with younger patients again being especially at risk.
People with acne are likewise at increased risk of mental health struggles as a result of their condition. A 2006 study from New Zealand examined 9,567 teenagers and discovered that students with acne had an increased risk of anxiety, depression, and even suicide. More recently, a study published in JAMA Dermatology found that people with eczema are more likely to have suicidal thoughts and to attempt suicide than people without eczema.
But with many of these studies, it’s difficult to definitively prove that the skin condition caused the mental health condition or vice versa. “In many ways it’s a chicken and the egg phenomena,” Adamson said. “I often wonder, is it the stress itself causing the acne to be worse? Or is it because you’re stressed, you’re not taking your meds as much, you’re less diligent. You may not perceive your behavioural changes because you’re preoccupied.”
Patient compliance, or the degree to which a patient follows their doctor’s instructions, is a major problem in medicine; that problem becomes even greater when a patient is stressed or depressed. A 2000 meta-study found that depressed patients were three times more likely than non-depressed patients to be noncompliant with their treatment regimens.
A 2007 editorial in JAMA Dermatology acknowledged the difficulty in precisely assessing the connection between mind and skin because of confounding factors like adherence. “Any study of interventions designed to affect skin disease by affecting the mind must consider the possibility that the effect is mediated by changes in behaviour, particularly compliance changes,” wrote the authors.
And because researchers generally aren’t allowed to do controlled experiments in which subjects are intentionally put into stressful situations, dermatologists rely on primarily observational studies, which are less reliable than randomised controlled trials.
“So it’s hard to tease out,” Adamson said. “Is it the stress? Or what the stress causes, which is you not paying attention to your health?”
Regardless of how, exactly, mental health affects skin conditions, what is clear is that a comprehensive approach to treating a patient’s overall health can only be beneficial. Jafferany noted that for some patients, “conventional dermatological treatments are not enough to treat the whole problem.” A patient with psoriasis, Jafferany said, may be stressed, anxious, and depressed as a result of their condition, and these mental health struggles often have an impact on the patient’s self-esteem, relationships, and job.
In these cases, Jafferany said, he might offer therapy, antidepressants, and anti-anxiety medication that will reduce the psychological impact of the skin condition on the patient—and, potentially, have an effect on the condition itself as a result.
“In my personal experience in those kinds of situations, couples or family counseling helps a lot,” Jafferany said. “So in combination with conventional dermatological treatment, antidepressant and anti-anxiety medication and psychotherapy play a major role. Overall it’s a holistic approach to the disease.”
Vashi thinks combined clinics could be helpful to patients, not least because it increases access to mental health for people who might typically be hindered from receiving treatment because of stigma. “We’re treating the whole person, and the whole person is also mental health,” she said. “I think there is a place and space for multidisciplinary care… often if patients need help, they’re gonna be much more apt to see someone in that kind of scenario, as opposed to seeking it on their own.”
Jason Reichenberg, a dermatologist at the University of Texas at Austin, said that some non-medical treatments can be useful for treating symptoms of inflammatory skin conditions. “There have been studies showing that patients with psoriasis improved more quickly when they practiced relaxation techniques in addition to their standard treatment,” he wrote in an email.
“We know that habit-reversal therapy can decrease the symptoms of eczema in children, by helping them deal with their itching in other ways.”
Still, Reichenberg said, more research is needed to fully understand which patients stand to benefit the most from comprehensive, psycho-dermatological treatment as opposed to traditional dermatological treatment consisting of oral and topical medications.
“I hope that someday we will see that some people’s bodies truly respond to stress differently and release different amounts of stress hormones that can affect their body,” Reichenberg said. “As we look at creating a patient-centered medical home involving not just their primary care provider but also a psychologist, a social worker, a dietician, and other medical specialists, we will recognise that the physician is not the only one who can affect a patient’s health.”
Ultimately, Vashi said, even if a patient’s condition isn’t life-threatening, it can still affect their happiness, and that’s a worthy concern, too. “We treat skin cancers and melanoma and these are life threatening, but most of what we see in our patients they can live with. You can live a long healthy life with acne, you know?”
As knowledge about the skin-mind connection continues to grow, practitioners will be more well-armed to treat their patients’ diverse and complex array of medical concerns. Regardless of whether the dermatological community decides to tackle further research and clinical care in the form of a single field or in a more traditionally separated format, people living with comorbid psychological and skin disorders stand to benefit from care that takes into account the potential links between their conditions.