Key points

It has long been accepted that certain emotional states can become evident in ones skin. For example, a person flushes when embarrassed, and the extremities become cold when one becomes stressed. In the past decade or so, it has become accepted that there is a unique dialogue between one’s psyche and one’s skin. Beyond transient states of emotion, the skin and mind interact in many disease states that are just now being studied. In some psychopathological states in which the skin is clearly involved, such as trichotillomania, delusional parasitosis, and dermatitis artefacta, treatment goals are primarily psychiatric. In other disease states, treatment options and goals are not so clear. In conditions that cause emotional stress, such as alopecia and urticaria, treatment of the physical ailment can alleviate the psychological burden caused by the disease. Other disease states, such as atopic dermatitis (AD), psoriasis, and acne, among others, can be exacerbated and alleviated by psychogenic factors. In these states, in which research suggests there exist interplay between the mind and the body; treatment options are not so straightforward. These states certainly not only lead to a degree of emotional unrest but also can be caused or exacerbated by the stress and other psychological factors.

Although intellectually, medical professionals find it easy to reject a rigid assertion of a mind-body dichotomy philosophy, practical medical language is riddled with its implication. Often psychiatric consultation services are posed the question “is the condition real or is it psychiatric?” A pejorative tone is struck with the labeling of a condition as psychogenic. Pediatricians and pediatric subspecialists are trained to diligently pursue a differential diagnosis and then rule out those that do not match up, leaving the correct diagnosis that should imply a best course of action for treatment. When this process turns up no objective findings, often the parents are then told the symptoms are psychiatric, and a mental health consultation is ordered.

Pediatricians naturally feel that their skill set is exhausted, and one needs to logically bring in an expert from a different skill set, a psychiatrist. The patient is then handed over to the new clinician, leaving parents and patient often feeling disbelieved or abandoned, angry, and dissatisfied with care.

Parents naturally are advocates for their children getting quality medical care and relief of symptoms where often a “stress” or psychological component is the last thing on their minds, and any suggestion of psychological or psychiatric interventions is met with indifference, distain, or overt hostility. They may seek more expert opinions from centers with larger reputations, leading to many costly and nonproductive workups.

Perhaps it is best to try and rid one’s vocabulary of terms such as psychosomatic and introduce the notion that many skin symptoms have a stress component either in cause or in effect from the beginning of a new evaluation. Introducing a mental health professional as an embedded member of the treatment team from day one of the evaluation has often produced a higher level of acceptance and satisfaction. It is critically important that the pediatrician/pediatric subspecialists and mental health professional stay engaged and be willing to consider emotional and physical causes and manifestations from the initiation of an evaluation.

In the adult literature, such states are fairly well studied. However, research among children (ages 0–18 years) is lacking. Furthermore, psychocutaneous disorders can pose a large developmental obstacle during the adolescent years when the individual begins to develop a distinct sense of self. Behavioral and environmental factors can affect not only the disease process itself but also the treatment programs a young patient can follow.

In children and adolescents, disease states and treatment regimes can also place a burden on caregivers. Furthermore, research suggests that dysfunction in a child’s home environment can further affect certain psychocutaneous disorders. Therefore, effective treatment should not only be aimed at the physical and the psychological but also fit within the context of a child’s family structure and overall home environment.

Research by Jafferany and colleagues suggests that there is a significant need for education in psychocutaneous disorders from the perspective of both dermatologists and psychiatrists. Fried believes that psychocutaneous research medicine has come of age and that treatment should include what they term a “skin-emotion” specialist. In caring for a child, pediatricians would certainly need to be a part of this mix as well.

This article builds on the work done by Czyzewski and Lopez by identifying those pediatric psychocutaneous disorders in which clinical psychiatry would be beneficial in management of the disease. The authors use current literature to examine certain disease processes and explore the interplay between a child’s psyche and skin within the framework of mind-body interaction. Furthermore, they explore the impact these disease states have on the individual, the child’s family, and development of the self. Finally, the authors make recommendations for treatment and identify further areas needing research.

The impact on the individual

Dermatologic ailments account for 15% to 20% of visits to family practices, yet the effect of these conditions is only partially appreciated. Skin conditions can seem insignificant or surface-level nuisance. However, they can have profound effects on the individual patient. As a significant portion of one’s physical presentation to the world, the skin plays a role in determining one’s identity. When there is a pathologic condition that affects one’s skin, it can alter the perception of the self, especially for children.

AD, an inflammatory skin condition, presents unique problems for the developing child. It affects between 15% and 20% of children and accounts for 2.7% of all concerns presenting to family physicians. In an infant, AD can affect skin sensation and emotional development through altered parent/child bonding, which depends on physical contact in the early years. AD is known to interfere with sleeping patterns, causing insomnia due to discomfort, and research has shown increased levels of psychological disturbance in patients with AD compared with controls.

According to Saunes, in the comprehensive, population-wide Young-HUNT study, there is “a strong and consistent association between mental distress and AD.” Further, the psychological burden of this disease can manifest itself as “headache and neck or shoulder pain” in both boys and girls. “However, for adolescents with AD, the association between symptoms and mental distress was stronger for boys than for girls.” Reporting of symptoms varied with sex and age, with the 17- to 19-year age group reporting more symptoms than the younger, 13- to 16-year age group. However, girls reported more mental distress symptoms across the board than boys. As the investigators mention, this is somewhat expected, as adolescence is a fragile period of life when feeling good and looking good are both paramount goals but increasingly fleeting for the developing teen.

It is accepted that stress can cause exacerbations of AD and that states of emotional unrest can precipitate outbreaks. It has been theorized that the hypothalamic-pituitary-adrenal (HPA) axis is involved in the mind-body interaction between stress and symptoms of AD via increased blood cortisol levels. Asfar and colleagues found that children with AD do not, in fact, have more anxiety or higher levels of cortisol than control groups. However, they also postulate that the severity of symptoms associated with AD can cause increased anxiety.

Similarly, acne is another dermatopathological disorder with effects that extend beyond the skin. Depending on the source, the prevalence of acne among children is 30% to 100%, with 93.3% of 16- to 18-year olds affected. However, most health care professionals address only the physical ailments without addressing the full impact of the condition. In fact, individuals with acne suffer social, psychological, and emotional sequelae that are great as those reported by patients with chronic disabling asthma, epilepsy, diabetes, back pain, or arthritis on questionnaires. Only patients with cardiac disease reported higher impairment. The most well-studied psychiatric impact of acne is its association with teenage depression and anxiety, largely due to the social impact of the disease. However, this is not true across the board and the impact of acne, as with all skin conditions from person to person, which is why treatment strategies should be tailored to the individual as discussed later.

Summarizing the impact of acne beyond the physical, Sulzberger and Zaidens claim “there is probably no single disease which causes more psychic trauma, more maladjustment between parents and children, more general insecurity and feeling of inferiority and greater sums of psychic suffering than does acne vulgaris.” It has also been found that acne impairs a child’s quality of life, mood, and overall self-esteem. Gathering together multiple studies relying on teen questionnaires, Dunn and colleagues demonstrated acne having between moderate to severe effects on teens’ quality of life. According to Niemeier and colleagues, acne’s impact on one’s quality of life leads to greater levels of depression and anxiety. A similar effect was found on an individual’s self-esteem, with girls being the most affected by facial lesions.

Acne also has effects on an individual’s mood. Rapp and colleagues demonstrated that anger is a significant factor in both quality of life and satisfaction with treatment among acne sufferers. Furthermore, emotional upset can also happen during the course of acne. Psychiatric comorbidity is also frequently encountered in the presence of acne. Picardi and colleagues found a high degree of psychological comorbidity (>30%) among acne sufferers. With a higher degree of depression among those with acne, it is important to assess suicidal ideation during patient encounters. Furthermore, the number of patients who actually seek treatment of acne far underestimates those who actually suffer from the disorder. In addition, with the high degree of psychiatric comorbidity, acne sufferers may have psychiatric disorders “hidden” behind their acne. Therefore, a psychiatric assessment may be needed.

Similar to AD, the relationship between stress and acne is complex, with each affecting and exacerbating the other. In a somewhat older study, Lorenz and colleagues demonstrated within days of a stressful interview where anger was intentionally induced, an exacerbation of acne was observed. As has been shown, the presence of acne is undoubtedly a stressor for many children. Furthermore, stress can increase acne severity. During times of stress in a child’s life, for example, during high school or university examinations, there is a higher correlation with increased acne severity. The exact relationship between acne and stress is yet to be elucidated, but hormone production, inflammatory neuropeptides, and increased sebum production have all been suggested.

Another chronic skin condition frequently linked to life stressors is psoriasis, the inflammatory, hyperproliferative disorder that can severely affect patient’s daily lives. The effect of the disease seems to decrease as patients age ; therefore, the most severe symptoms should be expected in children. The link between stress and exacerbations of psoriasis is not disputed. However, the mechanism by which emotional stress can exacerbate psoriasis is unclear. Some have proposed that dysregulation of the hypothalamic-pituitary axis could be the key. It is postulated that altered cortisol levels in patients with psoriasis modulating the HPA axis can lead to increased outbreaks. Decreased and increased cortisol levels have been found in patients with psoriasis. Therefore, the causal link between stress and outbreaks seems unclear, and more research elucidating this connection is needed.

Bilgic and colleagues examined the relationship between psoriasis, depression, and anxiety and the effect on the quality of life in children. Study and control groups were divided according to age into 2 groups, 8 to 12 years and 13 to 18 years, in an attempt to account for the psychological effect of puberty. Using a series of questionnaires, the investigators found that younger children with psoriasis are more affected by psychological factors than teenagers and that teenage measures are not sensitive enough to fully account for the impact of psoriasis. This study corresponds with similar findings in adults. The investigators expected to find an increased level of psychological impact among teens, but this was not observed, prompting the need for further research.

Evers and colleagues found that “daily stressors” may alter cortisol levels at “moments of high stress.” Furthermore, patients with persistently high levels of stressors had lower average blood cortisol levels. This finding suggests that the HPA axis is hypoactive in these individuals. This finding has also been seen in patients with stress-related disorders such as chronic pain and chronic fatigue, suggesting an overall downregulation of the HPA axis leading to hypocortisolism. Hypocortisolism is also seen in patients with a history of high level of childhood stressors. Evers and colleagues theorized that these patients may be particularly susceptible to the effect of stress on their psoriasis. Richards and colleagues found similar results in patients with stress-responsive psoriasis. They postulate that such patients are primed for exacerbations to their condition by altered HPA axis responses to stress.

Patients seem to believe that there is a link between stress and psoriasis flares. Heller and colleagues have dubbed those who believe emotional stress exacerbates their condition “stress responders,” and the prevalence of such ranges from 37% to 78%. Stress seems to affect not only the severity of outbreaks but also the duration for symptom resolution. Evers and colleagues found that greater than half of all patients with psoriasis report, albeit retrospectively, an increase in stress before an outbreak.

History is also important in those with psoriasis, as there seems to be a correlation between childhood trauma/stressors and psoriasis. Simonic and colleagues found negative life experiences at all periods of childhood development. However, the investigators found no correlations between the severity of psoriatic outbreaks and childhood trauma. Those affected with psoriasis did not significantly differ in the number of past positive experiences compared with control groups. This finding suggests a yet-to-be-elucidated relationship between past stress, aside from current stressors, and outbreaks of psoriasis.

The impact on the individual

Dermatologic ailments account for 15% to 20% of visits to family practices, yet the effect of these conditions is only partially appreciated. Skin conditions can seem insignificant or surface-level nuisance. However, they can have profound effects on the individual patient. As a significant portion of one’s physical presentation to the world, the skin plays a role in determining one’s identity. When there is a pathologic condition that affects one’s skin, it can alter the perception of the self, especially for children.

AD, an inflammatory skin condition, presents unique problems for the developing child. It affects between 15% and 20% of children and accounts for 2.7% of all concerns presenting to family physicians. In an infant, AD can affect skin sensation and emotional development through altered parent/child bonding, which depends on physical contact in the early years. AD is known to interfere with sleeping patterns, causing insomnia due to discomfort, and research has shown increased levels of psychological disturbance in patients with AD compared with controls.

According to Saunes, in the comprehensive, population-wide Young-HUNT study, there is “a strong and consistent association between mental distress and AD.” Further, the psychological burden of this disease can manifest itself as “headache and neck or shoulder pain” in both boys and girls. “However, for adolescents with AD, the association between symptoms and mental distress was stronger for boys than for girls.” Reporting of symptoms varied with sex and age, with the 17- to 19-year age group reporting more symptoms than the younger, 13- to 16-year age group. However, girls reported more mental distress symptoms across the board than boys. As the investigators mention, this is somewhat expected, as adolescence is a fragile period of life when feeling good and looking good are both paramount goals but increasingly fleeting for the developing teen.

It is accepted that stress can cause exacerbations of AD and that states of emotional unrest can precipitate outbreaks. It has been theorized that the hypothalamic-pituitary-adrenal (HPA) axis is involved in the mind-body interaction between stress and symptoms of AD via increased blood cortisol levels. Asfar and colleagues found that children with AD do not, in fact, have more anxiety or higher levels of cortisol than control groups. However, they also postulate that the severity of symptoms associated with AD can cause increased anxiety.

Similarly, acne is another dermatopathological disorder with effects that extend beyond the skin. Depending on the source, the prevalence of acne among children is 30% to 100%, with 93.3% of 16- to 18-year olds affected. However, most health care professionals address only the physical ailments without addressing the full impact of the condition. In fact, individuals with acne suffer social, psychological, and emotional sequelae that are great as those reported by patients with chronic disabling asthma, epilepsy, diabetes, back pain, or arthritis on questionnaires. Only patients with cardiac disease reported higher impairment. The most well-studied psychiatric impact of acne is its association with teenage depression and anxiety, largely due to the social impact of the disease. However, this is not true across the board and the impact of acne, as with all skin conditions from person to person, which is why treatment strategies should be tailored to the individual as discussed later.

Summarizing the impact of acne beyond the physical, Sulzberger and Zaidens claim “there is probably no single disease which causes more psychic trauma, more maladjustment between parents and children, more general insecurity and feeling of inferiority and greater sums of psychic suffering than does acne vulgaris.” It has also been found that acne impairs a child’s quality of life, mood, and overall self-esteem. Gathering together multiple studies relying on teen questionnaires, Dunn and colleagues demonstrated acne having between moderate to severe effects on teens’ quality of life. According to Niemeier and colleagues, acne’s impact on one’s quality of life leads to greater levels of depression and anxiety. A similar effect was found on an individual’s self-esteem, with girls being the most affected by facial lesions.

Acne also has effects on an individual’s mood. Rapp and colleagues demonstrated that anger is a significant factor in both quality of life and satisfaction with treatment among acne sufferers. Furthermore, emotional upset can also happen during the course of acne. Psychiatric comorbidity is also frequently encountered in the presence of acne. Picardi and colleagues found a high degree of psychological comorbidity (>30%) among acne sufferers. With a higher degree of depression among those with acne, it is important to assess suicidal ideation during patient encounters. Furthermore, the number of patients who actually seek treatment of acne far underestimates those who actually suffer from the disorder. In addition, with the high degree of psychiatric comorbidity, acne sufferers may have psychiatric disorders “hidden” behind their acne. Therefore, a psychiatric assessment may be needed.

Similar to AD, the relationship between stress and acne is complex, with each affecting and exacerbating the other. In a somewhat older study, Lorenz and colleagues demonstrated within days of a stressful interview where anger was intentionally induced, an exacerbation of acne was observed. As has been shown, the presence of acne is undoubtedly a stressor for many children. Furthermore, stress can increase acne severity. During times of stress in a child’s life, for example, during high school or university examinations, there is a higher correlation with increased acne severity. The exact relationship between acne and stress is yet to be elucidated, but hormone production, inflammatory neuropeptides, and increased sebum production have all been suggested.

Another chronic skin condition frequently linked to life stressors is psoriasis, the inflammatory, hyperproliferative disorder that can severely affect patient’s daily lives. The effect of the disease seems to decrease as patients age ; therefore, the most severe symptoms should be expected in children. The link between stress and exacerbations of psoriasis is not disputed. However, the mechanism by which emotional stress can exacerbate psoriasis is unclear. Some have proposed that dysregulation of the hypothalamic-pituitary axis could be the key. It is postulated that altered cortisol levels in patients with psoriasis modulating the HPA axis can lead to increased outbreaks. Decreased and increased cortisol levels have been found in patients with psoriasis. Therefore, the causal link between stress and outbreaks seems unclear, and more research elucidating this connection is needed.

Bilgic and colleagues examined the relationship between psoriasis, depression, and anxiety and the effect on the quality of life in children. Study and control groups were divided according to age into 2 groups, 8 to 12 years and 13 to 18 years, in an attempt to account for the psychological effect of puberty. Using a series of questionnaires, the investigators found that younger children with psoriasis are more affected by psychological factors than teenagers and that teenage measures are not sensitive enough to fully account for the impact of psoriasis. This study corresponds with similar findings in adults. The investigators expected to find an increased level of psychological impact among teens, but this was not observed, prompting the need for further research.

Evers and colleagues found that “daily stressors” may alter cortisol levels at “moments of high stress.” Furthermore, patients with persistently high levels of stressors had lower average blood cortisol levels. This finding suggests that the HPA axis is hypoactive in these individuals. This finding has also been seen in patients with stress-related disorders such as chronic pain and chronic fatigue, suggesting an overall downregulation of the HPA axis leading to hypocortisolism. Hypocortisolism is also seen in patients with a history of high level of childhood stressors. Evers and colleagues theorized that these patients may be particularly susceptible to the effect of stress on their psoriasis. Richards and colleagues found similar results in patients with stress-responsive psoriasis. They postulate that such patients are primed for exacerbations to their condition by altered HPA axis responses to stress.

Patients seem to believe that there is a link between stress and psoriasis flares. Heller and colleagues have dubbed those who believe emotional stress exacerbates their condition “stress responders,” and the prevalence of such ranges from 37% to 78%. Stress seems to affect not only the severity of outbreaks but also the duration for symptom resolution. Evers and colleagues found that greater than half of all patients with psoriasis report, albeit retrospectively, an increase in stress before an outbreak.

History is also important in those with psoriasis, as there seems to be a correlation between childhood trauma/stressors and psoriasis. Simonic and colleagues found negative life experiences at all periods of childhood development. However, the investigators found no correlations between the severity of psoriatic outbreaks and childhood trauma. Those affected with psoriasis did not significantly differ in the number of past positive experiences compared with control groups. This finding suggests a yet-to-be-elucidated relationship between past stress, aside from current stressors, and outbreaks of psoriasis.