3400-word article in DER SPIEGEL about the interplay of psychology and skin health and the new and upcoming medical field of psychodermatology. spiegel.de | archive
I‘ll post the different studies mentioned in the article below.
Machine translation from excerpts of the article:
Stress can intensify the skin's innate tendency toward inflammation, the physician explains. She says she regularly sees this connection in people who have psoriasis or—like Vanessa—atopic dermatitis, also known as eczema. "That's why we treat the skin and the mind in parallel."
Eisenberg's patients receive more than just tablets, ointments, or light therapy. They also learn, for example through relaxation exercises, how to take better care of their emotional well-being. According to Eisenberg, the psychotherapy is "always highly individualized" and tailored to each patient's specific skin condition.
This approach exemplifies a modern way of understanding the skin.
An increasing number of experts share this perspective. It lies at the heart of an interdisciplinary branch of medicine known as psychodermatology. In the Journal of Dermatological Science, South Korean researchers recently observed: "The skin, traditionally regarded as an external barrier, is now considered a neuroendocrine organ capable of communicating with the central nervous system."
In other words, the skin receives signals from the brain and relays them by releasing cytokines—chemical messengers produced by the body. In this way, the brain and the skin can, in a sense, communicate with one another in an ongoing two-way conversation.
Researchers have identified what is effectively a communication pathway between these two organs, and they are uncovering more and more details about how it works. As soon as a person experiences an emotion, chemical messengers travel from the brain along nerve fibers that extend all the way into the skin, where they terminate. These nerve fibers, in turn, are connected to the immune system.
This is how worries and stress quite literally get under the skin: signals released at these nerve endings cause blood vessels to dilate and attract specific immune cells, which then attack the body's own tissue—leaving the skin inflamed.
"That helps explain why some people suddenly develop more severe eczema or acne before exams," says human biologist Steinhoff. Psychological stress can also trigger or worsen conditions such as rosacea and alopecia areata (patchy hair loss) in the same way.
Overall, physicians with training in psychosomatic medicine distinguish among three broad categories of skin disorders. The first comprises conditions that arise from psychiatric disorders, such as delusional infestation(formerly known as delusional parasitosis), in which people mistakenly believe that tiny creatures—for example, parasites—are living on or beneath their skin. As a result, they damage their skin through excessive scratching and overuse of soap or disinfectants.
A second category includes patients whose skin has been disfigured, for example by a tumor or a burn. Many of these individuals also bear profound psychological scars.
The third group consists of people whose skin conditions are exacerbated by psychological stressors such as chronic stress.
For some complex, chronic skin diseases, even expensive medications are not enough. "This is where psychodermatology can broaden the range of treatment options and improve therapy," says dermatologist Eva Peters of the Department of Psychosomatic Medicine and Psychotherapy at the University Hospital of Giessen.
There is a profound hope underlying these words: the growing understanding of the skin–brain axis may not only help keep the skin healthier than has previously been possible. It may also help alleviate psychological distress—and preserve mental acuity.
Only now are researchers beginning to understand how these connections might be explained. When the skin is under stress, it releases certain signaling molecules—cytokines—which appear to be capable of triggering inflammation in the brain. According to more recent studies, this may help explain why people with psoriasis are also at increased risk of developing depression.
Conversely, novel medications that inhibit these cytokines can not only reduce inflammation in the skin but may also alleviate depression and anxiety, according to Steinhoff.
For a long time, however, dermatologists overlooked the fact that emotional experiences can also alter the skin's overall condition. Yet there were early indications. In January 1995, a devastating earthquake struck Japan. In just 20 seconds, more than 5,000 people were killed, and over 300,000 residents lost their homes. For many, the disaster quite literally got under their skin: among those who had atopic dermatitis, physicians observed a striking finding. More than one-third of the survivors experienced a worsening of their itchy eczema after the catastrophe.
More recently, researchers from China reported in the journal Science that they believe they can now explain why stress promotes skin rashes. They have uncovered a previously unknown biological interaction.
The researchers began with the observation that some people with atopic dermatitis have elevated numbers of a particular type of immune cell—eosinophils—in their skin. Under normal circumstances, these cells defend the body against worms and other parasites. However, this immune response can spiral out of control, causing the cells to attack the body's own skin tissue and trigger inflammation. The researchers' own studies showed that the greater the number of these immune cells present in a patient's skin during a stressful situation, the more severe the rash became.
But why do some people accumulate so many of these immune cells under stress in the first place? The researchers found a clue in experiments involving mice with eczema. When the scientists placed the animals on a high platform without protective side barriers, the mice became stressed, and the condition of their skin subsequently worsened.
Further investigations revealed that this was due to a particular type of nerve cell in the skin. Once activated by signals from the brain, these nerve cells attracted eosinophils, which then released inflammatory signaling molecules, causing the skin to become inflamed.
Whether the same sequence of events occurs in humans remains uncertain. Nevertheless, the findings are consistent with much of what psychodermatology has uncovered so far: flare-ups of psoriasis or atopic dermatitis are often the body's response to psychological stress.
Skin aging extends beyond aesthetic concerns and is increasingly recognized as a key contributor to brain aging through neuroendocrine, inflammatory, and neurochemical mechanisms.
Traditionally considered as a peripheral barrier, the skin is now recognized as a neuroendocrine organ capable of communicating with the central nervous system (CNS) via hormone secretion, cytokine signaling, and neurotransmitter modulation.
Recent literature has begun to formalize the concept of the skin-brain axis as a bidirectional communication system, particularly within the contexts of psychodermatology and neuroimmunology.
This review highlights how extrinsic factors such as ultraviolet (UV) radiation and intrinsic aging disrupt skin homeostasis and trigger systemic effects on brain functions.
Chronic UV exposure activates the cutaneous hypothalamic-pituitary-adrenal (HPA) axis and increases systemic cortisol levels, impairing hippocampal neurogenesis and cognitive function.
UV-induced alterations in neurotransmitters including glutamate, dopamine, and β-endorphins affect learning, memory, and emotion regulation.
Importantly, both photoaging and natural skin aging are associated with reduced synthesis of brain-derived neurotrophic factor (BDNF) in the skin, potentially diminishing systemic BDNF availability, and contributing to cognitive decline.
Recent studies explored the protective effects of sunscreen and moisturizers in mitigating cutaneous inflammation and reducing neurodegenerative risk.
Additionally, topical or dietary interventions, such as plant-derived polyphenols, may restore skin BDNF levels and enhance skin-brain resilience.
Collectively, these findings support a paradigm shift: preserving skin health is not only a dermatological goal, but also a promising strategy for mitigating brain aging and promoting cognitive resilience.
The Psychological Burden of Skin Diseases: A Cross-Sectional Multicenter Study among Dermatological Out-Patients in 13 European Countries, 2015, Dalgard et al.
Dalgard, Florence J.; Gieler, Uwe; Tomas-Aragones, Lucia; Lien, Lars; Poot, Francoise; Jemec, Gregor B.E.; Misery, Laurent; Szabo, Csanad; Linder, Dennis; Sampogna, Francesca; Evers, Andrea W.M.; Halvorsen, Jon Anders; Balieva, Flora; Szepietowski, Jacek; Romanov, Dmitry; Marron, Servando E.; Altunay, Ilknur K.; Finlay, Andrew Y.; Salek, Sam S.; Kupfer, Jörg
Abstract
The contribution of psychological disorders to the burden of skin disease has been poorly explored and this is a large-scale study to ascertain the association between depression, anxiety and suicidal ideation with various dermatological diagnoses.
This international multi-center observational cross-sectional study was conducted in 13 European countries.
In each dermatology clinic, 250 consecutive adult out-patients were recruited to complete a questionnaire, reporting socio-demographic information, negative life events and suicidal ideation; depression and anxiety were assessed with the Hospital Anxiety and Depression Scale.
A clinical examination was performed. A control group was recruited among hospital employees.
There were 4994 participants, 3635 patients and 1359 controls. Clinical depression was present in 10.1% patients (controls 4.3%, Odds Ratio 2.40 (1.67- 3.47)).
Clinical anxiety was present in 17.2% (controls 11.1%, OR 2.18 (1.68-2.82)). Suicidal ideation was reported by 12.7% of all patients (controls 8.3%, OR 1.94 (1.33-2.82)).
For individual diagnoses, only patients with psoriasis had significant association with suicidal ideation.
The association with depression and anxiety was highest for patients with psoriasis, atopic dermatitis, hand eczema and leg ulcers.
These results identify a major additional burden of skin disease and have important clinical implications
Web | DOI | PMC | PDF | Journal of Investigative Dermatology
Although psychological stress is thought to aggravate atopic dermatitis, the cellular and molecular mechanisms are not well established.
Tian et al. performed a retrospective analysis of patients with this condition and found correlations between elevated stress and increased accumulation of eosinophils in the skin (see the Perspective by Gaudenzio and Basso).
In mice, a distinct type of sympathetic neuron that innervated the skin relayed stress responses from the brain to eosinophils and exacerbated inflammation.
These neurons released a chemokine, CCL11, that recruited eosinophils. The ability of eosinophils to promote stress-induced inflammation was dependent on their expression of the adrenergic receptor β2.
These results suggest that, in combination with other treatments, managing stress or blocking stress-dependent signaling between neurons and eosinophils may help to alleviate dermatitis. —Sarah H. Ross
Structured Abstract
INTRODUCTION
Psychological stress is a well-established exacerbating factor for atopic dermatitis (AD), capable of worsening inflammation through complex interactions among the nervous, endocrine, and immune systems.
Stress hormones can directly compromise the skin barrier, promote inflammation, and intensify the sensation of itch.
Scratching in response to itch further damages the skin, creating a self-perpetuating cycle of inflammation and psychological distress.
Consequently, stress management is considered an integral component in the comprehensive management of AD.
RATIONALE
Eosinophilic infiltration is a pathological hallmark of AD.
Eosinophil-derived mediators, including granule proteins such as eosinophil peroxidase (Epx) and major basic protein (MBP), as well as cytokines such as interleukin-31 (IL-31), potently amplify inflammatory cascades and correlate with disease severity.
The mechanistic basis governing eosinophil recruitment and activation specifically within the context of psychological stress remains poorly understood, representing a significant knowledge gap in cutaneous neuroimmune communications.
Additionally, whereas sympathetic neurons exhibit target-specific organization and participate in peripheral immunomodulation during stress responses, the precise pathways through which psychological stress converges with atopy-associated inflammation remain incompletely delineated, particularly regarding their connection to eosinophil-mediated inflammation in stressed skin.
RESULTS
To determine the immune mediators and neural pathways through which stress signals aggravate skin inflammation, we conducted a retrospective analysis of AD patients and studied stress-challenged murine AD models.
Our analysis revealed a specific association between stress-induced eosinophilia and skin inflammation severity in AD patients.
In mice, genetic ablation of eosinophils (in EpxiCre-DTA mice) conferred protection against stress-exacerbated dermatitis.
Through chemical sympathectomy with 6-hydroxydopamine and surgical removal of the adrenal glands, we determined that peripheral sympathetic nerves, rather than the hypothalamus-pituitary-adrenal axis, mediates the stress-induced worsening of skin inflammation.
Using single-nucleus RNA sequencing and intersectional genetic approaches, we further identified two major populations of noradrenergic sympathetic neurons in mice, defined by prodynorphin (Pdyn) and neuropeptide Y (Npy) expression, that were activated by psychological stress.
Our functional studies suggested that skin-innervating Pdyn+ sympathetic neurons, but not their Npy+ counterparts, were both necessary and sufficient for driving stress-induced dermatitis and eosinophilia.
Optogenetic activation of Pdyn+ neurons promoted eosinophil recruitment and exacerbated inflammation, effects that were abolished upon eosinophil depletion.
These Pdyn+ neurons were found to release the chemokine C-C motif ligand 11 (CCL11), which acts on its receptor, C-C chemokine receptor type 3 (CCR3), to mediate eosinophil chemotaxis.
Finally, adrenergic signaling through adrenergic receptor beta2 (Adrb2) on eosinophils was critical, because eosinophil-specific Adrb2 knockout mitigated stress-induced exacerbation of dermatitis.
CONCLUSION
Our findings suggest that psychological stress exacerbates AD-like inflammation through a specialized subset of skin-innervating Pdyn+ noradrenergic sympathetic neurons that engage eosinophils through the CCL11-CCR3 chemotactic axis and Adrb2-mediated activation.
These results indicate that stress-induced eosinophilia could be a potential biomarker of AD severity and suggest that targeting the Pdyn+ sympathetic neuron-eosinophil interface may offer therapeutic benefit in mitigating the inflammatory sequelae of psychological stress.
The fact that stress is a completely generic concept with no clear definition and more combinations than there are permutations of how all the atoms in the universe can be arranged makes this even less convincing, and it's not the least bit convincing. Might as well be health whisperers. Damn will influencers make bank with this, though. It's basically white label scamfluencing.
It can't be defined. It can't be quantified, and so can't be counted. It can't even be recognized or assessed in a meaningful way. It's also never been lower in our entire history, which is saying a lot, but it's the singular cause of every illness and problem. Sure, buddy.
Some people are whining about 'woke' a lot, whatever that means. Others are whining about 'stress' a lot.
This is an important medical area because I've seen close up the utilisation of the ambiguity and choice to not have science and proper words that mean things has specifically in dermatology to hide those employing bigotry to do a bad job vs those who are competent and there being a big picture in some things.
For example they are not wrong in mentioning alopecia, someone I met first hand got put through hell by a deliberately abusive boss (in a new job that when I'd met him last before he was so excited about, and me too thinking it sounded great, that's mostly what we talked about) and in the space of a year developed a monk-like bald area on the entire back of his head.
So of course any topical treatment without acknowledging and demanding that dangerous situation be sorted out by the employer (and not the employee finding ways of 'coping' ........the biggest anti-mental health purpose of the fake CBT of psychosomaticists to try and switch blame to the person being kicked for 'choosing to bruise') seems to be missing a red flag that needed to be noted down with a serious medical confirmation of the impact, because it is basically an injury at that point.
But that doesn't mean that the same person should just abandon helping that person as there is a need for them to study whether any medical treatments also support it growing back better etc. and it certainly shouldn't be assumed that anyone who gets the same issue must have 'hidden trauma' and all that BS too. That's just bad medicine and bad thinking.
On the other hand someone who has foliculitis or ingrown hair issues something else wrong could end up with the wrong persons telling them 'not to pick', assuming they turned up because they picked rather than understanding it gets that bad etc. and I never got the psychology of that. But its very much there. And feels very much like basic misogyny - assuming women are complaining about nothing or pretending something caused by some weird nervous habit is being presented as if 'it just happened'.
Which is unforgivable given how uncompromising standards can often be for eg women in the workplace or school regarding presenting themselves. It's one thing saying 'NHS doesn't deal with cos...' then at least writing a note saying it is real and not BS being furled out that affects even options if someone is forced to save up to receive help privately if it isn't too late to have affected their career etc. But there is so much that goes on as actually political decisions and plain bigotry in who gets prioritised in society charading as if it were 'fact' and deluded false beliefs being spread about others instead having the false beliefs etc.
The ezcema thing is true to some extent too, but very much needs medical managing if it gets very bad. And I think you normally have to have some eczema before normally. But walking around feeling self-conscious, uncomfortable and then being unhelped will make the problem worse. ie the very opposite way around to how bps presents it and their 'cures' which lack empathy or understanding of the size of burden and impact making 'helping the eg skin problem' having extra value, rather than 'it being somehow unusual to not be able to weather other peoples's unjustified and inappropriate added bigotry or disdain' when acknowledging it's something people are brave to carry and making sure the public understand it would help and instead calling said people 'in need of mental health support' and then deliberately leaving that open to interpretation as to whether that's because they 'think wrong' is adding harm to harm.
SO I have big worries here about medicine not being oversighted when it talks about psychology - and it needs to stop being allowed to call anything therapy or mental health, when the problem is often eg injury from the impact of something or someone else and the profession has made it clear it wants to leave the difference between things that hurt and things that harm and cause open to flexibility and choice, so basically even those who weren't bigots end up being persuaded into actions that are those of bigots because they've been actively misled and forced to by culture of the system.
There is a parasitic element going on which perhaps didn't start with the front-liners but they I think certainly now keep it going as they want to keep forging further industry and careers in it. It might need real, qualified psychologists who can identify (which often needs listen to, not thinking they know better than, the individual - so they need to purge a big proportion of those who think like that from both psychiatry and clinical psych) and some therapists but only for certain things, but this army of therapists rolling out their supply led and making the BS fit why is apalling. Nevermind then claiming unlicensed people like physios and OTs who did short courses but its not actually their 'profession' basically calling names and changing the voice people get forever - that's not support or help. And someone making things up or influencing someone's support network in ways that go against people being heard or supported 'in the name of making them stronger' type BS that has been tested and has never been evidenced is wrong. But noone checks that isn't what they are sending people into.
Where there is something impacting the health then the medical professional needs to be required to write a strongly worded note stating that, basically truth, in order to make someone accountable if it is their action or inaction or inappropriate behaviour etc. that is part of the cause. Not refer someone off to someone who will make the victim accountable for getting hurt by it.
Psychosomatics or biopsychosocial unfortunately in reality and design is to charade the opposite in order to it seems obvious reverse blame and reverse truth. Proper psychology in the sense that is intended and trying to actually help and be 'mental health' very much knows that finding out the truth on the cause is important and stopping that source, not imposing falsities and inappropriate non-therapies to enforce those falsities to distort the truth.
I don't know how medicine can continue when it has this issue of such a dark problem of some coded language where they all pretend to 'be indending to help' whilst the system they are sending individuals to instead a switch-and-bait that won't even measure whether what they get handsomely funded to supposedly 'be their purpose' is measured without issues of coercion such as perceived threats and leading questions and design issues that manipulate with ceiling and floor effects etc in order to cheat. Then use that to distort truth and even impose on people's identity and who they are.
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