BJD

British Journal of Dermatology

R E V I E W A RT I C L E

Psychodermatological aspects of atopic dermatitis

M.S. Senra1 and A. Wollenberg2
1
2

Department of Dermatology, Ipanema Hospital, Rio de Janeiro, Brazil

Department of Dermatology and Allergy, Ludwig Maximilian University, Munich, Germany

Summary
Correspondence
Marcia S. Senra.
E-mail: marciasenra@yahoo.com.br

Accepted for publication

17 April 2014

Funding sources
This study was funded by an unrestricted grant
from Pierre Fabre Dermo-Cosmetique, France.

Conflicts of interest
M.S.S. received an honorarium from Pierre Fabre
to write this paper. A.W. has no conflicts of
interest to declare.
DOI 10.1111/bjd.13084

Psychodermatology is an evolving area of science that focuses on the interaction

between the mind, skin and body. It is known that various neuroendocrine
mediators including adrenocorticotropin, b-endorphin, catecholamines and cortisol are produced in response to stress. The resulting increase in endogenous
glucocorticoids can disrupt the skins barrier function, leaving it vulnerable to
inflammatory disorders like atopic dermatitis (AD). In turn, AD is associated with
high levels of stigmatization, social withdrawal, anxiety and depression among
patients and their carers. It is well known that the stress caused by AD can make
the symptoms of the disease worse. Therefore, the goal of psychodermatological
treatment is not only to improve the condition of the skin, but also to teach
patients/carers how to cope with the disease. This requires a multifaceted
approach, and time and patience, to ascertain the needs of individual patients. A
multidisciplinary team that includes a dermatologist, psychiatrist and psychologist
will be necessary to deliver high-quality, tailored care to patients.

Emotions are an important factor in all skin diseases. Psychodermatology is an evolving area of medicine that focuses on
the interaction between the mind, skin and body in order to
help treat skin disorders: Dermatology is focused on the
external visible disease and psychiatry is focused on the nonvisible disease.1
Psychological factors affect the management of skin conditions in more than a third of all dermatology patients; therefore, it is important to consider these factors in the treatment
of chronic dermatological conditions.2,3 This is especially relevant for atopic dermatitis (AD) as there is no cure and patients
often experience a lifelong struggle with the condition.1,4
More than other skin diseases, AD exemplifies the balance
between inherited factors, environmental influences and psychosocial issues. Many studies have shown that patients with
AD also have a history of chronic stress and experience severe
impairment in their quality of life (QoL), resulting in significant emotional distress.5,6
Although there are many accepted classifications of psychodermatological diseases, the most commonly used system
divides these into four types: psychophysiological disorders;
psychiatric disorders with dermatological symptoms; dermatological disorders with psychiatric symptoms; or miscellaneous
conditions.7 AD is classified as a psychophysiological disorder
as it is not caused by stress, but appears to be precipitated or
exacerbated by stress in some patients, and emotional factors
can determine the natural course of the disease.5 Stress
38

British Journal of Dermatology (2014) 170 (Suppl. s1), pp3843

responder patients with AD experience a clear and chronological association between stress and the exacerbation of their
disease, whereas the emotional state of no-stress responder
patients has no effect on AD.
Many patients with AD develop secondary psychological
problems due to the appearance of their diseased skin. Personality traits and/or psychiatric morbidity, which can affect the
disease, can also lead to secondary psychiatric disorders. In
1978, Griesemer published a study involving 4576 patients,
which addressed the incidence of emotional triggering of
common dermatoses.8 Stressful life events preceding the onset
of itching were found in > 70% of the patients with AD.9
Research into psychoneuroimmunology the interaction
between psychological processes and the nervous and immune
systems has highlighted the role of neuropeptides, hormones
and neurotransmitters in psychodermatological disorders. The
correlation between neuroimmunological pathways and skin
inflammation is now well known, and some degree of brain
skin connection underlies any inflammatory skin disease.10,11
The interaction between the nervous system, skin and immunity can be explained, in part, by the release of mediators from
cutaneous cells when facets of the psychoneuroimmunology
system are destabilised.12 Activation of the neuroendocrine system also produces several adaptive changes, including cognitive
arousal, mobilization of fuel stores, and the suppression of
vegetative functions (sexual activity, food ingestion). This
triggers a cascade of events that allow the so-called fightflight
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Psychodermatology of AD, M.S. Senra and A. Wollenberg 39

reaction, an adaptation that is critical for survival after acute

provocation.
Taken together, AD causes stress to the patient and AD may
be triggered by stress. Hence, it must be viewed as a chronic
inflammatory skin disease with a strong psychodermatological
component. Diagnosing any underlying psychiatric factors is
essential to determine an effective treatment plan.

Stress and immunity

Stress represents an internal or external force that threatens to
disrupt the homeostatic balance of an organism. It can be
studied as a constellation of events that begins with a stimulus
(the stressor) that precipitates a reaction in the brain (stress
perception), which then activates physiological systems in the
body (stress response). Stress can be categorized in at least
two ways: acute and chronic. Acute stressors are known to
enhance immunity, but chronic stress has an adverse effect on
health.13
Selye defined general adaptation syndrome (GAS) as the
sum of all nonspecific systemic reactions that occur in
response to an extended and continued exposure to stress.14
He divided GAS into three phases, with the first being the
alarm phase (stress perception), after which additional physiological systems are activated; the second phase is resistance,
when the body tries to adapt to the stressor; and the third,
chronicity, leads to exhaustion, distress and disease. Also
included in this list is the flare up of pre-existing dermatosis.
Since this initial definition, research into stress and immunity
has challenged the traditional concept of stress playing a central role in inducing/enhancing allergies, and studies now
suggest that certain types of stress induction could alter the
stress response and instead lead to the induction of tolerance.15,16
The neuroendocrine basis of stress is well known. Both
physical and psychological stressors induce neuroendocrine
responses that can affect several aspects of skin physiology.11,13 The systemic stress response affects two biological
systems: the hypothalamicpituitaryadrenal axis, which regulates the release of adrenocorticotropin, b-endorphin and
cortisol; and the sympathoadrenal medullary system, which
regulates the release of epinephrine and norepinephrine.11
Catecholamines and cortisol have potent effects on the
immune system. They mediate the differentiation of T-helper
(Th) cells to Th2 cells, to the detriment of the development
of Th1 cells and, as a consequence, an increased allergic
inflammatory response.17 Nerve terminals in cutaneous sensory nerves release neuropeptides, such as calcitonin generelated peptide and substance P, which have a variety of
effects on the local inflammatory response.15,18 Mast cells
which, once activated, release further proinflammatory mediators that contribute to this response also play a central role
in neurogenic inflammation.19
Cortisol acts as a negative feedback mediator in the hypothalamus and inhibits the further release of corticotrophin. A
recent study showed that patients with AD may have an inher 2014 The Authors
BJD British Association of Dermatologists

ited deficiency in the function of their hypothalamus: when

exposed to experimental stressors they respond with a blunted
production of cortisol, which could help explain flares in the
presence of stressors.17

Stress and the skin barrier

Psychological stress is not only a well-known trigger factor of
AD in humans, but may also lead to abnormal skin barrier
function and AD flares.7 The mechanism appears to involve a
stress-induced increase of endogenous glucocorticoids, which
may, in turn, disrupt barrier function and stratum corneum
cohesion, as well as epidermal antimicrobial function.20
Garg et al. reported that psychological stress affects epidermal
permeability barrier homeostasis, acting as a precipitant for
inflammatory disorders like AD; individuals with high levels of
perceived psychological stress had a significantly greater delay
in barrier recovery rates than those reporting a low perceived
stress level.13 Acute psychosocial and sleep deprivation stress
may actually decrease skin barrier function in women and may
be related to stress-induced changes in cytokine secretion.21
Further research into how psychological stress itself alters
epidermal function has shown that lipid synthesis is inhibited,
resulting in abnormalities in barrier function and homeostasis.
Furthermore, this research shows that topical treatment to
restore epidermal lipids reversed these abnormalities, and
could prove to be a valuable therapeutic option.22

Psychodermatological aspects of itch

The itchscratch cycle that is responsible for so much of the
misery and chronicity of AD is very fertile ground for psychodermatology. Emotional factors can cause, and frequently
heighten, the itching and scratching behaviour, which can
lead to serious impairment in QoL.
Via a web-based questionnaire, Dawn et al.23 examined the
frequency, intensity and perceived characteristics of pruritus
among 304 patients with AD. More than half of the participants reported pain (59%) and a sensation of heat (53%)
associated with itch. Episodes of itch were reported at least
once a day in 91% of patients, and 68% reported five episodes
per day.
More than 98% of the patients described their pruritus as
annoying, burning, unpleasant and bothersome. Sensations
such as insects crawling on the skin, pain and heat correlated
with itch intensity. Some patients reported that scratching
pleasure increased with itch intensity. One possible explanation for this is that scratching activates motivation networks in
the brain, while deactivating areas involved in unpleasant
emotions.24
Recent findings have brought to the fore the involvement
of novel regulatory pathways in the modulation of itch. In the
skin, cells such as lymphocytes or eosinophils interact with
the neuronal cells by releasing neurotrophins, neuropeptides
and cytokines; increased production of these factors is thought
to lead to the exacerbation of itch in conditions like AD.25
British Journal of Dermatology (2014) 170 (Suppl. s1), pp3843

40 Psychodermatology of AD, M.S. Senra and A. Wollenberg

Psychiatric aspects and comorbidities of

patients with AD
In a culture that values smooth, perfect skin, disfigured skin
can cause stigmatization, social withdrawal, anxiety and
depression. Personality characteristics, such as a sense of helplessness and worry, are increased by these factors. An understanding of a patients mental burden of anxiety, difficulties in
dealing with anger, depressive symptoms associated with
greater severity of pruritus and excitability is essential for successful psychodermatological treatment.1 Dieris-Hirche et al.
found significantly higher levels of suicidal ideation, anxiety
and depression among adult patients with AD,26 although the
severity of depression and the increase in the risk of suicide
did not correlate with the clinical severity of the dermatologic
disorder.27
It is important for dermatologists to learn to go beyond the
diagnostic label and try to assess the nature of suffering in
each individual case. Even in patients with a mild presentation
of AD, the psychosocial and economic burden of the disease
can be profound.28 Diagnosing an underlying psychiatric component in a patient involves several factors. First, the physician
needs to establish a good relationship with the patient. In
addition, the physician should evaluate the patients level of
functioning, as well as physical and psychosocial stressors that
may influence the level of functioning. Moreover, the physician should evaluate affective components that influence the
functioning ability of the patient. Various psychosocial test
instruments have been described that can be used to evaluate
the patient (Beck Depression Inventory, Dermatology Life
Quality Index, Skindex questionnaire).1

Quality of life issues

QoL is a broad concept, influenced by physical health, psychological state, level of independence and social relations. The
World Health Organization defines QoL as the individuals
perception of his position in life in the context of culture and
value systems in which he lives and in relation to his goals,
expectations, standards and concerns.29 QoL instruments provide a measure of whether a disease limits an individuals ability to fulfil a normal role in society, and can be used to assess
treatment outcomes and the burden of illness, which is
important for health care and political decision makers.
The impact of AD on QoL is unexpectedly high. Studies
using the health-related QoL (HRQoL) measure have shown
that chronic relapsing diseases like AD affect the physical,
psychological, psychosocial and occupational aspects of the
patient, at great cost to both the patient and society. Like
psoriasis, the impact of AD on HRQoL has been shown to be
comparable with that of other major diseases, including cancer, arthritis, heart disease, diabetes and depression, affecting
major aspects of both physical and mental functioning.30
Patients suffering from AD miss work with greater frequency
than those with other chronic medical conditions like diabetes
and hypertension.31
British Journal of Dermatology (2014) 170 (Suppl. s1), pp3843

Adults with AD frequently suffer from mental health issues,

and from a parental point of view, children with generalized
AD have the same impairment in QoL as children with cystic
fibrosis and renal disease.32 Another study of infants found
that patients with AD had a significant excess of dependency
or clinginess (50% vs. 10%), fearfulness (40% vs. 10%) and
behavioural problems (50% vs. 12%) compared with a control
population.33
A lack of positive nurturing during childhood may lead to
disorders and behavioural problems in adulthood.34 Examples
of such problems are self-image issues, hostile personality
characteristics, dysthymic states and neurotic symptoms all
of which are frequently observed in people with common skin
conditions such as AD.35
Early relationships are also important because they influence
the organization of stress and emotions. As AD frequently
starts in the first year of life, it may affect the parentchild
relationship. Some mothers of children with AD are more
depressed, and feel more hopeless and overprotective as a
result of the increased stress of having to care for affected
children. Children with AD have been noted to have a less
secure attachment, which can increase feelings of stigmatization.31 Caring for children with AD can also disrupt the family
dynamic, affecting the interaction between them and their
families, which may lead to conflict between parents or with
healthy siblings.32 Dysfunctional family dynamics may lead to
a lack of therapeutic response: 45% of children with AD
whose mothers received counselling and psychological treatment were clear of lesions compared with 10% in the group
receiving conventional therapy alone.36
Furthermore, the costs involved in managing a chronic condition like AD, both direct (e.g. treatment-related costs) and
indirect (e.g. loss of productivity), can be significant, affecting, in particular, families on lower incomes.31,32 Overall, AD
has considerable personal, social and financial consequences
both for the patient and his/her family, and also for the community.

Trauma and atopic dermatitis

Traumatic events, including natural disasters (i.e. the Great
Hanshin earthquake in Japan in January 1995), cause an
increase in psychological stress, which can lead to a higher
incidence of AD in populations of affected geographical
areas.37 Furthermore, strong links have been illustrated
between stressful life events and the development of conditions that may also apply to AD. A study by Sandberg et al.38
illustrated that children with high baseline stress levels have
an increased risk of having an asthma attack following an
acute stressful event compared with children with lower levels
of chronic stress who have a delayed and lower (yet still
significant) risk.
Alexithymia alexis (no words) and thymus (emotion)
is a personality trait characterized by difficulties in differentiating and describing feelings. Willemsen et al.39researched
this and concluded that dermatologists should be aware of its
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Psychodermatology of AD, M.S. Senra and A. Wollenberg 41

association with dermatological disease. Alexithymia may act

as a triggering factor for AD: The alexithymia is composed of
the following factors: difficulty in identifying feelings and distinguishing between feelings and the bodily sensations of
emotional arousal; difficulty in describing feelings to other
people; constricted imaginative processes, as evidenced by a
paucity of fantasies and a stimulus-bound, externally-oriented
cognitive style.39 Several researchers have linked alexithymia
with early traumatic experiences or insecure attachment with
caregivers.40 Children who are confronted with extreme stress
events and neglect are at greater risk of developing a dysfunctional balance between their sympathetic and parasympathetic
autonomic systems.41
A wide range of somatization is seen in dermatology, which
can culminate in post-traumatic stress disorder (PTSD) symptoms: nightmares, flashbacks, somatic sensations (pain, burning sensations, numbness, tingling, crawling), autonomic
hyperarousal and dissociative reactions.42 Autonomic hyperarousal and problems that affect regulation in PTSD may manifest a range of dermatological complaints. The autonomic
instability and hyperarousal in PTSD may causally trigger a
stress-reactive dermatosis such as AD. These symptoms are
triggered or exacerbated by stress and psychological trauma.
They are considered traumatic memories that could not be
remembered but were triggered by stressful situations such as
body memories.27

Doctorpatient relationship
The relationship between the patient and the healthcare provider is important, especially in clinical dermatology, because
psychological problems are often associated with skin conditions. As a consequence, treatment alone may not be enough
for long-term management, and high-quality consultations are
necessary.43 Adherence to treatment is difficult during the
course of chronicity and flare-up of the disease, but can be
improved with the aid of a dermatologist.44
The language used by a dermatologist should be clear and
simple, administered with empathy and compassion, and
adapted to each patient. Dialogue should provide explanations
to promote an understanding of the diagnosis; how long the
symptoms will last; a description of the treatment; and the
patients expectations and preferences all of which are
important aspects of the art of medicine. The patient can sense
whether the doctor empathizes with his/her suffering.
Hajjaj et al.45 explored types of management decisions in
dermatology and the identification of factors influencing these
decisions. Decisions are influenced by many factors: clinical
ones, such as ineffectiveness of therapy, adherence to the
prescription, side-effects of medications, chronicity of the
disease, and deterioration or improvement in the skin condition; and nonclinical factors, such as a patients QoL, time
commitment, friends and relatives, treatment cost and travel
difficulties.45
The duration of consultations is important for patient satisfaction, especially for those who are anxious or fearful that
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BJD British Association of Dermatologists

they have a serious condition. Poot suggests using the SOAP

method to structure a consultation: S (subjective symptoms);
O (objective signs); A (assessment); and P (plan).43 Patient
participation in therapeutic decisions is critical in choosing
which treatment can be integrated into his/her lifestyle.
The doctorpatient relationship has similarities with the
parentchild relationship, reproducing a shadow of what was
experienced in the past. According to Ainsworth et al. and
Fonagy, patterns of bonding in the attachment theory are
secure, anxious/avoidant, anxious/resistant and disorganized/
disoriented.46,47 These patterns influence the doctorpatient
relationship.39 Understanding this will help doctors to deal
with many patient reactions that are not directed at the doctor, but are directed at someone from the patients earlier life
a mechanism called transference.48
However, countertransference explains why a doctor may
feel irritated or impatient while unconsciously remembering
someone from his/her own past and projecting this onto the
patient.48 Doctors should seek to discover a patients emotions beyond nonverbal manifestations and facial expressions.
The identification of so-called mirror neurons, which are
activated both during an action and when you observe the
same action performed by another, have been proposed to
provide a potential mechanism that may enable us to perceive
not just other peoples actions, but the intentions and emotions behind those actions.49 These neurons are located in the
prefrontal cortex and the insula, and develop during
infancy.48
Structured educational programmes for patients with AD
have also been shown to improve the management of the disease in several age groups. This topic is covered in more detail
in this issue by Barbarot and Stalder.50
Managing symptoms and addressing incorrect coping
behaviour is only possible with a multifactorial approach
using an interdisciplinary team. Management programmes
working at the interface of dermatology, psychiatry and psychology are useful for general patient treatment, as well as
psychological interventions. Treatment may include brief
dynamic psychotherapy, biofeedback, cognitivebehavioural
therapy, relaxation techniques and hypnosis.51,52
Incorporating some psychodermatological know-how and
therapeutic armamentarium will prepare dermatologists to deal
with these difficult patients. Future investigations that explore
the interconnection between psychological stress and the cutaneous innate and adaptive immune responses will enhance
our understanding of skin immunology and immunologically
mediated skin diseases, provide unique insight into the mind
and body connection and may lead to new treatment programs that will improve patient care.53 Pharmacological interventions include the selected use of anxiolytics,
antidepressants and sometimes antipsychotics. In cases with
patients who resist referral or who are unable to obtain psychological service, these drugs may act as a temporary measure. Once a patient is able to work through his or her
individual trauma, the dermatological symptoms are no longer
an issue.53
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42 Psychodermatology of AD, M.S. Senra and A. Wollenberg

Conclusions and recommendations for the

treatment of patients with atopic dermatitis
The psychological effect and influence of stress in AD are well
established, and the specific features are age-dependent.
In adults, AD can affect interpersonal relationships, decrease
sexual desire, reduce work productivity, and affect social and
leisure activities. People affected by this disease are more restless in their sleep, wake more often, spend less time asleep
and report daytime fatigue. AD has an impact on QoL and
psychological well-being especially, which leads to psychiatric
and psychological comorbidities, such as anxiety, depression
and suicidal ideation.1,2
In children, AD causes irritability, clingy behaviour, sleep
disturbance, anxiety and depression. Some mothers are more
depressed, and feel more hopeless and overprotective, and
family members can also have problems with sleep, time management, financial issues and relationships.31 The worsening
of the disease due to stress has been well documented.5
As clinicians, we believe that disease severity does not necessarily correlate with the patients perception of his/her disability. Even asymptomatic patients can sense an impact of
AD on their QoL. In our own experience, maladaptive
schemes of cognitive and emotional patterns in patients with
chronic diseases such as AD will need tailored treatment
plans.
The best approach is to observe both the skin and the psyche during the consultation, assessing the patients mental status while maintaining a level of empathy or even compassion
toward the patient. It is important to focus on the impact of
the disease on QoL, and talking about the influence of stress
and unresolved traumatic experiences is essential.
Both time and patience are needed to get to know each
patient. The better trained the doctor, the better he/she will
be able to treat the patient. The goal is not merely to cure the
disease manifestations, but also to teach each patient or parent
to deal with the disease. The patientdoctor interview provides
indicators of a psychological co-diagnosis, and discerns
whether there is a need for a psychiatric consultation and the
use of psychotropic drugs, such as doxepin, trimipramine, bupropion, naltrexone, paroxetine or fluvoxamine, to relieve
pruritus.
Offering alternative therapies and psychological interventions to selected patients, such as those discussed in this article
(e.g. relaxation techniques) may have positive effects on the
skin, itch and scratching behaviour. Decreasing symptoms and
coping behaviour are only possible with a multifaceted
approach. Examples include cognitivebehavioural therapy,
brief integrated psychodynamic therapy and therapy based on
body orientation.
Medical personnel are responsible for establishing therapeutic activities, planning treatment sessions (usually once a week
for 20 weeks, based on personal experience), and choosing
the focus of treatment to allow the patient to be healthy, both
physically and emotionally, and able to see the transforming
power of the effects of change.
British Journal of Dermatology (2014) 170 (Suppl. s1), pp3843

Acknowledgments
We would like to thank MedSense, High Wycombe, U.K., for
providing editorial assistance, which was funded by Pierre
Fabre Dermo-Cosm
etique, France.

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