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Elizabeth H. Hamilton, MD, PhD
Amy Stein, MD
Julie Dodge, PA-C
4321 Medical Park Dr., #102
Durham, NC 27704
Telephone: (919) 220-7546 (SKIN)

Our Skin, Our Minds, Our Emotions

“There are very few instances in dermatology that do not involve some form of mental or emotional component.” That is the consensus of the providers at Regional Dermatology in Durham, Dr. Elizabeth Hamilton, Dr. Amy Stein, and Julie Dodge, PA-C. “In fact,” says Dr. Stein, “when I reflected on it, it became apparent that there are few cases in our practice where some form of psychiatry or psychology is not needed to support the patients.”.

“It’s interesting how such significant health issues as hypertension and diabetes are hidden from us,” she says, “while the skin shows itself with all of its glory and problems. And the problems are not hidden. People can be very distracted and embarrassed and even overwhelmed by things that are reflected in the appearance of their skin.


“The relationship between dermatology and the emotional and mental aspects of our bodies,” says Dr. Stein, “is increasingly being recognized in the practice of dermatology.”

Notes Julie Dodge: “Psychodermatology has been a popular area of study in Europe and is now getting attention in the United States. Our journals frequently report studies linking skin disease to other measures of health especially mental health.

Amy Stein, MD

“Psychodermatology specialists,” she says “identify three types of such disorders. First are skin conditions that are clearly affected by stress, such as acne, rosacea, and psoriasis. In a second category are psychological conditions that are caused by disfiguring skin disorders, which include scarring. Finally there are skin problems caused by psychiatric disorders.”

The Physical Impact of Stress

“Acne,” notes Dr. Stein, “is an example of a skin disorder that is affected by physical or emotional stress. Psoriasis is another example. The stress does not cause psoriasis but contributes to worsening skin disease. I have a patient who had fairly minor localized psoriasis. When she lost her husband, her psoriasis not only spread but became much more difficult to control.”

Elizabeth Hamilton, MD, PhD

Adds Dr. Hamilton: “There are episodic skin conditions that are notorious for flaring in times of stress. Dyshidrotic eczema (also known as pomphylx) comes to mind. The patient develops small water blisters usually on the sides of the fingers that resemble poison ivy. This is common among college students and typically flares around exam time.

“We see many, many students from schools in the area, and over time we have come to make a clear connection between schools that are known to be demanding and rigorous with the percentage of students who have acne. The more challenging the school environment, the higher percentage of students who have issues with this skin problem. Stress is not your friend when you have acne.”

The Psychological Impact of Skin Problems

And there are skin conditions that contribute psychological problems to varying degrees, points out Dr. Stein. “I treated a teenager with severe nodular cystic acne who was depressed not only by his appearance but also the pain associated with the problems. At first, he would hold his head down during our visits and not make eye contact or speak. He wore his hair long to cover his face and would never take off his shirt—even on the hottest days in the summer. After a five-month course of isotretinoin (previously known as Accutane), his acne was clear—even his scarring was improved. He was transformed in to a happy, smiling, talkative young man with a short haircut!”

Julie Dodge, PA-C

Julie Dodge and Dr. Hamilton agree that almost any chronic skin condition that is visible can have a negative impact on self-esteem. Eczema and psoriasis are common examples. Granuloma Annulare is a less common condition but it shows up on the hands and arms so it is difficult to conceal.

Hair loss, Dr. Hamilton point outs, is a particularly difficult problem of this kind. “And I acknowledge this to my patients by letting them know that ‘We are all attached to our hair and no one wants to lose it. Hair loss can be caused by a variety of stressors or can cause anxiety if it progresses to the point that it cannot be camouflaged.’”

The Impact of Psychiatric Disorders

“The least common mental health concerns are skin problems caused by psychiatric disorders,” says Dr. Stein. “Frankly, we are glad they are rare because they are difficult to manage and treat. One disorder is called Delusions of Parasitosis. An individual can be normal in every way—mentally and otherwise—but they get the notion that a bug or parasite has invaded their bodies.”

Julie Dodge recalls “I had a patient with this condition and she would bring in bags of dead skin and lint for me to look at. She wanted me to look at it under the microscope to determine the type of bug. On the skin, she had sores from trying to dig out the bugs and was convinced that they were crawling out of her body. The problem with these patients is convincing them that their minds are playing tricks on them. Yes, they do see the bugs but it is a type of hallucination. It requires psychiatric medication but frequently patients are resistant to this approach.”

“Not all problems are quite this dramatic” says Dr. Hamilton. “As a confessed picker, some of us pick at bumps, pimples to the point that the spot takes on a life of their own. I describe them as ‘pets’—the more attention you give them, the more they come back. It can be one spot, which I consider in the normal range or it can be more problematic with widespread areas of open painful sores that heal with unsightly white scars. Anxiety is likely a common factor.”

The Common Emotional Component

“Sometimes the emotional component of dermatology practice is less obvious but more common,” notes Dr. Hamilton. “For example, it may come in the form of tension at the beginning of a skin exam for a melanoma patient and relief at the end of the exam when no new cancers are detected.”
Dr Stein agrees adding: “When a biopsy is done to determine if there is skin cancer, there is the anxiety of having to wait for a biopsy result.”

They all agree that patient education and formulating and facilitating a treatment plan that suits the individual is the best way to support them if they do have a biopsy that indicates skin cancer or any other skin disease.