Psychodermatology: beyond the skin

In our Madrid clinics at the International Dermatology Clinic and the Ruber International Hospital, we see every day how the skin becomes a true mirror of our emotions: suffering sometimes manifests itself through the skin.

Dr. Elena Tévar Valiente , a brilliant dermatologist and psychotherapist at our clinic, with whom I have been fortunate enough to work for over 20 years, sums it up clearly: "The skin and the brain share the same embryonic origin, which explains their close connection." This statement invites us to look beyond the visible and understand that, in many cases, dermatological diseases are much more than simple skin problems.

The skin as an emotional stage

Dr. Tévar emphasizes that between 25 and 30% of dermatological consultations present significant psychological impact. This means that, in addition to treating physical symptoms, it is essential to address the emotional dimension of the people who consult us. The practice of dermatology has led us to encounter several patients for whom the medical approach is not sufficient, since in some cases, " There is no skin disease as such," she points out, "what we see on the skin is induced or exacerbated by the patient themselves."

This is clearly seen in disorders such as dermatitis artefacta , a condition in which patients intentionally inflict injuries on themselves but deny responsibility. As Dr. Tévar explains, "These patients seek to assume the role of the sick out of a psychological need for care and medical attention." Many of these patients have histories of childhood abuse or neglect , and their skin becomes the site of emotional pain.

In the words of Dr. Tévar: "It is the somatic expression of psychological distress. We must ask ourselves: What has happened to this patient? Why do they need to be sick? Why do they need to see a dermatologist for care and treatment ? Treating these patients is particularly complicated because when you try to treat them, other lesions may develop , or they may even need to change doctors, because they really need care more than cure."

Stress as a trigger

In our clinics, we also treat patients with dermatological conditions triggered or aggravated by stress. Dr. Tévar explains that "patients often identify a clear chronological relationship between stress and the onset or worsening of their condition." This is observed in conditions such as acne, rosacea, alopecia areata , atopic dermatitis, psoriasis, vitiligo, urticaria, and seborrheic dermatitis.

Rosacea , for example, can be accompanied by intense social anxiety , although "interestingly, some patients with rosacea develop counterphobic mechanisms," says Dr. Tévar. " Rather than isolating themselves , they sometimes expose themselves excessively to their social environment to cope with their fear of redness."

Vitiligo , for its part, is often accompanied by fear, shame, insecurity, and sadness, especially in adolescents. "Twenty-five percent of patients report that the disease affects their sex life ," warns the doctor, who emphasizes the importance of addressing not only the physical aspect but also the emotional and social impact of the disease. In many cases of vitiligo, there is a triggering factor : the death of a loved one, work or financial problems , or the end of a romantic relationship. This disease sometimes influences many behaviors in patients who suffer from it: they avoid situations such as swimming in the pool, going to the beach, changing in locker rooms, shaking hands, certain sports in which their skin is exposed, etc.

In psoriasis , emotional stress is present in more than half of cases. "Patients often feel shame, anger, hopelessness, and in some cases, there's an increased risk of depression," the doctor adds. This can have an impact on personal relationships , self-esteem, work life, and even sexuality.

When the skin becomes an escape route

Other psychodermatological disorders include compulsive behaviors such as trichotillomania (hair pulling) and excoriation disorder (compulsive scratching). "These behaviors function as coping mechanisms in the face of stressful situations," explains Dr. Tévar. "While they do it, they feel temporary relief, but then guilt and anxiety set in. To calm down, they return to self-harm , in a cycle that is constantly reinforced." In these cases, the therapeutic approach should include not only dermatological treatment but also psychological support, helping the patient understand why they cannot control themselves and what has happened to them to make their skin the scene of their emotional suffering.

Dr. Tévar emphasizes the importance of the dermatologist maintaining an open and empathetic attitude . "Listening to the patient and allowing them to express their emotions and feelings about their disorder is key," she asserts. "The impact of the disease on their work, interpersonal, and social life must be explored."

Beyond psychotropic drugs , there is a basic supportive psychotherapy that can often be provided by the dermatologist himself or herself, and which will be very useful. It consists of maintaining an open, understanding, and listening attitude, trying to put oneself in the patient's shoes (empathize), providing information about the disease and clearing up the patient's doubts. We listen and examine the suffering behind the skin disease.

Conclusion

Modern dermatology must focus not only on artificial intelligence, but also on emotional intelligence , taking a comprehensive approach that combines dermatological treatment with psychological care . It's not just about healing the skin, but also about supporting the patient and offering them tools to understand and manage their emotions.

In short, psychodermatology reminds us that behind every skin lesion lies an emotional story that deserves to be heard with rigor, empathy, and humanity. As The Little Prince reminded us: "What is essential is invisible to the eye."