From Psyche to Skin: A Call for Interdisciplinary Care in the Management of Psychodermatologic Conditions

J Clin Aesthet Dermatol. 2025;18(3):67–70.

by Mary D. Sun, MD, MSCR; Brandon R. Block, BA; Simran Ohri, BA; and Timothy Rice, MD

*Dr. Sun and Mr. Block share co-first authorship of this article.

Dr. Sun is with Brigham and Women’s Hospital in Boston, Massachusetts and Harvard Medical School in Boston, Massachusetts. Mr. Block and Dr. Rice are with the Icahn School of Medicine at Mount Sinai in New York, New York. Ms. Ohri is with the Rutgers New Jersey Medical School in Newark, New Jersey. Dr. Rice is also with Mount Sinai Morningside in New York, New York and Mount Sinai West in New York, New York. 

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

ABSTRACT: Despite increasing academic discourse surrounding psychodermatology, few dermatologists or psychiatrists demonstrate a clear understanding of the field. Barriers to physician awareness are double-edged, stemming from both inadequate educational opportunities and patient non-disclosure of psychodermatologic symptoms during clinical encounters. It is crucial that medical practitioners, especially in the field of dermatology, become accustomed to recognizing, diagnosing, and treating psychocutaneous disorders, which disproportionately affect members of historically marginalized populations. In this commentary, we propose recommendations for pedagogic supplements to be implemented throughout medical, post-graduate, and post-residency education to build familiarity with this subdiscipline and confidence in managing its associated conditions. In particular, we endorse the integration of components of psychiatry education into dermatology residency training and current practice, as skin symptoms tend to be more openly disclosed than mental health struggles, so dermatologists are often the first physicians to encounter many of these conditions. We also advocate for interdisciplinary collaboration to bridge the gap between the uniformity of standard specialty training and the complexity of psychocutaneous disease.

Keywords: Psychodermatology, mind-skin axis, psychophysiological disorders, social determinants of health, medical education, interdisciplinary training

Introduction

Psychodermatology is an emerging subspecialty that focuses on interactions between the mind and the skin. Cutaneous and nerve cells share a common embryologic origin: the ectoderm. There is a bidirectional relationship between these systems, as illustrated by the hypothalamic-pituitary system, which regulates both behavior and skin pigmentation.¹ This complex interplay creates the potential for various pathologies along the mind-skin axis.

Researchers tend to group psychodermatologic diagnoses into three main categories.¹ First, there are primary psychiatric disorders with body-focused repetitive behaviors, which can lead to self-inflicted skin and hair lesions. A common example is trichotillomania, characterized by the compulsive urge to pull hair. Inversely, secondary psychiatric disorders arise from the psychosocial burden of managing a skin condition. For example, patients with alopecia areata can experience anxiety, depression, and social phobias as a direct consequence of hair loss. The third category comprises psychophysiological disorders, where dermatologic disease is modified or aggravated by psychosocial triggers.^1,2–4 Approximately 30 percent of chronic skin conditions are thought to be influenced by psychiatric disturbances.⁵ Numerous studies suggest a high prevalence of psychodermatologic correlates in conditions such as pruritus, acne,⁶ atopic dermatitis,^7–10 vitiligo,¹¹ psoriasis,^12–15 herpes simplex,¹⁶ and zoster,¹⁷ which are associated with psychosocial factors such as race, gender, and socioeconomic status.

To ensure comprehensive care, dermatologists and psychiatrists alike benefit from concerted efforts to understand the interplay between cutaneous pathologies and psychological distress. This is especially crucial in meeting the health needs of vulnerable patient populations disproportionately affected by psychosocial risk factors. In this commentary, we describe the current gap in medical education regarding psychodermatology and highlight the undue burden that it places on patients with undiagnosed or mismanaged psychodermatologic conditions, especially members of historically marginalized groups. Finally, we summarize these findings and devise a series of recommendations to address current deficiencies in medical education and dermatologic practice.

Gaps in Physician Awareness

Despite the growing body of literature on psychodermatology,^3,18 timely recognition and effective treatment of these conditions remains inadequate.¹⁹ One study found that only 21 percent of psychiatrists and 18 percent of dermatologists demonstrate a clear understanding of psychodermatology.¹⁹ According to a similar publication, 90 percent of practitioners in both specialties are not aware of any patient resources on the topic.²⁰ 

Barriers to recognition and awareness of psychodermatologic issues can be traced back to medical school education. Most medical schools devote few, if any, hours to dermatology education in their curricula,²¹ placing students at an innate disadvantage in terms of the recognition of dermatologic conditions, let alone psychocutaneous disease. Moreover, traditional curricula introduce students to the core medical specialties individually, with minimal exposure to interdisciplinary subspecialties. This can be detrimental to both physicians-in-training and patients alike; the former are not challenged to integrate specialty-specific knowledge, and the latter are consequently met with perspectives that may be too narrow for their presentations. 

Education continues to be primarily mono-disciplinary during residency, as specialty-specific board exams do not cover interdisciplinary subspecialties. The focus on testable material continues with continuing medical education (CME) content, which is the primary source of formal medical education for practicing physicians. This may result in practice gaps that continue to widen after graduation.

Lack of Patient Discourse and Recognition

Importantly, patients with psychiatric conditions may not disclose cutaneous symptoms. This is sometimes attributable to burden from disease states in which skin and/or hair lesions result from lack of self-care, as seen in severe depression. Fear of social stigma can play a role in silencing patients with behavioral conditions such as hypersexual disorder, which is associated with cutaneous comorbidities such as condyloma acuminata.²² Individuals are also less inclined to divulge self-inflicted symptoms, as often occurs with psychotic and obsessive disorders.²³ 

Individuals with skin conditions are similarly reluctant to discuss coinciding mood symptoms with dermatologists. These patients tend to experience heightened sensitivity to psychiatric stigma. Suboptimal education on mental health also contributes, leading many to believe that psychological complaints are not relevant or are inappropriate to discuss during clinical encounters.²⁴ Failure to consider psychiatric history can result in dermatologists prescribing medications that are contraindicated for those with mental health issues. For example, isotretinoin and biologics commonly prescribed for inflammatory skin conditions have been linked to suicidal ideation.²⁵ 

Psychodermatologic Issues in Historically Marginalized Populations

Certain patient populations are disproportionately affected by psychosocial factors that uniquely predispose them to dermatologic illness, and vice versa. It is important that physicians, especially dermatologists, consider the increased burden of these health issues in historically marginalized groups.

The increasing incidence of psychiatric issues among women underscores the importance of exploring psychosocial factors in female-identifying patients endorsing dermatologic symptoms.²⁶ Social media use has been linked to the recent phenomenon of “Snapchat dysmorphia,” with associated increases in requests for elective plastic surgery.^27,28 It has also been correlated with decreased patient insight in body image disorders, disordered eating patterns, sleep disturbances, and suicide attempts, all of which are primarily observed in female-identifying populations.^29–33 These psychosocial influences have the potential to aggravate pre-existing skin diseases as well as to precipitate cutaneous manifestations of primary psychiatric illness.²³ This underlies the importance of increased recognition of dermatologic and psychiatric symptoms in women, as there is often a direct and synergistic relationship between the two.

Similar effects have been observed in sexual minority men with regard to body image, eating disorders, and anabolic steroid use.³⁴ For example, the inappropriate use of exogenous testosterone has been linked to a number of dermatologic complications such as acne vulgaris.^35,36 A recent cross-sectional study found associations between sexual orientation, indoor tanning use, and skin cancer risk.³⁷ Psychosocial factors such as stigma, discrimination, and hostile social environments can lead to elevated levels of distress, which can manifest as body image hyper-fixation and increased engagement in health risk behaviors. Indoor tanning can serve as a coping method for dissatisfaction with physical appearance, particularly among sexual minority men, whose skin cancer prevalence is significantly higher compared to that of heterosexual men.^37–39

Transgender and gender-nonconforming individuals are also at significantly increased risk for psychiatric comorbidities with links to cutaneous pathologies.^40,41 It is estimated that 50 percent of this population sees dermatologists for various skin pathologies.^42–44 Moreover, gender-affirming therapies and procedures create unique, often unmet, needs in patients receiving cross-sex hormone therapies. Masculinizing and feminizing contouring procedures can have both psychiatric and dermatologic implications.^43,45 Interdisciplinary awareness of psychodermatology interactions is therefore important to mitigating adverse health outcomes for LGBTQ+ patients. 

While psychodermatology research focusing on lower SES adolescents is limited, emerging studies have begun to demonstrate the intricate relationship between social environment, economic background, age, mental health, and dermatologic health. An exploratory study of adolescents in Colombia found strong associations between dermatologic conditions and demographic characteristics, psychiatric history, and current psychiatric disorders. Relative to the general adolescent population, there was a greater proportion of study adolescents with dermatologic conditions who also presented with depression, anxiety, and/or suicidal ideation.⁴⁶ Furthermore, lower SES adolescents are more frequently exposed to stressful life events associated with mental health risks and sustained levels of cortisol,⁴⁷ a hormone with wide-ranging effects including alterations in skin barrier and immune cell functions.⁴⁸ While many of these issues require public policy solutions, physicians can improve the diagnosis and treatment of psychodermatologic sequelae associated with socioeconomic disadvantage.

Recommendations

Given the serious impacts that psychodermatologic disease can have on patients, it is crucial that psychodermatology be integrated into medical education and dermatologic practice. In this section, we aim to address the low rates of physician familiarity by suggesting educational supplements that can be implemented at the medical school and post-graduate levels, as well as in CME activities for practicing dermatologists.

Medical schools have made numerous attempts to improve their curricula over the last decade, spurred in part by the centennial of the Flexner Report.⁴⁹ Expanding interdisciplinary education would be consistent with this spirit of reform. Indeed, several subspecialties already provide early exposure through didactics as early as the pre-clinical years; efforts in psychodermatology can be modeled on these precedents.^50–52 During the clinical years, there are numerous opportunities for rotating students to present on topics of interest during protected learning time with peers and preceptors.^{46–48,53,54} For example, students rotating in psychiatry, especially those with an interest in dermatology, might be encouraged to explore content related to the recognition and management of psychodermatologic disorders.

In dermatology residency training, program directors can diversify educational opportunities by addressing emerging cross-specialty research and offering electives in psychodermatology. In addition to adequately preparing residents for board examinations, didactics could incorporate interdisciplinary offerings tailored to enhance exam-relevant instruction. Some researchers have also posed the creation of “psychocutaneous clinics” for dermatology and psychiatry residents. In fact, one such clinic has already been established at the University of Wisconsin-Madison, receiving over 800 referrals between 2002 and 2018.⁵⁵ These opportunities encourage trainees from both specialties to engage directly with and learn from one another, bestowing the opportunity to diagnose, treat, and gain comfort with psychodermatologic conditions early in their careers.^55–57

Most importantly, practicing dermatologists and psychiatrists must be well-prepared to handle psychodermatology cases.^19,20 This is especially true for dermatologists, as patients with secondary psychiatric and psychophysiological disorders are more likely to seek medical attention for skin symptoms. For example, a dermatologist might notice that their patient with severe acne vulgaris is demonstrating characteristic signs of major depressive disorder, stemming from poor self-image. Similarly, a thorough work-up of a patient being treated for psoriatic flare-ups may reveal that symptom onset corresponds with particular stressors. Such vigilance on the part of the dermatologist not only aids in making a more informed diagnosis but also helps to facilitate timely referral to a psychiatrist, thereby ensuring comprehensive care. Existing knowledge gaps could be addressed via cross-specialty educational engagements at academic medical centers, as suggested above, and by developing CME activities for dermatologists. 

Another key point to consider is that patients with psychodermatologic conditions may initially present to colleagues in family medicine, pediatrics, or plastic surgery. Accordingly, these providers would benefit from some base level of psychodermatology education to improve screening and referrals.⁵⁸ Outreach efforts could be made by dermatologists well-versed in psychodermatology to assist other specialists in familiarizing themselves with some of the more common presentations of psychodermatologic issues.

Conclusion

There are great benefits to be had in developing educational models for psychodermatology content at multiple levels of training. The high prevalence of psychodermatologic conditions and interactions, particularly in historically marginalized patient populations, is made even more clinically salient by the disabling impacts of these disorders. Raising awareness of psychodermatology across multiple clinical environments, from the classroom to the exam room, is achievable through existing mechanisms of medical education. It can be reasonably inferred that these efforts would have an outsized positive impact on health outcomes in dermatology, psychiatry, and beyond. Patients with psychocutaneous and stress-related disorders need providers with sufficient interdisciplinary knowledge to place them within the proper diagnostic context and to provide integrative care. The incorporation of psychodermatology into dermatology education and practice is an important first step to meeting the health needs of these patients, who are too often overlooked and underserved. 

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