Sometimes we refer to it as a snowball effect.
Other times we identify it as a vicious circle. But call it what you will, we all know the chain of events that we are describing when one undesired circumstance causes another – a domino effect, as it were – only to find that the second negative outcome amplifies the unwanted characteristics of the first, which subsequently reinforces the consequences of the second, and back and forth, and so on and so on . . .
And so one might describe the tenuous relationship between eczema and mental health: the itchy skin, often dry and cracking, exacerbates the anxiety (or the depression, or the inattention, or the hyperactivity), whereas the altered perceptions and the body’s accompanying stress response associated with certain mental health conditions can make the eczema much worse, or at least seem so, and cause more scratching, which causes more skin thickening and discomfort.
It is by now well-established that a number of mental health symptoms and psychiatric diagnoses – from anxiety and depression to attention deficit-hyperactivity disorder (ADHD) and learning disabilities to a general impairment in psychosocial functioning – are more common in both adults and children with eczema than in the general population. What’s more, the severity of the eczema correlates with the severity of the mental health disorder: the worse the thickening of the skin, or the more severe or conspicuous the redness or scabbing is, the higher the degree of the patient’s distressed mood or compromised focus. In fact, people with skin conditions in general, and not just eczema, suffer from heightened levels of psychological distress.
But we also know that flares of psychological stress also cause flares in eczema, particularly flares that are associated with scratching and an increased perception of itch.
So which do you treat – the skin discomfort that causes the mental anguish, or the psychological distress that leads to scratching and disease exacerbation – when it is not entirely clear which factor is the “first domino to fall”, or which one is the chicken, and which one is the egg?
The answer, of course, is that we should be addressing both.
The greater weight of the evidence produced by academic research suggests that it is eczema that increases the risk and severity of mental illness, and one of the most powerful mechanisms through which this occurs is nighttime itchiness and the resultant sleep disturbance: Itching and skin soreness can cause both decreased sleep and poorer sleep quality, and results in daytime sleepiness – a known risk factor for mood disorders and ADHD, as sleep deprivation and tiredness lead to mood changes and impaired social functioning.
But the mental health problems incited by the skin inflammation associated with eczema is not just limited to sleep: There is, of course, distraction caused by skin that feels itchy in the moment – and this is an imposing situation to navigate for a child with ADHD or a learning disability. And for many people, eczema causes distraction even in the absence of itch, as some patients are internally preoccupied by the social embarrassment they feel in moderate to severe skin disease – a well-known phenomenon in adolescents – as well as the distorted perception of how severe the skin condition actually is.
And though we want our family members to accept themselves for who they are and how they appear, it makes sense to treat the eczema – especially when itching is involved, and especially when the treatments have little in the way of side effects – when it can have such a positive impact on our mental well-being. Moisturizers and topical prescription therapies are generally safe and effective in reducing symptoms and skin involvement, and should be utilized regularly when prescribed by a healthcare provider. Body washes – specifically those that contain hypochlorite – are also safe and have been shown to be disease-modifying in the treatment of eczema.
Coming at the eczema-mental health nexus from the other angle, if you want to treat the eczema, then you also have to treat the stress – and this is, in fact, the official policy of the American Academy of Dermatology. In the control of itch, habit reversal training, progressive muscle relaxation training, and cognitive behavioral therapy have all been reported to be beneficial in chronic eczema. Cognitive behavioral therapy may also be useful in helping patients restructure the perception of their own disease severity, and promote social engagement and improved social functioning – including an improved sense of self-acceptance.
It is a holistic approach – one that addresses both our skin and our behavior – that is most likely to improve both eczema and mental health disorders when the two co-exist. And it is this multidisciplinary approach that will take the vicious circle, reverse its direction, and create a virtuous one.