Out of no fault of our own, 2020 and the beginning of 2021 has undoubtedly been one of the most stressful years many people have experienced. With the anxiety and uncertainty surrounding the global pandemic [1] and civil unrest [2], plus one of the most contentious and important US elections [3] in recent history, I think it's hard to find someone who isn't stressed. Unfortunately, for a lot of people, this is showing on their faces and bodies: we're talking sensitised skin, "random" rashes (spoiler: they're not random), blotchiness, eczema [4], psoriasis, rosacea [5], urticaria (hives), and acne. [6]

When we asked experts if stress affect the skin, the answer was undeniably yes. Stress absolutely, 100 percent can affect the skin in a multitude of ways.

But we wanted to know exactly how stress affects the largest organ of the body, how we can potentially prevent skin conditions due to stress from occurring or worsening, and how to treat conditions during a flare-up. That's why we called upon some of the best psychodermatologists from both the UK and the US to break it down. The field of psychodermatology is critical when discussing the topic of stress and skin conditions because it's one that combines both dermatology and psychology. Psychodermatology not only treats the dermatological problem someone has, but it also looks into potential underlying psychological causes and impacts of the condition. This holistic approach allows for better understanding and management of chronic skin conditions, especially for those living under prolonged periods of stress.

So, How Does Stress Affect the Skin Exactly?

"One of the main ways that stress affects the skin is through something called the HPA axis, the hypothalamic pituitary adrenal axis, which is basically, our body's stress axis," said UK-based psychodermatologist, Dr Alia Ahmed [7]. "When you perceive stress, your brain recognises it, and it kicks off a number of processes in the body, which leads to the release of chemicals and hormones, most of which drive inflammation, both in the body and also in the skin. "The main chemical that's involved is something called cortisol, which is the main culprit implicated in a lot of skin conditions."

The increase in cortisol production from the adrenal glands causes a number of things to happen in the body. "This stress hormone stimulates the grease glands in our skin, making them produce more sebum. As a result, many people find their skin breaks out during stressful times," said Dr Sharon Wong [8], a London-based consultant dermatologist and tricho-derm. "The cortisol also creates an inflammatory environment in the skin, which is a common trigger for conditions such as eczema and psoriasis," she added. Dr Wong noted that cortisol also suppresses our immune system, making us more prone to infections.

In addition to this, neurochemical signals released by the brain in response to stress can influence the immune function in the skin. What does that mean exactly? Under stress, our skin may be less able to defend itself, in turn delaying the healing process and driving allergic responses.

If all of that wasn't enough, this also ultimately affects the skin's natural barrier. Dr Amy Wechsler [9], a New York City-based board-certified psychiatrist and dermatologist [10], describes the skin under stress as being "leaky." "Inflammation causes the surface of the skin — the barrier of the epidermis — to become more leaky," she explained. "It leaks water, therefore your skin is drier. [Your skin] is also more likely to let things in that it wouldn't otherwise, so you might be sensitive and get itchy rashes; things you normally wouldn't experience."

"Stress also has indirect, knock-on effects, such as poor eating and sleeping habits, which can add even more stress to the body," added Dr Wong. A skin condition flaring in itself can be a stressful situation, which in turn, can worsen the condition, leading to a vicious cycle.

How Does Stress Manifest in the Skin?

Now that we understand what's happening inside our bodies when we're stressed, we wanted to know how exactly this can present itself on the outside, so on the face and body. Unsurprisingly, stress can manifest on the skin a variety of ways.

Everyone experiences and internalises stress differently, so it makes sense that stress will affect people's skin in different ways, too. One of the first things to look at is whether you are experiencing short-term or long-term stress, as this can affect whether a skin condition becomes chronic.

Short-term stresses, such as knowing you've got an important presentation coming up, can cause temporary problems on the face and body, including being hot, sweaty, flushed, blotchy and itchy, said Dr Ahmed.

However, if you're experiencing long-term stress, the axis in your brain becomes activated and is activated all of the time. Even during times when you're not stressed, your body processes it as a stressful environment; so when it comes to your skin, it's not uncommon for someone to experience persistent dryness and itchiness. Dr Wechsler also explained that, "cortisol can break down collagen, which is why someone who's dealing with stress feels like they've developed wrinkles overnight."

Long-term periods of stress is also when existing skin conditions like eczema, psoriasis, and rosacea tends to become aggravated. "We don't sometimes know exactly why this happens," said Dr Ahmed, "but it has a lot to do with the skin barrier, as well as your immune response and inflammation caused by the HPA axis. "We know that people with psoriasis and eczema who have a high level of stress, their skin disease tends to be more severe."

The Link Between Stress and Acne

When it comes to stress and acne, things become a bit more complicated. You need a number of things to develop acne: "you need acne-causing bacteria, you need oil, and also clogged pores, and stress can aggravate all of these things," explained Dr Ahmed. "Stress can aggravate your oil production, reduce your natural immunity to the bugs that cause acne, and it can cause dryness and itchiness, so that your pores get clogged more easily and disrupt your natural skin barrier." Whilst not everyone who is stressed will get acne, Dr Ahmed explained that there is enough evidence to reasonably link that people who are prone to it might experience acne breakouts during periods of prolonged stress.

On the other hand, not everyone who is exposed to prolonged periods of stress experiences these chronic conditions. There are a number of other, less obvious ways that your skin might be affected when you're stressed out. One of which is that you may also generally find your skin is a little more sensitised than normal. "Before [the stressful period] people may not have even noticed if someone near them was wearing perfume, but because your skin barrier becomes disruptive when stressed, you might find that it's now making you itchy." said Dr Ahmed.

"When someone is stressed out, their skin, which wasn't usually sensitive, can become temporarily sensitised," added Dr Wechsler. "This means that before [the stress], they could use any moisturiser, any fragrance, and any skincare ingredient with no problem, but now, if there's a product with fragrance in it [11], they might get a rash from it."

So, it's clear that stress can lead to a number of potential skin issues, but luckily there are things you can do to help it. That's why, when it comes to prevention and treatment, the field of psychodermatology is so important.

How Can We Prevent Skin Conditions Caused By Stress From Occurring?

"We obviously cannot control or prevent stressful events from happening, nor the day-to-day cumulative work-related or personal stresses, but what we can proactively do is improve our stress management," said Dr Wong. "The way that stress and anxiety is handled has a powerful way of modifying those chemical changes in our body (and skin) to prevent the onset of skin conditions that are stress induced, but it can also help [your skin] to recover from these conditions."

At Dr Ahmed's practice, before prescribing any sort of treatment, she typically starts by asking patients if their skin condition, such as eczema or psoriasis, gets worse with stress (keeping a symptom diary can help with determining this). If they answer yes, she begins work with them to figure out what those triggers are. "The best thing to do after you've received your diagnosis and if you think there is a strong link with stress is to work out where the stress is coming from and at what points in your life you become more stressed," Dr Ahmed explained. "We all have stress, but everybody perceives it and deals with it differently. For people who feel like their skin gets worse during stressful episodes, trying to avoid those triggers is important in preventing them from becoming aggravated."

Once that stress link as been made, looking deeper into the sources of the stress, whether that's relationship issues, low self-esteem, anxiety, depression, or lack of body confidence, for example, is important. "Many of these things make people feel stressed, because they're emotionally distressed, therefore their body perceives that as stress," Dr Ahmed said. She noted that for some people, cognitive behavioural therapy (CBT) helps them hugely with turning negative thoughts into positive ones, which can be extremely helpful to prevent a flare-up during or prior to a stressful situation.

What Treatment Options Are There For Skin Conditions Caused (or Worsened) by Stress?

Despite our best efforts, sometimes all of the prevention in the world still doesn't stop a skin condition from flaring up. This is where the holistic management in psychodermatology comes in. "Of course, some people just get better with one cream, but if it's a chronic problem and it's causing emotional distress, it's helpful to tackle all factors," said Dr Ahmed.

At Dr Wong's clinic, "skin conditions are treated with standard medical therapies but where there is a big stress element, concomitant stress management is absolutely key," which includes CBT and mindfulness-based stress reduction (MBSR), and even healthy habits such as eating nutritional foods, exercising, and taking time for yourself.

"The level of intervention required will vary from person to person and can range from practising mindfulness and meditation, through to more formal psychological treatments such as CBT or taking medications to help," said Dr Ahmed. Further to this, due to the quick nature of a flare-up, Dr Ahmed suggests that you have medical help contact details on hand in case you need to modify or change your treatment entirely, noting that this is a situation that often happens for people flaring severely. If you haven't yet been diagnosed, this is an important step in being able to manage your symptoms most effectively.

Additionally, Dr Ahmed recommends that her patients with chronic skin conditions know what to do as soon as possible when having a flare-up. That could be things such as using more moisturiser, making sure you're using medicated or prescribed creams correctly, avoiding irritants such as specific skin care ingredients and certain fabrics, and making sure you're well hydrated.

When it comes to managing stress, there are a number of practical ways to help with this. Dr Wechsler noted that one of the most important ways of reducing stress is a good sleep routine. "Stress and not sleeping well often go hand in hand. Adults typically need seven-and-a-half to eight hours of sleep at night," she said. "One of the good things is that when we're asleep, cortisol is at its lowest and the molecules (beta endorphins and growth hormones) that help to heal the skin, are at their highest. These anti-inflammatory molecules keep the cortisol low, which is why naps are so good."

If you're struggling with sleep, Dr Wechsler suggests maintaining good sleep hygiene such as having no caffeine after 5 p.m., trying not to watch stressful TV shows (or the news) a couple of hours before bed, trying not to use your phone or laptop too late, and instead reading a book, having sex, or hanging out with friends on Zoom.

In addition to sleep, Dr Wechsler said another easy thing to maintain is a skincare routine (bonus points if it's one recommended by a dermatologist), as this not only helps keep your skin happy but it also adds an element control back into your everyday life.

Finally, get some fresh air, as it's been proven to lower cortisol levels said Dr Wechsler. We might be living in a pandemic and currently under lockdown in the UK, but it's incredibly beneficial, if possible, to step outside for a little while every day.

Has Pandemic Stress Had a Direct Impact on Some Skin Conditions?

When I asked the experts if the pandemic has had a direct impact on the number of patients they're seeing in the clinic, the unanimous answer was "Yes!" "From the very beginning, people were breaking out in acne and rashes," said Dr Wechsler.

"Some of [the conditions] are directly related to the practices we've developed during the pandemic — for example, people have developed hand dermatitis from using more hand sanitising gel and increased handwashing," said Dr Ahmed. Both Dr Ahmed and Dr Wechsler have also seen increased irritation in patients' skin as a result of wearing a face mask. "The other thing that we're seeing is people's existing skin conditions becoming worse, which can be related to the COVID stress," said Dr Ahmed.

If you have a skin condition that has either occurred or is worsening, whether it be caused by the pandemic or not, it's important to seek help and not self-diagnose. Visiting your GP or a dermatologist can help diagnose and come up with a treatment plan to manage your symptoms. If you think your condition is triggered by stressful situations or events, consider booking an appointment with a psychodermatologist to get to the root cause.