Beneath the Skin


Interview with Dr. Evan Rieder, Dermatologist and Psychiatrist Evan Rieder, MD didn’t set out to be one of a small handful of doctors in the United States double-board certified in dermatology and psychiatry. As a medical student, he found himself torn between two areas of study. “I felt like I could really connect with people in psychiatry on a very deep level and that everything was not so algorithmic like it is in the rest of medicine,” he says. Then he rotated through dermatology and was drawn to the quick procedures and quick diagnoses of the field. But for him, it was more than just a personal connection; he intuitively saw a link between the two seemingly opposite specialties. 

“I recognized that a lot of people had anxiety and mood issues that seemed to be related to their skin and no one was really addressing it,” he remembers. “It turns out 30 percent of dermatology visits have some sort of psychological component.” Dermatological diseases like eczema, psoriasis, and acne often have a “psychological overlay,” as he calls it, which means those who suffer from them can experience depression, anxiety, and other psychological issues in connection with the skin disease. Almost any reason someone seeks out a dermatologist could have a psychological component, in fact. “Whether it’s skin cancer and the anxiety related to that or a cosmetic procedure, it’s all psychology,” he says. “To a certain extent, all dermatologists practice psychiatry, except some of us do it a little bit more and are asking more questions.”

He sought out to become a sort of interpreter between the two fields, not just for his patients, but for his colleagues as well. Now he is one of the leaders in a fairly new medical specialty called psychodermatology - if perhaps an unwitting one. “I don’t like the term psychodermatologist - it sounds like a crazy person who is a dermatologist,” he laughs. But whatever you call it, it’s clear he was onto something from the beginning and now science is catching up, in no small part thanks to him. We sat down with Dr. Rieder to get to the bottom of the mind-skin connection and what exactly that means for our skincare routines.

Let's get right into it. Is there a proven connection between skin and mind?

The skin and the brain come from the same place embryologically. The nervous system and the skin are intertwined so you can sort of extrapolate that to the entire brain. We're still working that out, but we know that these connections do exist and we see that mostly through inflammatory skin conditions that often get worse with stress and molecules like cortisol, which is the quintessential stress molecule, that gets upregulated both in inflammatory skin conditions and sometimes with psychological states as well. And then there are things that we know anecdotally, but we don't have all the science to totally back it up yet.

Is this relationship between psychology and dermatology always about the physical connection?

There are so many psychological overlays to dermatology and one I deal with a lot is around cosmetic issues because I practice a good deal of cosmetic dermatology. There is a large interaction between what's going on in social media and the ways that it plays with our own psychology. We're sort of bludgeoned with these images of celebrities and influencers who not only have features that are not necessarily achievable but are getting cosmetic work done where things don't look natural. It can change our own perception of what is attractive. Our self-esteem is so intertwined in how we feel and if we don't feel like we can present ourselves in the best manner, we’re not going to feel well. There is data to suggest that cosmetic procedures when performed in a tasteful manner can allow people to have a better quality of life and have better self-esteem. These are the things that I constantly think about.

It’s interesting that there is a science to back up the idea that people can feel better and have higher self-esteem with cosmetic procedures, but is there a line between doing it in order to create self-esteem and doing it in order to fuel low self-esteem?

I don't think the data has been looked at like that. Patients report feeling better, looking better, having more confidence. And then observers, when these procedures are done in the standardized settings and with the appropriate dosages, report that they see people look great after having the procedures. But I don't know how much data there is about when enough is enough and the reasons for people getting these procedures and whether they are doing them for the right reasons. I can only speak anecdotally that these are things we need to think about.

Cosmetics are a big component of this intersection between psychology and dermatology, but do other skin issues have psychological components too?

A lot of them do. Anything that's going to affect your appearance, especially the parts of your body that are exposed to the world at all times like your hands, face, or neck, is going to lead you to feel potentially self-conscious about how you look or make other people come to judgments about what's going on on your skin. That creates the potential for psychological impact. We know eczema and psoriasis flare with stress. When people start losing their hair or when people have depigmented conditions if you have skin of color, these are all things that have profound implications psychologically.

Is that stress connection one of the cornerstones of this idea of the mind-skin relationship?

Stress is not going to make a skin condition come out of the blue that you didn't have before, but it can certainly make an existing one worse. Take acne, for instance. A high school kid has to take an exam, they’re stressed about it so they break out, and then they feel more stressed about being broken out. It’s a feedback loop. Cortisol goes up. It’s a stress response which on a microbiological level can make acne worse and there are receptors in the skin that we have been able to link to that. It’s a vicious cycle of stress begetting a skin condition and then that skin condition begetting stress and going back and forth. That's a universal concept in the world of skin conditions.

In the case of acne, are there any psychological issues at play besides stress?

Especially with acne that's moderate to severe, there is an association between acne and depression. But even though acne scarring and severe acne are associated with psychological stress and depression, these are not things that people need to live with. Now more than ever there are treatments that are widely available. There's a movement towards acne positivity now, which I support, but I'd like to see people feel like the skin is just an organ that they can feel neutral about. 

What do you think people get wrong about psychodermatology?

I just don't see a lot of interest in talking about it. When you bring up this concept, a lot of dermatologists shy away from it. A lot of times it takes a little bit more time to get to the bottom of some of these conditions where there's an intersection between the skin and the mind. It can take a little bit more patience and I think that's where it's difficult to find dermatologists that are even interested in talking about it because it's just not what they’re trained to do. 

Do you find patients receptive to this idea?

I do, but not everybody needs to have that conversation. Sometimes people will come to me and they'll like the fact that I'm trained in both specialties and they'll respond really well. When people have a skin issue that does not go away very quickly, they're all about talking about it because these are things that people think about all the time.  

Is it enough to say that if you take care of your skin it could improve your mental health or vice versa?

I don't think that’s wrong, but it can mean a lot of different things. If you take care of your skin, it's a kind of marker of other things, like a self-care marker. It's like, “I'm invested in my health, I'm doing something for myself even though it may seem small or superficial.” I can't back this up with data, but it's an indication that someone is more attentive and more attuned to themselves holistically. That's something I intuitively believe in. When people are actually willing to invest in their skin, I think it helps them really attend to their own self-care and well-being.

How can someone develop a mental health-friendly skincare routine?

Any investment you can put in your skin and do it on a routine basis means that you are interested in your appearance and interest in your appearance is inextricably linked for a lot of people to their psychological well-being. Whether that's using evidence-based treatments like retinoids and sunscreen for anti-aging purposes or even basic skin hydrators, it is taking an interest and giving yourself time for self-care which can reduce stress and anxiety levels in the moment. It's a mindfulness experience. Most people are going to get some sort of psychological benefit from that. There are no medicines or cosmeceuticals that are available that I would say are anti-stress medicines - like rub this on your face and it's going to make you less anxious or less depressed, but I know that mindfulness exercises work and mindfulness for me is getting in touch with the moment. Skincare is like a very easy way to do that for people who are willing to spend the time doing it.

So it's not just about what the products themselves are doing for your skin, but that you're making the conscious choice to do something for yourself?

Correct. It's like when I have insomnia, I listen to a progressive muscle relaxation or a deep breathing exercise or even ASMR. What these things do is they take you out of the thoughts that are in your head. Skincare is an analogous phenomenon. It's just all these fine motor movements; you have to use your fingertips to apply things in a very delicate manner. It's a mindfulness exercise, getting in touch with the moment. And even if it's just for five minutes, it’s relieving yourself from the stresses of the day.