For years, Melissa P.*, 30, thought the white flakes that kept appearing in her dark hair were really bad dandruff. That’s what doctors told her, she says. It wasn’t until well-meaning friends raised concerns that she went to a different doctor, who diagnosed her with psoriasis.
Melissa started getting corticosteroid injections to help manage her psoriasis, but the condition escalated during an especially hard period of her life that included domestic violence. “As life became more complicated and more real-world stuff was happening, the psoriasis became worse,” she tells SELF, explaining that due to the violence she was experiencing, she didn’t feel safe enough to travel to get the injections. Her psoriasis plaques—dry, raised lesions covered with scales—were bigger and in noticeable areas where she couldn’t cover them, like around her eyebrows and on her forehead. “My psoriasis had never been worse than it was then,” Melissa says.
Melissa was diagnosed with generalized anxiety disorder and depression as a teenager and was later diagnosed with both post-traumatic stress disorder (PTSD) and complex PTSD, which is associated with prolonged, repeated, or multiple incidences of trauma. Getting help for her mental health involved a combination of inpatient trauma treatment, therapy, and mindfulness techniques.
In addition to bettering her mental health, these techniques have also helped Melissa take some control over her psoriasis. “For me, [stress] makes the plaques worse,” she says. “When I can see I’m getting really stressed and worked up, I do mindfulness exercises so I can talk myself out of it. Sometimes I can even feel psoriasis coming on—I’ll scratch my forehead or my eyebrows and I’ll start to see a plaque. I really have to be mindful and conscious of how I respond to a situation if I don’t want an outbreak.” When you understand the connection between psoriasis and mental health, you’ll see why.
There are various kinds of psoriasis.
The most common type of psoriasis is plaque psoriasis, the Mayo Clinic explains, and it’s characterized by those dry, raised areas of skin known as plaques. The color of the plaques depends on your skin color. The American Academy of Dermatology (AAD) says that people with darker skin tend to have plaques that are brown or violet with gray scales, while plaques tend to appear red or pink with silvery-white scales on lighter skin. Plaques can occur on any part of the body, including under the nails and inside the mouth, but are usually found on the scalp, elbows, knees, torso, and genital areas, according to the Journal of the American Medical Association (JAMA). The plaques can be small or large, concentrated in one area or spread out, and may also be itchy or sore. They likely won’t be present all the time; the National Institute of Arthritis and Musculoskeletal and Skin Diseases says that psoriasis flares can wax and wane.
There are other types of psoriasis, including pustular psoriasis, which describes pus-filled blisters that mainly affect people’s hands, feet, and fingertips. The Centers for Disease Control and Prevention (CDC) estimates that approximately 10% to 20% of people with psoriasis also experience psoriatic arthritis, a disease that makes joints swollen and painful. The Mayo Clinic has a more extensive list of the various types of psoriasis.
The cause of psoriasis is more than skin-deep.
People often think of psoriasis as only a skin disease, but it’s actually a chronic autoimmune disease that affects the skin, the CDC explains. The issue, specifically, seems to be T cells. These are the cells that are supposed to attack invaders like bacteria and viruses when they get into your bloodstream. The Mayo Clinic explains that in people with psoriasis, the T cells attack healthy skin cells while also triggering excess production of new skin cells. A supply of new skin sounds like a good thing, but in people with psoriasis, these new skin cells move to the epidermis (the top layer of skin) too fast, creating a buildup that forms plaques. These hyperactive cells can also lead to those pus-filled lesions involved in pustular psoriasis.
“The skin is the body’s largest organism—it is its defense against the world—so it makes sense that the immune system is very active in the skin,” Tina Bhutani, M.D., M.A.S., a dermatologist and codirector of the University of California San Francisco (UCSF) Psoriasis and Skin Treatment Center and of the UCSF Dermatology Clinical Research Unit, tells SELF. But, she adds, researchers aren’t sure why some people get psoriasis and others don’t.
“We know patients have a genetic predisposition, but in addition, there’s something environmental that happens to trigger their psoriasis,” Dr. Bhutani explains. “In some, that might be an infection, in others that might be some kind of stressor, like a psychological or physical stress on the body.”
The relationship between psoriasis and mental health can be a vicious cycle.
Research has shown that psoriasis can contribute to or worsen various mental health conditions, including depression, anxiety, bipolar disorder, eating disorders, and more. If you have psoriasis, you might be intimately familiar with how this works—especially right now, given that basically all of us are feeling mental strain in unprecedented ways thanks to the new coronavirus.
While it’s a bit of a chicken-and-egg situation, Dr. Bhutani says that mental health conditions like anxiety or depression may kickstart the onset of psoriasis or trigger and exacerbate flare-ups. Beyond that, “There are studies showing that major stressful life events, such as a death in the family, can result in the new onset of psoriasis,” Joel Gelfand, M.D., MSCE (Master of Science in Clinical Epidemiology), professor of dermatology and epidemiology and director of the Psoriasis and Phototherapy Treatment Center at the Perelman School of Medicine at the University of Pennsylvania, tells SELF.
On the other hand is the fact that having psoriasis may contribute to you developing a mental health condition (or make it worse). “There are studies that show patients with psoriasis are more likely to develop issues such as anxiety and depression over time,” Dr. Gelfand says.
Anyone who has worried about not fitting in with narrow definitions of beauty can understand how having a visible skin condition could take a toll on someone’s mental health. “One can imagine how the physical [stigma] of psoriasis—especially when plaques affect exposed areas of the skin—can affect mood and interpersonal interactions in a negative way,” Evan Rieder, M.D., an assistant professor of dermatology at NYU Langone who is board-certified in both psychiatry and dermatology, tells SELF. “These can happen both through how someone with psoriasis views [themselves], but also through the reactions of others to their skin.”
Like many people with psoriasis, Jennifer Pellegrin, 36, knows all too well how the condition can impact a person’s social life and mental health. She was diagnosed with psoriasis when she was 15 and with psoriatic arthritis at 25, followed by depression a year later and then anxiety. “Psoriasis causes an exacerbation of my [mental health conditions],” she tells SELF in an email. “I go through days sometimes where I cancel all plans. I can be looking forward to going out, start to get ready, and boom: Anxiety hits. I feel hideous and won’t leave the house.”
In addition to the more obvious ways psoriasis and mental health can play off each other, experts have done a fair amount of research into the biological mechanisms that may connect psoriasis and various mental health conditions. A 2016 systematic review in the Journal of Clinical and Aesthetic Dermatology looked at 57 studies on the subject, noting that psychological stress and depression can boost the release of pro-inflammatory cytokines, which are molecules released as part of the immune response. The inflammation they cause seems capable of further exacerbating the symptoms of both psoriasis and conditions like depression. However, there’s conflicting research on this; some of the literature hasn’t found definitive associations between psoriasis and psychological issues like stress.
Ultimately, having psoriasis doesn’t definitely mean you’ll develop a mental health condition (or vice versa). Other factors, like a family history of any of these conditions, matter as well. But the connection is very real for some people. If you’re one of them, it’s impossible to ignore the impact psoriasis can have on your mental and emotional well-being.
Psoriasis treatments often target the mental and physical aspects of the illness.
Time for some good news: Pretty much the only upside of the relationship between psoriasis and mental health is that if you can control or limit one, you may be able to impact the latter. Pellegrin can attest to this.
“Treating my psoriasis helps me maintain my mental health,” she says. “In December 2018, I was put on a biologic and I cleared almost 90% in a month.” A biologic is a drug for moderate to severe psoriasis that alters immune system function, the Mayo Clinic explains. “I remember getting out of the shower and crying. I had never seen that much clear skin,” Pellegrin says. She eventually became an advocate for the National Psoriasis Foundation as a way of fighting back against her condition and its myriad effects. “I hate the physical attributes of psoriasis and the pain and fatigue that I endure, yet I am stronger than this disease,” she tells SELF.
If you think you have psoriasis, trying to consult with a dermatologist can be a good first step, since they are specifically trained to treat skin conditions. (There are even dermatologists who do online appointments, which can be especially helpful in the age of the new coronavirus.) But given the connection with your mental health, you should also consider seeing a therapist if you don’t already or discussing your psoriasis with your therapist if you do. (Here’s advice for having a successful teletherapy appointment.) Either way, the doctors you consult might recommend seeing other specialists depending on how exactly your psoriasis and mental health seem to be interconnected.
“If a patient is actively depressed or suicidal, I have them see a psychiatrist at the same time [as a dermatologist],” Dr. Bhutani explains. “If I think they have good coping mechanisms and that the disease is a big part of the reason they’re depressed, then we treat their disease. If they’re still having the mental health issues despite their psoriasis getting better, I have them see a mental health professional.” Beyond professional interventions like cognitive behavioral therapy, she recommends coping methods like meditation, mindfulness, and yoga.
“Those feeling stigmatized, anxious, or depressed about their psoriasis—especially if these feelings are interfering with daily activities such as sleep, work, or social relationships—should discuss these issues with their dermatologist, primary care provider, or mental health professional,” Dr. Gelfand says. You shouldn’t have to deal with your psoriasis or your mental health alone. Help is out there for both.
*Name has been changed to protect privacy.
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Originally Appeared on SELF