Dr Anthony Bewley, Consultant Dermatologist at Barts Health NHS, explains the complex links between eczema and psychological well-being. This article, based on a talk given by Dr Bewley, was published in Exchange 175, March 2020.
Emotional impact of eczema
Eczema is much more than just a skin disease. It can really affect how you feel, how you behave and your self-esteem. There are two common misperceptions about how eczema can affect your skin. The first is that small amounts of eczema don’t matter and don’t cause psychological distress. But small amounts of eczema can be really troublesome, and can really matter when it affects intimate parts of the body, the scalp – or, for that matter, any part of the body.
Some people with eczema cope well and seem to thrive psychologically but others struggle. What’s really important is that individuals, their family and friends, and their healthcare professionals do not undermine the experience of living with eczema by saying things like ‘Stop scratching’, ‘It’s only eczema’ or ‘It’s just your skin; it’s not that important.’
The second misperception is that a ‘hidden’ disease does not matter. Eczema affecting the face and hands carries its own challenges. When I was at school (I had eczema as a teenager), other children would sometimes say ‘What’s wrong with your hands?’, or ‘What’s that on your skin?’ But eczema underneath clothes is just as itchy, and individuals with eczema know that it’s there even if nobody else can see it.
Topical treatments for psoriasis and eczema require a significant time commitment, which adds to the stress of coping with the skin disease. And the messages from healthcare professionals about which cream to use, and where, can be confusing.
Avoiding confusion about treatments
- Write down any instructions from your doctor or nurse during your consultation.
- Ask for clear signposts to non-promotional, non-advertising information sources about how to cope with eczema.
The brain-skin connection
A 2013 report by the All-Party Parliamentary Group on Skin (APPGS) recognised that although mental health needs have increased in recent years, they are still viewed as largely separate to physical needs. However, nerves in our bodies have neuropeptides that connect the brain to the skin, so it’s not surprising that if you’re feeling anxious and/or depressed, it may have an effect on your skin.
Conversely, anger, depression, anxiety and low self-esteem can all be psychological effects of eczema. Stress leads to skin disease, and having a skin disease is very stressful, so the whole cycle between stress and skin disease is perpetuating. Experiments show that if you have stressed individuals and non-stressed individuals and you do skin stripping (which is where the top layers of the skin are removed), the stressed people repair that damage much more slowly than the non-stressed people.
So it’s not just about the inflammation that we get: the repair and recovery from having an inflammatory skin disease is also very important.
Sometimes, eczema can cause low morale and, in extreme cases, suicidal thoughts. If you know someone with eczema, please don’t be afraid to ask them if they are okay and how they are coping in life and with their eczema. By asking someone how they feel, you actually halve the risk of that person acting on suicidal thoughts. It’s so important to talk about any extreme feelings with your healthcare professionals as well.
Sleeplessness is another psychological effect of eczema and it can lead to dysfunction, which increases stress. ‘The itch’ is one of the things linked to sleeplessness. From research, we know if you have a chronic long-term sleeplessness, in extreme cases it can lead to suicidal thoughts and self-harm. The main links with suicidal behaviour and people with eczema are the sleeplessness and the involuntary, unrelenting itch.
Getting psychological support
The APPGS report highlighted: ‘It is vital that health professionals are knowledgeable of, and sympathetic to, the patient’s physical and mental needs. Patients should feel able to express their concerns and have their worries allayed.’ So, if you have a longstanding skin disease like eczema, it’s really important that you have access to something that will address the psychological impact of having a skin disease.
Struggling to cope with the psychological aspects of your eczema?
- Tell your GP. GPs are usually helpful about signposting individuals to helpful psychological support. Sometimes, GPs will even suggest medication.
- Look up your local Improved Access to Psychological Therapies (IAPT) service. Most regions have their own service, so look up the one local to you online.
- Seek counselling or support from local UKCP-registered practitioners. Trained counsellors and psychotherapists can help patients find their own answers to life’s issues (www.psychotherapy.org.uk).
[GPs and psychological services should offer telephone or video call options if seeing patients face-to-face isn’t possible at the moment.]
Run-down of self-help techniques
Mindfulness
Mindfulness is a technique that trains people to focus on the moment, to avoid stressing about ‘what may be’, and to observe dispassionately any negative thoughts.
Meditation
A technique that trains one to relax, become more self-focused and self-reliant, and to distance oneself from the day-to-day stresses of life.
Relaxation techniques
Relaxation techniques include other techniques mentioned – but also simply chilling out and allowing oneself to have some space and time to oneself.
Hypnotherapy
Many people have a fear of hypnosis based on sensational theatrical shows, but hypnotherapy is not about that theatrical sensationalism. Instead, it trains people to relax and focus on strengthening resilience and holistic wellbeing.
Habit reversal therapy
Habit reversal therapy (HRT) was developed in 1973 and was used in the beginning as part of treatment for some compulsive anxiety-related disorders. According to studies, HRT reduced about 99% of the nervous habits after three weeks of training. Soon after, it was also successfully used to decrease the amount of scratching in patients with itch-related dermatoses, such as eczema and psoriasis. Further studies showed that those who had medical treatment in addition to HRT, when compared to patients who had medical treatment alone, had greater improvement in the clarity of their skin and a greater decrease in scratching.
So what actually is HRT? It’s a therapy that identifies the habit component of the ‘itch–scratch’ cycle in the hope of breaking it. It usually comprises four consultations, each being an hour long. In the first consultation, the healthcare professional will identify the habits and the most likely times of the habits and then give the person with eczema a clicker counter. Over the next four weeks following their initial appointment, they are asked to click every time they scratch or rub at their skin.
To try to replace the habit of scratching at the skin, the person with eczema will adopt a different non-harmful habit, such as clenching their fist. HRT has been proven through research to be an effective way of breaking the ‘itch–scratch’ cycle.
Don’t suffer in silence
The most important message is that individuals with eczema don’t need to suffer in silence. Living with eczema is a challenge both for your skin and for your psychological well-being. There is help and support available to help with both. Managing the skin and the psychological aspects of living with a skin disease gets the individual with eczema better more quickly and for longer.
Other Exchange articles you might find helpful
Part 1: Cognitive Behavioural Therapy, and Acceptance and Commitment Therapy (Exchange 166, December 2017). Dr Helen Mortimer, Clinical Psychologist at Solihull Hospital, explains how Cognitive Behavioural Therapy, and Acceptance and Commitment Therapy, can be helpful in alleviating distress caused by eczema.
Part 2: Managing stress (Exchange 167, March 2018). Dr Helen Mortimer describes ways to manage stress with relaxation and mindfulness exercises and explains how habit-reversal therapy can help to break the cycle of itching and scratching.