There seems little doubt that stress affects skin – and not in a good way. As dermatologists, we have often heard from our patients how the stress in their lives is making their skin condition worse. Big pimples erupt just before prom night, or as a wedding approaches. Eczema (or atopic dermatitis) flares during exams or from stress at work. It seems there is widespread belief among patients, if not always their doctors, that stress is bad for health – in general, and across a wide swath of medical conditions. This bad effect of stress on health is most often attributed to weakening (or in some cases perhaps, an over-reacting) of the immune system
But this concept – stress affecting the immune system – seemed too vague. We wondered, “Where’s the beef?” We were indeed convinced from our clinical practice that stress does indeed affect some skin diseases, and especially atopic dermatitis (or eczema). And knowing that the skin barrier is impaired in this condition, we thought that this might be a good place to begin to investigate how stress can affect the skin.
We started our explorations of how stress affects skin with a group of 21 medical, dental and pharmacy students.
We first measured their skin barrier function, (we measured the rate that water (amount/time) evaporates from their skin surface), during a time of low stress – when they first returned, well rested from their break during the holiday season. We also measured the rate of barrier recovery, following an insult or injury to the barrier, such as by washing away the skin fats (lipids) with a solvent, such as acetone (e.g. nail polish remover). We like to call this the ‘treadmill’ examination of the skin. Like its namesake, the cardiac treadmill test, it can pick up subtle and early signs of a weak barrier.
Six weeks later, we again measured their skin barriers during their mid-term examinations – a high stress time, and then another six weeks later after their spring break – for another time of low stress (1). We also asked the students to complete two standardized quizzes that measure perceptions and experiences of stress. One quiz asks questions, such as ‘my boss of hates me’, to determine what the subject perceives as a hostile environment. The other questionnaire evaluates more internalized modes of stress, such as depression, anxiety and fatigue.
There were striking differences in barrier recovery – the method that captures early signs of a weak skin barrier – using the skin treadmill test during these settings of high vs low times of stress. The students as a group demonstrated significant delays in barrier recovery during the exam period, in comparison their recovery rates when just returning from vacations.
Stress was clearly bad for the skin barrier – but it was especially hard on the skin of those students who felt stress the most.
When we compared the students who showed more evidence of stress on their standardized quizzes during exam time with those who evidenced less stress, we found intriguing differences in how their skin barrier’s were faring. The barrier recovery of the more ‘hang-loose’ students, who showed little evidence of psychological stress in their answers to the quizzes, remained unaffected by the exam period. In contrast, the most stressed-out students, particularly those measuring high on the scale of anxiety, depression and fatigue showed the slowest rates of barrier recovery during exams.
It seems that all forms of psychological stress are detrimental to the skin barrier.
Other investigators have demonstrated impaired barrier function in other types of high stress settings. Richard Granstein and his colleagues at Cornell University found a compromised barrier related to the stress of job interviews or sleep deprivation, while others have linked an impaired barrier with the fatigue associated with international travel, and the stress associated with marital dissolution.
These studies clearly supported our patients’ impression that stress was bad for their skin, but to better understand why this was and how stress was hurting the skin barrier, we would need to return to the laboratory and use our ‘volunteers’ there, laboratory strains of mice, to find the answers.