Chapter 3. Stress
Individuals with atopic dermatitis frequently have enormous problems with self-image and self-esteem. Their abnormal looking skin interferes with peer group relationships and the sleep disturbance which accompanies this illness is a continuous source of stress for the family. Stress is one of the most reproducible triggers of atopic dermatitis. The mechanisms underlying this observation are poorly understood.
However, neuropeptides released from nerve fibers are known to induce itching. Embarrassment and frustration results in flushing which occurs as the result of increased blood flow to the skin, not only causing erythema, but also bringing inflammatory cells to the local tissues. Finally, recent studies indicate that stress can cause the activation of immune cells which may control skin inflammatory responses.
Efforts should be made to identify sources of stress including marital separation and teasing from peers or siblings. Psychological counseling should be offered to deal with feelings of guilt, anxiety and anger that will arise from having chronic atopic dermatitis. In situations where stress triggers increased scratching behavior modification can be useful in channeling their scratching into more useful activities. When available, art therapy and play therapy may helpful for such patients.
In patients with excessive anxiety, depression, itching and sleep difficulties, psychotropic drugs may be required. Benzodiazepines and buspirone are helpful anxiolytics that have been used to control anxiety in atopic dermatitis. Doxepin at bedtime can also help control the itching which disturbs sleep. In some patients, depression can interfere with their ability to follow a skin care routine. Such individuals may benefit from treatment with antidepressant drugs such as tricyclics or specific serotonin reuptake inhibitors (SSRIs).
In patients with poorly controlled atopic dermatitis, psychiatric referrals should be considered not only for pharmacologic intervention but to identify situations and patters of behavior that are stressful and that trigger flares.