A few days after my first Botox injections, the neurotoxin calcified, rendering my forehead useless. My emotional inventory was limited to a handful of available expressions: closed-mouth smile, open-mouth smile, enormous cartoon grin. But instead of unbridled happiness and joy bursting forth from my every nose pore, I didn’t feel a thing. I didn’t feel bad, but I didn’t feel fantastic, either. To strangers, I looked like I was either feeling happy or nothing at all.
Despite the relative newness of psychodermatology as a field of study, the connection between your mind and your skin is neither novel nor medically experimental. In the human embryo, the central nervous system and the cutaneous (skin) system descend from the same layer of cells. We’ve known about it “since embryologists figured that out a century or so ago,” says Amy Wechsler, another one of the handful of psychodermatologists (board-certified MDs in both specialties) in the United States. “There are many physical neurological connections between the brain and the skin, and they’re bidirectional. I just don’t think that people focused on it for a long time.”
The term “psychodermatology” was coined as early as the ’70s (in Dutch and French medical literature). It was more recently defined in a 2001 report published by the American Academy of Family Physicians that outlines a series of skin disorders that are aggravated by emotional stress, including eczema and psoriasis, and skin-related psychiatric disorders, like delusions of parasitosis, or Morgellons disease, characterized by the feeling that bugs or other foreign creatures are living under your skin.
In 2006, the same year Allure first covered psychodermatology, the National Institutes of Health published a study linking problem acne and increased rates of depressive tendencies in teens. A little over a decade later, a report in the Journal of the American Medical Association found that dermatology patients with atopic dermatitis were 44 percent more likely to have suicidal thoughts than those without; they were 36 percent more likely to act on those thoughts. Atopic dermatitis is the most common type of eczema, afflicting about 30 million Americans.
And then there was the Botox and depression study in 2014, scientifically rooted in the psychiatric connection between our moods and our face. If the Darwinian theory holds, it’s worth noting that Botox isn’t making you happier but is in theory making you less sad—taking peaks and valleys and bringing them closer to baseline, which is similar in effect to antidepressants that have proven benefits for people with major depressive disorder. Since 2019, scholarship on psycho-dermatologic topics, from alopecia to eczema, has more than doubled.
Despite all of this, there are still far fewer psychodermatologists than UFOlogists or chemtrail conspiracy theorists. The psychodermatologists I have spoken to tell me that most of their practice comprises cosmetic and medical dermatology: good, old-fashioned mole removal and filler injections. (When I asked Dr. Rieder about treating my eczema, the psychodermatologist’s approach bore a striking resemblance to the regular dermatologist’s approach: Use fewer moisture-stripping soaps and apply a corticosteroid. Wear tights when running. Don’t scratch your legs, even if they are begging to be scratched.) Most of these doctors’ psych cases are appraised and then referred elsewhere—they simply don’t have the time to take on weekly 45-minute cognitive behavioral therapy sessions. Instead, a psych-derm will look at your acne, put you on a treatment plan, ask about your sleep patterns and any major life events or stressors that could exacerbate skin conditions like acne, teach you some breathing exercises.
“You would think people go to a doctor’s office just to have a diagnosis and get a treatment,” says Dr. Wechsler. “They also want to be understood.”
At many points during this reporting process, I cannot help one question from bouncing off the walls of my brain: Are beautiful people more likely to be happy?
I know that it shouldn’t be true; that despite the fragrance ads and the deluge of income bestowed on our nation’s hottest people, mood disorders do not discriminate. But if a person is constantly exalted for their appearance, would they have higher self-esteem and therefore an easier time dealing with anxiety and depression? Could Botox improve my mood because it makes me more attractive?
James Murrough, MD, a psychiatrist and associate professor of psychiatry and neuroscience at Mount Sinai Hospital in New York City, does not seem to think so. Self-esteem, he says, is not clinically defined by any one aspect of self-image; it’s a combination of many things. (He believes most baseline self-esteem levels develop in early childhood through adolescence.) But, he concedes, a negative physical perception of self affects a not- insignificant portion of depressive patients—around 20 percent.
“Positive self-image has been shown to be very important—a protective or resilient factor against stressors that may otherwise trigger major depression or a clinical anxiety disorder,” he says. It doesn’t happen overnight, but with “positive self- care, through healthy relationships,” self-image can be improved.