Skin & Psych: Addressing Psychological Stress in Pediatric Atopic Dermatitis Care

Psychological stress is a recognized trigger for atopic dermatitis flares, but discussing its role with patients requires careful communication, according to Peter Lio, MD, clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine and founding director of the Chicago Integrative Eczema Center.

In a recent Skin and Psych podcast interview, Lio discussed how stress and poor sleep can worsen atopic dermatitis through physiologic effects on the skin barrier. He also shared strategies for introducing mental health support, simplifying treatment plans, and strengthening patient trust.

Stress, Sleep, and the Atopic Dermatitis Cycle

Lio emphasized that stress is not simply a perceived trigger but one with measurable biologic effects. He referenced a study in which healthy college students were deprived of sleep for 1 night before investigators measured skin barrier function, demonstrating a significant decline after sleep loss.

He noted that the findings underscore the burden experienced by patients with atopic dermatitis, many of whom live with chronic sleep disruption caused by itch.

How can you expect to heal if you can't break this cycle? Said Lio.

At the same time, Lio cautioned clinicians against attributing disease flares solely to stress. He explained that some patients interpret those conversations as suggesting their disease is "all in their head," which can damage the therapeutic relationship. Instead, he presents stress management as one component of a comprehensive treatment plan alongside medical therapy.

Reducing Stigma Around Mental Health Referrals

Lio said conversations about mental health can be challenging because some patients and families associate psychiatric referrals with antidepressant medications and stigma.

To help lower that barrier, he said he frequently recommends hypnotherapy as an introductory option.

"I love hypnotherapy, and I work with a wonderful hypnotherapist," - Lio.

He explained that framing hypnotherapy as guided relaxation often feels more approachable to families and can help establish a relationship with a mental health professional.

If additional support becomes necessary over time, that relationship can naturally expand to include psychotherapy or medication management.

Avoiding Treatment Overload

Lio also stressed the importance of keeping treatment plans manageable. Rather than providing families with numerous recommendations at once, he prefers individualized eczema action plans that include product photographs, clear instructions, and approximate costs to improve adherence.

He also cautioned against excessive supplement use, comparing it to polypharmacy when patients take multiple products with uncertain benefits or interactions.

"Can we just clean this up?" said Lio.

He noted that simplifying treatment plans to fit what families can realistically maintain often leads to better long-term adherence than continually adding new interventions.

Building Rapport Around Treatment Preferences

Lio said patient preferences played a central role during development of the 2023 atopic dermatitis clinical practice guidelines. Rather than insisting on treatments patients are reluctant to use, such as topical corticosteroids, he recommends working collaboratively to identify acceptable alternatives.

"We can bridge as opposed to battle," said Lio.

Lio said preserving trust early in the therapeutic relationship allows clinicians to revisit treatment discussions over time if an alternative approach does not achieve adequate disease control.

Click here to catch up on all episodes of the Skin & Psych podcast series, in collaboration with Psychiatric Times.