‘Holistic health’ is becoming an increasingly familiar term in the public domain but what might it actually mean in the context of skin health? As a dermatologist with training in psychology and behavioural neuroscience, I’ve recently been asking myself this question and thinking about what more holistic approaches to our current models of skin health management might look like.

My thinking has been inspired by a trip to Kerala in South India with a group of UK dermatologists earlier this year. We attended a clinic which combines Western medicine, Ayurveda, Yoga, and meditation to manage lymphedema, a chronic condition which causes swelling of the body’s tissues. What was practiced was the idea of not just focusing on the condition or the skin in isolation, but considering the person as a whole and how that person interacts with the world around them, and the results were extraordinary.

Here in the UK, psoriasis is a chronic skin condition where interdisciplinary care is already starting to evolve. Combined clinics with dermatologists and rheumatologists have been shown to better manage what we are now starting to consider is a systemic inflammatory condition. This is a great development but – when thinking about my observations in Kerala – perhaps it hasn’t gone far enough. A true multidisciplinary approach might be even more beneficial. For instance, it has long been understood that that skin conditions can lead to poor physical and psychological health, but can the inverse also be true? Drawing on my own observations of treating patients with psoriasis, I’ve started thinking more broadly about approaches that may help us start connecting more of the dots to provide even better care to patients.

Nutrition and Physical Heath

We know that levels of obesity are high in patients with psoriasis but what comes first, obesity or psoriasis? The facts are not clear but the feeling emerging is that it could work both ways. Studies have shown that some people gain weight after the onset of psoriasis¹. This weight gain is likely to be multifactorial, but people may choose not to eat well and exercise as they don’t feel good about their bodies. Other studies have also suggested that being overweight at an early age could be associated with psoriasis in later life². In my own practice, I have been struck by the improvement I see in psoriasis in my patients who have lost weight due to fasting over Ramadan. This suggests that modifying nutritional health might in turn modify skin disease. A pathophysiological link between obesity and psoriasis has not been definitively established but growing evidence supports the theory that as obesity is a proinflammatory state it may cornubite to other systemic inflammatory conditions such as psoriasis. Are we missing a trick by not considering diet as a complementary part of treating the condition?

Psychological Health

Time and time again we see that stress and anxiety can trigger a flare of psoriasis and inversely a flare of psoriasis can lead to a huge amount of anxiety and depression. Many physicians have observed that mood can improve long before any improvements are seen in the skin when initiating targeted biologic treatments for psoriasis. Could this be due to the expectation of improved skin? Could it be that the patients feel they are being looked after and that their problem is being proactively and thoughtfully addressed? If so, it suggests that the quality of communication and care giving are a crucial part of the treatment itself. There is even research that explores theories of how inflammation could be implicated in disorders of the mind³. If this is the case, could the anti-inflammatory mechanism of these biologics be having an impact on mental health?

Environment and Emotional Stress

Many patients I see with severe skin conditions often cite a particularly traumatic event in life which they feel may have triggered the condition. Of course, there are many complex factors at play and these instances could be the result of recall biases. However, it has led me to ponder epigenetic processes which have emerged as a potential mechanism mediating the long‐lasting modifications in gene expression. These can be influenced by the environment and our emotional states. It appears these changes can also be passed down through generations⁴. Could trauma lead to modifications in genes which influence and lead to disease? Could therapeutic techniques to understand and manage this trauma also benefit skin health?

While the ideas I’ve discussed here are, for now, merely thought-starters, I believe they all deserve further research and exploration to see how we might move more towards a holistic approach to skin-care. This is why the work of Nutritank in the promotion of nutrition and lifestyle medicine is important in helping start conversations and bridge these disciplines.

In thinking more holistically I certainly don’t mean to oversimplify the challenges of treating, managing and living with chronic conditions, or suggest that nutrition, yoga or psychological interventions alone can cure them. I do, however, feel that we urgently need to open our minds more to seeing disciplines like this which work together to strengthen the body, mind and spirit as an integral part of the process for achieving the best health possible and, in particular, to achieve what I am striving for the most: better skin health for all.

References

1. Herron MD, Hinckley M, Hoffman MS, et al. Impact of obesity and smoking on psoriasis presentation and management. Arch Dermatol. 2005;141(12):1527-1534.
2. Soltani-Arabshahi R, Wong B, Feng B, Goldgar DE, Duffin KC, Krueger GG. Obesity in Early Adulthood as a Risk Factor for Psoriatic Arthritis. Arch Dermatol. 2010;146(7):721–726.
3. Dantzer R, O’connor JC, Freund GG, Johnson RW, Kelley KW. From inflammation to sickness and depression: when the immune system subjugates the brain. Nat Rev Neurosci. (2008) 9:46–56.
4. Horsthemke B. A critical view on transgenerational epigenetic inheritance in humans. Nat Commun. 2018;9(1):2973. Published 2018 Jul 30.