Summer Forlenza, LMFT: Patient Resources for Breaking the Stress Cycle

The National Eczema Association (NEA) is highlighting the lived experience of eczema with weekly themes throughout October as part of Eczema Awareness Month. Each week sheds light on different aspects of the disease.

Dermatology Times recently spoke with Summer Forlenza, LMFT, a licensed marriage and family therapist and eczema patient, to discuss the NEA's theme: "Tools for living your most ecz-pressive life with eczema." Forlenza explored the stress cycle in relation to eczema and resources for guiding patients through long-term stress management and emotional wellness.

Transcript

Forlenza: My name is Summer Forlenza. I'm a licensed marriage and family therapist, and I've had eczema since I was born. I have managed it my entire life, and I'm really curious now in my work about the connection between our mind and our body, and sort of the symptoms that show up in our body and how we work with that in the mind.

Dermatology Times: How does stress influence eczema flare-ups, and what is the connection between emotional well-being and the severity of symptoms?

Forlenza: Eczema is a psychophysiological disorder, which means that there's a really strong interplay between what's happening in our body and what's happening in our mind, so what's happening on the body when we have eczema affects our mind and vice versa. What we actually see is that about half of eczema patients identify stress as a trigger to their eczema. We know that stress can play a really strong role in increasing your symptoms and keeping them around for longer, like starting a flare and then having that flare stick around for longer. We also know that stress has a direct impact on our immune system's ability to function. There's a ton of connections between the amount of stress that we're feeling and how our eczema is showing up, and how we're able to modulate their eczema, how we're able to treat it.

Dermatology Times: How does the “stress cycle” function in the context of eczema, and how patients can break that cycle?

Forlenza: When we're talking about the stress cycle, what we're talking about is the body's innate way of managing stress, and our goal when we're working with the stress cycle is not to break it, but to complete it. What happens is we get exposed to a stressor. Let's say a stressor is an allergen; I'm allergic to pretty much the whole world, so when I get exposed to an allergen, my body reacts, but also I feel stressed because I recognize, "Oh, this is going to show up on my skin. This is going to be something I have to manage." The next thing that's going to happen is that my body is going to release cortisol and other stress hormones to try to prepare me to fight off whatever threat it is that it thinks that I'm encountering. Our body doesn't have a ton of options for how to actually respond to stressors. It's got your fight response, flight response, freeze, and a couple other ones. It's a limited group of things that we're working with when we're responding to stress in the body, so it's going to employ one of those. Then a lot of times, that's kind of where we stop. Maybe the stressor ends. I'm not around that allergen anymore, but we kind of pause there, and we kind of can get stuck in this place of feeling chronically stressed all the time.

What we want to do instead is complete the stress cycle by doing a couple things that signal to the body, signal to the nervous system, "Hey, the stressor's gone. We're safe." Now, we can move out of that fight or flight and into the rest and digest response. A couple of those things would be exercise, a lot of different kinds of exercise, and to get our heart rate up, spending time with people we love; getting a hug from people that pressure on the body is actually evidence based as well. Crying helps us really complete the stress response. When people say, "Don't cry; crying doesn't help," they're wrong. It's a very helpful way to complete the stress response. Laughter is very helpful, so watching a funny movie or stand up or just hanging out with a friend who's got a good sense of humor. We can do some breath work, that's also evidence-based. Creative expression, or something where we're working with art, where we're creating art, or music, doing something creative, like dance, can also be included in that. All of those will help us complete the stress response, and that just helps to reset the body so we're not chronically in that stressed out place that's keeping our cortisol high, that's keeping our our stress hormones really high.

Dermatology Times: What are some practical tools or strategies that individuals with eczema can use to manage stress and improve their daily quality of life?

Forlenza: One thing I like to think about when we are living with a chronic illness, and eczema is a chronic illness, I think that there's going to be important things about your daily routine and setting yourself up up for success. That means I want you to have 5 to 10 minutes in the morning, 5 to 10 minutes in the evening. It doesn't need to be very long, where you're intentionally doing things that help your body move out of fight or flight and into rest and digest. This can be breath work. If you have a breath work or a meditation practice, that's great. It's not for everybody, especially itchy people. That can be really, really hard, but that is an option. Other things might be dance. Dance is so good for mental health, and just choosing 1 song in the morning, 1 song at night, and just dancing the way you want to, can be really helpful.

But I think that the most impactful thing, if I was going to recommend just 1 thing, would be spending time with people who care about you. It's really easy to isolate when you have eczema, especially if your symptoms are pretty visible or you're flaring and you're in pain and you're exhausted. It's so easy to isolate, but we really know that spending time with people who care about you is one of the best things you can do to reduce stress. Take care of your body, and just making that a part of your routine and a part of your life is probably the best thing that you can do for yourself and for your skin.

Dermatology Times: How can dermatologists better support their patients in managing the emotional toll of living with eczema, particularly when they are not experiencing visible flare-ups?

Forlenza: One thing that I think dermatologists can and should do is acknowledge that eczema impacts our emotions, our emotional well-being, our mental health, and also that our mental health and our emotions impact our eczema. So just having a conversation with your patients about the interplay between those 2 things, getting a little curious with them. Do you notice when you're stressed, your eczema gets worse? Do you notice that when your eczema gets worse, your stress goes up? Having a conversation to notice those and then also just normalizing that, even when we're not flaring, when you've lived with eczema for a long time, you oftentimes develop a certain level of hyper vigilance to the environment around you. There's a lot of tension in your body, a lot of awareness of what's going on around you, because you're always wondering and worrying, "When's that next flare going to happen? When am I going to be exposed to something that's going to trigger my skin?" There can be a lot of fear and anxiety in the day-to-day life, even when you're not visibly flaring. I think normalizing that, helping clients, helping patients to recognize that that might happen, can be very helpful. Then I think ideally, having a good couple of mental health professionals who you trust with your patients who you can refer them to. Ideally, and this can be a little hard to come by, but ideally, mental health professionals who have an understanding of what eczema is and how it impacts mental health, and how your mental health impacts your eczema. If you can't find someone who specializes in eczema, because again, that's kind of few and far between, you can probably find somebody who works with chronic illness, and they're going to have the ability to ask the right tons of questions. Create the right kind of space to really support your patients.

Dermatology Times: What resources or programs do you recommend for patients to manage both the physical and emotional aspects of eczema?

Forlenza: One thing I think about when we're trying to manage physical and emotional aspects of eczema is just some foundational self care that, again, becomes a part of your routine. This might be something like noticing how you're feeling, tracking how you're feeling, tracking how your skin is doing, and just paying attention to see if there's connections. Journaling can be an easy way to do that, and I always tell people, journaling doesn't have to be traditional. I sit down and write it out by hand what I'm feeling. It can be totally up to you how you want to do this. There's lots of cute little apps. There's an app called Finch, where you like take care of a bird by doing little self care tasks, and it's actually really lovely. I love that app. But there's also a journaling app on a lot of phones. You can do a vlog to yourself. I've had clients who vlog to themselves day-to-day. You can do talk to text into your notes app. You can set up a bullet journaling system, but anything where you're tracking, "How am I feeling? How is that affecting my skin? How's my skin doing?" I think that's a really good place to start. Again, it can be 45 seconds a day; it does not have to be a huge commitment.

Then the other thing I'm going to come back to is that the most important thing for anyone with eczema, for anyone with any chronic skin condition, is finding a community of people who care about you, who are going to show up for you, and not isolating. Because when we isolate, it's very tempting, but when we isolate, it does tend to make everything a bit worse for us, mentally and emotionally. People who've lived through COVID probably recognize or have an awareness of that, and so the best thing you can do is find a couple of spaces where you're going to be around people, ideally in person, but if that's not possible, then Discord is a good place. Some place where you're in groups with other people, where you're talking about things you're interested in, where you're around people who care about you. This might be like a sports club. If you're on a team, maybe you're in a book club. It doesn't have to be anything really intense. It can be once a month at the minimum, but just something where you're spending time with other people who care about you, is just the best thing that you can do.

Dermatology Times: How do you advise individuals with eczema to maintain their mental and emotional health during periods of remission, not just during flares?

Forlenza: It can be kind of tricky to have to maintain your mental and physical health even when you're not flaring, because I know sometimes when I'm not flaring, I feel like I can do anything, and I'm going to do all of it as much as I can. I have so much energy. It feels so good, and sometimes that's great, and other times I kind of pay for it. I always like to say that we recognize that when we have a chronic condition, there's going to be times where we're flaring, and there's going to be times when we're better. Every time that I'm flaring, I remind myself this is temporary. I will have a better days in the future, and when I have good days, I like to remind myself this is temporary. Let's enjoy it, and let's be grateful for the good times that we get to have in the body and with my skin, and so gratitude for the good times awareness that flares are going to be a part of life and a part of your skin condition. We talk in therapy about this concept of radical acceptance, and that's cultivating an awareness of what is it that we can change, what is it that we can't change, and how can we work to accept? I'm going to have tough days. I'm going to be really, really itchy some nights. I'm going to be visibly flaring on my face, and I'm gonna have to go to work. That's going to happen, and I can be kind to myself when it does.

Then I'm going to have good days, and when those happen, I'm going to enjoy them. I'm going to be in the sun and feel the wind and exercise and do things that are hard to do when I'm flaring, and then when you also are doing well, I recommend that that's a time where you really work on resourcing yourself, so building that community and support system, engaging in altruism, so helping other people that's also really well evidenced to support our mental health. Giving back to your community in whatever way that looks like. Physical fitness when you're not flaring can help give you access to movement when you are. If you build up a level of fitness when you are not flaring, and just engaging in the things that resource you that keep you good when you have the energy and when you're not flaring, can be helpful.

Dermatology Times: What are the most critical components of long-term stress management for individuals dealing with a chronic skin condition?

Forlenza: I think when we're talking about managing our stress long-term, when you have a chronic skin condition, knowing how to complete your stress cycle and giving yourself a chance to do that on a regular basis is really, really helpful. I sometimes talk with my clients, who are very high achieving people, a lot of times they're in creative fields. One of the things that I think keeps a lot of those folks going in really high pressure, really intense jobs, is they are regularly discharging the stress and anxiety from their body by completing the stress cycle. They're dancing, they're singing, they're moving their body. They're spending time with people they care about. They are oftentimes practicing some form of meditation and mindfulness, and that's just a part of their life and a part of what they do. We are actually capable of doing all kinds of very stressful, very intense things. Humans are really, really capable, if we give ourselves a shot to help our body do what it naturally does to manage stress, rather than keeping ourselves kind of trapped in this state of chronic stress that can lead to that burnout. I'm going to come back to remembering that probably the most important part of your self care routine is your relational self care, connecting with people, building friendships, showing up for people, helping others. That is, we know, one of the best things ever for human beings. There's also that piece of radical acceptance. Eczema doesn't have a cure, so that means we're going to have good days. We're going to have hard days. When the hard days come, we're not going to be shocked or surprised that they're there. You're [going to be] like, "Yep, okay, this is a part of my condition, and I have a plan." I always like to encourage people to have some sort of flaring plan. Mine involves ice packs and a lot of rest. Sometimes I take the day off work if I really need to, because getting rest and sleep is the best thing to heal my skin, but it's going to be different for everyone. Having a little bit of a plan so that when it happens, not if, when it happens, you know exactly what to do is going to help you feel more prepared, and hopefully help you kind of finish up with that flare as soon as possible.

The dermatologists who've had the biggest impact on me have been the ones who took time to listen, and I really felt like they cared about my experience. I think a lot of people with eczema have had experiences in dermatology where we feel kind of rushed. We feel like, "All right, just take this steroid, just take this cream. Let's go." Especially when your eczema is a little more complicated or severe or disabling, that can feel really disheartening, because it's a big process to get to the dermatologist. It takes a lot of effort and time out of your day and things like that, so the dermatologists, even if their treatment plan wasn't different, when they took the time to listen to me and make me feel like they cared about what I thought and what I wanted and what my goals were, that's what's made the biggest impact on me.

Then the other thing I would say is just to trust your patients, because people have eczema know their skin better than anyone. Even if there's a certain cream or lotion that works really well for most people, if they're saying it doesn't work for them, trust them. They're probably right, because we're really intimately acquainted with all the things that go on with our skin. Eczema is kind of a weird condition, as I'm sure they're very aware, because it's so different from person to person. There's not really a standard way of of showing up or treating it. The last thing is: Thank you to dermatologists who specialize in eczema, because I know it's hard work, and I know that there's a lot of demands in the medical field, but there's some really awesome dermatologists who've made a huge impact on me and really helped me get to live my life and the way that I want to, and I'm grateful for them.

[Transcript has been edited for clarity.]