Stress Rashes

alopecia hair loss stress rash

September 16, 2021

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How common are rashes seen with stress?

Stress has been well documented as affecting a number of skin diseases including hives or urticaria, itching (pruritus), alopecia areata (autoimmune hair loss), psoriasis, eczema, hyperhidrosis (excess sweating), telogen effluvium, and acne. This is actually a very common connection to find in practice when evaluating patients.  Stress has also been linked to flares of certain chronic skin diseases such as psoriasis and hives.  Some studies have actually shown stress that as many as 90% of patients experiencing a flare of psoriasis as reporting at least one stressful event in the 6 months before the flare. 

(There is an interesting reason why the skin and stress are so closely linked. The skin and nervous system develop from the same origin: the embryonic ectoderm.  There is a very real connection based on the fact that both develop from the same cells.)

What do stress rashes look like?

When most people think of “stress rashes” they are thinking about eczema or hives.  The classic scenario is someone experiencing a stressful situation either at work or at home.  While managing the situation they cannot help but itch or scratch their skin.  They often focus on the “easy to reach” areas- arms, legs, and back of the scalp.  The area along the mid-upper back is classically spared because it's just out of reach.  They are often convinced there is something on their skin - a "creepy-crawly” sensation is common. Sometimes they will feel pinpoint areas that they cannot help but want to dig or pick out of their skin.  



Alopecia areata, or hair loss in circles, is a type of autoimmune hair loss. This will appear as hair loss in distinct circles most commonly. It’s always remarkable that in spite of some even seeing large volumes of missing patches of hair - it is so rare that a patient actually remembers losing the hair or seeing it come out. With other types of hair loss, people will complain that their hair is falling out in clumps.  With alopecia areata, it appears at times that a significant volume of hair loss occurs but they do not recall seeing it on a pillow or in the shower!  

Psoriasis can present as pink scaling plaques most commonly on elbows, knees, scalp, hands, and feet.  It can also appear as raw pink plaques in the folds: under the arms, under the breasts, between the legs.

Telogen effluvium is a cycle change in the growth of hair after a stressful occurrence.  The hair starts to fall out at the root. A little white bulb can be seen at the end of each hair follicle.

Is there a medical term for stress rashes? 

Stress urticaria is the most common term for the hives associated with stress.  However, the other stress associated rashes are based on the appearance noted above.

What are the typical causes of stress rashes? 

Any kind of stress qualifies-  physical, mental, or emotional stress.  

Physical stresses include recent illnesses (viral, bacterial), recent surgeries, recent pregnancies, new medications, long-distance travel.

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Mental or emotional stresses include new jobs, challenging work environments, loss of job, relationship problems, etc.



How can you treat/prevent a stress rash? 

Treating and preventing stress-induced rashes is a two-fold approach. 

The first step is treating the specific type of rash that is occurring. Hives are best managed with routine antihistamines.  I tend to recommend taking a 24-hour acting antihistamine such as Zyrtec or Claritin every night at the same time for at least a 6-week stretch to start with no breaks.  Give yourself a period of time with no flares and re-assess.

For other stress-induced rashes, it is important to focus treatment on the specific manifestation of the rash.  Alopecia areata, for example, is treated with scalp injections.

The second step in managing stress-induced rashes is to recognize these rashes as a “check engine light” on your skin that tells you when you are managing more than you can handle. When I take the time to point this out to patients I find that patients are better able to understand the impact of stress on their skin and learn to use it as a clue that they need to take some time for themselves or seek help.


Is there a mechanism by which stress impacts the skin?


Although there are many theories to the mechanism of stress hives or urticaria, one of the most common theories relates to an increase in catecholamine levels in our bloodstream. These are hormones released when we are under stress. These can cause mast cells to release histamine. The histamine is responsible for the itching and hives. Many times we see a pale halo around the hives- this is because epinephrine, one of the catecholamines, causes vasoconstriction around the hive giving it a pale ring.


Psoriasis and stress are thought to share some pathways. For psoriasis, activated T cells from our immune systems release inflammatory cytokines such as IL 6, IL 1, and TNF alpha. These in turn cause skin cells to proliferate and plaques to form. These same markers have been seen as elevated in people dealing with stress or depression. Although these pathways continue to be elucidated and this is a very watered down description given the fact that the nuances can confuse someone unfamiliar with the terms- in simplistic terms: if someone is prone to psoriasis but not experiencing any plaques as yet (perhaps because their T cells haven’t produced those cytokines) may find that a stressful event will trigger those cytokines to develop and cause psoriatic plaques. 

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