Psoriasis is a chronic, immune-mediated disease that is known to involve systemic inflammation. The estimated global prevalence of the disease ranges from 0% in Taiwan to 8.5% in Norway. In the United States, the prevalence is approximately 0.91%, with incidence estimates of 40.8/100,000 person-years in children and 78.9/100,000 person-years in adults.1

“It is important to note that psoriasis affects more than just the skin – medically, it also affects joint and heart health,” explained Raja Sivamani, MD, MS, CAT, an assistant professor of clinical dermatology at the University of California, Davis. “Psychologically, it affects people with higher rates of anxiety and depression, and we know that stress affects psoriasis as well,” he told Dermatology Advisor.

The Stress-Psoriasis Link

Anecdotal evidence and some research findings reveal that patients with psoriasis commonly cite stress–whether from life events, psychological or personality-based difficulties, or inadequate social support–as a factor that precedes the onset or exacerbation of the condition. A 2015 cross-sectional study published in BMC Dermatology stated: “A genetic–environmental interaction seems to offer a plausible aetiological explanation of psoriasis, and psychological distress has often been suggested as an important trigger.”2

Various results show that most physicians and patients believe that stress plays a key role in psoriasis, with 37% to 78% of patients reporting a link between stress and disease exacerbation.3 These patients may be referred to as “stress reactors” or “stress responders.” While multiple retrospective studies support such an association, the limited volume of well-designed trials and prospective research on the topic precludes the establishment of a causal relationship.

In addition to a possible role in psoriasis onset and exacerbation, stress has also been associated with more frequent flare-ups, worse disease severity, and reduced treatment efficacy. Earlier findings demonstrated that patients with higher levels of psychological stress had a slower rate of disease clearance (nearly twice as long) with photochemotherapy compared with patients who had lower stress levels.4 Improved “clinical parameters as a result of psychological interventions adds further evidence for the association between psychological distress and psoriasis,” wrote the authors of the investigation described in BMC Dermatology.2

Possible Mechanisms Underlying Role of Stress in Psoriasis

Several studies observed that, contrary to the normal stress response, patients with psoriasis who were exposed to stress exhibited reduced hypothalamus-pituitary-adrenal (HPA) axis responses and elevated sympathetic adrenomedullary (SAM) system responses.3 Lower cortisol levels and higher levels of epinephrine and norepinephrine were noted among patients with psoriasis during emotional stress compared with control participants.5,6 Other results further demonstrate lower salivary and serum cortisol levels in stress responders vs nonresponders with psoriasis.7

“These blunted HPA axis and elevated SAM system responses to stress may be crucial in better understanding the inflammatory characteristics of psoriasis, particularly in stress-responders,” wrote the authors of a 2011 review on the topic.3 “For instance, decreased secretion of cortisol and increased levels of epinephrine and norepinephrine may stimulate the release of mast cells, affect skin barrier function, and upregulate proinflammatory cytokines, which could thereby maintain or exacerbate psoriasis severity.”8 It has been proposed that there may be similarities between this process and the psoriasis flares that result from steroid withdrawal in steroid-induced psoriasis rebound.

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Treatment Implications

Psychological treatment approaches have demonstrated improved psoriasis outcomes. “Medications are important in controlling the disease, but an approach that thoughtfully includes one’s emotional and psychological state is necessary to help patients with psoriasis,” said Dr Sivamani. “They should feel comfortable speaking to their doctors about any anxieties or personal issues they may have, as psoriasis can also affect self-confidence, interpersonal relationships, and sexual well-being.”

To assess whether a patient is a stress responder, clinicians should start by simply asking whether the patient believes that stress often worsens the severity of their condition, as recommended in the 2011 review.3 If the answer is affirmative, the following additional questions may help with further assessment.

  • Have you experienced any recent stressful life events?
  • Do you feel depressed or anxious?
  • Do you have friends or family members who provide you with adequate social support?
  • Do you feel you can manage the level of stress in your life? 

Patients who are determined to be stress responders, but who are otherwise psychologically healthy, should be educated about stress reduction and relaxation techniques that may improve outcomes, such as meditation, deep breathing, and yoga. In one study, patients assigned to a mindfulness meditation-based stress reduction intervention delivered via audiotape during ultraviolet light therapy experienced more rapid clearance of lesions compared with control participants who received light therapy without the mindfulness intervention.9 Similarly, a 2015 pilot study found improved disease severity and quality of life in patients who received 8 weeks of mindfulness-based cognitive therapy as an adjunct to usual psoriasis treatment compared with controls.10

Pharmacologic treatment with antidepressants and anti-anxiety medications may also be efficacious in certain cases. If indicated, patients should be referred for appropriate mental health assessment and treatment, and providers may consider coordinating care with a mental health practitioner. “Even if a psychiatric disorder has been ruled out… many patients nonetheless show distinct signs of psychological distress which, in turn, may affect subjective perception of skin symptoms and exacerbate their suffering,” as noted in a review published in Psychotherapy and Psychosomatics. “Thus, a substantial number of patients may benefit from a mutual and respectful collaboration among dermatologists, psychiatrists and clinical psychologists.”11

References

  1. Parisi R, Symmons DPM, Griffiths CEM, Ashcroft DM; Identification and Management of Psoriasis and Associated ComorbidiTy (IMPACT) project team. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol. 2013;133(2):377-385.
  2. Remröd C, Sjöström K, Svensson Å. Subjective stress reactivity in psoriasis – a cross sectional study of associated psychological traits. BMC Dermatol. 2015; 15:6.
  3. Heller MMLee ESKoo JY. Stress as an influencing factor in psoriasis. Skin Therapy Lett. 2011;16(5):1-4.
  4. Fortune DG, Richards HL, Kirby B, et al. Psychological distress impairs clearance of psoriasis in patients treated with photochemotherapy. Arch Dermatol. 2003;139(6):752-756.
  5. Arnetz BB, Fjellner B, Eneroth P, Kallner A. Stress and psoriasis: psychoendocrine and metabolic reactions in psoriatic patients during standardized stressor exposure. Psychosom Med. 1985;47(6):528-541.
  6. Buske-Kirschbaum A, Ebrecht M, Kern S, Hellhammer DH. Endocrine stress responses in TH1-mediated chronic inflammatory skin disease (psoriasis vulgaris)–do they parallel stress-induced endocrine changes in TH2-mediated inflammatory dermatoses (atopic dermatitis)? Psychoneuroendocrinology. 2006;31(4):439-446.
  7. Richards HL, Ray DW, Kirby B, et al. Response of the hypothalamic-pituitary-adrenal axis to psychological stress in patients with psoriasis. Br J Dermatol. 2005;153(6):1114-1120.
  8. Evers AWM, Verhoeven EWM, Kraaimaat FW, et al. How stress gets under the skin: cortisol and stress reactivity in psoriasis. Br J Dermatol. 2010;163(5):986-991.
  9. Kabat-Zinn J, Wheeler E, Light T, et al. Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychosom Med. 1998;60(5):625-632.
  10. Fordham B, Griffiths CEM, Bundy C. A pilot study examining mindfulness-based cognitive therapy in psoriasis. Psychol Health Med. 2015;20(1):121-127. doi:10.1080/13548506.2014.902483
  11. Picardi A, Abeni D. Stressful life events and skin diseases: disentangling evidence from myth. Psychother Psychosom. 2001;70(3):118-136.