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Effect of Daily Stressors on Psoriasis: A Prospective Study

2009; Elsevier BV; Volume: 129; Issue: 8 Linguagem: Inglês

10.1038/jid.2008.460

1523-1747

E.W.M. Verhoeven, Floris W. Kraaimaat, E.M.G.J. de Jong, Joost Schalkwijk, P.C.M. van de Kerkhof, Andrea W.M. Evers,

Psoriasis: Treatment and Pathogenesis

psoriasis area and severity index TO THE EDITOR Many patients (37–88%) with psoriasis believe that there is a causal relationship between stressors and their skin disease (Gupta et al., 1989Gupta M.A. Gupta A.K. Kirkby S. Schork N.J. A psychocutaneous profile of psoriasis patients who are stress reactors: a study of 127 patients.Gen Hospl Psychiatry. 1989; 11: 166-173Abstract Full Text PDF PubMed Scopus (132) Google Scholar; Nevitt and Hutchinson, 1996Nevitt G.J. Hutchinson P.E. Psoriasis in the community: prevalence, severity and patients' beliefs and attitudes towards the disease.Br J Dermatol. 1996; 135: 533-537Crossref PubMed Scopus (224) Google Scholar; Yosipovitch et al., 2000Yosipovitch G. Goon A. Wee J. Chan Y.H. Goh C.L. The prevalence and clinical characteristics of pruritus among patients with extensive psoriasis.Br J Dermatol. 2000; 143: 969-973Crossref PubMed Scopus (314) Google Scholar; O'Leary et al., 2004O'Leary C.J. Creamer D. Higgins E. Weinman J. Perceived stress, stress attributions and psychological distress in psoriasis.J Psychosom Res. 2004; 57: 465-471Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar; Zachariae et al., 2004Zachariae R. Zachariae H. Blomqvist K. Davidsson S. Molin L. Mork C. et al.Self-reported stress reactivity and psoriasis-related stress of Nordic psoriasis sufferers.J Eur Acad Dermatol Venereol. 2004; 18: 27-36Crossref PubMed Scopus (71) Google Scholar; Fortune et al., 1998Fortune D.G. Richards H.L. Main C.J. Griffiths C.E. What patients with psoriasis believe about their condition.J Am Acad Dermatol. 1998; 39: 196-201Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, Fortune et al., 2005Fortune D.G. Richards H.L. Griffiths C.E. Psychologic factors in psoriasis: consequences, mechanisms, and interventions.Dermatol Clin. 2005; 23: 681-694Abstract Full Text Full Text PDF PubMed Scopus (179) Google Scholar), and this relationship has received increasing attention over the years (Pacan et al., 2003Pacan P. Szepietowski J.C. Kiejna A. Stressful life events and depression in patients suffering from psoriasis vulgaris.Dermatol Psychosom. 2003; 4: 142-145Crossref Scopus (31) Google Scholar; Reich et al., 2003Reich A. Szepietowski J.C. Wisnicka B. Pacan P. Does stress influence itching in psoriatic patients?.Dermatol Psychosom. 2003; 4: 151-155Crossref Scopus (45) Google Scholar; Gaston et al., 1991Gaston L. Crombez J.C. Lassonde M. Bernier Buzzanga J. Hodgins S. Psychological stress and psoriasis: experimental and prospective correlational studies.Acta Dermatol Venereol Suppl (Stockh). 1991; 156: 37-43PubMed Google Scholar). Although some earlier studies have found that over 60% of the patients with psoriasis retrospectively report to have experienced stressful life events in the month before the exacerbation of their skin disease (Gupta et al., 1988Gupta M.A. Gupta A.K. Kirkby S. Weiner H.K. Mace T.M. Schork N.J. et al.Pruritus in psoriasis. A prospective study of some psychiatric and dermatologic correlates.Arch Dermatol. 1988; 124: 1052-1057Crossref PubMed Scopus (154) Google Scholar; Pacan et al., 2003Pacan P. Szepietowski J.C. Kiejna A. Stressful life events and depression in patients suffering from psoriasis vulgaris.Dermatol Psychosom. 2003; 4: 142-145Crossref Scopus (31) Google Scholar; Reich et al., 2003Reich A. Szepietowski J.C. Wisnicka B. Pacan P. Does stress influence itching in psoriatic patients?.Dermatol Psychosom. 2003; 4: 151-155Crossref Scopus (45) Google Scholar), evidence for a prospective relationship between stressors and disease outcome is, thus far, lacking. The aim of this study is therefore to investigate the relationship between the experience of daily stressors and the change in disease outcome (disease severity and itch) 4 weeks later in patients with psoriasis. We hypothesized that only at moments of relatively high levels of daily stressors there would be a relationship between stressors and an increase in itch and disease severity 4 weeks later. Participants for this study were recruited from the Departments of Dermatology at the University Medical Centre St Radboud and the Canisius Wilhelmina Hospital, Nijmegen, the Netherlands. This study was approved by relevant ethics committees and conducted according to the Helsinki principles. Written inform consent was obtained from all participants. For the purpose of this study, the participants were followed up for over 6 months with monthly measures of disease severity (Psoriasis Area and Severity Index (PASI); Frederiksson and Pettersson, 1978Frederiksson T. Pettersson U. Severe psoriasis: oral therapy with a new retinoid.Dermatologica. 1978; 157: 238-244Crossref PubMed Scopus (2127) Google Scholar), itch impact of skin diseases on daily life (ISDL; Evers et al., 2008Evers A.W.M. Duller P. van de Kerkhof P.C.M. van der Valk P.G.M. de Jong E.M.G.J. Gerritsen M.J.P. et al.The impact of chronic skin diseases on daily life (ISDL): a generic and dermatology-specific health instrument.Br J Dermatol. 2008; 158: 101-108PubMed Google Scholar), and daily stressors (everyday problem check list (EPCL); Dekkers et al., 2001Dekkers J.C. Geenen R. Evers A.W.M. Kraaimaat F.W. Bijlsma J.W.J. Godaert G.L.R. Biopsychosocial mediators and moderators of stress-health relationships in patients with recently diagnosed rheumatoid arthritis.Arthritis Care Res. 2001; 45: 307-316Crossref Google Scholar; Vingerhoets et al., 1989Vingerhoets A.J.J.M. Jeninga A.J. Menges L.J. Het meten van chronische en alledaagse stressoren. Eerste onderzoeks ervaringen met de alledaagse problemen lijst (APL). [The measurement of daily hassles and chronic stressors: the development of the everyday problem checklist (EPCL, Dutch; APL)].Gedrag Gezondheid. 1989; 17: 10-17Google Scholar). The study sample consisted of 62 patients with a mean age of 52.3 years (SD 13.2 years, range 21.9–79.7) at the start of the study. Of all the participants, 72.6% were male and 27.4% were female. Furthermore, 4.8, 66.1, and 29.1% of them had a primary, secondary, and tertiary education level, respectively. For each participant, the month in which the participant reported the most daily stressors (highest EPCL score), as well as the month in which they reported the least, (lowest EPCL score) was determined. Prospective relationships between daily stressors and changes in disease outcome 4 weeks later were subsequently examined by calculating Pearson's correlation coefficients between the EPCL daily stressor scores and the change in disease severity (PASI) and itch. For this purpose, residual gain scores were used to measure the change in PASI and itch. These scores take into account the individual baseline levels and the control for regression to the mean effects (Kerlinger, 1975Kerlinger F. Foundations of Behavioral Research. Holt, Rinehart and Winston, New York1975: 714Google Scholar). Mean levels of disease severity, itch, and daily stressors in the month in which patients experienced the highest and lowest levels of daily stressors are presented in Table 1, showing significant differences between the moments of highest and lowest reported daily stressors. When patients reported the highest level of daily stressors, they also experienced significantly more itch and a more severe disease than when they reported the lowest level of daily stressors. In addition, Pearson's correlation coefficients between daily stressors and changes in disease severity (PASI) and itch 4 weeks later are presented in Table 2. Only at the moment that patients reported the highest amount of daily stressors there was a positive, significant correlation between daily stressors and the increase in disease severity (PASI) and itch. No such relationships were found at the moment patients reported the lowest amount of daily stressors, nor any at other monthly measurement moments (data not shown). None of the demographic variables (gender, age, and educational level) was further related to the change in disease severity (PASI) or itch at this moment of highest or lowest stress (data not shown).Table 1Level of daily stressors and disease outcome (means, standard deviations, and paired samples t-test) at the moments patients reported the most and the least daily stressorsMost daily stressorsLeast daily stressorsDaily stressors16.8 (SD 10.9)5.1 (SD 5.8)t=13.6, P<0.001Disease severity7.0 (SD 4.4)6.0 (SD 4.3)t=2.5, P<0.05Itch6.3 (SD 3.0)5.6 (SD 3.0)t=2.0, P<0.05 Open table in a new tab Table 2Pearson's correlation coefficients between the change in disease outcome and daily stressors at the moments patients report the highest and lowest amount of daily stressors1A positive correlation indicate that a high level of daily stressors is associated with an increase in disease severity/itch.Change disease severityChange itchHigh amount of daily stressors0.28*P<0.050.26*P<0.05Low amount of daily stressors−0.01−0.05P<0.01.* P<0.051 A positive correlation indicate that a high level of daily stressors is associated with an increase in disease severity/itch. Open table in a new tab P<0.01. Our results are in line with those of other studies focusing on the relationship between stressors and disease outcome. For example, significant prospective relationships between daily stressors and an increase in disease severity have been reported in patients with atopic dermatitis (King and Wilson, 1991King R.M. Wilson G.V. Use of a diary technique to investigate psychosomatic relations in atopic dermatitis.J Psychosom Res. 1991; 35: 697-706Abstract Full Text PDF PubMed Scopus (104) Google Scholar; Salewski and Lissner, 2002Salewski C. Lissner A. Coping with a chronic illness: processes underlying perceived stress and coping behavior in adolescents with atopic eczema.Dermatol Psychosom. 2002; 3: 132-138Crossref Scopus (3) Google Scholar). For other chronic inflammatory diseases, such as rheumatoid arthritis, prospective relationships between daily stressors and disease severity have also particularly been found at moments when patients reported heightened levels of stressors (Affleck et al., 1997Affleck G. Urrows S. Tennen H. Higgins P. Pav D. Aloisi R. A dual pathway model of daily stressor effects on rheumatoid arthritis.Ann Behav Med. 1997; 19: 161-170Crossref PubMed Scopus (56) Google Scholar; Zautra et al., 1997Zautra A.J. Hoffman J. Potter P. Matt K.S. Yocum D. Castro L. Examination of changes in interpersonal stress as a factor in disease exacerbations among women with rheumatoid arthritis.Ann Behav Med. 1997; 19: 279-286Crossref PubMed Scopus (82) Google Scholar, Zautra et al., 1998Zautra A.J. Hoffman J.M. Matt K.S. Yocum D. Potter P.T. Castro W.L. et al.An examination of individual differences in the relationship between interpersonal stress and disease activity among women with rheumatoid arthritis.Arthritis Care Res. 1998; 11: 271-279Crossref PubMed Scopus (102) Google Scholar). These findings support the idea that, in particular, the experience of a relatively high level of daily stressors can influence the course of chronic inflammatory diseases, including psoriasis. When interpreting the results of this study, several limitations have to be kept in mind. Although the patients who completed this study did not differ from non-completers, there could have been a selection bias because more than half of our study population consisted of older males. Although gender differences have been reported, for example, in the hypothalamic–pituitary–adrenocortical axis response to psychological stressors, future studies should address the influence of gender on the stress–disease relationship (Kudielka and Kirschbaum, 2005Kudielka B.M. Kirschbaum C. Sex differences in HPA axis responses to stress: a review.Biol Psychol. 2005; 69: 113-132Crossref PubMed Scopus (981) Google Scholar). Furthermore, to control for medication effects, we included only patients whose medication regimen was stable in the 3 months before the start of the study, which might explain the rather low disease severity in the study sample. Moreover, during this study we had to exclude six patients because their medication regimen was changed, which suggests that the disease severity also showed less variability than usual. In addition, we cannot exclude the fact that the study design with repeated assessments might have influenced patients' attitudes and behavior, such as compliance with applying topical medication. To our knowledge, only preliminary prospective results have been reported earlier about the influence of daily stressors on disease severity and itch in patients with psoriasis. Although our results should be replicated, our findings indicate that the possible effect of daily stressors on disease outcome should be noticed within daily practice, particularly when patients report that they are going through a stressful period. The authors state no conflict of interest. We thank all persons from the UMC St Radboud and the Canisius Wilhelmina Hospital situated in Nijmegen, The Netherlands, for their contribution to the recruitment of participants and support in collecting the data required for this study: H Alkemade, M Baecke, B van Bergen, M Berger, A Beugels, D Broekhuis, S de Klerk, M Kooijmans-Otero, J Lambrichs, A Meijer-Marcu, A Pietersen, R Smits, S Rösener, I Vermeulen, L Vos-van der Ven, R te Winkel-Slotboom, and L Zimmerman.