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Significance of Stress

Studies define stress along three general categories: 1) major stressful life events (e.g., change of employment, major personal illness, financial problems), 2) psychological or personality difficulties, and 3) lack of social support.[5] Regardless of how stress is defined, studies consistently support a relationship between stress and psoriasis.[5–12] Furthermore, a majority of patients consider stress to be the main cause for exacerbation of their psoriasis, ranking it above infections, trauma, medications, diet, or weather.[6]
For example, Seville[7] examined 132 psoriasis patients whose psoriasis had completely cleared with anthralin therapy and were followed over 3 years. Fifty-one patients (39%) recalled specific incidents of stress within 1 month prior to psoriasis exacerbation. The study further observed that the incubation time from specific incidents of stress to psoriasis exacerbation was between 2 days to 1 month.[7] In a subsequent study, Al'Abadie et al.8 assessed 113 psoriasis patients and determined the incubation time from stressful event to onset of psoriasis was significantly longer than that from stressful event to exacerbation of psoriasis.[8]
In a study of 127 psoriasis patients, Gupta et al.[5] found differences between patients who reported that stress flared their psoriasis (stress responders) and patients who reported no association (non-stress responders). Stress-responders described significantly more flare-ups during the 6 months prior to admission, experienced more psoriasis-related daily stress, and relied more upon the approval of others. They also had more severe psoriasis in "emotionally charged" body areas, such as the scalp, face, neck, forearms, hands, and genital region. However, total percentage of body surface affected by psoriasis was not significantly different.
Similarly, Zachariae et al.[9] showed that stress responders differed significantly from non-stress responders. Stress responders tended to self-report greater disease severity than non-stress responders, even though clinical measures of disease severity (e.g., Psoriasis Area Severity Index) did not vary between groups. Stress responders were, however, found to have more plaques of psoriasis on visible areas than non-visible regions.[9]
Unlike these above studies, Verhoeven et al.[10] found a significant association between stress and disease severity. This prospective study of 62 psoriasis patients determined high levels of daily stressors to be related to an increase in disease severity 4 weeks later.[10]
Finally, stress may not only worsen psoriasis severity, but it may also adversely affect treatment outcomes. Fortune et al.[13] found that psychological stress impaired the rate of clearance of psoriasis in patients undergoing psoralen + ultraviolet A (PUVA) treatment. Patients with high-levels of worry cleared with PUVA therapy almost two times slower than those with low-levels of worry.[