(edited from the skintherapyletter.com article: Stress as an Influencing Factor in Psoriasis)
Psoriasis is a chronic, inflammatory skin disease that affects approximate 2-3% of the general population.1 Although the exact cause is unknown, current evidence suggests that genetic and environmental influences are contributing factors. Among these factors, emotional stress is considered to play an important role in the aggravation and worsening of psoriasis.2
Stress has been indicated as a trigger in many skin conditions, including eczema, acne, and chronic urticaria. With each of these conditions, there are individuals who experience a close chronologic association between stress and worsening of their skin disease, and other individuals for whom their emotional states seem to be unrelated to the natural course of their skin disorder. These two groups are considered “stress responders” and “non-stress responders.” 3
The proportion of psoriasis patients who believe stress affects their skin condition (i.e., “stress responders”) is considerably high, ranging from 37% to 78%. Stress may worsen psoriasis severity and may even lengthen the amount of time to effectively treat the disease.
Breaking this stress cycle may be an important part of any therapeutic approach. Thus, stress reduction through psychotherapy and medication may be useful in treating psoriatic individuals who have high stress levels.
Significance of Stress
Studies define stress along three general categories:
- Major stressful life events (e.g., change of employment, major personal illness, financial problems)
- Psychological or personality difficulties
- Lack of social support5
Regardless of how stress is defined, studies consistently support a relationship between stress and psoriasis.5-12 A majority of individuals consider stress to be the main cause for the worsening of their psoriasis, ranking it above infections, trauma, medications, diet, or weather.6
For example, a study examined 132 psoriasis patients whose psoriasis had completely resolved with anthralin (a medication which is effective at slowing down the growth of skin cells and has anti-inflammatory properties) and were followed over 3 years. 7 Fifty-one patients (39%) recalled specific incidents of stress within 1 month prior to psoriasis aggravation.
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A study of 127 psoriasis patients5 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.
Another study10 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. Another study13 found that psychological stress decreased the success rate of treatment in patients undergoing psoralen + ultraviolet A (PUVA) treatment. Patients with high-levels of worry healed with PUVA therapy almost two times slower than those with low-levels of worry.13
Stress and Psoriasis: A Vicious Cycle
Psoriasis itself can serve as a stressor. Psoriasis can be a disfiguring skin disease with much attached social stigmata. Accordingly, some individuals with psoriasis often suffer significant interpersonal and psychological distress. Patients commonly experience difficulties in social interactions, especially in meeting new people and forming romantic relationships. In general, most patients demonstrate adverse psychological consequences, including poor self-esteem, anxiety, depression, and for some, even develop suicidal thoughts.18
As psoriasis can cause considerable stress for patients and increased levels of stress are likely to exacerbate psoriasis, the disease process, thus, becomes a self-perpetuating, vicious cycle.19 Therefore, successful course of treatment should integrate methods of stress reduction, including psychotherapy and pharmacotherapy.
Stress Management
Some relatively easy and feasible stress reduction techniques are yoga, deep breathing exercises, and meditation, just to name a few. More intensive approaches to stress reduction, like psychotherapy or pharmacotherapy, may also be reasonable recommendations. Whether a person is simply experiencing situational stress or suffering from a diagnosable psychiatric disorder, it may be advisable for that individual to consult a mental health professional as long as emotional factors (such as stress) play an important role in the natural history of their psoriasis.
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Psychotherapy and Stress Reduction
Psychotherapy may be beneficial for psoriasis patients. Group therapy has been found to be a useful and supportive treatment.21 Group therapy provided patients with knowledge about psoriasis and helped them better cope with their skin disease. Talking to other psoriasis patients enabled participants to learn how to manage disease-related stress and gain self-confidence.21
Case reports have described improvements in psoriasis severity with relaxation and stress reduction techniques, such as hypnosis and thermal biofeedback.22,23
Additionally, in a study of 37 patients treated with ultraviolet B (UVB) or PUVA therapy, it was found that stress reduction helped accelerate the rate of healing. 25
Pharmacotherapy and Stress Reduction
Medications may also be helpful to psoriasis treatment. Studies have demonstrated improvements in psoriasis with oral administration of antidepressants, such as the tricyclic antidepressant (TCA) imipramine (Tofranil®), the monoamine-oxidase inhibitor (MAOI) moclobemide (Manerix®), and buproprion-SR (Wellbutrin®).26-29
Pharmacologic Treatment Recommendations
When pharmacologic treatment is considedered appropriate for stress reduction, SSRIs should be considered for first-line therapy. Despite reported cases of SSRI-associated flares of psoriasis,30-32 SSRIs have certain merits in the treatment of psoriasis patients experiencing depression. As well, these agents may possibly provide additional benefits for non-depressed psoriatics who are stress responders. SSRIs, such as fluoxetine, paroxetine, Zoloft®, and Lexapro®, are generally safe and better tolerated than other classes of antidepressants.33
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In addition, anti-anxiety medications may be helpful for short-term use in specific stressful situations for stress responders. For instance, alprazolam (Xanax®) is a fast-acting medication, with both anti-depressant and anti-anxiety effects, that may be beneficial in these situations. Because it has a shorter and more predictable half-life, as compared with other medications, there is less risk of accumulation in the body when used over long periods of time. However, Xanax can be highly sedating and potentially addictive,34 and therefore, treatment should be limited to short-term use on the order of a few weeks to a maximum of a few months.
An extensive number of clinical studies exist that support stress as an exacerbating factor in psoriasis.5-12 People who are identified as stress responders may especially benefit from stress reduction through psychotherapy and/or pharmacotherapy.
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