Evaluating the Role of Stress in Skin Disease

Abstract

Psychosocial stress can play an important role in upto one-third of dermatology patients. Stress (defined as a stimulus that poses a challenge to homeostasis) is reported to be a factor in three major clinical situations: (i) when stress arises secondary to the effect of the skin disease upon quality of life. Stress from feelings of stigmatization and social alienation can lead to increased suicide risk. The skin disease-related stress may contribute further to clinical exacerbations of some stress-reactive dermatoses; (ii) when stress exacerbates a stress-reactive skin disorder e.g., psoriasis, atopic dermatitis, acne, chronic idiopathic urticaria; and (iii) when the dermatologic disorder is essentially a cutaneous sign of a stress-related psychiatric disorder (obsessive-compulsive and related disorders, dissociative disorders, posttraumatic stress disorder) e.g., skin picking disorder, trichotillomania, dermatitis artefacta. Three major types of stressors are encountered clinically and each requires a different approach to management: (a) stress from daily hassles secondary to impact of the skin disorder upon the quality of life. In such patients it is important to treat the skin disorder aggressively, and recognize that even minor disease in easily visible body regions or the genital area can lead to significant disease-related stress and therefore requires attention. A referral to support groups for patients with similar disorders is usually helpful; (b) major external life events such as bereavement and marital problems. Refer patient for counseling; and (c) major traumatic life events such as sexual assault, where the individual’s coping capacities are overwhelmed. If posttraumatic stress disorder is present, the underlying autonomic nervous system reactivity can be a predisposing factor for recurrent flare-ups of the stress reactive skin disorder. Such patients need to be referred to a qualified mental health professional for emotional stabilization, as direct enquiry about the trauma history can result in psychiatric decompensation.