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The Psoriasis Treatment Plan

The Impact of Stress on Psoriasis

Below is an article outlining the impact of stress on psoriasis. I have written brief summary points that include the main messages, but do read of the full article below if you would like to know more. 

Summary POints: The Impact of Stress on Psoriasis

Complete The Stress Questionnaire

The Stress Questionnaire will help indicate how stressed you are feeling at the moment and this will help to highlight what changes may help to reduce your psoriasis symptoms in PART 3: Lifestyle. 

More Information on Stress

Full Atricle: The Impact of Stress on Psoriasis.

When asked, many patients say that stress was related to their first psoriasis flare-up, or exacerbates their symptoms if they have it already.  The idea that psychological stress is a risk factor for psoriasis dates back over twelve hundred years, when a Persian physician, Jasaliq, documented how he treated a patient with psoriasis. All those centuries ago, Jasaliq suggested a relationship between this patient’s symptoms of psoriasis and his “severe interpersonal conflicts”. He went on to describe using psychotherapy techniques to treat his patient, many of which have evolved for use today (1)

On average, 46% of patients believe psoriasis is reactive to stress, and 54% of patients can recall a major life event preceding the onset exacerbation of psoriasis (9) Some studies suggest this supports the idea that stressful events are associated with the course of chronic inflammatory skin diseases such as psoriasis (13) Figure 2 shows that over the years, an increasing number of patients believe that stress negatively impacts their symptoms of psoriasis. 

Patients believe stress causes psoriasis

The percentage of patients believing in reactivity to stress, as described by 19 surveys over time. Reproduced from Snast et al (2018):

However, as with most things, it’s a bit more complicated than that. Most patients also feel that stress is a consequence of having psoriasis. This means that their perception of how much stress initiated the disease onset may be unreliable(10) In addition, many dermatologists also believe that stress plays a significant role in Psoriasis which may also, inadvertently, contribute to the patient’s belief that psoriasis is aggravated by stress.


Does Stress Cause or Exacerbate in Psoriasis patients?

In the 1950’s the first surveys suggested that patients believed that their emotional stress had an influence the onset or exacerbation of psoriasis symptoms (2) In the 1960s, life event inventories were developed which assessed positive (e.g. marriage) or negative (e.g. the death of a spouse) events in a patient’s life and the results were used to give an indication of the amount of external stress in a person’s life. (3).

Recently, Snast and colleagues (2018) published the first systematic review, which aimed to provide an overview of the literature linking psychological stress with exacerbation and onset of psoriasis (6) The review highlights that while results from observational studies suggest an association between stress and the exacerbation or onset of psoriasis, these studies rely on a patient’s memory and results can therefore be inconsistent. Further inaccuracies and inconsistencies in study results are due to the use of different tools to measure stress, as well as recall periods of between 6 months and 5 years which is likely to give very inaccurate results. Also, any patients with psoriasis already believe stress is a risk factor, so it is likely their responses to survey questions will reflect that preconceived bias (4). Some studies reviewed only major life events but ignored daily and chronic contributors to stress. All of these factors mean that the studies that have been carried so far on the relationship between stress and psoriasis are largely too different and inaccurate to be reliable. However, while there is no high-quality evidence to support the link between psychological stress preceding the onset of psoriasis, there is some evidence to support the theory that stressful events in the preceding 6 months, can cause disease exacerbation. However, according to Snast et al (2018), there is only one study that doesn’t rely on patient memory and this study found no significant difference between patients and controls (people without psoriasis). This suggests that stress isn’t a preceding factor for psoriasis onset or exacerbation for everyone.

Do Physiological Mechanisms Support a Relationship Between Stress and Psoriasis?

The brain-skin connection: The mechanisms which explain the interaction between stress and psoriasis are not fully understood. However, recent studies suggest we adapt to chronic stress, which includes stress-induced immune suppression (5). Background psychological stress, such as a broken-down car or daily commute, may contribute to the severity of chronic inflammatory diseases, such as psoriasis, by dysregulating hypothalamic–pituitary–adrenal (HPA) axis activity. The HPA axis is a major neuroendocrine (brain-hormone) system that controls our reaction to stress and regulates many body processes, including digestion, the immune system, mood and emotions, sexuality, and energy storage and expenditure. This means that stress can impact almost every aspect of our body functions.

In studies, exposure to experimental stress has been linked to altered HPA axis activity and immune dysfunction in patients with Psoriasis. Altered HPA axis activity is often characterised by a decrease in cortisol levels (18) which suggests that lowered cortisol levels mediate chronic inflammation and increased inflammatory responses due to a reduction in the immune-suppressive effect of normal cortisol levels.

You may remember that Psoriasis is an inflammatory disease, and therefore lower cortisol levels, which results from increased stress, are likely to increase the level of inflammation in the body and cause an increase in the severity of psoriasis symptoms. So far, we know that patients with psoriasis show a relationship between reduced cortisol levels and daily stress. Evidence also suggests that patients with persistently high levels of stress have lowered cortisol levels which may make them more vulnerable to the effects of stress on their disease because of the resulting up-regulation of pro-inflammatory mediators (22). This theory has been illustrated in studies where high-stress exposure has been shown to result in increased disease severity a month later. (16,17)

So, susceptible patients with psoriasis are likely to have lower cortisol levels in response to high-stress periods and this is similar to stress-related disorders such as post-traumatic stress disorder, chronic fatigue and chronic pain (23) as well as patients with chronic inflammatory diseases such as rheumatoid arthritis. (18-21).

In future studies, more information is needed to establish the role of other markers of HPA axis activity that may be involved in the HPA axis hypoactivity. Also, the role of key markers of the pathology of psoriases, such as skin mast cells or specific immune-related responses (such as altered cytokine reactivity after stress exposure) needs to be investigated to get a better understanding of the underlying stress–disease relationship in psoriasis.

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