Psychosocial Stress and Psoriasis
Psoriasis is a chronic disease that can
have substantial psychological and social impact on a patient’s
life. For the patient, psoriasis can be far more than "just a skin
However, close family members or
patient’s friends may not understand the disease.
The psychological impact is likely to
be heightened when the onset of disease was early in life—when the
patient was most vulnerable to psychosocial trauma. Psychological
problems can arise from the feelings of the patient about his/her
appearance, social rejection, guilt, embarrassment for self and
family, and emptiness.
There may also be feelings (sometimes
with justification) that psoriasis has limited the patient’s career
success because employers did not understand the nature of the
disease. Patients may also deny themselves enjoyment of leisure
activities because of embarrassment and fear of rejection, and the
disease often makes patients feel unattractive to the opposite sex.
A number of studies have shown that
psychological stress is often caused by psoriasis, and can be a
factor in "flares" of psoriasis. Conversely, psychological stress
can affect the course of the disease as well as contribute to
psychological problems such as depression, anxiety, and unfocused
anger. The way stress affects the patient varies from individual to
individual; the most common manifestations are psychological
depression, anxiety, and obsessional behaviors (Gupta MA, Gupta AK. Psychodermatology: an update. J Am Acad Dermatol 1996;
The way in which stress, depression and
anxiety influence the course of psoriasis is not known. Some studies
suggest that the influence may be through an effect on the immune
Pruritus (itching)—a common symptom of
psoriasis—may correlate with stress as both cause and effect.
Pruritus and stress are two-way mechanisms in psoriasis. Chronic
pruritus contributes to psychological stress, and psychological
stress can exacerbate psoriasis, making it worse or causing it to
The patient who experiences constant
itching is understandably stressed. Scratching in response to
pruritus will inflame the skin further, causing the psoriasis
patches to become thicker and more resistant to treatment. Constant
scratching can also be a source of psychological friction with
family members—e.g., "Can’t you stop that constant scratching?"
Psychological stress can make pruritus
worse by mechanisms that are not entirely understood. These
mechanisms may include activation of itch-inducing neurochemical
pathways, variation in skin temperature and blood flow, and sweating
(Koblenzer CS. Psychological and psychiatric aspects of itching. In:
Bernhard JD (ed.) Itch: Mechanisms and Management of Pruritus. New
York: McGraw-Hill; 1994:347-356.).
Pruritus contributes to stress and that
stress can lead to pruritus. This cycle can contribute to
psychological problems including depression, anxiety, aggressive
behaviors, obsessional behavior, and alcoholism (Gupta MA, Gupta AK.
Psychodermatology: an update. J Am Acad Dermatol 1996;
The patient with psoriasis should seek
help from a dermatologist when psoriasis is complicated by
psychosocial difficulties. If psychosocial problems are contributing
to the patient’s symptoms, the dermatologist should be taken into
the patient’s confidence (McKenna MB, Stern RS. The outcomes
movement and new measures of the severity of psoriasis. J Am Acad
Dermatol 1996; 34:534-538). Disease often responds better when there
is an effective doctor-patient relationship. In some cases,
psychosocial problems may be alleviated when the patient is enrolled
in a support group or referred for psychological counseling (Zachariae
R,Oster H, Bjerring P, Kragballe K. Effects of psychologic
intervention on psoriasis: A preliminary report. J Am Acad Dermatol
1996; 34:1008-1015.). The patient may ask his/her dermatologist to
conduct a family counseling session that will help family members to
better understand the nature of the disease and the role that family
members can play in reducing psychosocial stress.
Christopher E, Mrowietz U. Psoriasis.
In: Freedberg IM et al (Eds.) Fitzpatrick’s Dermatology in General
Medicine, 5th ed; 1999:495-521.
All content solely
developed by the American Academy of Dermatology
For an overview, visit the AAD pamphlet
Psoriasis and Psoriatic Arthritis.