PsoriasisNet Article
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 disease."

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; 34:1030-1034).

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 system.

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 flare.

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; 34:1030-1034.).

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.

Reference:
Christopher E, Mrowietz U. Psoriasis. In: Freedberg IM et al (Eds.) Fitzpatrick’s Dermatology in General Medicine, 5^th ed; 1999:495-521.

For an overview, visit the AAD pamphlet Psoriasis and Psoriatic Arthritis.

Supported by an educational donation provided by Abbott.