Dermatologic disease – related stress, i.e., stress and daily hassles from impact of skin disorder upon the quality of life. Children and adolescents may experience bullying. Important factor in cosmetically disfiguring disorders
Onset/exacerbation of stress- reactive dermatoses that tend to be cosmetically disfiguring e.g., acne, psoriasis, atopic dermatitis
Stress and hassles from having to live with a chronic and usually cosmetically disfiguring dermatologic condition can be a perpetuating factor
Major stressful life events – e.g., loss of job, marital stress, death of spouse
Onset/exacerbation of a wide range of stress-reactive dermatoses
Unresolved stressors may lead to perpetuation of dermatologic disorder
Traumatic life events i.e., events that overwhelm the patient’s coping capacity e.g., history of severe neglect, sexual abuse, trauma of war etc. May affect patient years after the initial event, as patients may get triggered by a person or event that reminds them of the trauma. May be associated with autonomic nervous system (ANS) dysregulation
Autonomic dysregulation and hyperarousal may predispose to exacerbations stress-reactive and self-induced dermatoses
Onset/exacerbation of a wide range of stress-reactive dermatoses, especially disorders associated with autonomic hyperarousal e.g, urticaria. May precipitate self- induced dermatoses. Also onset of other stress-reactive dermatoses e.g., psoriasis
Perpetuation of a wide range of stress-reactive dermatoses, especially disorders associated with autonomic hyperarousal. Factor in chronic idiopathic urticaria and chronic self-induced dermatoses e.g., acne excoriee, dermatitis artefacta
A practical approach to the initial assessment and management of psychosocial stressors in the dermatology patient
Stress and Immune Function of the Skin
The skin serves as both (i) an immune organ and metabolically active interface between the individual and the outside world during sleep and wakefulness, (ii) an organ of communication throughout the life span- at neurobiological, psychological and social levels . Due to its strategic location, the skin plays a critical role in preserving homeostasis , as it is regularly exposed to potentially dysregulating stimuli, both physical and psychosocial. A critical function of the epidermis is permeability barrier homeostasis, and acute psychological stress can prevent skin barrier function recovery in humans which can lead to exacerbations of conditions like atopic dermatitis, psoriasis and contact dermatitis . It is important to recognize that the relationship between stress and immune function is complex , as the enhanced immuno-protection (e.g., increased efficacy of immunization and wound healing) that may be associated with acute (typically lasting minutes to hours) psychological stress, can also exacerbate immune-mediated dermatologic disorders such as psoriasis and atopic dermatitis . Sleep disruption and deprivation, and circadian-rhythm disruption (e.g., due to rotating shift work) are associated with increased stress, and can exacerbate many dermatologic disorders as a result of an enhanced pro-inflammatory state .
The Skin as an Organ of Communication
Changes Over the Life Cycle
The skin plays an important role as an organ of communication across the life span- this role of the skin also forms a basis for the relation between skin disorders and psychosocial stress. Right after birth skin-to-skin contact between the neonate and the mother is known to have a significant beneficial impact on the infant’s capacity for autonomic regulation  and socialization in later life  – both these factors are directly associated with better capacity for managing stress. The psychosocial development of an infant with dermatologic disease may be adversely affected if the caregiver is reluctant to sufficiently touch or hold the infant. In later life, a cosmetically disfiguring dermatologic disorder, affecting the ‘emotionally charged’ body regions such as the genital region and the easily visible body regions, especially the face , can lead to significant stress due to feelings of stigmatization and social exclusion . The overall appearance of the skin, even when minimally flawed, can have a profound effect on the body image especially during adolescence and young adulthood when the individual is especially vulnerable to peer disapproval and social exclusion including bullying . The skin, especially facial skin, is one of the most easily visible indicators of chronological age. The idea that chronological age itself does not signal the beginning of old age, and that one can get older without the signs of aging, has become increasingly prevalent . Over the last several decades old age has started to acquire increasingly negative connotations and often normal intrinsic aging is viewed as a medical and social problem that needs to be addressed by health care professionals and an aging appearance can be a source of significant distress . Cutaneous body image dissatisfaction and resultant interpersonal sensitivity and feelings of social alienation have been associated with increased suicide risk .
Cultural and Ethnic Factors
The clinician should be sensitive to the fact that the dermatology patient’s cultural and ethnic background may have an important effect on how their skin disorder affects their quality of life and resultant disease-related stress. There are also cultural differences in the physiology of the stratum corneum barrier which plays an important role in stress reactive dermatoses. Studies have shown that a lighter skin tone is preferred by both individuals of European Caucasian descent and cultures and ethnic groups with a darker skin color [16, 18]. The term ‘ethnic skin’ has been used in the medical literature to describe skin of color, traditionally of Fitzpatrick skin types III-VI . This does not define any particular race, ethnicity, or culture. The clinician should be aware that in many cultures the preference for fair or lighter colored skin is quite pervasive, as lighter skin is associated with several perceived benefits including job, beauty and marriage opportunity [20, 21], and the perception that an individual’s skin is not ‘fair’ enough can be a source of social stigmatization and stress for the individual. As a result harmful practices like skin bleaching may be carried out , which can further enhance the dermatologic morbidity associated with the skin condition. It is important for the clinician be sensitive to these issues and make an effort to mitigate the perpetuation of stress resulting from deep-rooted belief systems regarding preferred skin color [16, 20].