The cause of SD is multifactorial but incompletely understood. Endogenous factors such as lipids, hormones, and the host immune system as well as exogenous factors including seasonality and the skin flora, in particular Malassezia species, have been discussed [4, 34]. A recurring factor in the appearance of SD episodes has been the psychological status of the patient: stress, anxiety, and emotion have been suggested and described as triggering flares [7, 14, 35–38]. Stress and psychological comorbidities have commonly been accepted to be linked with exacerbations of dermatologic disease, including SD [35, 38–40]. Likewise, dermatologic disease has been known to negatively impact quality of life [40, 41]. Formal studies of the link between SD and stress are few. A study of 2159 patients with SD found that the most common clinical profile included a history of stress, depression, or fatigue prior to the flare 76.4 % (P < .0001) [7]. In a study of 82 patients, Misery et al. found that stress was reported as the main triggering factor, whether it be the initial outbreak or a flare [37]. The stress associated with these flares was more associated with anxiety than depression; however, based on the Beck Depression Index Score, patients with facial involvement were more depressed [37]. Öztas et al. reported increased dermatology life quality index (DLQI) scores compared to healthy controls in patients with SD and suggested that SD may predispose patients to depression [36]. In a recent study by Araya et al., 28.3 % of participants identified emotional stress as a trigger for their SD outbreak [14]. Further, using the DLQI, Araya et al. report that SD has a moderate impact on patient quality of life, however, of note 3.6 % of patients reported an extreme affect; embarrassment was among the greatest complaints [14].

SD is a common dermatologic disease with a varying clinical course and degree of severity. The link between stress and SD, both as an exacerbating factor and as a consequence of the disease, should be carefully considered when caring for patients. Management of both patients’ psychological wellbeing and skin will have a potential synergistic effect on prognosis. Special attention should be given to patients with life-altering comorbidities in order to anticipate SD flares and to aid in the patients’ ability to maintain a positive and realistic outlook. It is highly suggested to inform all patients that SD is likely to recur and that ongoing treatment may be necessary. Ultimately, more well designed, large studies are required to better understand the relationship between stress and SD, and how co-management of the mind and the skin can impact prognosis.