Abstract

Background The purpose of the study was to evaluate the possible role of stress before
the onset/extension/recurrence of psoriasis.
Patients and method One hundred and sixty-nine outpatients with psoriasis and 169 age
and gender matched controls were enrolled. The design was a case-control study (controls
had skin diseases with low psychosomatic component). Stressful life events were evaluated using Holmes and Rahes Social Readjustment Rating Scale.
Results In the psoriatic group, there was a female predominance (66%) and a median age
47.55 years (SD = 20.32). In all, 10.65% of patients had family history of psoriasis. More
than 54% of cases experienced at least one stressful event (47.36% for onset, 63.51% for
recurrence/extension), compared with 19.52% of controls (v2 = 42.71, P < 0.0001). The
odds ratio was 4.92. There was a significant difference in the mean number of stressful
events between patients and controls (P < 0.0001). Women with psoriasis vulgaris and
men with guttate psoriasis seemed to be more sensitive to stressful events. We divided the
events described by Holmes and Rahe into three categories: family, personal, and job/
financial problems. Family matters were mentioned by 42.7% of psoriatic patients, statistically significant compared with controls (P < 0.0001). In 35% of psoriatic cases, the
stressful event was represented by the illness/death of someone dear. Both personal
(25.6%; P = 0.02) and job/financial problems (31.6%; P < 0.0001) were significantly
different compared with controls.
Conclusions Stressful events could be highly related to psoriasis (especially in
recurrences/extensions). Problems related to family are the most often involved with
counseling being suggested.

important problems in their lives.

Odds ratios were calculated and v2 and t-test were used to
study the differences between the groups, considering a
significant difference for P 0.05.

Results
General data about the groups

In the psoriasis group, there was a clear female predominance. There were 112 women (66%) and 57 men
(33%). The median age was 47.55 years (SD = 20.32) in
psoriatic cases and 46.43 years (SD = 20.18) in controls.
There was not a significant difference (P = 0.15) related
to the median age between men (50.66 years; SD =
21.07) and women (45.96 years; SD = 19.74).
The localization of psoriatic lesions appears in Table 1.
In all, 57.4% of patients had psoriasis vulgaris. A total of
27.2% had the onset less than 3 months before the study
and 43.7% of psoriatic patients had recurrence/extension
of old lesions (higher rate for women, Table 1). Fourteen
females and four males with psoriasis had a family history of the disease (10.65% whole group; 7% males;
12.5% females).
The distribution of the patients according to the socio
professional level was: high level (including students)
23.7%; average level 18.3%; low level (housewife/
unemployed/retired) 58%. We included students in the
high-level group because they have free and easy access to
consultations and therapy, and usually they are more
eager to get treatment. In our country, the group of housewives/unemployed/retired usually has reduced material

Table 2 Stress involvement according to the type of psoriasis

Psoriasis Guttate
vulgaris
Women 36 (62)
Men

19 (48.7)

Psoriasis

Inverse

Scalp

psoriasis palmo-plantaris psoriasis psoriasis

10 (47.6)
6 (60)

6 (42.8)
1 (50)

Values in parenthesis are percentage.

1 (50)

9 (52.9)
4 (66)

Report

Psoriasis and life events

possibilities and an expected rate of giving up long-term

treatments.
In all, 23.07% of psoriatic patients experienced pruritus (33 females 29.6%; six males 10.5%). A total of
7% of patients were already undergoing psychiatric therapy (nine females 8% and three males 5%). Depressive disorder was diagnosed in eight patients and anxiety
disorder with depressive elements in four patients. An
additional 48 psoriatic patients (28.5%), 40 females and
eight males, described some symptoms of anxiety, but
refused a psychiatric visit. Therefore, we used anxiolytic
drugs as adjutants (tianeptin, bromazepam). Ten patients
(6%) had diabetes mellitus associated and five patients
(3%) had thyroid involvement.
Dermatologic diagnoses for controls are presented in
Table 1. The distribution according to socio-economical
level in controls was: high level 18.3%, average level
27.3%, and low level 54.4%.
Stress involvement

Psoriatic patients mentioned at least one potential stressful event in 92 cases (54.4%) compared with 33 cases in
controls (19.52%). The odds ratio was 4.92 [95% CI:
3.028.00]. This difference was significant (v2 = 42.71,
P < 0.0001). There was no significant statistical difference
(P = 0.29) comparing men and women with psoriasis
(52.63% for males; 55.35% for females). Stressful events
were described by 47.36% of patients with first episode
(27 females; 18 males) and by 63.51% of patients with
recurrence/extension (35 females; 12 males).
Thirty-seven of early onset cases (28 women and nine
men) claimed the involvement of stressful events (56%).
On the other hand, we compared patients with ages
under and over 40 years old. In all, 57.8% of patients
under 40 years old (37 cases) and 52.38% (55 persons)
mentioned a stressful situation. There was no statistical
significance between the two groups (P = 0.49).

Manolache, Petrescu-Seceleanu, and Benea

From the 39 psoriatic patients experiencing pruritus,

20 cases (51.28%) described a stressful event (two men;
18 women). In the group of psoriasis vulgaris, 62% of
women and 48.7% of men described the presence of
stress. A total of 47.6% of females and 60% of males
with guttate psoriasis mentioned a stressful event. Women
with psoriasis vulgaris and men with guttate psoriasis
seemed to be more sensitive to stress (more details in
Table 2).
Data regarding the number of stressful events are
described in Table 3. We found a significant difference
between the mean number of stressful events in psoriatic
patients and in controls (P = 0.0001, t = 4.81, df = 336).
Most of psoriatic patients (50%) noticed one potential
stressful event before the onset/recurrence/extension of
the lesions. Comparing the presence of major life events
(separation, death/illness of a family member, pregnancy,
personal illness/accident, dismissing/unemployment, debts
>10 times average salary), there was a significant difference (P < 0.0001) between patients and controls. Regarding the types of events mentioned (Table 4), the most
important matters in the psoriasis group were related to
family (42% of the stressful situations) (v2 = 37.093,
P < 0.0001). Among family problems, most often cited
were death/illness of a family member (29% among all
stressful life events). We also noticed other important situations: a family member leaving home to work abroad,
children starting/ending school, divorce of a child with
consequences for extended family.
Personal changes represented 25.64% of stressful situations in psoriatic patients. These changes were borderline
significant compared with controls (P = 0.02, v2 = 3. 85
for P = 0.0049). We mention personal illness/accident
and also change of residence (new situation in our country when many people have moved from blocks of flats to
houses in suburbs), representing 12% of total stressful
events.

Table 3 Number of stressful events in psoriasis group compared with control group

Job/financial problems represented 31.65% of stressful

events described by psoriatic patients. These kind of problems were significantly different compared with controls
2010 The International Society of Dermatology

(P < 0.0001, v2 = 11.71 for P = 0.0006). The situations

most often mentioned were related to the change of economic status, changes in responsibilities at work or
International Journal of Dermatology 2010, 49, 636641

changes in schedule/job conditions. For men, there were

no significant differences in patients and controls regarding personal and financial problems.
In patients with psoriasis vulgaris, there were 45.3%
family matters, 33.3% financial/job matters, and 21.4
personal matters. In patients with guttate psoriasis, there
were 39.6% personal changes, 32% financial problems,
and 28% family matters. In patients with scalp lesions
only, there were 53% family matters, and 23.5% for personal and financial problems. In patients with palmoplantaris lesions, there were 70% family matters.
Discussion
Even though there has been a constant interest regarding
stress involvement in psoriatic patients for almost
40 years, and there are only a few case-control studies.2,7,8,11,12 We have tried to overcome the limits of questionnaires inviting patients to complete the list mentioning
other potential stressful situations with an impact on their
lives. The limitation of checklists regarding the possibility
to escape some events from the memory was attenuated by
the result of the higher impact of major life events which
are easily remembered.
We found a female predominance, different from Finzis
results with male predominance.13 The median age was
comparable with other observations.13 Our result of family history of psoriasis (10.65%) is lower than that of
Raychaudhuri study14 (54%). Pruritus was experienced by
23% of our patients, a result similar to Yasudas study15
(19.5%), but much lower than others that are describing
pruritus up to 80%.16,17 Stress could also aggravate not
only lesions, but also pruritus in psoriatic patients.15,16
Early onset (<40 years old) such as stress was reported to
be more readily triggered by environmental factors.18
There are different data in the literature. Results regarding stress involvement are starting from values of 35% (for
onset),19 4550% (for onset),11,15,20 up to 6072% (for
onset21,22 or exacerbation19,23,24). Incubation period differs from 15 d (honeymoon) 23 to 1 month before the onset/
exacerbation,25 3 months,21 or 6 months.11,22 There is a

Manolache, Petrescu-Seceleanu, and Benea

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