Psychological stress and psoriasis. A systematic review and meta-analysis

Abstract

Background

Psychological stress has long been linked with psoriasis exacerbation/onset. However, it is unclear if they are associated.

Objective

To determine if antecedent psychological stress and psoriasis exacerbation/onset are associated.

Methods

A comprehensive search of Pubmed, PsycINFO, Cochrane library, and clinicaltrials. gov databases was performed. Studies investigating the association between preceding psychological stress and psoriasis exacerbation/onset were classified as cross-sectional, case-control or cohort. Surveys evaluating beliefs regarding stress-reactivity were analysed separately. Suitable studies were meta-analysed.

Results

Thirty-nine studies were included evaluating 32,537 patients: 19 surveys, 7 cross-sectional, 12 case-controls and 1 cohort. Based on surveys and cross-sectional studies, 46% of patients believed their disease was stress-reactive and 54% recalled preceding stressful events. Case-control studies evaluating stressful events rates prior to psoriasis exacerbation (N=6) or onset (N=6) varied in time lag to recollection (≤9 month to ≥ 5 years). Pooling 5 studies evaluating stressful events preceding psoriasis onset yielded an OR of 3.4 (95%CI, 1.8-6.4, I² =87%), however the only study evaluating documented stress disorder diagnosis reported similar rates (OR 1.2, 95%CI, 0.8-1.8) between patients and controls. Four studies evaluating stressful events prior to psoriasis exacerbation reported comparable rates with controls, while 2 found more frequent/severe preceding events among psoriasis patients. A small prospective cohort study reported a modest association between stress-levels and psoriasis exacerbation (r = 0.28, p < 0.05).

Conclusions

The association between preceding stress and psoriasis exacerbation/onset is based primarily on retrospective studies with many limitations. No convincing evidence exists that preceding stress is strongly associated with psoriasis exacerbation/onset.

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