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

Psychological stress and psoriasis: A systematic review and meta-analysis. I Snast, 1 * O Reiter, 1 * L Atzmony, 1 YA Leshem, 1 E Hodak, 1,2 D Mimouni, 1,2† L Pavlovsky 1 1 Department of Dermatology, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel

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

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  1. Psychological stress and psoriasis: A systematic review and meta-analysis ISnast,1* O Reiter,1* L Atzmony,1 YA Leshem,1 E Hodak,1,2 D Mimouni,1,2† L Pavlovsky1 1Department of Dermatology, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel *Drs. Snast and Reiter, and †Drs. Mimouni and Pavlovsky contribued equally Funded by an unrestricted grant from Pfizer British Journal of Dermatology. DOI: 10.1111/bjd.16116

  2. Introduction What’s already known? • It is a common knowledge among psoriasis patients and their physicians that psychological stress aggravates psoriasis • Observational studies have suggested a link between preceding psychological stress and psoriasis exacerbation and onset 1Rigopoulos et al, Eur J Dermatol, 2010

  3. Objective • To determine if preceding psychological stress and psoriasis exacerbation and onset are associated

  4. Methods (1) • A systematic search of 5 databases by 2 reviewers was performed • Studies investigating the association between preceding stress and psoriasis exacerbation and onset • Controls: healthy or participants with minor skin disorders Inclusion criteria

  5. Methods (2) • Sample size < 10 or non-plaque subtypes of psoriasis • Studies assessing the effect of stress on psoriasis clearance • Newcastle-Ottawa Scale (NOS) Exclusion criteria Quality assessment

  6. Methods (3) Studies classification: • Studies were classified and analysed as cross-sectional, case-control or cohort. Beliefs regarding stress-reactivity were analysed separately.

  7. Results • Thirty-nine heterogeneous studies were included (32,537 patients): • Surveys: 19 • Cross-sectional: 7 • Case-control: 12 • Cohort: 1 Total citations=1526 Exclusion based on abstracts=1405 Full text assessment=64 Exclusion based on full text=25 Studies included=39 • Results were not affected by studies’ quality

  8. Results Surveys & cross sectional studies • Based on surveys, 46% of patients believed in reactivity to stress, with a positive trend over time • Based on cross-sectional studies, 54% of patients recalled major life events preceding psoriasis exacerbation/onset • Studies lacked control group and failed to report on the time lag to recollection Prevalence of belief in reactivity to stress

  9. Results Case control studies • All patients were compared to controls without psoriasis • Studies varied in the time lag to recollection (≤9 month to ≥ 5 years) • Studies neglected daily and chronic stressors 12 case-control studies evaluated preceding stressful life events rates : Psoriasis exacerbation N=6 Psoriasis onset N=6

  10. Results Case control studies • Pooling 5 studies evaluating stressful events rates prior psoriasis onset yielded OR of 3.4 (95%CI, 1.8-6.4) • However, the only study reporting documented stress disorder diagnosis found similar rates • Four studies evaluating patients with a resent psoriasis exacerbation found comparable rates, while 2 failing to report on the recollection time found more frequent/severe events among psoriasis patients

  11. Results Cohort studies • One prospective cohort study (62 patients) evaluated the association between daily stress level and psoriasis exacerbation • A modest correlation coefficient of 0.28 (p < 0.05) was found between stress and disease exacerbation • An absolute PASI worsening of 1 was reported between minimum and maximum stress levels 1Verhoeven et al, Br J Dermatol, 2009

  12. Discussion What does this study add? • Patients beliefs of stress reactivity is not an evidence for a causal relation • Case-control studies were inconsistent and failed to report on the time lag to recollection, highlighting the importance of proper reporting in future studies • The sole prospective study found a modest association between stress and psoriasis exacerbation. Further prospective studies are needed

  13. Conclusions What does this study add? • No convincing evidence exists that psychological stress is strongly associated with psoriasis exacerbation and onset • This conclusion is psychologically beneficial for patients and has therapeutical and occupational implications

  14. Call for correspondence • Why not join the debate on this article through our correspondence section? • Rapid responses should not exceed 350 words, four references and one figure • Further details can be found here

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