ARTICLE
Auteur(s) : Laurent Misery1, Luc
Thomas2, Denis Jullien2, Frédéric
Cambazard3, Philippe Humbert4, Louis
Dubertret5, Laure Dehen5, Guy
Macy6, Sami Boussetta7, Charles
Taieb7
1Service de dermatologie, CHU Brest, Brest,
France
2Service de dermatologie, Hôtel-Dieu, Lyon, France
3Service de dermatologie, CHU Saint Etienne, Saint
Etienne, France
4Service de dermatologie, CHU Besançon, Besançon,
France
5Service de dermatologie, Hôpital Saint Louis, Paris,
France
6Laboratoires dermatologiques Ducray, Lavaur, France
7Département de santé publique, Laboratoires Pierre
Fabre, Boulogne, France
accepté le 27 Février 2008
Due to the visibility of skin lesions and the high prevalence of
physical symptoms such as itch, pain or fatigue [1], skin diseases
are known to adversely affect quality of life [2, 3] and to induce
physical and psychological stress. On the other hand, stress is
also able to enhance the severity of skin diseases [4-6] through
biological mechanisms [7-12].
These mechanisms involve the neuro-immuno-cutaneous system [7]
and hypothalamic-pituitary-endocrine axis [12]. In response to
physical or psychological stressors, the hypothalamus and pituitary
gland release neuropeptides, inducing the release of catecholamins
and cortisol by adrenal, whereas the skin is able to produce
neuropeptides such as corticotrophin-releasing hormones, substance
P or calcitonin gene-related peptides in response to stress.
Through membrane receptors, all these neurotransmitters can
modulate the properties of skin cells. Among these cells,
inflammatory cells are most sensitive to neurotransmitters. Hence,
inflammatory dermatoses are believed to be more rapidly and more
efficiently modulated by stress.
Some studies have evaluated the impact of skin diseases on
psychosocial well-being [13, 14] or on quality of life [2, 15, 16],
and several studies have been performed on perceived stress in
specific diseases, such as psoriasis [17], atopic dermatitis [5],
alopecia areata [18] or seborrheic dermatitis [19]. We carried out
a comparative study of both perceived stress and quality of life in
several skin diseases.
Patients and methods
The study was carried out from 20-25 November 2006. For 5
consecutive days, outpatients (more than 18 years-old) from the
consultations of 5 departments of dermatology in France (Besançon,
Brest, Lyon, Paris, Saint Etienne) answered self-administrated
questionnaires evaluating self-perceived stress and quality of
life. Demographic data and diagnoses were collected by
dermatologists.
Self-perceived stress was evaluated by PCV-Metra (abbreviation
for: Prévention Cardio-Vasculaire en MEdecine du TRAvail) [20].
This self-administrated questionnaire consists of 9 subscales, with
4 modes of answer, scored from 0 to 3. The content of the 9 items
covers the multiple facets of perceived stress and its
consequences: “feeling of being under pressure”, “impatience”,
“irritability”, “intrusive thoughts about work”, “inability to
entertain”, “discouragement”, “morning fatigue”, “food
compensation”, “compensation by smoking”. Stress global score is
defined as the sum of the 9 elementary scores, allowing scores from
0 to 27.
Quality of life was evaluated using SF-12 (abbreviation for:
Short Form- 12 questions) [21]. The SF-12 is a short version of the
SF-36, a generic measure making possible the assessment of health
status in the general population. It is a self-questionnaire.
Responses to questions are dichotomous (yes/no), ordinal (excellent
to poor) or express a frequency (always to never). Two scores can
be calculated from these 12 questions: a Physical Component Summary
(PCS-12) and a Mental Component Summary (MCS-12). There is no
overall score. Missing data are left as missing data. In the case
of a non-response to a question forming one of these sub-scales,
the score cannot be calculated. Thus, a given subject can have a
PCS-12 score but no MCS-12 score. After processing of the abnormal
responses and reversed items, each response was assigned a
coefficient. PCS-12 and MCS-12 scores were obtained by summation.
Lastly, they were transformed (mean 50 and standard deviation 10)
for comparison with American “standards”, allowing a direct
interpretation of scores compared to the general American
population. Therefore, scores above or below 50 are above or below
the mean of the general American population. The higher the score,
the better the quality of life.
Statistical analysis was carried out using SAS V8.2 Software
(SAS Institute, Raleigh, NC, USA). Quantitative variables are
described by the average and the standard-deviation. Nominal and
ordinal qualitative variables are described by the number and the
percentage for each modality of the variable. The Chi2 test or the
Fisher’s exact test (if conditions for application were not met)
was performed to compare qualitative data and the Student t-test or
an ANOVA design (if more than 2 groups) for quantitative data. All
statistical tests were two-sided and performed at the 5%
significance level.
Results
During the study period, 658 outpatients agreed to answer a
questionnaire. The mean age was 48.9 years (± 19.3). Among them,
56.5% were women and 43.5% were men. The causes of consultation
were pigmented tumours (18.1%), atopic dermatitis (10.6%),
psoriasis (10.2%), acne (5.4%), urticaria (2.6%), seborrheic
dermatitis or vitiligo (0.7% each) and others (51.6%). These skin
diseases had been diagnosed within one year or less in 34.6%,
between one and five years in 32.2% and five years and more in
33.2%. An aggravation of skin lesions as a reason for consultation
was declared by 39.1%.
Atopic dermatitis (20.9%) and acne (10.2%) were the first two
motivations for consultation under 35 years whereas pigmented
tumours (21.3%) and psoriasis (10.2%) were the motivations for
those over 35 years. The mean ages of outpatients were 28.3 years
for acne, 36 years for atopic dermatitis, 46 years for psoriasis
and 52.2 years for pigmented tumours. The sex ratio was in favour
of women, except in psoriasis.
The mean stress score was 9.39 (± 4.30), mean PCS-12 47.17 (±
10.03) and mean MCS-12 42.76 (± 11.02). Differences in stress
scores according to centres were significant: 10.53 in Paris, 9.22
in Lyon, 9.18 in Saint Etienne, 8.89 in Besançon and 8.81 in Brest
(p < 0.05). The scores for health-quality of life were similar
in all centres. There were no significant differences in PCV-Metra,
PCS-12 or MCS-12 scores according to how long the current symptoms
had been going on. PCV-Metra and MCS-12 scores were more elevated
in women (10 versus 8.6 and 41.2 versus 42.7; p = 0.001) but there
was no difference in physical quality of life between men and
women. PCS-12 score was higher if patients consulted for a recently
aggravated skin disease (45.5 versus 47.9; p < 0.05) without
repercussion on MCS-12 or PCV-Metra scores. The correlation between
the perceived stress score and mental quality of life was
significantly high (RSpearman= – 0.6, p < 0.001)
(figure 1) but
not with physical quality of life (RSpearman=
– 0.03, p = 0.59).
Stress scores (figure
2) were different for psoriasis, acne, urticaria, atopic
dermatitis and pigmented tumours (p < 0.05). The scores for
quality of life were not significantly different according to
diseases. In patients with psoriasis, PCS-12 and MCS-12 scores were
diminished if patients had a recent exacerbation of lesions
(respectively 42.6 versus 51.6 and 36 versus 44; p < 0.05). The
stress score was not significantly modified in these patients but
MCS-12 and PCV-Metra scores were strongly correlated (R =
– 0.77).
We compared inflammatory or immune dermatoses (psoriasis, atopic
dermatitis, acne, vitiligo, herpes, urticaria, etc.) and non
inflammatory dermatoses (tumors) in 462 patients with only one
reason for consultation and with a clear pathogeny (inflammatory or
not): 54.55% suffered from non inflammatory dermatoses and 45.45%
from inflammatory skin diseases (table
1). Mean ages were different: 52.9 versus 41.8 years (p
< 0.001). Women were respectively 58% and 51%. The stress score
was higher in inflammatory dermatoses (9.92) than in others (8.77;
p < 0.01). PCS-12 scores were not different and MCS-12 scores
seem to be more altered in patients with inflammatory dermatoses
(41.88 versus 44.04; p = 0.055). In patients with inflammatory skin
diseases, the perceived score was higher when the skin diagnosis
was older than 5 years (11.1 versus 9.3; p < 0.05) whereas it
was not the case in the other patients. There was no significant
difference according to whether there had been a recent
exacerbation or not in the two subsets.
Table 1 Comparisons between inflammatory and non
inflammatory dermatoses
|
% or mean (SD)
|
Inflammatory dermatoses (N = 210)
|
Non inflammatory dermatoses (N = 252)
|
P-values
|
|
% Women
|
50.7
|
58.8
|
0.086
|
|
Mean age
|
41.8 (17.5)
|
52.9 (18.9)
|
< 0.001a
|
|
Mean perceived stress scores
|
9.9 (4.5)
|
8.8 (3.9)
|
0.009a
|
|
SF-12 scores
|
|
|
|
|
Physical component summary
|
48.0 (9.7)
|
46.9 (10.0)
|
0.25
|
|
Mental component summary
|
41.9 (11.0)
|
44.0 (10.5)
|
0.055b
|
aSignificant P-values (p < 0.05).
bP-values near significance.
Discussion
To our knowledge, this is the first study comparing both perceived
stress and quality of life in many skin diseases. Because it was
performed in academic departments, the population studied is
different from the French population who suffer from skin diseases
[22] but we found similar data on quality of life as with diseases
in general practice [13]. However, our aim was to compare some
frequent diseases and our data allows comparisons between
psoriasis, atopic dermatitis, acne and pigmented tumours, as well
as between inflammatory and non-inflammatory skin diseases.
Dividing skin diseases into these two categories appears
pertinent when comparing diseases which are sensitive to stress
with others which are not, because there was a significant
difference in stress levels. In another word, the stress levels of
psoriasis or acne and pigmented tumours are clearly discordant. The
absence of an associated difference between perceived stress and
physical quality of life and the correlation between perceived
stress and mental quality of life suggests that inflammatory
dermatoses, such as acne or psoriasis, are really more influenced
by psychological factors (or they cause more psychological
impairment) and that people consulting for pigmented tumours could
be used as controls in studies about the relationship between
stress and diseases. Differences in quality of life are less
significant than those in perceived stress. This is probably due to
the absence of a distinction between treated and non-treated
patients in our study, a 6-week treatment being able to
dramatically improve quality of life [23]. However, people with
psoriasis could be used as positive controls and people with
pigmented tumours as negative controls in further studies about
stress and quality of life.
Patients with psoriasis could be used as positive controls.
Psoriasis was previously described as the skin disease which is the
most sensitive to stress: stress is involved in 80% of psoriasis
rashes [24]. In our study, patients with psoriasis were those with
the highest stress scores and the lowest quality of life scores. In
our study, people suffering from psoriasis were more often men than
women and were older than other patients. Because women and young
people have higher stress scores and more decreased quality of
life, it means that perceived stress, alterations in quality of
life and psychological suffering are dramatically important in
psoriasis.
In patients with inflammatory skin diseases, the perceived score
was higher when the skin diagnosis was older than 5 years and there
was no significant difference regarding whether there had been a
recent exacerbation or not. That suggests that a high level of
perceived stress could be more associated with the chronicity of
these diseases rather than with the onset of rashes. The presence
of polymorphisms of beta-adrenergic-receptor genes [25] or the
roles of alexithymia and emotional awareness [26] could help us to
understand this.
However, understanding the relationship between the objective
disease severity, illness-related stress, health-related quality of
life and depressive symptoms is very difficult [17]. With a similar
method, the prevalence of depressive symptoms in outpatients with
skin diseases was assessed to be 23.6% [14]. In accordance with
recent studies on psoriasis [17], we suggest that specific problems
in everyday life and altered quality of life of patients with skin
diseases may induce depression and subsequently a higher perceived
stress. This perceived stress, enhanced by stressful life events,
will aggravate both inflammatory skin diseases and psychiatric
symptoms [27], whereas psychiatric co-morbidity has an impact on
quality of life [16]. These data are supported by biological data:
as seen above, the release of neurotransmitters by the nervous
system is able to act on inflammation and immunity. However, the
skin is also able to produce inflammatory mediators and
neurotransmitters [28], which can modulate brain (and psychic)
activity by themselves. Hence, the health care of patients with
skin diseases needs to be careful, with attention to both skin and
well-being to break this vicious circle.
Acknowledgements
This evaluation was made possible thanks to the grant of the
« Atopie » Fundation.
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