Correlation between Stress and Dermatology Life Quality Index in

Psoriasis Vulgaris Patients

Nyoman Suryawati, I. G. A. A. Praharsini, Irene Jessica Soputro

Department of Dermatology and Venereology, Faculty of Medicine Universitas Udayana, Sanglah Hospital, Bali,

Indonesia

Keywords: stress, DASS-21, DLQI, psoriasis vulgaris, cross-sectional study

Abstract : Psoriasis vulgaris is a chronic inflammatory disease of the skin comprising chronic relapse. This condition

has frequently caused discomfort, social stigma, psychological disorders such as depression, anxiety, and

stress affecting psoriasis vulgaris patients’ quality of life. This cross-sectional study aimed to identify

relationship between stress and quality of life in psoriasis vulgaris patients. Study sample included 42 psoriasis

vulgaris patients ranging from 16 to 65 years old during October-December 2017 period, fulfilling inclusion

and exclusion criteria. Stress was measured using Depression, Anxiety and Stress Scale-21 items (DASS-21)

scoring system, while quality of life was measured using Dermatology Life Quality Index (DLQI) scoring

system. Data was analyzed using SPSS 20 with Spearman’s Rho correlation test. The result showed most of

psoriasis vulgaris patients were male (69.05%), Balinese ethnic group (83.33%), senior high school graduate

(47.62%) and private sector employee (52.38%). Mean age of psoriasis patients was 45.93 ± 11.07 years old

with first onset ranging from 1 to 30 years and mean onset was 8.26 ± 7.6 years. Stress measurement using

DASS-21 found stress range between 0-42 and mean range was 10.81 ± 10.00. Quality of life measurement

using DLQI found score range between 0-23 and mean range was 10.74 ± 6.44. This study found stress as

risk factor of increased DLQI in psoriasis patients (PR 6.80, CI 95%; 0.96-48.33; p<0.05) and increased stress

score had positive correlation with DLQI (r=0.53; p<0.05). According to quality of life variable measurement,

stress was found to have positive correlation with symptoms and feelings (r=0.41; p<0.05) and daily activities

(r=0.38; p<0.05).

1 INTRODUCTION

Psoriasis is a chronic inflammatory disease of the skin

comprising chronic relapse. Psoriasis prevalence has

been reported variably between 0.1%-3% in various

population, with highest prevalence reported in

Denmark (2.9%), and low prevalence was reported in

Asia (0.4%) (Gudjonsson, 2012). Psoriasis is

characterized by presence of skin disorders such as

erythematous plaque covered by multiple layers of

thick white scales. Psoriasis vulgaris may cause

psychological disorders such as shyness, anxiety,

depression, stress, and social stigma reducing

patients’ quality of life (Gudjonsson, 2012), (Sharma,

2011), (Bhosle, 2006), (Basavaraj, 2011), (Nasren,

2008). Psoriasis affects patients’ quality of life which

may cause significant pressure on daily basis and

patients’ psychological morbidity (Basavaraj, 2011).

Stress is an individual condition caused by

environmental interaction considered as demand and

threat for the well-being of an individual. The cause

of stress is not only physical factors but also

emotional factors (Kenari, 2014). There are several

methods to measure stress, one of which is

Depression, Anxiety and Stress Scale (DASS). At

first, DASS scoring consisted of 42 questions, but

Lovibond and Lovibond (1995) created shorter

version composing 21 questions (DASS-21). DASS-

21 technique has been used frequently by

psychologists or clinicians because of its validity and

good reliability (Oei, 2013).

Quality of life defined as the ability to perform

daily activities according to an individual’s age and

role in the community. Quality of life measurement

of patients with skin disorder can be done using

Dermatology Life Quality Index (DLQI), a valid,

simple, and practical questionnaire (Bhosle, 2006).

Suryawati, N., Praharsini, I. and Soputro, I.

Correlation between Stress and Dermatology Life Quality Index in Psoriasis Vulgaris Patients.

DOI: 10.5220/0008150100310034

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 31-34

ISBN: 978-989-758-494-7

Numerous studies had reported the relation

between psoriasis vulgaris severity and patients’

quality of life, but only few studies managed to

identify relation between stress and patients’ quality

of life along with other variables of psoriasis vulgaris

patients’ quality of life. This study aimed to identify

the relation between stress and quality of life in

psoriasis vulgaris patients.

2 METHODS AND RESULTS

This study used cross-sectional design with sample

number of 42 persons. Samples were recruited from

psoriasis patients visiting dermatology and

venereology clinic in Sanglah General Hospital,

fulfilling inclusion and exclusion criteria, during

October-December 2017 period. Psoriasis vulgaris

diagnosis was confirmed by anamnesis and physical

examination, and for doubtful cases, histopathology

examination was performed.

Stress level was measured using DASS-21

consisting 21 questions and each question comprising

7 questions to measure depression, anxiety, and

stress. In DASS-21, stress scale was sensitive to

chronic non-specific arousal. Each question was

scored from 0 to 3 and final score was obtained from

total score multiplied by two. Total score ranged from

0 to 42. Stress measurement were classified into

normal (score 0 – 10), mild (score 11- 18), moderate

(score 19 – 26), severe (score 27 – 34), and extremely

severe (score 35 – 42).

Quality of life measurement using DLQI

consisting 10 questions related to quality of life

variables including: symptoms and feelings, daily

activities, leisure, work or school, personal

relationships and treatment filled by patients. DLQI

score was attained by adding 4 point to each variable

scoring from 0 to 3. Total score ranged from 0 to 30.

Highest score indicated great influence to

patients’ quality of life (Bhosle, 2006).Data was

processed using SPSS 20 software. Descriptive

analysis was performed to identify subjects’

characteristics. Data normality test was performed

using Kolmogorov-Smirnov. Correlation between

stress and DLQI as well correlation between stress

and each quality of life variable were analyzed using

Spearman’s Rho test. Statistical analysis was

considered significant when p<0.05.

Psoriasis patients involved in this study were 42

persons, including 29 males (69.05%) and 13 females

(30.95%), Balinese ethnic group (83.33%), senior

high school graduate (47.62%) and private sector

employee (52.38%). Mean age of psoriasis patients

was 45.93 ± 11.07 years old with first onset ranging

from 1 to 30 years and mean onset was 8.26 ± 7.6

years. Family history of psoriasis was found in 4

patients (9.52%) with stress as the most common

triggering factor found in 31 patients (73.81%). Stress

measurement using DASS-21 found stress range

between 0-42 and mean range was 10.81 ± 10.00.

Quality of life measurement using DLQI found score

range between 0-23 and mean range was 10.74 ± 6.44

(Table 1).

This study identified stress as risk factor of

decreased quality of life in psoriasis patients (PR

6.80, CI 95%; 0.96-48.33; p<0.05). Increased stress

score had positive correlation with decreased

patients’ quality of life (r=0.53; p<0.05) shown in

Figure 1. According to quality of life variable

measurement, stress was found to have positive

correlation with symptoms and feelings (r=0.41;

p<0.05) and daily activities (r=0.38; p<0.05) (Table

2).

Table 1. Characteristic of the subject

Table 2. Correlation between stress and each quality of life

variable

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

Figure. 1. Scattered plot graphic of correlation between

stress and D

3 DISCUSSION

In this study, mean age of psoriasis patients was 45.93

± 11.07 years old. This result was consistent with

previous study in India (2014) stating mean age of

psoriasis patients was 49.45 ± 14.8 years old, as well

similar study in Croatia (2013) with mean age of 49.9

± 14.8 years old. Psoriasis can affect individuals of all

ages although it tends to occur in adults rather than

children and its incidence decreases in elderly.

Several previous studies showed increased psoriasis

incidence with age. Psoriasis incidence increases over

the age of 39 years old and it is predicted to decline

during elderly (Parisi, 2013).

This study found majority of psoriasis patients

were males comprising as many as 29 persons

(69.05%). This result was consistent with studies in

Taiwan (2013) and China (2013) obtaining psoriasis

vulgaris events were more common in male than in

female patients with a ratio of 2:1 (Tseng, 2013),

(Wu, 2013). Generally, it was known that psoriasis

number of events was almost the same both in male

and female patients. There has been no evidence

showing phenotype difference of psoriasis vulgaris in

both sexes (Griffiths, 2010).

Genetics was alleged to play role in pathogenesis

of psoriasis vulgaris. From this study, family history

of psoriasis was found in 4 patients (9.52%). This

result was consistent with Shobaili, et al study

identifying family history of psoriasis in 8.4%

patients (Alshobaili, 2010).

In this study, stress was found to be a triggering

factor for psoriasis lesion in 31 patients (73.81%).

Stress is one of triggering factors for exacerbation of

psoriasis lesion and approximately 40-80% psoriasis

vulgaris exacerbation is caused by stress. Severe

psoriasis vulgaris condition may cause stress,

meanwhile stress is able to worsen psoriasis

symptoms (Basavaraj, 2011). Stress can aggravate

psoriasis vulgaris condition and prolong healing time

of the disease. Stress effect on psoriasis vulgaris

exacerbation is possibly mediated by immunology

effect involving hypothalamus-pituitary-adrenal

(HPA) axis and increase in reactivation of

sympathetic adrenomedular (SAM) leading to

activation of mast cells which cause neurogenic

inflammation (Basavaraj, 2011), (Cohen, 2007),

(Coimbra, 2014). Psychological stress causes

phenotypic changes in circulating lymphocyte and

considered as important trigger for T-helper1 cell-

polarized inflammatory in psoriasis (Basavaraj,

2011).

Measurement of mean stress score was 10.81 ±

10.00 and mean DLQI score was 10.74 ± 6.44. Stress

score had moderate correlation with DLQI, r=0.53;

p<0.05 which showed that higher DLQI score

indicated higher patients’ stress level measured by

DASS-21. In this study, positive correlation between

stress and quality of life variables such as symptoms

and feelings (r=0.41; p<0.05) and daily activities

(r=0.38; p<0.05) were identified. Those results

showed that higher stress level had greater effect on

both symptoms and feelings and daily activities

variables in psoriasis vulgaris patients.

4 CONCLUSION

Stress affected quality of life in psoriasis patients.

This study found higher stress level had greater effect

on patients’ quality of life, particularly in symptoms

and feelings, and daily activities variables. According

to the results of this study, it is concluded that

screening for stress as triggering factor of psoriasis

vulgaris is essential, thus prompt treatment for stress

can be performed which eventually leads to increased

quality of life in psoriasis vulgaris patients.

ACKNOWLEDGEMENT

We gratefully thank all of the patients for agreeing to

participate in our study.

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