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ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 178-182

Stressful major life events and chronic urticaria: Its role in induction or exacerbation of the disease


Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Mangalore, Karnataka, India

Date of Submission25-Aug-2020
Date of Decision29-Mar-2021
Date of Acceptance18-Jun-2021
Date of Web Publication26-Aug-2021

Correspondence Address:
Preeti Ganesh Choudhari
Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_116_20

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  Abstract 


Background: The skin and central nervous system are derivatives of embryonic ectoderm. There is an etiological factor of stressful life events in various skin diseases such as chronic urticaria through psychosomatic mechanisms. Many observations and case series are reported in favor of this opinion. Objectives: To evaluate the stressful life events within one year, six months and a month preceding onset or exacerbation of lesions in chronic idiopathic urticaria cases enrolled in this study. Material and Methods: It is an Observational descriptive questionnaire-based study, which included minimum of 50 patients of chronic idiopathic urticaria and important stressful events were noted in these subjects using Gurmeet Singh's presumptive stressful life events (PSLE) scale. Results: Out of 50 cases, stressful life events preceded the exacerbation of the chronic urticaria in 16 (32%) patients. Amongst them 12 (24%) showed slight degree and four (8%) showed moderate degree of stress and none of the cases reported great degree of stress. Among 16 cases, eight (50%) cases noticed exacerbation within six months of experiencing stressful life event with higher degree of severity in older age group (p = 0.004). Financial loss or problem was the most common stressful life event seen in four out of 16 cases (25%) (p = 0.000). Few desirable events were also found as stressors in four cases accounting for 25%. Conclusion: These results support association between psychological factors and exacerbation of the disease. The need for stress management programs in high stress scores to cope up with the stressful events, will further help in reducing the morbidity.

Keywords: Chronic urticaria, stress, presumptive stressful life events scale


How to cite this article:
Choudhari PG, Hundi GK, Sukumar D. Stressful major life events and chronic urticaria: Its role in induction or exacerbation of the disease. Clin Dermatol Rev 2021;5:178-82

How to cite this URL:
Choudhari PG, Hundi GK, Sukumar D. Stressful major life events and chronic urticaria: Its role in induction or exacerbation of the disease. Clin Dermatol Rev [serial online] 2021 [cited 2021 Dec 1];5:178-82. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/2/178/324558




  Introduction Top


The skin plays a vital role as a sensory organ in socialization processes from birth till the entire life cycle. It is a central organ of communication, which is responsive to various emotional stimuli and also affects an individual's identity and self-esteem.[1]

The skin and the central nervous system that are related embryologically, as the epidermis and neural plate are derived from the embryonic ectoderm. As they have common embryonic origin, they share several hormones, neurotransmitters, and receptors. It has been postulated that there is an etiological factor of stressful major life events and various skin diseases through psychosomatic mechanisms.[2]

A host of studies have suggested the role of stressful life events as an etiological factor of various skin diseases such as psoriasis, urticaria, alopecia areata, atopic dermatitis, and eczema. The role of stress in psoriasis and urticaria was studied because both are chronic diseases with remissions and exacerbations, which provide platform for examining the same. Till date only few prospective studies are reported in literature which suggest that stress is one of the causal factor implicated in the occurrence of chronic idiopathic urticaria. Further research is mandatory in the form of prospective studies with more statistical power.[2],[3]

The aim of this study is to evaluate the stressful life events within 1 year, 6 months, and 1 month preceding onset or exacerbation of lesions in chronic idiopathic urticaria cases enrolled in this study using Gurmeet singh's presumptive stressful life events (PSLE) scale. This scale is suitable for the Indian population, using stressful life events relevant to our culture and standardized for our population.[3]


  Materials and Methods Top


It is an observational descriptive questionnaire-based study. The study was done in a tertiary care hospital in the southern part of Karnataka. A total number of 50 patients with a clinical diagnosis of chronic idiopathic urticaria attended to the outpatient department of Dermatology with an age group between 18 and 65 years were included in the study. Patients with chronic urticaria associated with autoimmune diseases, diabetes mellitus, vitiligo, rheumatoid arthritis, pernicious anemia, and Helicobacter pylori-induced gastritis were excluded from the study. Data were collected from December 15, 2019, to June 1, 2020, after obtaining clearance from the Institutional Ethical Committee (FMIEC/CCM/545/2019). Written and informed consents were obtained from each person enrolled in the study.

All studied patients were subjected to complete history taking and general and dermatological examination. Sociodemographic data, medical history, and family history were recorded. The history regarding the age of onset of the disease, duration of disease, and treatment taken for the same was noted. Any important stressful event in their lives in 1 year, 6 months, or 1 month preceding onset or exacerbation of disease was noted using Singh's and Kaur PSLE scale. Collected data were analyzed by frequency, percentage, and Chi-square test.

Presumptive stressful life event scale

To assess the stressful life events in the Indian patients, Singh et al. developed a list of 51 life events with the collaborations of Holmes and Rahe. The events were ranging in severity from death of a spouse to going to a pleasure trip. These scaled events are again divided into desirable, undesirable, or ambiguous and personal or impersonal. The scale used in this study is modified version of social readjustment rating scale used in a study done by Gupta and Gupta.[4] The patients were asked to rate the stress related with each event in the checklist on four points. Scale with rating of “1” denotes “not at all,” “slight degree of stress” denoted by “2,” a rating of “3” denotes “moderate degree of stress,” and “4” denotes “a great deal of stress.”


  Results Top


The detailed demographic data of 50 chronic idiopathic urticaria cases enrolled in this study are depicted in [Table 1].
Table 1: Demographic details

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The number of cases having stressful life events preceding the onset or exacerbation of the disease is shown in [Table 2] and [Figure 1]. Out of 50 cases, 16 patients reported the presence of stressful life events preceding the exacerbation of chronic urticaria, and none of them reported the same preceding the induction of the disease.
Table 2: Stressful life events in cases

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Figure 1: Stressful life events in cases

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The highlights of actual level of stress in the studied cases are depicted in [Table 3] and [Figure 2].
Table 3: Level of stress in cases

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Figure 2: Level of stress in cases

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Out of the 16 cases who experienced stressful life events preceding exacerbation of the disease, maximum patients belonging to the older age group developed exacerbation within 6 months of experiencing stressful life events which was statistically significant (P = 0.004) [Table 4] and [Figure 3].
Table 4: The exacerbation of chronic urticaria and the duration of stressful life event

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Figure 3: Percentage of cases who experienced the stressful life events preceding specified periods of exacerbation of the disease

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The details of stressful life events experienced by the 16 out of 50 cases studied are shown in [Table 5] and [Figure 4]. Among 16 cases, 11 patients had undesirable stressful events (B – 7, 9, 15, 16, and 18) and four had desirable stressful events (A – 2, 3, 6). One patient had a ambiguous event as a stressor (C3). In our study, we found that financial loss or problems was the major stressor in four cases which caused moderate degree of stress and preceded 1 month to 1 year of exacerbation of chronic urticaria, which was statistically significant (P = 0.000). Eight patients showed a higher degree of stress which preceded 6 months of exacerbation of chronic idiopathic urticaria which was statistically significant (P = 0.004). With the above data, the cases with undesirable events as stressors with longer duration were significant contributors in exacerbation of chronic idiopathic urticaria. The cases with desirable and ambiguous events as stressors for longer durations were not statistically significant in exacerbation of the disease. In this study, none of the patients reported stressful life events preceding the induction of disease, and none of them suffered high degree of stress. This study did not include control group which decreases the relevance of the data.
Table 5: Particular stressful life events experienced by cases

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Figure 4: Particular stressful life events experienced by the cases

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  Discussion Top


As it is rightly said that sound mind will lead to the sound body, there are innumerable evidence in medical literature which support this statement. There is a specific entity called Psychosomatic disorder, condition that affects mind and body in which psychological stresses adversely affect physiological functioning. The psychosocial factors affect the nervous, endocrine, and immune system, stressful life events are the prime examples for the same.[5] The various dermatological conditions such as chronic urticaria, psoriasis, atopic dermatitis, seborrheic dermatitis, alopecia areata, lichen planus, and pemphigus are reported to have a psychosocial entity in their causation or exacerbation.[2]

Urticaria of minimum 6 weeks duration is considered the chronic urticaria, which is most commonly associated with autoimmune, connective tissue, and metabolic diseases. In chronic idiopathic urticaria, there are no above-mentioned associations with unable to ascribe specific etiology, which accounts for 50% of the chronic urticaria cases. In our study, chronic idiopathic urticaria cases were included with exclusion of chronic urticaria associated with autoimmune, connective tissue, and metabolic diseases.

Engel in 1977 noted that social and psychological factors are co-determinants of health and illness and these provide the opportunity to look into the doctrine of multicausality of all diseases.[6] These codeterminants vary in each person with also showing variations in successive episodes of the same illness in the same patient. According to Lipowski, it is a challenging task to determine the extent of contribution by the psychosocial factors in the causality of the aforementioned dermatological diseases.[7] Very few studies have been done to identify the role of stressful life events in chronic urticaria; among the available studies, the results vary from 40% to 90%.[8] This clarifies the aim and the limitations of our study.

According to Selye, on exposure to stressful conditions, certain adaptation processes occur by the interplay of various organs such as the hypothalamus, pituitary, cerebral cortex, limbic system, and adrenal gland generating classic stress response.[9] This classic stress response not only elevates the levels of neuroendocrine hormones and autonomic neurotransmitters but also has its impact on the immune system. The changes noted in the immune system are decreased levels of natural killer cell cytotoxicity, reduced mitogenic responses, increased interferon synthesis in lymphocytes, increased IgA levels, and increased neutrophil phagocytosis.[10]

A study done by Rees, with 100 cases of chronic urticaria and angioedema which was compared with surgical controls, showed that 51% of patients had stressful life situations as compared to 8% in surgical controls.[11] Another survey done by Michaelsson on 43 patients with chronic urticaria reported that 77% experienced mental tension and fatigue preceding the exacerbation of the disease.[12]

A study done by Lysketsos reported that significantly higher scores were observed in 28 urticaria inpatients compared to 38 cases of other skin diseases in stress experienced during the year preceding the onset or exacerbation of their illness as measured by social readjustment rating scale.[13] Fava et al. found that 90% of the patients with chronic urticaria were exposed to stressful life situations before disease onset.[8]

In our study, maximum number of patients reported exacerbation of the chronic urticaria within 6 months of stressful life situations, the findings are consistent but low compared to other studies.

It is worth making clear that no perfect methods exist for measuring stressful events, as it differs in different ethnic groups with different social backgrounds. Here, we have adopted life event checklist called Gurmeet singh's PSLE scale which is designed for the Indian population. Life event interviews are more reliable as they assess precisely the timing of exposure to life events and the onset or relapse of the disease compared to the checklists, but they are time-consuming and expensive.[2]


  Conclusion Top


Overall, these results support the view of the association between psychological factors and the onset or exacerbation of the disease. However, these results need to be replicated with large samples with a control group and taking patients with recent onset of the disease, thus minimizing the recall bias, which is a serious issue in such study design with increasing time. There may be a need for stress management programs in patients with high-stress scores and can help the individual to cope up with the stressful events which further helps in reducing the morbidity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Malhotra SK, Mehta V. Role of stressful life events in induction or exacerbation of psoriasis and chronic urticaria. Indian J Dermatol Venereol Leprol 2008;74:594-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Picardi A, Abeni D. Stressful life events and skin diseases: Disentangling evidence from myth. Psychother Psychosom 2001;70:118-36.  Back to cited text no. 2
    
3.
Singh G, Kaur H. Presumptive stressful life events scale (PSLE): A new stressful life event scale for use in India. Indian J Clin Psychol 1981;8:173-6  Back to cited text no. 3
    
4.
Gupta MA, Gupta AK. Stressful major life events are associated with a higher frequency of cutaneous sensory symptoms: An empirical study of non-clinical subjects. J Eur Acad Dermatol Venereol 2004;18:560-5.  Back to cited text no. 4
    
5.
Farber EM, Rein G, Lanigan SW. Stress and psoriasis. Psychoneuroimmunologic mechanisms. Int J Dermatol 1991;30:8-12.  Back to cited text no. 5
    
6.
Engel GL. The need for a new medical model: A challenge for biomedicine. Science 1977;196:129-37.  Back to cited text no. 6
    
7.
Lipowski ZJ. Psychosomatic medicine in the seventies: An overview. Am J Psychiatry 1977;134:233-44.  Back to cited text no. 7
    
8.
Fava GA, Perini GI, Santonastaso P, Fornasa CV. Life events and psychological distress in dermatologic disorders: Psoriasis, chronic urticaria and fungal infections. Br J Med Psychol 1980;53:277-82.  Back to cited text no. 8
    
9.
Selye H. The general adaptation syndrome and the diseases of adaptation. J Clin Endocrinol 1946;6:117-230.  Back to cited text no. 9
    
10.
Palmblad JE. Stress-related modulation of immunity: A review of human studies. Cancer Detect Prev Suppl 1987;1:57-64.  Back to cited text no. 10
    
11.
Rees L. An etiological study of chronic urticaria and angioneurotic edema. J Psychosom Res 1957;44:122-31.  Back to cited text no. 11
    
12.
Michaëlsson G. Chronic urticaria. A clinical study with special reference to vascular reactions mediated by the kallikrein-kinin system. Acta Derm Venereol 1969;49:404-16.  Back to cited text no. 12
    
13.
Lyketsos GC, Stratigos J, Tawil G, Psaras M, Lyketsos CG. Hostile personality characteristics, dysthymic states and neurotic symptoms in urticaria, psoriasis and alopecia. Psychother Psychosom 1985;44:122-31.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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