The response of skin disease to stress: changes in the severity of acne vulgaris as affected by examination stress.

BACKGROUND Although emotional stress has long been suspected to exacerbate acne vulgaris, previous reports addressing its influence on acne severity have been mainly anecdotal. OBJECTIVES To elucidate the possible relationship between stress and acne exacerbation by evaluating changes in acne severity during nonexamination and examination periods and to assess the possible relationship of these changes in severity with perceived examination stress by using previously validated scales measuring acne severity and perceived stress. DESIGN Prospective cohort study. SETTING General university community. PARTICIPANTS A volunteer sample of 22 university students (15 women and 7 men) with a minimum acne vulgaris severity of 0.5 on the photonumeric Leeds acne scale (baseline scores, 0.50-1.75). MAIN OUTCOME MEASURES Participants were graded on their acne severity using the Leeds acne scale, and had their subjective stress levels assessed with the Perceived Stress Scale questionnaire during both nonexamination and examination periods. RESULTS Subjects had a higher mean grade of acne severity and mean perceived stress score (P<.01 for both) during examinations. Using regression analysis and adjusting for the effects of confounding variables, such as changes in sleep hours, sleep quality, diet quality, and number of meals per day, increased acne severity was significantly associated with increased stress levels (r = 0.61, P<.01), while self-assessed change in diet quality was the only other significant association (P =.02). CONCLUSIONS Patients with acne may experience worsening of the disease during examinations. Furthermore, changes in acne severity correlate highly with increasing stress, suggesting that emotional stress from external sources may have a significant influence on acne.