Association of psychological stress with skin symptoms among medical students
=============================================================================

* Ghada A. Bin Saif
* Hala M. Alotaibi
* Abdullateef A. Alzolibani
* Noor A. Almodihesh
* Hamad F. Albraidi
* Najed M. Alotaibi
* Gil Yosipovitch

## Abstract

**Objectives:** To evaluate the association between psychological stress and skin symptoms among medical students.

**Methods:** A cross-sectional study was carried out between January and June 2015. Electronic survey consists of Perceived Stress Questionnaire (PSQ) and Self-Reported Skin Complaints Questionnaire were distributed to all 1435 undergraduate students at College of Medicine, King Saud University (KSU), Riyadh, Saudi Arabia.

**Results:** Final analysis was performed on data from 529 (36.9%) students. Students were divided into three groups: least stressed students, n=135, PSQ index <0.39; highly stressed students, n=136, PSQ index >0.61; and moderately stressed students, n=258. Older age, female gender, during exam weeks, and fourth and fifth years of medical school (all *p*<0.01) were associated with the highest perceived stress levels. When compared to least stressed students, highly stressed students suffered from more oily, waxy patches or flakes on scalp (*p*≤0.0001), dry/sore rash (*p*≤0.0001), warts (p≤0.0001), pimples (*p*≤0.0001), itchy skin (*p*≤0.0001), hands itchy rash (*p*≤0.0001), hair loss (*p*≤0.0001), pull-out own hair (*p*=0.008), scaly skin (*p*=0.012), troublesome sweating (*p*=0.016), nails biting (*p*=0.028), and other rashes on face (*p*=0.028).

**Conclusion:** Various common skin conditions could appear in context of psychological stress among medical students.

Several studies have demonstrated a strong relationship between psychological stress (PS) and individuals’ health.That are including but not limited to cardiovascular diseases, bronchial asthma, and irritable bowel syndrome.1-3 Stress refers to the consequence of an organism’s failure to respond adequately to mental, emotional, or physical demands, actual or imagined.4 Psychological stress occurs when an individual perceives that environmental demands tax or exceed his or her adaptive capacity.5 Upon perception of PS, the central stress response leads to the activation of 2 major neuroendocrine systems; the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system to enable the organism’s adaptation to it.6 This stress response leads to variable physiological consequences. Exposure to chronic stress is generally considered to cause more long term health problems than acute stress, since chronic stress is most likely to result in prolonged and/or permanent physiological, emotional, and behavioral responses that may have a role in the etiology and or exacerbation of diseases.7

It is well known that the demands placed on medical students pose a tremendous challenge to their well-being, leading to a high rate of psychological distress.8-10 Medical studens are well-known to have high stress-levels in comparison to other students of higher education.11,12 The reported prevalence of PS among medical students using various measurements ranges from 30% to 63.7%.8,13-23

Psychological stress may adversely affect the emotional, social, and psychological well-being of medical students.24 A recent systematic review reveals that the summary estimate of the prevalence of depression or depressive symptoms among medical students was 27.2% and that of suicidal ideation was 11.1%.25 Psychological stress has many negative consequences on the skin which include impaired stratum corneum cohesion, disturbance of permeability barrier, alteration of the antimicrobial properties of the epidermal barrier, delayed wound healing, compromised epidermal innate immunity, and cutaneous homeostasis might be adversely affected.26-30 Thus alter immunity, favor progression of infections, and have the potential to affect chronic inflammatory skin diseases. Furthermore, some reports exist in favor of the role of psychosocial factors in the etiology and or exacerbation of certain dermatological diseases, for instance, atopic dermatitis, urticaria, psoriasis, rosacea, vitiligo, acne, and alopecia areata.31,32 However, Picardi et al33 stated, in their review on stress measurements in skin diseases, that “although a great number of papers on this subject have been published, unfortunately there appears to be a paucity of controlled studies adopting standardized methods for measuring stress”.

The goal of the present study is to evaluate the association between PS and various skin symptoms among medical students.

## Methods

### Study design and setting

We used a cross-sectional design. All students at the College of Medicine, King Saud University (KSU), Riyadh, Saudi Arabia were invited to participate through their university email. The electronic survey was distributed to all 1435 medical students. Two email reminders were sent out to medical students: the first one was 3 days after the first email, and the second one was 6 days after the first email. The survey was available between January 1, 2015 and June 30, 2015. All students at College of Medicine, KSU were included in this study. However, all other subjects and uncompleted surveys were excluded. This study was approved by the KSU Institutional Review Board. All volunteers provided informed consent and were free to withdraw from the study at any time.

### Survey instruments

The survey collected demographic information, including age, gender, school year, previous skin diagnoses and current study status namely, in a more relaxed period after the mid-year break or in a stressful period during exam weeks. Participants were asked to fill out 2 questionnaires: the Perceived Stress Questionnaire (PSQ) and the Self-Reported Skin Complaints Questionnaire (SSCQ).

### 1) Perceived stress questionnaire

The Perceived Stress Questionnaire is a validated 30-item measure formulated to describe experiences of stress applicable across a variety of situations. Perceived Stress Questionnaire emphasizes cognitive perceptions rather than emotional states or specific life events.34 The PSQ has been used to quantify perceived stress, and it was specifically intended for psychosomatic research.34,35 The PSQ has demonstrated good predictive values for stress-related diseases.35 Participants were instructed to consider the past 4 weeks “PSQ-recent” to rate the frequency of occurrence of the described experience on a 4-point scale: almost never, sometimes, often, and usually. Items were coded from 1 to 4 in accordance with Levenstein et al.34 The PSQ index ranges from 0 to 1. Higher scores indicate more severe perceived stress.34

### 2) Self-reported skin complaints questionnaire

The self-reported skin complaints questionnaire is a validated 10-item survey. Self-reported skin complaints questionnaire is a simple instrument to evaluate skin morbidity in an adult population. This uses self-reported skin complaints to predict clinical skin morbidity. This has been used in several large cross-sectional community-based studies.36-39 The answers to all items are scored on a 4-point scale: 1 = no; 2 = yes, a little; 3 = yes, quite a lot; and 4 = yes, very much.36 We modified the SSCQ by adding 6 items to assess specific complaints under the 10th item “other skin problems”. The additional items are the following: hair shedding, hair pulling, nail-biting, itchy scalp, scaly scalp, and facial scales. The answers to the modified SSCQ items were dichotomized so the answer “no complaints” was compared with the other 3 answers (“a little”, “quite a lot”, and “very much”). Thus, the new items only distinguished whether the student had the symptom or not.

### Statistical analysis

All data analyses were performed using Predictive Analytics Software (PASW) version 18 (SPSS-IBM, Chicago, IL, USA). Descriptive statistics for quantitative variables were presented as mean ± standard deviation (SD). The significance of differences was assessed using an independent t-test for continuous variables. Analysis of variance (ANOVA) with post hoc analysis was used to determine significance between groups. Statistical significance was set at *p*<0.05.

Since there are no cut-off scores for the Perceived Stress Questionnaire, the study participants were divided into 3 groups based on the 25th and 75th percentiles of the PSQ index: least stressed (LS) (scores ≤25th percentile); highly stressed (HS) (scores ≥75th perentile); and moderately stressed (MS) (all other scores).

Odds ratios (OR) and 95% confidence intervals were calculated to assess whether the highest stressed group had a higher probability of having skin complaints compared to the least stressed group. The answers for the modified SSCQ items were dichotomized to allow for the computation of OR.

## Results

### Participant’s characteristics

Of the 1435 students invited for the study, 5 responses were later dropped from the analysis due to incomplete data. The final analysis was performed on data from 529 (36.9%) students. Participants were between the ages of 18 and 24 years (mean = 20.6 ± 1.6; mode = 19); 208 (39.3%) were male and 321 (60.7%) were female. Further demographic information is displayed in **Table 1**.

View this table:
[Table 1](http://smj.org.sa/content/39/1/59/T1)

Table 1 
Demographic data of study participants.

**Table 2** shows the statistically significant difference in response rate between participants and non-participants with regard to gender or academic standing/years of study (*p*=0.0001 for both). The table shows that females participated in the study more than males. In addition, just over 58% of first year students and 51.9% of second year students participated in the study, more than other students, while fifth year students (10.6%) participated least.

View this table:
[Table 2](http://smj.org.sa/content/39/1/59/T2)

Table 2 
Difference in response rate per gender and year of study.

### Perceived stress among medical students

The mean PSQ index for the group was 0.5±0.16 (mode = 0.5, range = 0.11-0.93). The group was divided into LS, MS, and HS students. Least stressed students scoring was <25th percentile; (n=135, mean=0.31, SD=0.06, PSQ index <0.39); HS students scoring was >75th percentile (n=136, mean=0.71, SD=0.08, PSQ index >0.61); and MS students (n=258, mean=0.50, SD=0.06) (**Table 3**).

View this table:
[Table 3](http://smj.org.sa/content/39/1/59/T3)

Table 3 
Perceived stress level and dermatological complaints among medical students.

Age, gender, academic standing and school status were not equally distributed among the 3 perceived stress level groups (*p*=0.0001, *p*=0.001, *p*=0.001, and, *p*=0.002, respectively). Older age, female gender, during exam weeks, and fourth and fifth years of medical school were associated with the highest perceived stress levels (**Table 1**); thus, adjusted OR was calculated accordingly.

### Most commonly self-reported skin complains

Skin complaints among medical students are listed in **Table 3**. The most common skin complaints were loss of hair (67.2%), followed by pimples (63.1%), oily, waxy patches on scalp and/or flakey scalp (dandruff) (49.5%), and itchy skin (40.5%). Warts (9.5%) were the least cited complaint. When compared to LS students, HS students suffered from significantly more oily, waxy patches on scalp and/or flakey scalp (or dandruff), dry/sore rash, warts, pimples, itchy skin, itchy rash on their hands, hair loss, pull-out their own hair, scaly skin, troublesome sweating, nails biting, and other rashes on their face (**Table 4**).

View this table:
[Table 4](http://smj.org.sa/content/39/1/59/T4)

Table 4 
Self-reported skin complaints among highly stressed compared to least stressed medical students.

### Number of self-reported skin complaints for each student

In HS group, students had several skin complaints that were “5 complaints” (19.1%), followed by 6 and 4 complaints (17.6% and 12.5%, respectively), which is more than that in MS and LS groups (**Table 3**).

### Previously diagnosed dermatological diseases

Previous skin diagnoses are shown in **Table 3**. The most frequent diagnoses were acne (23.8%) and eczema (10.2%), both of which were the most frequent diagnoses in the HS group (31.6% and 13.2%, respectively). Seborrheic dermatitis was only reported in the HS group. No statistically significant differences were noted between highly stressed and least stressed students in respect to previous skin diagnoses.

## Discussion

The present study further supports the strong relationship between high stress perception and common skin conditions. Highly stressed medical students had higher prevalence of oily, waxy patches on scalp and/or flakey scalp (dandruff), dry/sore rash, itchy skin, itchy rash on their hands, and hair loss, warts, and acne. They also pull-out their own hair, bite their nails, and report troublesome sweating more frequently than less stressed medical students. Furthermore, the number of skin complaints by each highly stressed students were higher than less stressed students. Therefore, various common skin conditions could appear in context of psychological stress among medical students.

Our findings agree with Schut et al40 who reported on PS and skin symptoms in American undergraduate college students. Schut et al40 demonstrated that heightened stress levels are associated with pruritus, alopecia, oily/waxy/flaky patches on the scalp, hyperhidrosis, scaly skin, onychophagia, trichotillomania, and itchy rash on hands. Our findings also correlate well with other literature in this field.41-46

Perceived stress has a greater effect than the stressful event itself. When people face the same stressful situation, they may react differently. Psychological characteristics, personality, and previous experiences are likely to influence an individual’s perception and appraisal of stressful situations and how well the individual adapts or copes with the stressor; thereby, influencing the magnitude, duration, and quality of the physiological reaction.47-49 The present study found that female gender had a higher perceived stress levels. This is consistent with previous reports demonstrating that female gender is especially affected by stress during daily routines and during schooling.37,50,51 We also found that during exam week’s students suffer from more stress, which could be explained by exam fear, lack of study time, or sleep deprivation. Sleep deprivation is an intrinsic stressor that is increased in the modern lifestyle. Several studies revealed that sleep deprivation affects cognition,52,53 immune system,54,55 hormonal secretion, and metabolism.56-58 In contrast to Schut et al’s37 finding of no significant relationship between academic standing and the students PS levels, we found that the fourth and fifth years of medical school were associated with the highest perceived stress levels.

Being a medical student is a well-known risk factor for PS. Overall prevalence of stress among medical students in Saudi Arabia was 63.7% and severe stress was 25%,8 while the prevalence of stress was 31.2% in the United Kingdom,15 29.6%-46.2% in Malaysia,19,21,23 57% in Singapore,18 and 61.4% in Thailand.22

More than 30% of dermatologic disorders are influenced by psychological and psychiatric factors.59 An increasing number of studies have revealed that some skin diseases are caused, or exacerbated by, chronic PS, associated with certain personality traits, or a complication of psychiatric disorders.31,32,60 The role of PS has been described in a wide range of skin diseases, including atopic dermatitis, psoriasis, seborrhoeic dermatitis, urticaria, acne vulgaris, telogen effluvium, alopecia areata, pruritus, prurigo nodularis, and lichen planus.31-33,60-62

There is a complex neuro-immuno-cutaneous-endocrine network that may mediate the interplay between PS and skin disorders. Upon PS exposure, 2 major neuroendocrine systems are activated: HPA axis and the autonomic nervous system (sympathetic and cholinergic). Psychological stress alters HPA axis hormones, in addition to the secretion of stress mediators including, neuropeptides and cytokine profiles. Therefore, PS influences the immune response.6 All cutaneous and skin-infiltrating cell of the immune system have receptors for stress mediators, that includes mast cells, langerhans cells, neutrophils, and eosinophils (the protagonists of innate immunity), as well as B and T cells (the protagonists of specific adaptive immunity).63 Furthermore, there is a peripheral HPA axis in the skin that is equivalent to the central HPA axis.6 Therefore, skin under stress releases inflammatory cytokines, and locally produces CRH, ACTH, and glucocorticoids, in addition to sprouting of substance P+ nerve fibers.64 There is evidence that under chronic stress, the effects on the skin are complex and strongly caused by neuroendocrine and immune alterations that impair the ability of the skin to respond to environmental challenges. Humeral immunity predominates and there is a switch from innate nonspecific immunity and adaptive cellular, Th1-weighted response, to an adaptive Th2 profile. In addition to some errors in the specific immunity that may not properly distinguish “foreign” from “self”, so it may target the body’s own proteins, causing autoimmunity. Furthermore, mast cells seem to play a key role in excessive immunological responses to stress by triggering neurogenic inflammation.63 These stress induced changes of the skin may play a role in the exacerbation of skin disease.

The main strength of the current study is the large population of surveyed medical students and the high response rate. The main limitation of this study is the use of a cross-sectional design, which does not allow for the determination of a causal relationship between the variables. Another limitation is the use of SSCQ rather than a dermatologist diagnosis. However, SSCQ is a validated instrument. This study highlights the importance of assessing common skin problems in medical students and their high association with stress. Dermatologists should be aware that these conditions could appear in context of emotional stress.

## Acknowledgment

*This study was supported by the College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Kingdom of Saudi Arabia*.

## Footnotes

*   Disclosure
    
    Authors have no conflict of interests, and the work was not supported or funded by any drug company. This study was supported by the College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Kingdom of Saudi Arabia.

*   Received September 21, 2017.
*   Accepted December 6, 2017.


*   Copyright: © Saudi Medical Journal

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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