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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 24  |  Issue : 2  |  Page : 81-83

Does psychological stress trigger or exacerbate vitiligo: More data are needed


1 Division of Dermatology, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Division of Dermatology, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia

Date of Submission21-May-2019
Date of Acceptance11-Nov-2019
Date of Web Publication10-Nov-2020

Correspondence Address:
Dr. Mohammed I Aljasser
Division of Dermatology, King Saud Bin Abdulaziz University for Health Sciences, P.O. Box: 3660, Riyadh 11481
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_26_19

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  Abstract 


Background: Vitiligo is a common disorder characterized by depigmentation due to autoimmune destruction of melanocytes. The role of psychological stress in causing vitiligo is not well characterized. Purpose: This article aims at reviewing the role of stress in triggering and/or exacerbating vitiligo. Methods: Seven relevant studies were found in the literature search. Results: Most of the studies support the theory that stressful life events may trigger the onset or the progression of vitiligo. Conclusion: Studies depended mainly on retrospective reporting of stressful events could be a major source of bias.

Keywords: Dermatology, life events, psychological stress, skin, stress, stressful event, vitiligo


How to cite this article:
Almutairi SN, Aljasser MI. Does psychological stress trigger or exacerbate vitiligo: More data are needed. J Dermatol Dermatol Surg 2020;24:81-3

How to cite this URL:
Almutairi SN, Aljasser MI. Does psychological stress trigger or exacerbate vitiligo: More data are needed. J Dermatol Dermatol Surg [serial online] 2020 [cited 2020 Nov 25];24:81-3. Available from: https://www.jddsjournal.org/text.asp?2020/24/2/81/300389




  Introduction Top


Vitiligo is the most common disease causing mucocutaneous depigmentation.[1] It affects approximately 1% of the world's population.[2] Vitiligo is associated with significant stigma and psychological disturbance, especially in dark-skinned populations.[3] The main player in the pathogenesis of vitiligo is autoimmune destruction of melanocytes. Melanocytes are specifically destroyed by cytotoxic CD8+ T cells.[1] Other pathogenic mechanisms may include abnormal oxidative stress response by melanocytes, melanocyte epidermal attachment abnormalities, and neural factors.

Several environmental factors have been associated with the initiation or worsening of vitiligo such as trauma and some chemicals.[4] Many patients think stress is a cause of vitiligo.[5] Patients commonly ask in practice about the relationship between stress and vitiligo. Stress as a possible environmental factor affecting the natural history of vitiligo has not been emphasized much in the literature with only a few published studies. This review aims at describing the role of psychological stress as a triggering or exacerbating factor of vitiligo.


  Methods Top


A PubMed search was performed up to June 2018. The following keywords were used: Vitiligo, “vitiligo AND stress,” “vitiligo AND stressful,” “dermatology AND stress,” “skin AND stress,” “vitiligo AND life AND events,” and “vitiligo AND psychological AND stress” [Figure 1]. Relevant articles were selected through reviewing the titles and abstracts. Only articles published in English were included. Additional papers were obtained after reviewing the reference list of the selected relevant articles. Duplicated articles were excluded.
Figure 1: PubMed search strategy flowchart

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  Stress in Adults With Vitiligo Top


A case–control study assessed the role of stress before the onset of alopecia areata and vitiligo.[6] The Holmes and Rahe's social readjustment rating scale was used for both cases and controls. Participants were asked to complete a questionnaire and then interviewed by the research team. Thirty-two patients with vitiligo were enrolled. Patients had either new-onset vitiligo within the past 9 months or new disease activity. More than half of the patients reported a preceding stressful event, and this was statistically significant when compared to the control group. Stressful events included family problems (such as death of a family member), personal problems, and job/financial problems. The most commonly reported stressful event was personal problems (47%), especially during examination periods.

Stressful events were assessed in 73 patients with vitiligo and 73 age/gender-matched controls.[7] The disease onset in all patients with vitiligo was within the past 3 years. The proportion of stressful life events occurring a year prior to onset of vitiligo was measured by the Schedule of Recent Experience. This is a questionnaire with 42 items that gathers information about life events. Vitiligo patients reported more stressful life events in comparison to the control group (P < 0·001). The two most frequently reported life events preceding the onset of vitiligo were major changes in financial state and sleeping habits. Other events included bereavements, major changes in eating habits, change in residence, and sexual difficulties.

The role of stressful events as a trigger in vitiligo was evaluated in 31 patients with vitiligo and 116 controls.[8] All vitiligo patients had onset or exacerbation within the past 3 months. The Paykel's Interview for Recent Life Events instrument was used for the assessment of stressful events. Additional instruments were used including the “Experiences in Close Relationships” questionnaire, Toronto Alexithymia Scale (TAS-20), and Multidimensional Scale of Perceived Social Support. The total number of stressful events and the number of undesirable, uncontrollable, or major events were similar between cases and controls. However, exposure to 3 or more uncontrollable life events was more prevalent in patients with vitiligo (P < 0·01).

A study aimed to identify the psychological factors that may precede vitiligo onset by distributing a questionnaire to 1541 adult vitiligo patients.[9] Of all patients, 821 (56.6%) faced at least one stressor or death event within 2 years before the onset of vitiligo. Those stressors included death of a loved one (16.6%) and stressful life events (51%) such as work/financial problems (10.8%), end of a long-term relationship (10.2%), and family problems (7.8%). The presence of multiple stressors was associated with more frequent symptoms in vitiligo patients, such as itching and/or burning sensation.


  Stress in Children With Vitiligo Top


In a case–control study including 34 children with vitiligo, stress involvement before the onset of vitiligo and during its subsequent progression was assessed.[10] Stress was reported in 53% of the vitiligo group as compared to 17.6% in the control group (P = 0.005). Events were mostly related to school, so that patients experienced the stress at the beginning of education, examinations, or when changing the school. Psychosocial trauma was identified as another potential trigger.

Another study was conducted to determine the most common triggers in pediatric vitiligo and psoriasis.[11] This study included 153 patients, 65 with vitiligo and 88 with psoriasis. Data were collected by questionnaire, clinical examination, and histologically proven diagnosis. Possible identified triggers for vitiligo included psychological factors (57%), inflammatory reaction (30%), physical trauma (9%), and other triggers (3%). Stressful life events were divided into both acute and chronic events. Acute stressful life events (16%) included changing the place of living, birth of new child, and death of one parent. Chronic events included alcohol abuse in family (11%), disharmony in family (10%), disharmony at school (6.6%), being a refugee (4%), war events (3.9%), and parents' divorce (3%).

The association of stressful events with childhood vitiligo onset or extension was assessed in 21 vitiligo patients and 21 controls.[12] Patients had either new-onset vitiligo within the past 9 months or new disease activity. Both children and parents were interviewed. Children with vitiligo had higher proportion of stressful life event (57%) as compared to controls (24%; P = 0.059).


  Conclusion Top


Although there are only a few studies, most of them support the theory that stressful life events may trigger the onset or the progression of vitiligo. Studies depended mainly on retrospective reporting of stressful events which could be a major source of bias. Further research work with well-designed prospective studies is needed before any definitive conclusions can be reached about stress and vitiligo.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ezzedine K, Eleftheriadou V, Whitton M, van Geel N. Vitiligo. Lancet 2015;386:74-84.  Back to cited text no. 1
    
2.
Ezzedine K, Lim HW, Suzuki T, Katayama I, Hamzavi I, Lan CC, et al. Revised classification/nomenclature of vitiligo and related issues: The vitiligo global issues consensus conference. Pigment Cell Melanoma Res 2012;25:E1-13.  Back to cited text no. 2
    
3.
Sehgal VN, Srivastava G. Vitiligo: Compendium of clinico-epidemiological features. Indian J Dermatol Venereol Leprol 2007;73:149-56.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Manga P, Elbuluk N, Orlow SJ. Recent advances in understanding vitiligo. F1000Res 2016;5. pii: F1000 Faculty Rev-2234.  Back to cited text no. 4
    
5.
AlGhamdi KM. Beliefs and perceptions of Arab vitiligo patients regarding their condition. Int J Dermatol 2010;49:1141-5.  Back to cited text no. 5
    
6.
Manolache L, Benea V. Stress in patients with alopecia areata and vitiligo. J Eur Acad Dermatol Venereol 2007;21:921-8.  Back to cited text no. 6
    
7.
Papadopoulos L, Bor R, Legg C, Hawk JL. Impact of life events on the onset of vitiligo in adults: Preliminary evidence for a psychological dimension in aetiology. Clin Exp Dermatol 1998;23:243-8.  Back to cited text no. 7
    
8.
Picardi A, Pasquini P, Cattaruzza MS, Gaetano P, Melchi CF, Baliva G, et al. Stressful life events, social support, attachment security and alexithymia in vitiligo. A case-control study. Psychother Psychosom 2003;72:150-8.  Back to cited text no. 8
    
9.
Silverberg JI, Silverberg NB. Vitiligo disease triggers: Psychological stressors preceding the onset of disease. Cutis 2015;95:255-62.  Back to cited text no. 9
    
10.
Manolache L. The psychosocial aspects of vitiligo: A focus on stress involvement in children with vitiligo. In: Vitiligo-Management and Therapy. In-Tech; 2011.  Back to cited text no. 10
    
11.
Barisić-Drusko V, Rucević I. Trigger factors in childhood psoriasis and vitiligo. Coll Antropol 2004;28:277-85.  Back to cited text no. 11
    
12.
Manolache L, Petrescu-Seceleanu D, Benea V. Correlation of stressful events with onset of vitiligo in children. J Eur Acad Dermatol Venereol 2009;23:187-8.  Back to cited text no. 12
    


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