Psychological Stress and Atopic Dermatitis: A Focus Group Study.

BACKGROUND: Atopic dermatitis (AD) is a chronic inflammatory skin disorder. It is often reported to be worsened by psychological stress. OBJECTIVE: To explore the role of psychological stress and related triggers in AD, and its connection to worsening of this disease, focusing on patients' perspectives. METHODS: In total, 28 patients with AD were included in focus groups. Topics regarding psychological stress and psychological triggers were discussed. RESULTS: The hypothesis that psychological stress may have impact on eczema and its pruritus was supported by all of the patients. Distinguishing the worsening effect of psychological stress from effects of physiological triggers, such as infection, climate and allergic factors, was claimed to be difficult by many patients. Most of the patients thought that chronic stress affected the AD more when compared to acute stress. Family problems, financial problems, work overload, school exam periods, lack of structure at work, and unforeseen events were identified as important psychological triggers. Conventional treatment/therapy with topical corticosteroids and emollients, UV light treatment, were suggested as possible treatments, as well as psychological intervention and physical exercise. CONCLUSION: Psychological stress is an important factor to consider in the management of patients with AD. In particular, chronic stress tends to worsen AD. The type of stress can possibly also affect the quality of the pruritus experienced by the patients. Unforeseen events and decision making were frequently mentioned as important triggers. Furthermore, physical exercise was reported to provide beneficial effects.

Effects of brodalumab on psoriasis and depressive symptoms in patients with insufficient response to TNF-α inhibitors.

The objective of this study was to evaluate emotions of depression and anxiety in psoriatic patients that due to insufficient response to tumor necrosis factor-alpha inhibition (TNF-α), underwent a treatment switch from TNF-α to interleukin 17 inhibition using brodalumab. The Self-rated Montgomery-Asberg Depression Rating Scale and the Hospital Anxiety and Depression Scale were used to assess depression and anxiety. A total of 20 patients with psoriasis were enrolled in the study. They were monitored for a period of 3 months following the transition to brodalumab treatment. The results showed a significant improvement in both the Psoriasis Area and Severity Index as well as symptoms of depression; anxiety symptoms showed a reduction, though not statistically significant. Perhaps of more interest, the positive effects on depression and anxiety seem to be independent of the reduction in skin related psoriatic lesions. These findings highlight the importance of addressing depressive and anxiety symptoms, together with psoriasis severity and quality of life, when managing patients with psoriasis.

The Importance of Assessing Burning and Stinging when Managing Rosacea: A Review.

Rosacea, a chronic condition usually recognized by its visible presentation, can be accompanied by invisible symptoms, such as burning and stinging. The aim of this review is to gather the most recent evidence on burning and stinging, in order to further emphasize the need to address these symptoms. Inflammatory pathways can explain both the signs and symptoms of rosacea, but available treatments are still evaluated primarily on their ability to treat visible signs. Recent evidence also highlights the adverse impact of symptoms, particularly burning and stinging, on quality of life. Despite an increasing understanding of symptoms and their impact, the management of burning and stinging as part of rosacea treatment has not been widely investigated. Clinicians often underestimate the impact of these symptoms and do not routinely include them as part of management. Available therapies for rosacea have the potential to treat beyond signs, and improve burning and stinging symptoms in parallel. Further investigation is needed to better understand these benefits and to optimize the management of rosacea.

Psoriasis and alcohol.

Psoriasis is a chronic inflammatory skin disease that may be triggered or worsened by several factors, including alcohol. A higher than average alcohol consumption is common among individuals with psoriasis. Neurobiological signaling affected by alcohol intake includes a range of neurotransmitters, such as the dopaminergic, serotonergic, and tachykinergic systems, involved in reward and drug-seeking. These neurotransmitters may also have an impact on the inflammatory processes per se in psoriasis. Future therapy may, therefore, be targeted at neurotransmitter networks involved with both alcohol intake and the inflammatory processes.

Tachykinin upregulation in atopic dermatitis.

Context: Atopic dermatitis (AD) is a chronic, inflammatory, itching skin disorder, which may worsen due to stress, depression and anxiety. Tachykinins may be involved in inflammation signaling as well as they may have a role in stress, depression and anxiety. Objective: This study aimed to measure the expression of tachykinin markers, in the skin of patients with AD, and the correlation of these tachykinins with clinical and psychodemographic parameters. Materials and methods: Twenty-eight adult patients with AD were investigated regarding tachykinin expression in skin biopsies, using an immunohistochemical technique. The patients were characterized with clinical and psychodemographic parameters. Results: The number of substance P and neurokinin (NK)A positive nerve fibers, as well as NKA positive mononuclear dermal cells, was increased in lesional compared to non-lesional skin. Interestingly, the depression score and the number of dermal NK-1 receptor (R) positive cells in lesional as well as in non-lesional skin showed a correlation. Conclusion: These findings indicate an upregulation of the tachykinergic system in the inflamed skin of AD.

Serotonergic Markers in Atopic Dermatitis.

Stress and anxiety may worsen atopic dermatitis (AD) through the serotonin system. Serotonergic expression was measured in 28 patients with AD in relation to extent of the disease (SCORing of Atopic Dermatitis; SCORAD), pruritus intensity (visual analogue scale; VAS), anxiety traits (Swedish Universities Scales of Personality; SSP) and depression (Montgomery-Åsberg Depression Rating Scale-Self assessment; MADRS-S). Biopsies were taken from lesional and non-lesional AD skin, and investigated for expression of serotonin, its receptors 5-HT1A and 5-HT2, and serotonin transporter protein (SERT), using immunohistochemistry. 5-HT1AR-immunoreactivity (ir) was higher in lesional skin in apical epidermis and in mast cell-like cells in dermis, and 5-HT2AR-ir in apical epidermis and on blood vessels. In contrast, a basement membrane 5-HT2AR-ir signal was higher in non-lesional skin. The distribution of SERT-ir in the basal epidermal layer was higher in lesional skin. Positive and negative correlations were found between serotonergic markers and SCORAD, inflammation, pruritus intensity, anxiety traits, and depression score, indicating that serotonergic mechanisms are involved in AD.

Alcohol intake measured by phosphatidylethanol in blood and the lifetime drinking history interview are correlated with the extent of psoriasis.

BACKGROUND: Psoriasis has been reported to be associated with alcohol consumption. OBJECTIVE: To investigate the level of alcohol intake in individuals with psoriasis and correlate intake with the extent of disease and pruritus. METHODS: Twenty-nine outpatients (15 females and 14 males) with stable chronic plaque psoriasis of moderate severity were recruited. The Psoriasis Area and Severity Index (PASI) and the degree of pruritus (visual analogue scale) were compared with measures of drinking habits as determined by the Lifetime Drinking History (LDH), the Alcohol Use Disorders Identification Test and whole-blood phosphatidylethanol (PEth), an alcohol-specific biomarker. RESULTS: The majority of patients were social drinkers with moderate alcohol consumption as determined by PEth and LDH. Alcohol consumption correlated significantly with the PASI score. There was no correlation between alcohol use and pruritus. CONCLUSION: The level of alcohol consumption is correlated with the extent of psoriasis.

Adult atopic dermatitis patients and physical exercise: a Swedish questionnaire study.

Physical activity promotes health and prevents disease. When patients with atopic dermatitis (AD) undertake exercise, the itch often gets worse due to sweating, and this may reduce their engagement in physical exercise. The aim of this study was to determine the level of physical exercise in patients with AD compared with a control group from a normal population. Our hypothesis was that patients with AD have a lower level of physical exercise due to their skin disease. A total of 110 patients with AD and 196 subjects from a normal population, age range 20-34 years, answered a questionnaire. Eleven patients with AD underwent an in-depth interview. The patients with AD had the same level of physical exercise and attitude to physical exercise as the normal population. Therefore, our hypothesis could not be confirmed. In conclusion, the skin symptoms of AD do not appear to be an obstacle to moderate physical exercise.

Chronic mild stress modulates 5-HT1A and 5-HT2A receptor expression in the cerebellar cortex of NC/Nga atopic-like mice.

Atopic eczema symptoms may worsen due to stress. In the present study, the cerebellar cortex of the atopic-like mouse NC/Nga was studied regarding the effect of chronic mild stress on expression of two well-characterized serotonergic receptors (R), 5-HT1A and 5-HT2A. In total 24 mice were used. Sixteen of these mice were subjected to unpredictable stressors for 12 weeks, and 8 mice were used as controls. In order to evoke an eczema, a mite antigen was applied to 16 mice from week 9 of the experiment. Thus, three groups of mice, stressed eczematous (SE), non-stressed eczematous (NSE) and stressed control (SC), respectively, were obtained. The expression of the 5-HT1AR was analyzed using quantitative immunohistochemistry. For evaluation of 5-HT2AR a semi-quantitative technique was used, the cell density and signal intensity being measured. The highest average value for 5-HT1AR expression, in the Purkinje cells, was recorded in the NSE group, while the lowest average was in the SC group. 5-HT1AR expression differed significantly between the groups. The highest average value for density of 5-HT2AR positive Purkinje cells was evident in the SE group, while the lowest was in the SC group, this difference between groups also being statistically significant. In addition, the signal intensity was highest in the SE group, with a difference compared to the other groups. In conclusion, chronic mild stress modulates serotonergic receptor expressions in the cerebellar cortex of atopic-like mice.

Polymorphisms in the serotonin transporter gene of patients with atopic dermatitis-association with personality traits related to high level of anxiety.

CONTEXT: The symptoms of atopic dermatitis (AD) are often aggravated by anxiety, and the serotonin transporter (5-HTT) has been shown to be of importance in this context. Three polymorphisms affecting transcription of this gene are known: a repetitive element, in the promoter region (5HTTLPR), a variable number tandem repeats (VNTR) within intron 2 referred to as STin2, and a single-nucleotide (A/G) polymorphism (SNP) located within the 5-HTTLPR. OBJECTIVE: To examine for possible relationships between these polymorphisms and aggravation of AD by stress. MATERIALS AND METHODS: Thirty-three patients with a history of such aggravation, together with 33 age- and gendermatched healthy control subjects, were recruited. The Karolinska Scales of Personality questionnaire was employed to evaluate anxiety-related personality traits and genomic DNA was extracted from blood samples and analyzed using the polymerase chain reaction. RESULTS: Although the prevalence of the short and long alleles of 5-HTTLPR did not differ between the patients and healthy controls, there was a tendency towards high prevalence of the short (10-copy) variant of STin2 among the patients. When the study population was further analysed by subdivision into subgroups all AD patients with high- anxiety traits carried the short variant of STin2. In the corresponding healthy control group, the prevalences of the 10-and 12-copy variants were 62% and 38%, respectively (P < 0.01). CONCLUSION: These findings indicate a possible association between the 10-copy variant of STin2 and aggravation of AD by anxiety.

Effect of chronic mild stress on serotonergic markers in the skin and brain of the NC/Nga atopic-like mouse strain.

Atopic eczema is often worsened by stress. While acute stress is associated with increased turnover of serotonin (5-hydroxytryptamine; 5-HT), chronic stress causes a decrease. In chronic stress, there is a decrease of the 5-HT1A receptor (R)- and an increase in the 5-HT2AR-responsiveness to 5-HT. In the present study, the impact of chronic mild stress on the expression of 5-HT1A and 5-HT2A receptors and serotonin transporter protein (SERT) was investigated in eczematous skin and brain of atopic-like NC/Nga mice. Twenty-four NC/Nga mice were subjected to chronic mild stress for 12 weeks, and eczema was induced by applying a mite antigen (Dermatophagoides pteronyssinus) on the ears for the last 4 weeks. The mice were divided into three groups, eight per group, stressed eczematous (SE), non-stressed eczematous (NSE) and stressed control (SC). The biopsies were analysed by immunohistochemistry, using a streptavidin-biotin technique. There was an increased number of 5-HT containing dermal mast cell-like mononuclear cells in the skin of mice with eczema (SE and NSE, respectively) compared with the SC, and a tendency to more 5-HT-positive cells in the SE compared with the NSE group. Increased 5-HT1AR immunoreactivity (IR) in the skin and hippocampus of the eczematous groups compared to the control group was seen, but no difference between the SE and NSE groups. The epidermal immunoreactivity for 5-HT2AR was highest in the SE and NSE compared to the SC group, and was also higher in the SE compared to NSE. 5-HT2AR expression was also seen on nerve bundles, the number and intensity of such bundles being decreased in the SE compared to the NSE group. In the CA1 area of the hippocampus, there was an increase in the quantity of cells immunoreactive for 5-HT2AR in the SE versus the NSE group and also in the SE versus the SC group. SERT-IR was found also on nerve bundles with a decreased number in the SE compared to the NSE and SC group. There is a modulation of the expression of serotonergic markers in the eczematous skin and brain of the atopic-like mouse during chronic mild stress.

Decreased innervation of eczematous skin in NC/Nga atopic mice during chronic mild stress.

BACKGROUND AND AIM: A connection between chronic mild stress and altered innervation in the skin of an atopic mouse strain, NC/Nga, was studied. MATERIAL AND METHODS: We used three groups of mice, stressed control (SC, stressed but not immunized with a mite antigen), non-stressed eczematous (NSE, not stressed but immunized) and stressed eczematous (SE, stressed and immunized). RESULTS: There was a decrease of protein gene product (PGP) 9.5 positive nerve fibers in SE compared to SC mice, in both epidermis and dermis, also in SE compared to NSE mice. Also a decrease in growth associated protein (GAP)-43 positive nerve fibers was seen in SE compared to SC, in both epidermis and dermis. CONCLUSION: Chronic mild stress in atopic mice leads to decreased innervation in eczematous lesions.

Serotonergic mechanisms in human allergic contact dermatitis.

Expression of serotonin (5-hydroxytryptamine; 5-HT), 5-HT receptors 1A (5-HT1AR) and 2A, and serotonin transporter protein (SERT) was studied in positive epicutaneous reactions to nickel sulphate in nickel-allergic patients, at 72 h post-challenge with the antigen. In addition, the effects of 5-HT2AR agonist 2,5-dimethoxy-4-iodoamphetamine (DOI), and the selective serotonin reuptake inhibitors (SSRIs) citalopram and fluoxetine, were tested on nickel-stimulated peripheral blood mononuclear cells from nickel-allergic patients, regarding their proliferation and interleukin (IL)-2 production, as well as the effect of these SSRIs on a murine Langerhans' cell-like line (XS52), regarding its IL-1beta production. Serotonin-positive platelets were increased in the inflamed skin compared with control skin. A decrease (p <0.01) in 5-HT1AR-positive mononuclear cells was evident in the eczematous skin compared with control skin, whereas 5-HT2AR- and SERT-positive cells were increased (p <0.001 for both) in the eczematous skin. Treatment of nickel-stimulated peripheral blood mononuclear cells with 5x10(-5) mol/l of DOI inhibited (p <0.01) the proliferation of nickel-stimulated peripheral blood mononuclear cells, while no effect was found regarding IL-2 production. Citalopram at 10(-6) mol/l tended to inhibit the production of IL-1beta by the XS52 cell line. These results indicate the implication of the serotonergic system in the contact allergic reaction.