Is Stress Triggering Your Skin?

Stress Triggering Your Skin
Stress Triggers
Learn how to better identify and manage your stress triggers

Stress is a well-documented trigger AND comorbidity of many skin conditions including psoriasis, eczema, rosacea and acne.  But stress is very much a subjective term.  Learning what it is that your mind and/or body finds stressful is the key to managing your flares and the answer might surprise you…

The skin is innervated by a network of cutaneous nerves and research has discovered that certain neurochemicals play a significant role in many skin conditions by modulating inflammation, cellular growth, immune response and wound repair.  Certain characteristics of chronic skin conditions such as symmetrical distribution, sparing of de-nervated skin and initiation of a flare after stress indicates nerves may play a significant role in the pathogenesis of multiple chronic skin conditions, including psoriasis, eczema, rosacea, acne and more.

What types of stress can flare the skin?

There are 3 stages of stress to be aware of when it comes to skin flares, as different stages can have a different effect on the health of your skin.

  1. Alarm – This stage is also known as fight or flight.  It is the acute stage of stress where your cortisol, heart rate and blood pressure increase as a protective mechanism.  Due to the anti-inflammatory nature of cortisol, you may not experience any symptoms during this phase.
  2. Resistance – During this stage, the body attempts to adapt to the stressful situation.  If the stressful event ceases, the body returns to normal.  If not, the body continues to produce stress hormones, creating imbalances in the endocrine, immune and nervous systems.  This is where symptoms may begin, often with new lesions appearing in new places.
  3. Exhaustion – After extended periods of stress, the body becomes exhausted from trying to maintain a balance in stress hormones.  Your immune system can becomes vulnerable to infection, fatigue and lack of concentration set in and feelings of anxiety and depression are common.  This is where a skin flare can become chronic.

Identifying your stress:

Many of us associate stress with a negative emotional experience, such as a relationship break up, argument, loss of job, financial difficulty and so on.  These are certainly stressful events, but they have something more than negative emotions in common….CHANGE.

As a practitioner of many years, I have found that change is a major driver of skin flares, and what we consider a “Primary” or “Initiating” Trigger.  The interesting part is that the change may even be a positive one, such as taking on a promotion, giving birth to your first child, buying your new home or getting married.  Patients with chronic skin conditions are often very sensitive to changes in their environment.  Even simple changes in weather or temperature can be enough to initiate a flare. 

However, once the patient has adapted to the change, the skin should clear, right?

If it doesn’t clear, this indicates that “Secondary” or “Exacerbating” triggers are still present.  This can include everyday stressors such as being busy, poor sleep, poor diet, nutrient deficiencies, obesity and so on.  These place not only a mental but a physical stress on the body, again exhausting its defense mechanisms. 

So how can you manage your stress, even if you don’t feel stressed?

The answer is ROUTINE!  The nervous system loves routine.  Creating a pattern around when you go to bed, when you wake up, when you eat, what you eat and when you exercise, takes a lot of pressure off your nervous system and the stress response, allowing it to adapt, rather than stay in a constant state of alarm.  Of course, if your routine is not so unhealthy, you may need to make some initial dietary and lifestyle changes, such as less caffeine, less technology, more time outdoors, more vegetables, less processed foods, more water and less alcohol (Read more here).  But once you have, keeping them consistent enough to create a new habit, will give your nervous system the rest it needs, in order to start healing. 

If you are suffering from depression or anxiety and need support, please follow this link for more information.

Jessica Simonis

Clinical Skin Nutritionist

Practitioner Integrative Dermatology

Circadian Rhythm and Chronic Skin Conditions – What’s the link?

Circadian Rhythm and Chronic Skin Conditions

Keeping a chronic skin condition stable when your hormones are running wild can feel like a constant uphill battle.  Not only do we have fluctuating male and female hormones to contend with, but there are stress hormones, sleep hormones and glucose regulating hormones to name a few, all of which work together to create our natural internal rhythm or “circadian clock”.

When we are in balance, our circadian rhythm responds to external cues appropriately.  For example, we are energetic during the day light, sleepy at sun down, hungry during the middle of the day and if female, menstruating in a 4 weekly pattern.   In modern day life, where blue lit screens are often the last thing we see before bed, gyms are open 24/7 and the working day starts and finishes in the dark, it’s no wonder our rhythms go awry. 

So how does this affect the skin?

 Like many organs, the skin is regulated by a central clock known as the suprachiasmatic nucleus which receives light through the retina and passes messages along to other internal clocks via neural and hormonal pathways. It also has its own internal clock system which regulates changes in activity according to the time of day.  For instance, research has shown skin to do the majority of DNA and cellular repair work during the night time.  Skin cells also divide and proliferate more at night, are less hydrated, more acidic and at a slightly higher temperature than during the day, often setting the scene for an uncomfortable night’s sleep for many eczema and psoriasis sufferers.

What can you do to regulate your circadian rhythm and improve your skin?

It’s all in the timing:  Research has shown that the application of topical skin treatments is best timed at night to not only help alleviate the symptoms but to also help optimize repair at a time where the skin needs it most.

Routine, routine, routine:  A regular routine is essential to a healthy circadian and hormonal rhythm.  Chronic disruption to routine such as through shift work, irregular eating patterns or frequent travel can contribute towards flares.  Do your best to time activities within your control, such as regular meal times, breathing exercises, and limiting blue light exposure and/or caffeine before sleep.

Rise with the sun:  The best way to reset your rhythm is to rise with the sun.  Get your 15 minutes of vitamin D exposure and enjoy what nature has to offer before – there’s no better way to start your day. =2

Types of Psoriasis – FLEXURAL/INTERTRIGINOUS (INVERSE PSORIASIS) and GENITAL PSORIASIS

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Inverse psoriasis

 also known as flexural or intertriginous psoriasis is a rare form of psoriasis that occurs in the flexural skin folds. Plaque psoriasis is most commonly found on the trunk and extensor surfaces of the body, such as the knees, elbows, sacral (lower back) area, and scalp whereas Inverse psoriasis is found in the folds of the axilla (armpits), submammary (breast) folds, and groin (inguinal) and buttock folds. It can occur in any area where two skin surfaces meet. The inguinal fold is the most commonly affected area, followed by the axilla and the external genitalia. The skin at the inverse body sites differs from skin at extensor sites with less epidermal keratinization (thinner skin) and more sweat glands. The most evident difference between classical plaque-type psoriasis and inverse psoriasis is the lack of, or less, scaling. The lesions are usually well demarcated, erythematous (red), and are often shiny, appear moist, weepy and fissured. The irritation may be increased in inverse psoriasis as a result of the rubbing and sweating involved in the skin folds. 1, 2   

Approximately 3–7% of psoriasis patients present with inverse psoriasis and patients with palmar psoriasis have a greater chance of having inverse psoriasis as compared with plaque psoriasis. In one study of 170 psoriasis patients with palmar involvement, 5.3 times more patients had inverse psoriasis than patients with plaque psoriasis. Development of inverse psoriasis has been reported as a paradoxical side effect to treatment with infliximab for Crohn’s disease and hidradenitis suppurativa. Inverse psoriasis has been observed to be more common in the obese population possibly due to the rubbing of the skin folds. 1, 2

Inverse psoriasis affecting the genitalia seems to be underreported and undertreated; and approximately 35% patients with genital psoriasis never speak to their physician about their genital lesions. Nearly 70% of Physicians do not offer treatment for genital lesions. 3

Flexural Psoriasis 3

A study on the quality of life and sexual life in 487 patients with genital psoriasis concluded that3:

  • patients with genital lesions report even significantly worse quality of life than patients without genital lesions;
  • sexual distress and dysfunction are particularly prominent in women;
  • sexual distress is especially high when genital skin is affected;
  • the attention given to possible sexual problems in the psoriasis population by healthcare professionals is perceived as insufficient by patients.     

Flexural Psoriasis 2

Results of several questionnaire-based surveys show that involvement of the genital skin region occurs in 29–40% of patients with psoriasis. The genital area may frequently be involved in cases of inverse psoriasis. Of 48 patients with inverse psoriasis, the external genitalia were involved in 38 (79.2%). 4

Flexural Psoriasis 1

In another report researchers stated that patients with genital psoriasis have significantly worse quality of life (QoL) scores compared with patients without genital lesions. In addition, numerous patients with psoriasis have sexual dysfunction. Between 25–40% of patients reported a decline of sexual activity since the onset of psoriasis, mainly due to diminished sexual desire, embarrassment of physical appearance and inconvenience caused by scaliness of the skin or topical therapy. Particularly in women with genital psoriasis, sexual distress is higher and sexual function is more significantly impaired compared to those without genital lesions. 4

Inverse psoriasis is often misdiagnosed for bacterial or fungal intertrigo. Intertrigo is inflammation of opposed skin folds caused by skin-on-skin friction that presents as erythematous, macerated (moist, broken, soft skin) plaques. Secondary bacterial and fungal infections are common because the moist, denuded skin provides an ideal environment for growth of microorganisms. Candida is the most common fungal organism associated with intertrigo. Intertriginous candidiasis also presents as well demarcated, erythematous patches but with tell tale satellite papules or pustules at the periphery (around the edges). Candida, Staphylococcus aureus and Malassezia furfur have been shown to colonize psoriatic skin lesions so diagnosis for flexural psoriasis is sometimes not easy. Candida species have been isolated from the skin of 15% of psoriasis patients compared to only 4% in the control group. 5, 6 However, some studies have also suggested that Candida is not commonly found in psoriatic lesions of inverse of genital psoriasis.

Application of topical treatment in the intertriginous areas is considered as treatment under occlusion due to enhanced hydration and increased skin absorption. However, the inverse areas are considered more sensitive and prone to side effects from topical steroids (i.e. due to thinner skin at these locations). 2

 

REFERENCES

  1. Syed Z. U. and Khachemoune A.; Inverse Psoriasis Case Presentation and Review; Am J Clin Dermatol 2011; 12 (2): 1-4 1175-0561/11/0002-0001/$49.95/0
  2. Silje Haukali Omland  and Robert Gniadecki; Psoriasis inversa: A separate identity or a variant of psoriasis vulgaris?; Clinics in Dermatology (2015) 33, 456–461
  3. Meeuwi  K.A.P. et al.; Genital Psoriasis: A Systematic Literature Review on this Hidden Skin Disease;  Acta Derm Venereol 2011; 91: 5–11
  4. Meeuwis KAP, et al.; Genital Psoriasis Awareness Program: Physical and Psychological Care for Patients with Genital Psoriasis. Acta Derm Venereol. 2015, 95, 211–216
  5. Wilmer E.N. et al.; Resistant “Candidal Intertrigo” ”: Could Inverse Psoriasis Be the True Culprit?; doi: 10.3122/jabfm.2013.02.120210
  6. Taheri Sarvtin, et al.;. Evaluation of candidal colonization and specific humoral responses against Candida albicans in patients with psoriasis. International Journal of Dermatology. Dec2014,Vol.53Issue12, pe555-e560. 6p.