It has been established in recent years that the skin is a direct target of psychological stress via a cascade of hormones, neuropeptides, and neurogenic signals (causing nerve hypersensitivity and inflammation). The skin has been shown to be capable of launching its own local response to stress as well by producing many of the same substances that the brain produces, further enhancing the local effect at the skin level when someone is under acute or prolonged stress. It is no surprise that the skin can perceive and respond to stress similar to the brain and nervous system, since the two systems have evolved from the same germ layer during embryonic development.
The main skin cells (keratinocytes), mast cells (involved in allergy type reactions and inflammation), immune cells, and peripheral nerve endings all will have an effect on various cell behaviour and processes within the skin under stress that can lead to skin disruption, premature ageing and disease development.
The skin is rich in nerve endings, so when an individual is stressed the peripheral nerve endings secrete numerous substances such as Substance P and Nerve growth factor that contribute to hypersensitivity, inflammation, and allergic reactions.
Due to the impact of stress related hormones and peptides, and growth factors on the skin, stress can play a role in the development and exacerbation of skin disorders such as Eczema, Acne, Psoriasis, and Rosacea.
Psychological stress activates the autonomic nervous system to trigger release of catecholamines [e.g. epinephrine and norepinephrine] from the adrenal glands, and in situations of chronic stress corticotrophin releasing hormone [CRH] and ACTH (adrenocorticotropic hormone), mediate a release of glucocorticoids (Cortisol) from the adrenal cortex.
Here is a brief outline of some key stress mediators and the effect that they have on the skin:
Excess levels can cause atrophy and impaired wound healing by interfering with keratinocyte and fibroblast function. Keratinocytes are the primary skin cells that form the epidermis of the skin, and fibroblasts are responsible for collagen and elastin formation.
This manifests as atrophy and thinning of the skin, increased trans-epidermal water loss related to disruption to the skin permeability barrier, and easy bruising with impaired wound healing.
The skin barrier is also negatively impacted by excess cortisol as this effects the lamellar bodies in the skin cells which are responsible for lipid synthesis; the lack of essential lipids weakens the barrier resulting in dry skin, allergies and sensitivity, delayed healing and infections.
Excess glucocorticoids stimulate Insulin production and lead to insulin excess and Insulin resistance. Elevated Insulin stimulates IGF2 (Insulin growth factor) which increases growth of keratinocytes, and stimulates abnormal keratinocyte growth, (exacerbates Psoriasis and Acne) and increases androgens and testosterone release.
This is neuropeptide released in times of stress. Substance P stimulates sebaceous germinative cells and proliferation of sebaceous glands which results in excess oil production and blockage of the oil ducts and the development of acne. Substance P also activates mast cells, increasing histamine release and itch sensation. Substance P induces vascular permeability and inflammation, which aggravates conditions like Eczema and Rosacea.
Corticotropin Releasing Hormone (CRH):
CRH stimulates release of MSH (melanocyte stimulating hormone) causing hyperpigmentation and blotchy skin.
Catecholamines (Adrenaline, Noradrenaline)
Decrease blood perfusion to skin reducing availability of oxygen and nutrients resulting in poor texture and sallow / pallor. Catecholamines have also been shown to cause immune suppression, interfere with DNA repair and contribute to ageing.
While the effects of stress on the skin are only briefly outlined above, it illustrates the significant impact this can have on individuals predisposed to skin conditions. It is therefore imperative to minimise stress where possible in order to avoid any exacerbation of skin disorders.
There are some straight forward tips to reduce stress such as getting a good night’s sleep, exercising and following some simple dietary guidelines (listed below).
Reduce salt intake
Avoid skipping meals
Avoid refined, processed foods.
Avoid high fat foods
Do eat high fibre, low glycaemic index diet
In the following blogs we will present some relaxation techniques that are easy to implement and will have a direct effect in reducing the side effects of stress.
Dunn, Jeffrey HKoo, John; Psychological Stress and skin aging: A review of possible mechanisms and potential therapies; Dermatology Online Journal 19 (6): 1 University of Colorado, School of
Jessica M. F. Hall, desAnges Cruser, Alan Podawiltz, Diana I. Mummert, Harlan Jones, Mark E. Mummert; Psychological Stress and the Cutaneous Immune Response: Roles of the HPA Axis and the Sympathetic Nervous System in Atopic Dermatitis and Psoriasis; Dermatology Research and Practice Volume 2012, Article ID 403908, doi:10.1155/2012/403908
Ying Chen, John Lyga; Brain – Skin Connection: Stress, Inflammation and Skin Aging; Inflammation & Allergy – Drug Targets, 2014, 13, 177-190
Theoharis C. Theoharides, Jill M. Donelan, Nikoletta Papadopoulou, Jing Cao, Duraisamy Kempuraj, Pio Conti; Mast cells as targets of corticotropin releasing factor and related peptides; TRENDS in Pharmacological Sciences Vol.25 No.11 November 2004
Fatigue is a common and often disabling symptom that occurs in patients with chronic inflammatory and autoimmune diseases, cancer, neurological diseases and a number of other conditions in which inflammation and/or cellular stress occurs. Fatigue may be defined as ‘an overwhelming sense of exhaustion, tiredness, languidness, languor, lassitude, and listlessness. It is a subjective feeling which is distinct from weakness, and has a gradual onset. Fatigue can be Acute and/or Chronic (ongoing state of tiredness), that leads to mental or physical exhaustion, or both, and prevents people from functioning within normal boundaries.
There is emerging evidence that points to the innate immune system as an important ‘fatigue generator’, brought on by invading pathogens, autoimmune diseases, cancer or other ‘danger-signals’, as well as cellular stress responses. Many dermatological diseases and conditions demonstrate inflammatory or autoimmune features, suggesting that fatigue can be a common symptom in a number of chronic skin diseases. Also, psoriasis shares common pathways of immune signalling with other inflammatory diseases including psoriatic arthritis and rheumatoid arthritis (RA).1
The reduction of productivity and work capacity caused by fatigue has been studied by industrial psychologists. In these studies, the importance of physical or mental motivational factors has been clearly demonstrated. Real muscular weakness, however, cannot be detected in most individuals who complain about fatigue. The individual affected by fatigue is often unable to handle complex mental problems and tends to be less reasonable. Inferiority complexes may surface. In neurologic and psychiatric departments, anxiety and depression are frequently diagnosed in fatigued patients. 2
In one study stressed psoriasis patients, responding to a comprehensive series of questionnaires had the following physical and psychological symptoms: constant sensation of exhaustion (78.54%); memory problems (72.54%); constant fatigue (70.58%). In another study constant and excessive fatigue and the inability to work occurred in 56.86% (F) and 43.13% (M) of respondents. 3
In one clinical study researchers wanted to determine the relationship between fatigue and disease-related and psychosocial variables in psoriatic arthritis (PsA). They interviewed 499 patients attending the University of Toronto PsA Clinic using a modified fatigue severity scale (mFSS) questionnaire. Results showed that moderate fatigue occurred in 49.5% of PsA patients and severe fatigue in 28.7%. 4
In another clinical study in plaque psoriasis patients, researchers found nearly 50% of psoriasis patients suffered from substantial fatigue. The fatigue severity was also associated with smoking, pain, and depression, but not with psoriasis severity. 5
Because fatigue is a perceived phenomenon, researchers and clinicians rely on subjective measures to indicate the patients’ level of fatigue and impact on their quality of life. It gives an overall picture of the patient and where they are at and plays a roll in determining the need for intervention or effectiveness of treatment. The 9-item Fatigue Severity Scale (FSS) is one of the most commonly used self-report questionnaires to measure fatigue. 6
The FSS questionnaire contains nine statements that attempt to explore severity of fatigue symptoms. Read each statement and circle a number from 1 to 7, depending on how appropriate they felt the statement applied to them over the preceding week. A low value indicates that the statement is not very appropriate whereas a high value indicates agreement (1 disagree to 7 agree).
FSS Questionnaire 7
During the past week, I have found that:
My motivation is lower when I am fatigued.
Exercise brings on my fatigue.
I am easily fatigued.
Fatigue interferes with my physical functioning.
Fatigue causes frequent problems for me.
My fatigue prevents sustained physical functioning.
Fatigue interferes with carrying out certain duties and responsibilities
Fatigue is among my three most disabling symptoms.
Fatigue interferes with my work, family, or social life.
Circle closest to how you feel – (1 disagree, 7 agree).
FSS Scoring: Add up the circled numbers and divide by 9. ________
A Fatigue Severity Scale (FSS) score of 4 – defined as the patient is suffering from “Fatigue” and >?5.1 as suffering from “Severe Fatigue”.
Compare results with the following scores:
People who do not experience fatigue score about 2.8
People with Lupus score about 4.6
People with Lyme Disease score about 4.8
People with fatigue related to Multiple Sclerosis score about 5.1
People with Chronic Fatigue Syndrome score about 6.1
NOTE: The FSS might have difficulties distinguishing fatigue from depression (the influence of pain may influence scores on the FSS).
For those that have scored 5 or more it is seriously recommended that you see your practitioner and discuss the possibility as to whether you may also be suffering from depression.
Skoie I.M. et al.; Fatigue in psoriasis: a phenomenon to be explored; British Journal of Dermatology (2015) 172, pp1196–1203
Carneiro C. et al.; Fatigue in Psoriasis With Arthritis; SKINmed. 2011;9:34–37
Leovigildo E. S. et al.; Stress level of people with psoriasis at a public hospital; An Bras Dermatol. 2016;91(4):446-54.
Husted JA, Tom BD, Schentag CT, et al.; Occurrence and correlates of fatigue in psoriatic arthritis Annals of the Rheumatic Diseases 2009;68:1553-1558.
Skoie I.M. et al.; Fatigue in psoriasis – a controlled study; British Journal of Dermatology; 2017; DOI: 10.1111/bjd.15375
Valko PO, Bassetti CL, Bloch KE, Held U, Baumann CR. Validation of the Fatigue Severity Scale in a Swiss Cohort. Sleep. 2008;31(11):1601-1607.
Krupp LB, et al The Fatigue Severity Scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol 1989; 46:1121– 3.
The last in our 3 part series addressing psychological and psychiatric disorders associated with psoriasis.
Psychological and Psychiatric Disorders –
Substance dependence of abuse
1, 2, 3
It is thought that psoriasis has a direct effect on the development of sleep disorders due to the cutaneous (skin) symptoms of the condition. The skin is the primary circadian mediator of core body temperature (CBT), and a decrease in CBT in the late evening is an important mechanism for sleep initiation. Psoriasis has been associated with problems with thermoregulation and researchers have indicated that the reduced ability to dissipate heat is one factor in the inability to initiate sleep. Pruritus (itch) is another contributor to sleep disturbance and it is also regulated by circadian mechanisms. The threshold for pruritus is lowered in the evening due to complex circadian-mediated factors such as lower cortisol levels, decreased epidermal barrier function, and increased distal-to-proximal (distant limbs-to-body centre) gradient in skin temperature. Thus pruritus in psoriasis typically manifests or exacerbates mainly in the evening and worsens at night. 4,5,6
The inflammatory biological mechanism(s) that lead to initiation and exacerbation of psoriasis, also contribute to the development of systemic diseases e.g. depressive disease, hypertension (blood pressure), adverse cardiac events, diabetes, metabolic syndrome and obesity. All of these conditions are known to indirectly give rise to sleep-disordered breathing. The heightened pro-inflammatory state in conditions such as obstructive sleep apnoea syndrome (OSAS) and insomnia could in turn lead to exacerbations of psoriasis.4,5,6
A systematic review of the literature on the relationship between psoriasis, PsA, and formal sleep disorders identified an increased prevalence of OSAS with a 36-81% prevalence in psoriasis versus 2% for women and 4% for men in the general population.4,5 In one study researchers found that some patients with chronic psoriasis and concurrent OSAS showed improvement of their psoriatic lesions while on nasal continuous positive airway pressure (CPAP).6 OSAS leads to severe physical and, possibly, psychological stress to the body, e.g., by hypoxemia (low blood oxygen levels), increased blood pressure, tachycardia (fast or irregular heart rate), sleep fragmentation, reduction of deep sleep, reduction of REM sleep, hypersomnia (excessive sleepiness), and insomnia. It is known that OSAS also dysregulates the function of the patient’s autonomic nervous system and hormone system. It is felt that this might alter the homeostasis of the immune neuroendocrine network in the skin and may cause the initiation of psoriasis in the genetically predisposed individuals.4,5,6
Somatoform Disorders – psychosomatic symptoms
Somatization is the manifestation of psychological distress by the presentation of bodily symptoms such as feeling nausea due to anxiety, stress headaches, falling ill after a trauma and inability to cope with a disease.
Patients with psoriasis exhibit higher scores of hypochondriasis, hysteria, and somatization. As previously exposed hypochondriasis and hysteria may be connected with specific personality traits of patients with psoriasis of late-onset. Psychosomatic factors, namely stressful life events, lack of social support, and attachment insecurity, may explain why patients with psoriasis have greater scores of somatization. Moreover, the presence of depression in psoriasis may modulate itch perception and then exacerbate symptoms of pruritus.7 (Refer to Part 1 of this series) A systematic review of the psychosocial burden of psoriasis found that social stigmatization, high stress levels, physical limitations, depression, employment problems and other psychosocial co-morbidities experienced by patients with psoriasis are not always proportional to, or predicted by, other measurements of disease severity such as body surface area involvement or plaque severity. Some psoriasis patients had, even when their lesions were small and mild, levels of stress and loss of confidence that was not in keeping with the severity of their condition – which leads to the conclusion that they had maladaptive coping mechanisms in play e.g. self blame, blaming parents, social phobia, avoidance behaviours, substance and alcohol abuse etc. 9
Substance – Dependence of Abuse
In our previous blog Psoriasis and Alcohol (ethanol), we stated that patients with psoriasis experience considerable emotional distress, depression and social isolation due to the visibility of skin lesions, especially when the lesions are widespread and severe. Whilst it would be demeaning to state that all psoriasis patients with mild to severe psoriasis suffer from alcoholism, it has been confirmed in several Quality of Life studies that the percentage of psoriasis patients who admit to having a drinking problem may be as high as 32%. Research indicates that men are more likely to use alcohol excessively as a coping mechanism with the psychosocial burden of psoriasis. Consequently they are at a higher risk of developing depression – with the alcohol misuse and psoriasis as underlying causes. 4 Another study indicated that for women, excessive alcohol intake above a certain threshold (?30.0 g/d), may be associated with a significantly increased risk of Psoriatic Arthritis (PsA).5
Alcohol is known to inhibit inflammation and immune responses; however acute and chronic alcohol consumption have opposite effects on inflammatory cell activation. Results indicate that acute alcohol exposure is inhibitory, whereas chronic alcohol exposure leads to an increase in inflammatory cell responses.6
Research has confirmed that alcoholics are more susceptible to infections, as streptococcal infections are trigger factors for psoriasis, this increased susceptibility may be involved in the onset and progress of the disease. It is also known that measurable quantities of ingested ethanol are secreted through human skin. Transdermal ethanol derives from two processes: active secretion by eccrine glands, primarily sweat glands, and passive diffusion through the lipid layers of the skin. Ethanol disrupts the dermal barrier enhancing skin permeability for numerous chemicals and increases the solubility of penetrating chemical compounds.6
Research into the the use of illicit drugs and psoriasis is extremely limited. Methylenedioxymethamphetamine (MDMA), also called Ecstasy, has been reported to initiate Guttate Psoriasis. The researchers theorized that “While MDMA [the main ingredient in ecstasy] is taken for its psychomimetic effect, pharmacologically it increases the level of noradrenaline, serotonin and dopamine by inhibiting the reuptake mechanism. It is known that Patients with psoriasis already have increased levels of noradrenaline.”7 There are also anecdotal stories on support websites where psoriasis sufferers have spoken about the exacerbation of their psoriasis with the use of “meth” (Methamphetamine, Ice). Within our clinic we have had several patients whose psoriasis was initiated and exacerbated by the use of cannabis (street not medicinal), once they ceased the use of cannabis their psoriasis resolved. As long as they did not use cannabis they remained free of any psoriatic lesions.
Susskind W. and McGuire R.J.: The Emotional Factor in Psoriasis; Scot. med, J., 1959,4:503
Kessler R. C. et al.; Epidemiology of Anxiety Disorders; M.B. Stein and T. Steckler (eds.), Behavioral Neurobiology of Anxiety and Its Treatment, Current Topics in Behavioral Neurosciences 2, DOI 10.1007/7854_2009_9, # Springer?Verlag Berlin Heidelberg 2009, published online 3 September 2009
Nasreen S. et al.; Frequency and Magnitude of Anxiety and Depression in Patients with Psoriasis Vulgaris; Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 397-400
Brenaut E. et al.; Alcohol consumption and psoriasis: a systematic literature review. J Eur Acad Dermatol Venerol. 2013 Aug;27 Suppl 3:30-5. doi: 10.1111/jdv.12164.
Shaowei Wu et al.; Alcohol Intake and Risk of Incident Psoriatic Arthritis in Women; J Rheumatol. 2015 May ; 42(5): 835–840. doi:10.3899/jrheum.140808.
Farkas A, Kemény L.; Psoriasis and alcohol: is cutaneous ethanol one of the missing links?; • British Journal of Dermatology 2010 162, pp711–716
Tan B., Foley P.; Guttate psoriasis following Ecstasy ingestion;Australasian Journal of Dermatology45(3):167-9 September 2004?
So now the Christmas and New Year holiday season is upon us and for those of you who suffer from a skin condition, this time of the year can be challenging.
We all know that the intake of alcohol can be a trigger for many skin conditions such as psoriasis, eczema, urticaria etc. It is dehydrating and dehydration impairs the skin barrier. Alcohol also has the potential to weaken one’s immune system, this makes people with skin conditions more susceptible to bacterial infections and injuries, which in turn can trigger and exacerbate their condition.
For those of you who are yeast sensitive, the intake of drinks such as beer and champagne, both of which contain yeast, most certainly will aggravate their skin condition and could cause a major flare up. Those that are gluten sensitive or suffer from Celiac disease also have to be careful with their alcohol intake as some types of liquors e.g. vodka, bourbon etc. may use a starch-source for fermentation and these starch sources e.g. barley contain gluten.
This time of the year can be emotionally challenging, if you are experiencing family or relationship difficulties, you may be experiencing considerable emotional distress, depression and even social isolation. Try to reach out to friends and support groups for support during this time. It is important that you do not isolate yourself and allow your stress levels to escalate.
If tasks such as shopping or getting the house ready cause you stress, then make sure you plan ahead and allow yourself extra time.
Food of course is a big deal at this time of the year. Catching up with friends for barbecues, lunches, dinners at restaurants or at homes is an important tradition and catch up time for all of us.
Control on what is on the menu is often out of your hands, therefore it is important to choose your food wisely. So avoid all spicy foods or at least keep it to a minimum – if you eat spicy food at one sitting try to avoid another serve for a few days.
Avoid or at least keep to a minimum intake of tomatoes (including chutneys), smoked foods, red and processed meats. Try to select green vegetables, chicken, turkey, fish and moderate all other intake. Remember if you do have a food sensitivity, be it seafood, gluten, yeast, sugar then try to avoid it as much as possible. The golden rule is “If you ate it during one meal wait a few days before having it again” if you can’t avoid eating it then moderation is key.
If you are eating at the home of family member or friend then don’t be afraid to tell them of your eating requirements. Most people will be only too happy to oblige by either offering an alternative that you can eat or by modifying the dishes that they are preparing.
As mentioned earlier dehydration impairs the skin barrier so drink plenty of water. It is important to try to drink between one and a half litres to two litres of water a day and critical if you are drinking alcohol.
The most important thing is to try to enjoy your time with family and friends, don’t overdo the alcohol or food intake. Remember moderation and alternatives, drink your water, get plenty of rest. If you find yourself feeling stressed, make some time to chill out, meditate or listen to music.
So Check List:
Eat Greens, chicken, turkey, fish
Avoid tomatoes, spicy, red and processed meats, smoked foods, sugar
Avoid your trigger foods
Moderate alcohol intake
Keep stress to a minimum, plan ahead & get support
Atopic Dermatitis (AD) is a multifactorial, immune mediated, chronic and relapsing skin disease, with significant emotional distress, sleep disturbance and Quality of Life (QoL) difficulties. 1,2,3
Most cases of AD begin in childhood or adolescence, with more than 80% of pediatric patients having persistent symptoms of itch and dry skin in adulthood. The early age of onset and disease chronicity, plus impaired quality of life weighs heavily on a child’s psychological and behavioural development. This often leads to delayed social development throughout life and very high rates of psychological and behavioural disorders.5, The impairment of quality of life caused by childhood AD has been shown to be greater than or equal to other common childhood diseases such as asthma and diabetes, emphasising the importance of AD as a major chronic childhood disease.1,2,3
AD patients have been described with lower self-competence and self-efficacy, when compared with healthy individuals and there is also a clear relationship between the prevalence of a mental health disorder and the reported severity of the skin disease. 1,2,3
Psychological stress and AD symptoms seem to form a vicious cycle. However, the exact mechanism as to how stress affects AD is as yet largely unknown. Evidence suggests that stress stimulates the hypothalamic-pituitary-adrenal (HPA) axis releasing neuropeptides and neurotrophins, which influence the development and course of AD, inducing epidermal barrier dysfunction, and lowering the itch threshold.4
The current incidence of psychiatric disorders among dermatological patients is estimated at about 30-40% and the association between anxiety and depression, and AD is well documented in scientific and medical journals.1,2,3 AD and clinical depression interact closely, and causal relationships between the two conditions have frequently been observed; e.g. the onset or exacerbation of AD often follows stressful life events such as severe disease in a family member, divorce, or parental separation.5
This may reflect the psychological distress produced by both the stigma associated with visible AD skin lesions and the unpredictability of disease flares, and may be manifested by the high proportion of patients (approx. 60%) who reported being embarrassed by or self-conscious of their skin condition in various studies. The psychological burden can further negatively impact mood and QoL. Thoughts of suicide have been reported in 15% of patients in an AD population in Europe and up to 20% of individuals with severe disease.3
In Dermatology Life Quality Index (DQLI) questionnaires, approximately 46% AD patients report severe pruritus (itch) with almost 15% rating it as unbearable, 86% experience itching every day and approx. 42% state that they itch up to 18 hours per day. Nearly all patients also reported the frequent occurrence of bleeding, oozing, cracking, flaking, or drying of their skin. AD and itching has a significant impact on patient-reported sleep with approx. 68% of patients reporting that itch delayed falling asleep and occasionally or frequently woke them up at night, with up to 36% reporting that their sleep was disturbed every night. Loss of sleep may contribute to daytime sleepiness and fatigue, further reducing functional activities and adversely affecting mood and QoL due to the fact that sleep likely has a reciprocal relationship with mental health.3
Children with AD face a slightly different set of challenges and often have negative self-esteem (subjective perception of self-worth) and poor self-image (subjective perception of abilities, appearance). They experience frustration, fussiness, irritability, unhappiness, loneliness, self-consciousness and emotional sensitivity. Parents have reported that their AD children often cry, and are nervous and insecure. Researchers observed perfectionism, rigid and obsessive thought patterns, anxiety and depression, obsessive and compulsive traits in paediatric AD patients. Children with AD also have difficulties in social interaction and impaired social competence.6
Sixty percent of children with AD experience sleep disturbance caused by their disease, with 83% reporting sleep disturbance during exacerbations. The sleep of children with eczema was characterized by problems with settling and maintaining sleep while their daytime functioning was characterized by excessive daytime sleepiness and higher ADHD and Oppositional Behaviour scores as well as poor performance in daytime activities, specifically school performance.6 Problematic behavioural patterns that include hyperactivity, impaired attention, scratching to get attention; stubbornness, aggressiveness, disruptive and oppositional behaviour have been documented. A significant association was found between Attention Deficit Hyperactivity Disorder (ADHD) and AD. It is suggested that these behavioural difficulties are possibly mediated by disturbed sleeping patterns, difficulty in coping with the discomfort of AD and its treatment, disfigurement, stigmatisation and disciplinary challenges.7
Various studies have consistently indicated an association between AD and Autism Spectrum Disorder (ASD) and ADHD which is independent of environmental exposures and other comorbidities. Particularly infant AD appears to be associated with later development of ADHD symptoms. Children with previous or prevalent AD have an approximately 43 % increased risk to be diagnosed with ADHD or to display clinical ADHD symptoms.8, 9
It has been speculated that ADHD/ASD symptoms, AD, food hypersensitivity and sleep disruption may be linked by shared pathophysiological factors and that these impairments are characterized by a relevant developmental interplay, especially in early infancy and childhood. Disturbed sleep is a characteristic feature of ASD/ADHD and eczema and may be one mediating factor in the observed associations. However, other mechanisms may also be involved such as genetic or neuro-immunomodulatory mechanisms. It has been suggested that the non-allergic activation of TH1 and TH17 cells, which mediate the inflammatory processes, may be of relevance in the association between AD and ADHD. Also excessive cytokine release may impact on the central nervous system as they are able to pass the blood–brain barrier, thus possibly affecting both neurotransmission and brain circuits which are known to be involved in ADHD and/or affecting the sleep–wake rhythm.8, 9
Recent studies have also linked sleep disturbance to obesity and hypertension (blood pressure PB) in children. The long-term effect of increased BP are unknown in children, but it is possible that cumulative increases of BP are associated with cardiovascular disease later in life, similar to that observed in psoriasis. The mechanism of association between obesity and AD remains unknown. Previous studies have suggested that adipose (fat) tissue may directly influence the risk of AD. 10 The association between AD and in particular, central obesity – where excessive fat is stored around the stomach and abdomen, in particular, is of major concern. Central obesity has previously been reported to have particularly harmful effects on a variety of medical disorders, including asthma, dyslipidemia, diabetes, coronary artery disease, and myocardial infarction.
Also read our BLOGS – Stress, Anxiety, Depression – Atopic Eczema (AE)/Atopic Dermatitis (AD) and associated Itch
Stressed About Your Skin Condition – Identify Your Stressors and Your Stress Responses
Lewis-Jones S. (2006), Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. International Journal of Clinical Practice, 60: 984–992. doi:10.1111/j.1742-1241.2006.01047.x
Mina, Shaily et al. “Gender Differences in Depression and Anxiety Among Atopic Dermatitis Patients.”Indian Journal of Dermatology 2 (2015): 211.PMC. Web. 20 Oct. 2016.
Simpson M.I. et al.; Patient burden of moderate to severe atopic dermatitis (AD): Insights from a phase 2b clinical trial of dupilumab in adults; J AM ACAD DERMATOL MARCH 2016
Sang Ho Oh et al.; Association of Stress with Symptoms of Atopic Dermatitis; Acta Derm Venereol 2010 Preview
Sewon Kim er al.; The Association between Atopic Dermatitis and Depressive Symptoms in Korean Adults: The Fifth Korea National Health and Nutrition Examination Survey, 2007–2012; Korean J Fam Med 2015;36:261-265
Gouws A.; The Impact Of Atopic Dermatitis On The Psycho-Social Wellbeing Of Children And Their Families; Current Allergy & Clinical Immunology, March 2016, Vol 29, No 1
Camfferman D et al.; Eczema, Sleep, and Behavior in Children; Journal of Clinical Sleep Medicine, Vol. 6, No. 6, 2010
Schmitt J. et. Al.; Association of atopic eczema and attention-deficit/hyperactivity disorder – meta-analysis of epidemiologic studies; Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2015), 41, pp. 35-44. DOI: 10.1024/1422-4917/a000208
Tzu-Chu Liao et al.; Comorbidity of Atopic Disorders with Autism Spectrum Disorder and Attention Deficit/Hyperactivity Disorder; The Journal of pediatrics · February 2016 DOI: 10.1016/j.jpeds.2015.12.063
Silverberg J. I. et al.; Central Obesity and High Blood Pressure in Pediatric Patients With Atopic Dermatitis; JAMA Dermatology February 2015 Volume 151, Number 2
Scratching is the natural response to itch (Pruritus) and, by definition, inseparable from it. The act of scratching not only diminishes itch, but it has been found to be rewarding and addictive. The itch-scratch cycle is a complex phenomenon involving sensory, motor and emotional components. The urge to scratch can be remarkably intense because the reward provided by scratching brings such intense relief and may also be associated feelings of pleasure and enjoyment. Recent studies have shown that rating scratching as a pleasurable experience is correlated with the intensity of the underlying itch, both in patients with chronic itch and healthy individuals.1 Various functional brain imaging studies have discovered that the itch-scratch cycle in humans can be tracked to specific regions of the brain, including areas related to reward, pain sensation, and addiction.1,2
The Itch-Scratch-Rash cycle is commonly used to describe this ongoing, never ceasing, always constant itch that makes eczema very different from many other skin condition. Eczema has often been called the “Itch that Rashes” rather than the “Rash that Itches”.3
The itchier a patient feels, the more scratching of the skin that occurs and which ultimately lead to skin damage and the appearance of a red rash. Often, in chronic presentations it becomes a completely unconscious habit and patients are often not even aware that they are scratching. When a patient scratches, the skin becomes inflamed, this inflammation then causes the skin to itch even more, thus making it even harder for the patient to resist the urge to scratch. This vicious circle can become so severe that it causes sleeplessness, irritability, anxiety and stress. In extreme cases it can lead to significant excoriations (open, bloody and deep scratch wounds) on the skin or even severe lichenification (thickening of the skin) and pain.
The Practitioner and Patient need to recognize and address various aspects of itch, including:
(1) Identification and elimination of trigger factors;
(2) Maintaining the skin barrier through emollients – Oil based and Water Based;
(3) Targeting inflammation through topical medications and systemic (oral) medications
(4) Addressing psychological and behavioural components; and
(5) Education – understanding the condition.
The sensation of pruritus can be triggered by endogenous (internal) and exogenous (external) stimuli, which activate specific peripheral nerve endings in the epidermis and dermis layers of the skin.3
Allergies House dust mites, food allergens, air-born contact dermatitis (pollen, etc.), animals (e.g. cat dander), jewellery, certain cosmetic ingredients.
Physical stimuli Temperature: humidity, cold dry air, clothes rubbing on the skin.
Emotional Anxiety/Stress /Anger/ Depression.
How to rate your Itch4
Based on the Eppendorf Itch Questionnaire.
Rate each of the following from 0 to 4
The following describes your Itch………
Worse when Cold
Less when Cold
Worse when Hot
Less when Hot
Feels like ants
Comes in waves
Physical urge to scratch
I only can think of the Itch
When do you feel the need to Itch?
In the Morning
In the Evening
Worse in Bed
After a hot shower
After being outside
After being in the Sun
After Dusting, Sweeping/Vacuuming/ Changing beds
After eating certain foods
How would you describe the need to Scratch?
I find it enjoyable
It is a physical urge
It is compulsive
I forget when I do it
I always want to scratch
I find it satisfying
I find it pleasurable
It hurts but I cannot stop
What action do you take when you feel the urge to scratch?
I scratch with my nails
I scratch with my fingertips
I scratch with my knuckles
I use a pencil/pen/ruler/stick
I use a cold pack
I use a heat pack
I take a cold shower
I take a warm shower
I take a hot shower
I put the air conditioner on
I turn down the ducted heating
I dig my fingernails in
I bite my lip
I scratch until I bleed
I apply pressure
Which areas of the body do you scratch the most?
What distracts you from the urge to scratch?
Company distracts me
Reading a Book
Using a Computer/IPhone/IPad
Listening to music
Applying heat pack
Applying ice pack
Doing something with my hands (hobby)
When you understand your itch, when you itch, what you do when you scratch and what distract you from scratching, you may be able to plan your approach to your itch more methodically and with more control. You may decide that you need to start a meditation or behavioural therapy class to help you control the need to scratch. You may find that you will learn the best times to apply your creams so that you circumvent the urge to scratch e.g. applying creams before gardening or mowing the lawn or doing housework etc.
What can a Patient do to avoid or control the urge to itch?
Scratching is difficult to resist because it gives the mental impression of easing the itch – but this is only for the short-term. Eventually the sensation to itch comes back – even worse that before you scratched.
Basic tips to control the urge to itch:-
Keep nails short to avoid tearing the skin when scratching.
Keep cool. Over-heating can trigger the itch. Try to keep your body temperature as constant as you can, wear light layers of cotton clothes.
Avoid overheated rooms, keep ducted heating to a minimum, and at night keep the bedrooms cold.
Avoid heavy blankets and doonas – use cotton blankets if possible.
Gently rub with the back of the fingers, place pressure or gently pinch the area instead of scratching.
Use a cold compress
Parents of children often ask “How can I stop my child from scratching?” And as scratching is an instinctive reaction to itching which can become a compulsive/unconscious habit, that question is not an easy one to answer. Parents can help by keeping their child’s nails short and, especially at night, by covering their hands with cotton mittens.
With older children, it is important that you explain to them how scratching will actually make them feel worse, not better. And that their skin will become redder, more cracked and feel itchier and sorer.
Become aware of any habits of scratching that your or your child may be developing and take especial note as whether it is at a particular time of day, or during a particular activity, such as playing sport or just watching television. If you or the parents of a child become aware of these types of habits then it is important to try to break the habit.
Nonpharmacological Treatments for the Management of Atopic Dermatitis Itch
Cognitive-behavioural methods alter dysfunctional habits by interrupting and altering dysfunctional thought patterns (cognitions) or actions (behaviours) that damage the skin or interfere with dermatologic therapy. e.g. Itch-coping Training Programme or Habit Reversal Training, cognitive-behavioural methods for the reduction of itch and scratching behaviour, including self-monitoring, guidance in skin care and coping skills to manage itch- and scratch-triggering factors, stress-management methods with relaxation techniques and habit reversal. The habit reversal technique teaches patients to recognize the habit of scratching, identify situations that provoke scratching, and train them to develop a competing response practice, for example, a child who unconsciously scratches can be taught to recognize the early signs of the sensation of itch and instead of scratching be taught to clench his/her fists or place his/her hands underneath his/her legs as soon as they feel the sensation of itch.
Biofeedback can enhance the patient’s awareness of tension and help them to relax; improving skin disorders that flare with stress or that have an autonomic nervous system aspect. Biofeedback is a mind-body therapy that uses electronic instruments to assist patients to gain awareness and control over psychophysiological processes. The patient is connected to a machine that measures muscle activity, skin temperature, electrodermal activity, respiration, heart rate, heart rate variability, blood pressure, brain electrical activity, and brain blood flow and visually gives the patient feedback as they go through various “game” like tasks. Chronic itch, which may be somatic, emotional and cognitive, may be treated with therapies that can modulate the autonomic nervous system stress response. Behavioural biofeedback techniques that reduce stress and anxiety have been used to treat chronic pain and itch and could potentially alter the sympathetic over-activity noted in patients with AD.
Hypnosis / Meditation8
With proper training, an individual can intensify this trance state in himself or herself and use this heightened focus to induce mind-body interactions that help alleviate suffering or promote healing. The state of altered consciousness known as a “trance state” may be induced using guided imagery, relaxation, deep breathing, meditation techniques, self-hypnosis or by a trained medical practitioner. Researchers have used relaxation, stress management, direct suggestion for non-scratching behaviour, direct suggestion for skin comfort and coolness, ego strengthening, posthypnotic suggestions, and instruction in self-hypnosis. Their results were statistically significant for reduction in itch, scratching, sleep disturbance, and tension. Reported topical corticosteroid use decreased by 40% at 4 weeks, 50% at 8 weeks, and 60% at 16 weeks. For milder cases of atopic dermatitis, hypnosis along with moisturization can suffice as a primary alternative treatment. For more extensive or resistant atopic dermatitis, hypnosis can be a useful complementary therapy that reduces the amounts required of other conventional treatments.
Read also our Blogs for Psoriasis …. The same techniques can be used for Eczema
Simple Mental/Mind Relaxation Techniques Part 1 – For Psoriasis Patients
Simple Mental/Mind Relaxation Techniques Part 2 – For Psoriasis Patients
Papoiu A. D. P. et al.; Brain’s Reward Circuits Mediate Itch Relief. A Functional MRI Study of Active Scratching; PLOS ONE, www.plosone.org 1 December 2013, Volume 8, Issue 12, e82389
Mochizuki H. et al.; Chapter 23Brain Processing of Itch and Scratching; http://www.ncbi.nlm.nih.gov/books/NBK200933/?report=printable
Hong J. et al.; Management of Itch in Atopic Dermatitis; Seminars in Cutaneous Medicine and Surgery; Elsivier; doi:10.1016/j.sder.2011.05.002; Pg 71-88
Darsow U. et al.; New Aspects of Itch Pathophysiology: Component Analysis of Atopic Itch Using the ‘Eppendorf Itch Questionnaire’; Int Arch Allergy Immunol 2001;124:326–331
Shenefelt PD.; Psychological interventions in the management of common skin conditions; Psychology Research and Behavior Management 2010:3 51–63
Evers Et al.; Effectiveness of a Multidisciplinary Itch-coping Training Programme in Adults with Atopic Dermatitis; Acta Derm Venereol 2009; 89: 57–63
Tran BW. Et al.; Effect of Itch, Scratching and Mental Stress on Autonomic Nervous System Function in Atopic Dermatitis; Acta Derm Venereol 2010; 90: 354–361
Shenefelt PD. ;Hypnosis in Dermatology; Arch Dermatol / VOL 136, MAR 2000
Tobacco smoke contains numerous chemicals that exert inflammatory effects on the human body. Recent studies suggest that cigarette smoking may trigger the development of psoriasis through oxidative, inflammatory and genetic mechanisms. Smoking initiates formation of free radicals that stimulate cell signalling pathways active in psoriasis. Smoking damages the skin by increasing formation of reactive oxygen species (ROS) and decreasing the gene expression of antioxidants. Nicotine also stimulates innate immune cells integral to the pathogenesis of psoriasis. This perpetuates a cycle of chronic inflammation. Smoking also enhances expression of genes known to increase the risk of psoriasis.1,2,5
Research has found that increased smoking intensity corresponds to a higher risk of developing severe psoriasis whilst longer cumulative duration of smoking (pack-years) increases the likelihood of developing psoriasis. The study also demonstrated a graded increase in psoriasis risk with increasing exposure to passive smoke.
In one study, researchers investigated the associations between smoking status, quantity,duration, and cessation and exposure to environmental tobacco smoke and the risk of incident psoriasis in a total population of 185,836 participants from the Nurses’ Health Study (NHS), the Nurses’ Health Study II (NHS II), and Health Professionals’ Follow-up Study (HPFS). They reported that in the NHS, 20% of the cases of incident psoriasis might have been prevented by the elimination of smoking. Similarly, the population-attributable risk was 15% in the NHS II and 19% in the HPFS. For all participants, 17.5% of the incidents of psoriasis were attributable to having ever smoked. Evidence from past association studies seemed to indicate a stronger association between smoking and psoriasis in women than in men.3
Research has also shown that the risk increases with the number of cigarettes smoked daily. Studies have shown that smoking more than 10 cigarettes per day by men who are psoriasis patients may be associated with a more severe expression of disease in their extremities. In addition, smoking among both men and women who are psoriasis patients has been shown to reduce improvement rates and hence difficulty in achieving remission during treatment.4 In a multicentre case-control study of 404 psoriasis patients and 616 controls, the risk for psoriasis was higher in smokers compared with non-smokers, and the association with smoking was stronger and more consistent among women than men. A particularly strong association was also found between smoking more than 15 cigarettes per day and Palmoplantar Pustular Psoriasis (PPP). Several observational and case-control studies have demonstrated up to 94% prevalence of tobacco use in patients with PPP.6
As tobacco smoking also interferes with the bodies immunity by allowing colonization by perio -dontopathic bacteria and by acting as a local irritant, researchers have hypothesized that smoking may act as a trigger or permissive factor of periodontal disease in patients suffering from psoriasis. In order to test this hypothesis, the prevalence and severity of periodontal disease, Researchers assessed a group of smoking and non-smoking psoriasis patients and a group of smoking and non-smoking psoriasis-free controls. In this study it was statistically shown that psoriasis patients who smoke are at an approximately sixfold higher risk of developing severe periodontal disease, as compared to psoriasis patients who do not smoke.7
Another interesting observation was the frequent coexistence of a smoking habit and alcohol consumption in patients with psoriasis. In the literature, alcohol consumption has been described as a factor responsible for triggering psoriasis, but it is said that smoking increases the risk of the onset of the disease. Previous studies have indicated that smokers who drink are twice as likely to develop the disease as non-smokers and non-drinkers.8,9
It is well recognized that stress and anxiety acts in both the initiation and exacerbation of psoriasis. Psychosocial stressors include acute negative life events or chronic strains and have been implicated as risk factors for tobacco use. Psychological stress may influence smoking behaviour (e.g., initiation, maintenance, and relapse) through a number of mechanisms. Specifically, smoking may function as a coping behaviour, whereby nicotine is used to self-medicate in response to stress; it is also possible that exposure to stress may result in diminished self-regulation to control the urge to smoke. Previous observational studies illustrate that acute stressful events and greater exposure to chronic stressors (e.g., related to work, finances, or relationships) are associated with higher smoking prevalence compared to persons who did not experience these stressors.10
So in summary, studies suggest that cigarette smoking may trigger the development of psoriasis through oxidative, inflammatory and genetic mechanisms. Furthermore, smoking is associated with the clinical severity of psoriasis. Smoking also contributes to higher morbidity and mortality from smoking related disorders in these patients. It is, therefore, advisable, if possible to quit smoking, or at the very least, keep your smoking to a minimum, preferably under 10 cigarettes a day. Try to adopt other mechanisms to cope with your stress and anxiety and it is suggested that you read our other blogs on “Simple Physical and Mental Relaxation Techniques”. Using these techniques you may be able to reduce your stress and anxiety levels and this may allow you to cut down on the number of cigarettes you smoke.
Also read our blog “Psoriasis and Alcohol Intake”, “Stress, Anxiety, Depression and Psoriasis”, “Stressed about Psoriasis – Identify Your Stressors and Yours Stress Responses”, “Simple Physical Relaxation Techniques for Psoriasis Patients” and “Simple Mental/Mind Relaxation Techniques Part 1 and Part 2”
Armstrong AW, Armstrong EJ, Fuller EN, et al. Smoking and pathogenesis of psoriasis. Br J Dermatol 2011; 165: 1162-8.
Al-Rubaii A, Al-Ward N, Al-Waiz M. The age of onset of psoriasis and its relationship to smoking habits and stressful life events. Saudi Med J2003; 24:108.
Wenqing Li et al.; Smoking and Risk of Incident Psoriasis Among Women and Men in the United States: A Combined Analysis; American Journal of Epidemiology Advance Access published January 12, 2012; http://aje.oxfordjournals.org/content/early/2012/01/11/aje.kwr325.full.pdf+html
Behnam SM,Behnam SE, Koo JY.; Smoking and psoriasis.; Skinmed. 2005 May-Jun;4(3):174-6.
Armstrong AW, ; Psoriasis and smoking: a systematic review and meta-analysis; British Journal of DermatologyVolume 170, Issue 2, Article first published online: 18 FEB 2014
Freiman A. et al.; Cutaneous Effects of Smoking; Journal of Cutaneous Medicine and Surgery Volume 8 Number 6 December 2004
Antal M. et al.; Smoking as a Permissive Factor of Periodontal Disease in Psoriasis; PLOS ONE | www.plosone.org; March 2014 | Volume 9 | Issue 3 | e92333
Agnieszka B. Owczarczyk-Saczonek , Roman Nowicki; The association between smoking and the prevalence of metabolic syndrome and its components in patients with psoriasis aged 30 to 49 years; Postep Derm Alergol 2015; XXXII (5): 331–336 DOI: 10.5114/pdia.2015.54743
Naldi L, Peli L, Parazzini F. Association of early-stage psoriasis with smoking and male alcohol consumption: evidence from an Italian case-control study. Arch Dermatol1999; 135:1479–84.
Slopen N. et al.; Psychosocial stress and cigarette smoking persistence, cessation, and relapse over 9–10 years: a prospective study of middle-aged adults in the United States; Cancer Causes Control DOI 10.1007/s10552-013-0262-5
Psoriasis is a chronic inflammatory skin disorder and whilst the exact causes of psoriasis have yet to be discovered, the immune system and genetics are known to play major roles in its development. The immune system is somehow mistakenly triggered, which speeds up the growth cycle of skin cells among other immune reactions1.
Researchers show that whether a person develops psoriasis or not may depend on a “trigger”2. These Primary Triggers activate the condition.
Stress – anxiety, depression, psychological illnesses e.g. Post-Traumatic Stress Disorder.
Certain medicines e.g.:- – Anti-malarial– e.g. Doxycycline, chloroquine – Lithium– depression or psychiatric disorders – ACE Inhibitors- High blood pressure medication – Anti-inflammatory medicine – e.g. ibuprofen or Indomethacin – Beta blockers – taken by patients with heart failure – Corticosteroids– Prescribed for a variety of health conditions. Sudden discontinuation of relatively high doses can be a trigger.
Infections –in some people, usually children and young adults, a form of psoriasis called guttate psoriasis develops after a streptococcal throat infection (note: most people who have streptococcal throat infections will not develop psoriasis), upper respiratory infections such as such as streptococcal pharyngitis or sinusitis. People with weakened immune systems; such as HIVpatients, are more susceptible to psoriasis.
There are also a number of Secondary Triggers, and these exacerbate the condition once it has been activated, and will continue to worsen the condition. They are:-
Consumption of alcohol
Weather – exposure to cold
Not all psoriasis sufferers will react to all of the above triggers, so the best thing to do is to record consumption of foods, liquids etc., how you slept, what stresses you were under and any exposure to chemicals and other environmental triggers and at the same time monitor your symptoms e.g. increases itch, irritability, new lesions or worsening of existing lesions etc. Note that some triggers e.g. skin injuries may not show a flare-up up for up to 10 to 14 days after a triggering event, so if you noticed that you were bitten by mosquitos or insects record it with the date and then take note of any subsequent delayed flare ups.
Višnja Milavec-Pureti? et al.; Drug Induced Psoriasis; Acta Dermatovenerol Croat 2011;19(1):39-42
Kuchekar A.B. et al.; Psoriasis: A comprehensive review; Int. J. of Pharm. & Life Sci. (IJPLS), Vol. 2, Issue 6: June: 2011, 857-877 857
Are you having trouble controlling your thoughts and finding it difficult to let yourself float in the Full Body Scan Meditation or the Releasing Troubles and Worries Exercise?
WELL DON’T WORRY!!!!!!!
Here is a “Thought-Stopping” Exercise that can be used during either the Full Body Scan Meditation or the Releasing Troubles and Worries Exercise or when trying to get to sleep.
In thought-stopping, you would do this exercise FIRST. So lie on a yoga bed for the exercises or in bed to get to sleep.
Think about something that you know is worrying you and will keep you awake …… something troubling you that you will know your mind will churn over and make it difficult to relax or go to sleep. Force your mind to concentrate on that issue or person e.g. the project at work is in trouble and you know your boss is going to get angry at you and the team. Turn this over in your mind again and again and then suddenly in your mind “Shout Out” STOP!!!!!!. Breath easily and try to relax …… if you feel the issue creeping back into your mind ….. repeat the STOP exercise again and again until your mind releases the thought.
This STOP exercise basically is forcing your brain to recognize when to stop thinking about something …. It abruptly interrupts the thought process and makes the brain shift its focus … this is where the relaxation technique, that you have chosen should now be used.
A number of sites on the internet offer some wonderful guided meditations, and alternative Relaxation Techniques. Below we have listed some of the techniques and their links:-
Also read our blog “Stress, Anxiety, Depression and Psoriasis, Stressed about Psoriasis – Identify Your Stressors and Yours Stress Responses, Simple Physical Relaxation Techniques for Psoriasis Patients, Simple Mental/Mind Relaxation Techniques Part 1 – For Psoriasis Patients, Simple Mental/Mind Relaxation“
National Center for Health Promotion and Disease Prevention (NCP); Manage Stress Workbook; http://www.prevention.va.gov/mpt/2013/docs/managestressworkbook_dec2013.pdf
Relaxation Techniques for Health: What You Need To Know;National Institutes of Health; U.S. Department of Health and Human Services; https://nccih.nih.gov/sites/nccam.nih.gov/files/Get_The_Facts_Relaxation_Techniques_02-06-2015.pdf
It is important that you and you alone take control – find the solution that best helps you and ensure that you keep doing it – remember it comes down to your adherence to not only your treatment plan but also in your efforts to control your stress and increase your emotional resilience.
The next step is to test some simple Physical Relaxation Techniques and find the one that works for you:-
Use the following to help you release muscle tension.
1. Stand relaxed with your arms hanging at your sides and place your feet comfortably apart.
2. Tilt your head back and count slowly to five.
3. Roll your head forward and count slowly to five.
4. Exhale as you curl your body forward and bend at the waist; arms dangling down and slowly count to five.
5. Inhale slowly through your mouth as you slowly straighten up whilst raising your arms overhead – stretching as far as you can. Then drop your arms slowly to sides as you exhale though your mouth.
Repeat several times.
1. Use a yoga mat or a folded blanket – lie down with your back flat on the floor and place a book or large magazine on your stomach.
2. Bend your knees (you can close your eyes if this makes your more relaxed).
3. Inhales and push your stomach upwards (but not you upper chest) as far as you can and slowly count to five, then exhale slowly. You may also use the affirmative “I am relaxed” as you exhale.
Repeat several times.
Use the following after a physical reaction to a stressful situation to allow the physical changes of your stress reaction to subside and return to a non-stress state.
1. Sit (or lie) in a comfortable position in a quiet environment with eyes closed.
2. Start with your feet and mentally relax each muscle group moving up to the head—calf, thigh, waist, stomach, arms, chest, neck, face, and forehead.
3. Breathe in through your nose gently pushing your stomach out (but not your upper chest).
4. Breathe out through your mouth and let your stomach relax.
Repeat this exercise for 10-20 minutes.
When finished, open your eyes but remain seated or lying for several more minutes.
1. Lie flat on a yoga mat or a folded blanket – with your eyes closed and knees bent.
2. Beginning with your right foot, press foot firmly to the floor and count slowly to five, then relax for the count of five; repeat with the left foot.
3. Straighten legs out and press back of lower right leg firmly to the floor and count slowly to five, then relax for the count of five; repeat with left leg.
4. Press each of the following areas firmly to the floor and count slowly to five, and then relax for the count of five. (one at a time):
a. Back of thighs and buttocks
b. Lower back and shoulder blades
d. Back of head
REMEMBER: – to breathe normally as you press and relax. Repeat several times.
There are many other forms of Relaxations Techniques including, exercise, meditation, yoga, Tai Chi etc. On the internet there are many sites that offer other tips for relaxation exercises and meditation techniques…
Walking is an excellent form of exercise that will cost you nothing.
And of course other activities e.g. gyms and swimming pools will require membership fees to be paid.
Also read our blog “Stress, Anxiety, Depression and Psoriasis, Stressed about Psoriasis – Identify Your Stressors and Yours Stress Responses, Simple Mental/Mind Relaxation Techniques Part1, and Simple Mental/Mind Relaxation – Part 2“
National Center for Health Promotion and Disease Prevention (NCP); Manage Stress Workbook; http://www.prevention.va.gov/mpt/2013/docs/managestressworkbook_dec2013.pdf
Relaxation Techniques for Health: What You Need To Know; National Institutes of Health; U.S. Department of Health and Human Services; https://nccih.nih.gov/sites/nccam.nih.gov/files/Get_The_Facts_Relaxation_Techniques_02-06-2015.pdf