title: The response of skin disease to stress: changes in the severity of acne vulgaris as affected by examination stress.
abstract: BACKGROUND
  Although emotional stress has long been suspected to exacerbate acne vulgaris, previous reports addressing its influence on acne severity have been mainly anecdotal.
  
  
  OBJECTIVE
  To elucidate the possible relationship between stress and acne exacerbation by evaluating changes in acne severity during nonexamination and examination periods and to assess the possible relationship of these changes in severity with perceived examination stress by using previously validated scales measuring acne severity and perceived stress.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  General university community.
  
  
  METHODS
  A volunteer sample of 22 university students (15 women and 7 men) with a minimum acne vulgaris severity of 0.5 on the photonumeric Leeds acne scale (baseline scores, 0.50-1.75).
  
  
  METHODS
  Participants were graded on their acne severity using the Leeds acne scale, and had their subjective stress levels assessed with the Perceived Stress Scale questionnaire during both nonexamination and examination periods.
  
  
  RESULTS
  Subjects had a higher mean grade of acne severity and mean perceived stress score (P<.01 for both) during examinations. Using regression analysis and adjusting for the effects of confounding variables, such as changes in sleep hours, sleep quality, diet quality, and number of meals per day, increased acne severity was significantly associated with increased stress levels (r = 0.61, P<.01), while self-assessed change in diet quality was the only other significant association (P =.02).
  
  
  CONCLUSIONS
  Patients with acne may experience worsening of the disease during examinations. Furthermore, changes in acne severity correlate highly with increasing stress, suggesting that emotional stress from external sources may have a significant influence on acne.
authors.affiliation: Department of Dermatology, Stanford University School of Medicine, Stanford, CA 94305-5334, USA.
authors.forename: Annie
authors.initials: A
authors.lastname: Chiu
authors.forename: Susan Y
authors.initials: SY
authors.lastname: Chon
authors.forename: Alexa B
authors.initials: AB
authors.lastname: Kimball
mesh_terms: D000152:Acne Vulgaris / Q000473:pathology / Q000523:psychology*; D000293:Adolescent; D000328:Adult; D004521:Educational Measurement; D005260:Female; D006801:Humans; D008297:Male; D011446:Prospective Studies; D013315:Stress, Psychological / Q000175:diagnosis / Q000209:etiology; D011795:Surveys and Questionnaires