Association of Psychological Stress With Skin Symptoms Among the Population in Saudi Arabia: A Cross-Sectional Study

Background and aim Studies have shown a significant relationship between psychological stress (PS) and health, and it is widely believed that factors such as stress and anxiety may not only be the result of certain diseases but can also cause and exacerbate some diseases. There is a lack of research on PS and its association with other skin conditions. Thus, this study aimed to examine the association of PS with skin symptoms using objective scales in the general population in the Kingdom of Saudi Arabia (KSA). Methods A cross-sectional study was carried out between February 6, 2023, and April 4, 2023. We administered an electronic questionnaire survey, consisting of Cohen’s perceived stress scale and a self-reported skin complaint questionnaire, distributed via an online platform in the KSA. In all, 629 completed questionnaires were returned. Statistical analysis was conducted using RStudio. The results were presented as beta coefficients and their respective 95% confidence intervals (95% CIs). A p-value of <0.05 indicated statistical significance. Results The majority of the participants were female (71.7%, n=388), of Saudi nationality (93.2%, n=504), had a bachelor’s degree (68.6%, n=371), were aged 18-29 years (58.8%, n=318), and were residing in the Western region (39.9%, n=216). Acne (26.8%, n=145) and eczema (12.8%, n=69) were the most commonly reported skin conditions. The stress level was low in 30.5% of the respondents (n=165), moderate in 64.9% of the respondents (n=351), and high in 4.6% of the respondents (n=25). The average skin symptom score was significantly predicted by the presence of psoriasis (p < 0.001), eczema (p < 0.001), acne (p < 0.001), rash (p < 0.001), and baldness (p = 0.041). Furthermore, the average skin symptoms scores were significantly higher among participants with high stress (median = 1.6, interquartile range (IQR) = 1.4, 1.8) than among those with moderate (median = 1.4, IQR = 1.2, 1.8) and low stress (median = 1.4, IQR = 1.1, 1.4, p < 0.001). Conclusion The general population of Saudi Arabia reported multiple skin symptoms associated with stress. PS can cause various common skin conditions including loss of hair, eczema, and acne. This study highlights the importance of assessing common skin problems in the general population in the KSA and their strong association with PS. Various skin conditions including loss of hair, eczema, and acne can be caused by PS. Dermatologists should be aware of the context of PS when assessing patients with these conditions.


Introduction
Numerous studies have shown a significant relationship between psychological stress (PS) and health.PS has been linked to conditions including, but not limited to, irritable bowel syndrome, bronchial asthma, and cardiovascular disorders [1][2][3].PS is the result of the body's inability to appropriately respond to actual or imagined physical, mental, or emotional demands [4].PS occurs when an individual perceives that the environmental demands exceed their adaptive capacity [5].Upon perception of PS, two major neuroendocrine systems, the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis, are activated as part of the central stress response to PS to enable the organism to adapt to it [6].This stress response leads to various consequences for the body's physiological system.Chronic stress exposure is typically thought to be associated with a greater risk of long-term health issues than acute stress because

Study design and sample population
This was a web-based descriptive cross-sectional study that lasted from February 6, 2023 to April 4, 2023.The minimum sample size required for this study was calculated by OpenEpi version 3.0118, in consideration of the following: the population of Saudi Arabia is about 35,34 million inhabitants [20].Considering a confidence interval (CI) of 95%, anticipated frequency of 50%, and design effect of 1, a sample size of 385 participants was obtained.To account for possible data loss, a sample of 629 participants was required.All the residents of the KSA who were eligible to answer our questionnaire were included in the study by Google form required to answer tool.However, we excluded members who were not eligible, refused to participate, or had any mental disorders.

Questionnaire structure
The questionnaire was designed using Google Forms and distributed electronically via different social media platforms.The questionnaire was translated to Arabic (the native language of the participants) before dissemination, and the responses were translated back to English for analysis and publication.The questionnaire was inspired by a previous study conducted at the College of Medicine, King Saud University, Riyadh, KSA [21], with some modifications made to the section on demographic data.
The questionnaire was divided into three main sections.The first section consisted of questions on sociodemographic information, with nine questions on gender, nationality, age, residence area, marital status, educational level, occupation, monthly income, and history of skin conditions.
The second section consisted of the self-reported skin complaints questionnaire (SSCQ), which is a validated 10-item survey, used to identify self-reported skin symptoms and predict clinical skin morbidity.It has been used in several large cross-sectional community-based studies [22][23][24][25].It includes a multiple-choice grid table with 10 items, scored using a four-point scale: "1" denotes (No), "2" denotes (Yes, a little), "3" denotes (Yes, quite a lot), and "4" denotes (Yes, very much) [22].We modified the SSCQ by adding the following six items under the 10th item "other skin problems": hair shedding, hair pulling, nail-biting, itchy scalp, scaly scalp, and facial scales.The average skin symptom score (mean, standard deviation) for each patient was obtained by summing the scores on the 15 items.
The third section consisted of Cohen's perceived stress scale (PSS) questionnaire.A modified version of the 10-item PSS questionnaire was distributed in Arabic and English [7,26].The PSS includes questions on stressful situations in a person's life over the past month.Each question is scored on a five-point scale: "0" for (never), "1" for (almost never), "2" for (sometimes), "3" for (fairly often), and "4" for (very often).Reverse coding was performed for 4 questions: (items 4, 5, 7, and 8).The overall PSS score ranges from 0 to 40.A numerical variable was generated by summing the scores on the 10 items.This numerical variable was converted into a categorical variable with three categories: low stress (0-13 points), moderate stress (14-26 points), and high stress (27-40 points).These categories were coded as: "0" for low stress, "1" for moderate stress, and "2" for high stress [7,26].

Statistical analysis
Statistical analysis was conducted using RStudio (R version 4.2.2).Categorical variables were presented as frequencies and percentages, and continuous data were expressed as medians and interquartile ranges (IQRs).The demographic data and categorical variables of the stress level were subjected to cross-tabulation, and the statistical significance was tested using a Fisher's Exact Test for count data with simulated p-value based on 2000 replicates.The Mann-Whitney test was used to compare the average skin symptoms across demographic variables with two categories (gender and nationality), while the Kruskal-Wallis test was used to compare the variables with three or more categories (age, residential area, marital status, educational level, occupation, and monthly income).Independent predictors of high skin symptoms score were assessed by incorporating the significantly associated variables from the inferential analysis into a multivariable general linear model.The results were presented as beta coefficients and their respective 95% CIs.A p-value of <0.05 indicated statistical significance.

Ethical approval and informed consent
Ethical approval was obtained from the Biomedical Ethics Committee of the Faculty of Medicine at UQU, Makkah, KSA (approval number HAPO-02-K-012-2023-02-1437); the study was conducted in accordance with the Declaration of Helsinki.Electronic informed consent was obtained from each participant prior to administering the questionnaire.Confidentiality was ensured.The names or phone numbers of the participants were not collected.

Demographic characteristics and the history of skin conditions
Initially, we collected 629 responses on the online platform.However, we excluded 14 records of those who disagreed to participate and 74 responses for participants with mental disorders.Eventually, a total of 541 responses were analyzed.The majority of participants were females (71.7%, n=388), Saudis (93.2%, n=504), and had obtained a bachelor's degree (68.6%, n=371).More than half of the respondents were aged 18 to 29 years (58.8%,n=318) and were single (57.5%, n=311), and more than one-third of them were residing in the Western region (39.9%,n=216).The most commonly reported skin conditions included acne (26.8%, n=145) and eczema (12.8%, n=69, Table 1).

TABLE 1: Demographic characteristics and the history of skin conditions
The data has been represented as N, %; p-value is considered significant (p<0.05)

Description of stress
In general, the stress scale showed very good internal consistency, as indicated by a Cronbach's alpha value of 0.891 (15 items) (Table 2).Participants' responses to the PSS are illustrated in Figure 1.Regarding the stress score, the median (IQR) score was 18 (12 to 21) with a minimum of 0 and a maximum of 40.Stress was low in (30.5%, n=165), moderate in (64.9%, n=351), and high in (4.6%, n=25) of the respondents (Figure 2).Results of the inferential analysis showed that stress levels differed significantly based on the residential region (p = 0.005), educational level (p = 0.045), and history of eczema (p = 0.012) and acne (p = 0.004, Table 3).

FIGURE 2: The percentages of stress levels among participants
The data has been represented as N and %

Description of self-reported skin symptoms and the associated factors
Reliability analysis showed that the Cronbach's alpha value of the self-reported skin symptoms scale was 0.859 (Table 2).Participants answered "yes, quite a lot" or "yes, very much" more frequently for loss of hair (34.7%, n=187), scaly scalp (18.5%, n=100), and itchy scalp (18.1%, n=97, Figure 3).
> 25000   The data has been represented as beta and CI; the p-value is considered significant (p<0.05,p<0.001)

Discussion
The current study provides evidence of the strong relationship that exists between high stress levels and common skin disorders.The prevalence of psoriasis, eczema, acne, baldness, vitiligo, and rash was higher among individuals with moderate and high stress levels.Furthermore, the average skin symptom scores were significantly higher among participants with high stress levels than among those with moderate and low stress.Therefore, a variety of common skin disorders may manifest when individuals experience PS.We found that acne and eczema were the most commonly reported skin conditions that were statically and significantly associated with a moderate stress level (p = 0.004 and p = 0.012, respectively).Our findings are in line with the results of other studies on this topic [27][28][29][30][31][32].
In this study, acne was one of the most common skin conditions related to stress; however, other studies demonstrated that increased stress was not associated with acne emergence but with acne severity [28,32].
Even though stress and anxiety play a major role in causing acne, the study showed that the severity of acne was correlated with the stress level.Moreover, we also found that eczema was significantly associated with the level of stress [29].
The perceived stress levels were higher among women, consistent with the results of earlier studies showing that stress during daily activities and at school had a particular impact on females [23,33,34].In this study, we found that diploma, bachelor, and master/doctorate-level education was associated with the highest perceived stress levels.In contrast, another study found no significant relationship between academic standing and the student's PS levels [23].One study reported that heightened stress in undergraduate students was associated with pruritus, alopecia, oily/waxy/flaky patches on the scalp, hyperhidrosis, scaly skin, onychophagia, trichotillomania, and itchy rash on hands [35].
Psychological and psychiatric issues are associated with more than 30% of all dermatologic illnesses [36].
The connection between PS and skin problems is mediated by a complicated neuro-immuno-cutaneousendocrine network.The HPA axis and the autonomic nervous system (sympathetic and cholinergic) are the two main neuroendocrine systems that are activated in response to PS exposure.The HPA axis hormones are altered by PS, along with the release of stress-related mediators such as neuropeptides and cytokine profiles.PS consequently affects the immunological response [6].The immune system's cutaneous and skininfiltrating cells have receptors for stress mediators.Additionally, the skin is controlled by a peripheral HPA axis that is equivalent to the central HPA axis [6,39].As a result, when the skin is subjected to stress, it produces glucocorticoids, corticotropin-releasing hormone, and adrenocorticotropic hormone locally, resulting in an increase in the number of substance P-positive nerve fibers [40].Skin disorders caused by chronic stress are largely attributed to neuroendocrine and immunological changes that limit the skin's capacity to respond to environmental challenges [39].Moreover, chronic stress can lead to autoimmune disorders.Mast cells play a crucial in the immunological reactions to stress by inducing neurogenic inflammation; these stress-induced changes in the skin may play a role in the exacerbation of skin disease [39].
The main strength of our study is the sample size of 541 participants.One of the main limitations of this study is that the causal relationship between the variables could not be demonstrated due to the crosssectional study design.The use of the SSCQ rather than a dermatologist diagnosis is another limitation of our study.However, the SSCQ is a validated instrument.

Conclusions
The general population of Saudi Arabia reported multiple skin symptoms associated with stress.PS can cause various common skin conditions including loss of hair, eczema, and acne.This study highlights the importance of assessing common skin problems in the general population in the KSA and their strong association with PS.Various skin conditions including loss of hair, eczema, and acne can be caused by PS.Dermatologists should be aware of the context of PS when assessing patients with these conditions.

FIGURE 1 :
FIGURE 1: Participants' responses to the perceived stress scaleThe data has been represented as N and %; the p-value is considered significant (p<0.05)

FIGURE 3 :
FIGURE 3: Participants' responses to the self-reported skin symptom scaleThe data has been represented as N and %; the p-value is considered significant (p<0.05)

TABLE 2 : Description of the scores of stress and self-reported skin symptoms
The data has been represented as IQR; the p-value is considered significant (p<0.05)IQR: Interquartile range 2023 Altalhi et al.Cureus 15(11): e48657.DOI 10.7759/cureus.486575 of 14

TABLE 3 : Factors associated with stress levels among participants under study
The data has been represented as N and %; the p-value is considered significant (p<0.05)2023Altalhiet al.Cureus 15(11): e48657.DOI 10.7759/cureus.48657