Psychological Stress and Skin Symptoms in College Students: Results of a Cross-sectional Web-based Questionnaire Study
College can be a cause of increased psychological stress, especially given the complex social, academic, and financial pressures faced by today's students (1, 2). The association between psychological stress and the manifestation or exacerbation of different skin diseases is well established (3) (4) (5) (6) (7) (8) . Previous studies that demonstrated an association between stress and skin symptoms focused their analyses on a single skin disease. Therefore, this questionnaire-based
... al study aimed to assess the relationship between perceived psychological stress and the prevalence of various skin symptoms in a large, randomly selected sample of undergraduate students. MATERIALS AND METHODS The investigation was conducted at Temple University in Philadelphia, Pennsylvania, during the fall semester of 2014 by the Department of Dermatology and the Temple Itch Center. Five thousand undergraduate students aged 18-30 years were randomly selected and e-mailed an invitation to participate in a web-based survey. Electronic informed consent was obtained from all participants. The study was approved by the Institutional Review Board at Temple University School of Medicine. We utilized Research Electronic Data Capture (REDCap) to construct, host, implement, and collect the survey and subsequent data. To assess stress levels, we used the validated Perceived Stress Questionnaire (PSQ; 9) a 30-item questionnaire that measures self-reported psychological stress (9). The raw scores were combined to produce a PSQ index that varied from 0 to 1, representing lowest and highest levels of perceived stress, respectively. To assess skin complaints, we utilized a modified version of the Self-Reported Skin Questionnaire (SRSQ; 10). Statistics The statistical analyses were done using SPSS 22. The group was divided into low stress (LS), moderate stress (MS) and high stress (HS) students by determination of the 25 th and 75 th percentile of the PSQ index. Students scoring ≤ 25 th percentile (PSQ index ≤ 0.389) were regarded as lowly stressed, students scoring ≥ 75 th percentile (PSQ index ≥ 0.622) were regarded as highly stressed. All other students fell in the category of moderately stressed. Moreover, the answers concerning the (skin-) symptoms were dichotomized in such a way that the answer "no complaints" was compared with the other 3 answers ("a little", "quite a lot" and "very much"). Thus, we only distinguished whether the symptom occurred in the student or not. This dichotomization was done to allow the computation of odds ratios (OR). To compare the low and high stressed students regarding socio-demographic variables, χ 2 -tests as well as t-tests for independent groups were computed. Subsequently, OR and 95% confidence intervals were calculated to conclude as to whether the low stress group had a lower probability of having (skin-) complaints than the high stress group. Due to the fact that sex was not equally distributed in the groups, sex and stress severity were used as a covariate in the binary logistic regressions which were subsequently conducted using the skin symptoms as dependent variables. This made it possible to report OR and 95% confidence intervals (CI) adjusted for sex. RESULTS From the 482 students who participated, 60 had to be excluded due to incomplete data, unspecified sex and/or failure to meet inclusion criteria resulting in a final sample size of 422. The group was divided into LS, MS and HS students. Of the 422 subjects, 109 were designated LS, 201 MS, and 112 HS subjects. The mean ± SD age was 20.76 ± 2.09, with no difference in age among the 3 groups (all p > 0.05). There were no significant differences in the distribution of academic standing between the three groups (all p > 0.05). The total sample included 113 men and 309 women. There was a statistically significant difference in terms of sex distribution between the groups, with more women in the MS and HS cohorts (p = 0.005) in comparison to the LS group. When compared to LS subjects, HS subjects suffered from significantly more pruritus (p ≤ 0.001, adjusted OR 2.79 (95% CI 1.58-4.94)), alopecia (p ≤ 0.001, 2.87 (1.53-5.41)), oily, waxy, flaky patches on scalp (p ≤ 0.001, 2.61 (1.47-4.65)), hyperhidrosis (p = 0.001, 2.56 (1.46-4.47)), scaly skin (p = 0.002, 2.42 (1.30-4.51)), onychophagia (p = 0.011, 1.92 (1.11-3.32)), itchy rash on hands (p = 0.021, 2.54 (1.01-6.40)), and trichotillomania (p = 0.038, 2.42, (1.16-5.04)). Pimples, dry/sore rash, warts and other rash on the face all demonstrated no association with perceived psychological stress levels (all p > 0.05; Table I ). The frequencies of pruritus in HS, MS, and LS were 72% (n = 81), 56% (113), and 46% (50), respectively. The frequency of hair loss (alopecia) was 39% (n = 44) in the HS group, 30% (60) in the MS group, and 17% (19) in the LS group. The self-reported frequencies of oily, waxy, or flaky patches on the scalp in the HS, MS, and LS groups were 50% (n = 56), 41% (82), and 26% (28).