The relationship between stress and vitiligo: Evaluating perceived stress and electronic medical record data

Abstract

Vitiligo is a T-cell mediated skin disorder characterized by progressive loss of skin color. In individuals genetically predisposed to the disease, various triggers contribute to the initiation of vitiligo. Precipitating factors can stress the skin, leading to T-cell activation and recruitment. Though hereditary factors are implicated in the pathogenesis of vitiligo, it is unknown whether precipitating, stressful events play a role in vitiligo. To understand this, we utilized a validated perceived stress scale (PSS) to measure this parameter in vitiligo patients compared to persons without vitiligo. Additionally, we probed a clinical database, using a knowledge linking software called ROCKET, to gauge stress-related conditions in the vitiligo patient population. From a pool of patients in an existing database, a hundred individuals with vitiligo and twenty-five age- and sex-matched comparison group of individuals without vitiligo completed an online survey to quantify their levels of perceived stress. In parallel, patients described specifics of their disease condition, including the affected body sites, the extent, duration and activity of their vitiligo. Perceived stress was significantly higher among vitiligo individuals compared to those without vitiligo. ROCKET analyses suggested signs of metabolic-related disease (i.e., 'stress') preceding vitiligo development. No correlation was found between perceived stress and the stage or the extent of disease, suggesting that elevated stress may not be a consequence of pigment loss alone. The data provide further support for stress as a precipitating factor in vitiligo development.

Fig 1. Perceived stress is higher in vitiligo patients.

PSS scores of healthy versus and vitiligo age-matched patients were compared. Sample includes both males and females (n = 25). The dashed line indicates the cutoff score for stressed individuals (at PSS = 15). Statistical significance for PSS among the populations was determined by paired two-tailed t-test, P = 0.0396.

Fig 2. Perceived stress is higher among female vitiligo patients.

(A) PSS scores were compared between male (n = 56) and female (n = 47) vitiligo patients. Statistical significance was determined by Mann-Whitney test, P = 0.0143. (B-C) Scatter plot illustrates relationship between PSS scores and vitiligo duration (B, P = 0.7955); and between PSS scores and age (C, P = 0.8746). (B) and (C) include both male and female vitiligo patients. Dashed line indicates the PSS cutoff score for stressed individuals (at PSS = 15).

Fig 3. Perceived stress is not associated with disease progression and self-reported depigmentation.

(A) Violin plots depicting the distribution of PSS among the three stages of vitiligo progression. Colored dashed line and number indicate the median values. (B) Violin plots depicting the distribution of PSS in the four categories of self-reported depigmentation. Dashed line indicates the PSS cutoff score for stressed individuals (at PSS = 15).

Fig 4. Bi-phasic age groups of vitiligo diagnosis.

The ROCKET database was probed to determine the number of patients diagnosed with vitiligo. Total, male and female vitiligo populations are shown.

Fig 5. Prevalence and timing of metabolic stress parameters among vitiligo patients.

(A) The odds of expressing a comorbidity among vitiligo patients, compared to the general patient population expressed as an odds ratio. A value of 1 indicates odds equal to the general patient population. Values greater than 1 indicates greater, and lower than 1 indicates smaller odds. The error bars indicate the upper and lower confidence intervals (B) Timing of diagnosis for indicated comorbidities compared to the diagnosis of vitiligo among patients.

Fig 6. Prevalence and timing of prescription drugs for metabolic stress.

(A) Odds ratio depicting the odds of being prescribing statins of beta blockers among vitiligo patients compared to the general patient population. The error bars indicate upper and lower confidence intervals. (B) Timing of first drug prescription compared to the timing a vitiligo diagnosis was made among patients.