Clinical report
Ramón MARTÍN-BRUFAU1 Psoriasis lesions are associated with specific
Santiago ROMERO-BRUFAU2
Alejandro MARTÍN-GORGOJO3
Carmen BRUFAU REDONDO4,5
Javier CORBALAN1
Jorge ULNIK6
1 Department of Personality,
Assessment and Psychological Treatment,
University of Murcia, Av. Juan Carlos I,
6, 7◦ H, 30008, Murcia, Spain
2 Mayo Clinic Robert D. and Patricia E.
Kern Center,
Rochester, MN,
United States of America
3 Dermatology Department, Hospital
General Universitario Gregorio Marañon.
Clinica Ruber & Clinica Dermatologica
Internacional, Madrid, Spain
4 Service of Dermatology,
General Hospital Reina Sofía,
Murcia, Spain
5 Department of Dermatology and
Venereology,
University of Murcia, Spain
6 Faculty of Psychology,
Buenos Aires University
Reprints: R. Martín-Brufau
<ramonmail@gmail.com>
Article accepted on 06/4/2015
P soriasis is a highly frequent dermatological dis-
ease that is especially prevalent in the psychiatric
patient population and can significantly decrease
the quality of life, causing a great deal of psychologi-
cal suffering [1, 2]. Psoriasis patients are also at a higher
risk of manifesting psychopathological symptoms during
childhood and adolescence [3, 4]. It has also been asso-
ciated with personality alterations [5, 6] and emotional
distress in adults beyond what would be expected by the
skin lesions alone [7]. Although this higher distress is
extensively documented, there is evidence that physicians
frequently overlook this emotional suffering and patients
are often left with their psychological needs unattended
[8].
Research published to date has focused on common psy-
chiatric syndromes, like depression and anxiety [1, 4, 9]
or the global stress response [10, 11], but, to our knowl-
edge, very few studies published so far have focused on
more specific emotions, which can provide a picture of
the specific psychological profile of psoriasis patients, with
some exceptions which focused on a narrow spectrum of
doi:10.1684/ejd.2015.2577
emotions like anger [12] or shame [13]. Other studies
that included a wider range of negative emotions and psy-
chopathology symptoms were limited by a relatively small
sample [14]. Only one recent study explored the relation-
ships between emotions and skin lesions in a large sample
EJD, vol. 25, n◦ 4, July-August 2015
To cite this article: Martín-Brufau R, Romero-Brufau S, Martín-Gorgojo A, Brufau Redondo C, Corbalan J, Ulnik J. Psoriasis lesions are associated with specific types of
emotions. Emotional profile in psoriasis. Eur J Dermatol 2015; 25(4): 329-34 doi:10.1684/ejd.2015.2577
Eur J Dermatol 2015; 25(4): 329-34
types of emotions. Emotional profile in psoriasis
Background: At present there is still controversy about the relationship
between emotional stress and psoriasis lesions. Most of the published
literature does not include the broad spectrum of emotional response.
Objective: The aim of this study was to evaluate the association between
skin lesions and emotional state in a large sample of patients with
psoriasis. Methods: 823 psoriasis patients were recruited (mean age
45.9 years, 55.7% female) and answered two online questionnaires:
lesion severity and current extension were evaluated using a self-
administered psoriasis severity index (SAPASI); emotional state was
assessed using the positive and negative affect schedule (PANAS). Sec-
ond order factors were calculated and correlated with the SAPASI.
Results: We found positive associations between the extent and severity
of skin lesions and the negative and submissive emotions, a neg-
ative correlation with dominance emotions and no association with
positive emotions. Conclusion: Our data supports the relationship
between emotions and skin lesions. It also allows for discrimination
of the associations between psoriasis lesions and the specific type of
emotions.
Key words: psoriasis, emotions, psychodermatology, PASI, Self-
administered PASI, PANAS
of psoriasis patients, using Skindex, but this tool is oriented
to the dermatological patient’s quality of life rather than to
their emotional profile [15].
To sum up, two of the limitations of the literature about pso-
riasis and emotions are 1) that the studies often have low
sample sizes, and 2) the instruments used are focused on
measuring general symptoms of anxiety, depression or psy-
chological distress that do not include a broader spectrum
of the possible emotional responses (guilt, embarrassment,
sadness, humiliation, but also happiness, hope, joy, etc.).
So there is a need to identify the emotional profile of
the psoriasis patients in order to better understand their
psychological suffering. Also, exploring the relationship
between their emotional profile and their skin lesions can
be important to understand the mechanisms underlying this
psycho-dermatological disease.
Different models and classification of emotions have been
proposed. Two of the most accepted models are 1) the
positive and negative affect schedule model, or PANAS
model, also known as the consensual model, based on
a distinction between positive and negative emotions
[16], and 2) the PAD model of emotions, which uses
three dimensions (Pleasure, Activation and Dominance)
to classify the human emotions [17]. Following these
frequently used classifications of emotions, the aim of
this study was to explore the emotional profile of a large
329
sample of psoriasis patients and its relationship with the
severity and extension of skin lesions measured by the
psoriasis area severity index (PASI).
Methods
Participants and procedure
Participants were psoriasis patients who belonged to the
main association of patients with psoriasis in Spain (Acción
psoriasis). The inclusion criteria were: having a diagno-
sis of psoriasis at the moment of the survey, being able to
read and write in Spanish and, because of the nature of the
survey (online), having access to internet and basic web
navigation skills. Regarding exclusion criteria, all patients
suffering from another dermatological condition other than
psoriasis were excluded from the sample before statistical
analysis. In order to generalize the results and have a rep-
resentative sample of the general psoriasis population, no
exclusion was made regarding psychopathology or sever-
ity of psoriasis. Informed consent and ethical requirements
were approved by the Committee of the Spanish Associa-
tion of Psoriasis.
Data collection was performed in February 2013 (started
on the 1st until the 14th ), using online surveys. The Span-
ish Association of Psoriasis Patients sent an email to
the patients containing the link to the online question-
naires and their responses were automatically stored in an
online database for subsequent analysis. All patients were
informed about the characteristics of the study and asked
to sign an online informed consent sheet before they had
access to the online questionnaires. Age, sex and marital
status of each patient were collected online along with the
questionnaires in the survey, which required approximately
15 minutes to complete. Participants were debriefed after
the questionnaires were finished and sent. The survey was
sent to a total of 1238 patients. This online procedure has
been able to obtain large samples of patients in a relatively
short period of time. This procedure has not only practi-
cal advantages but also methodological ones, as it provides
large samples, reduces the risk of maturation of the sam-
ple and provides patients from different regional cultural
context within the country.
Instruments
To evaluate both the emotional and the skin state two fre-
quently used instruments that could be easily responded
online were used:
The state of the skin
The most commonly used methods to assess the state of
the skin in psoriasis are the Psoriasis Area and Sever-
ity Index (PASI) and the Body Surface Area (BSA).
BSA only measures the percentage of the body surface
affected. PASI combines the extension of the affected area
of the body and the severity of psoriasis, measured in
terms of intensity of redness, scaling and thickness of the
psoriatic lesions in each location: head and neck, upper
extremities, trunk and lower extremities. In this case the
330
dermatological state of the skin, measured by the sever-
ity of the lesion and its current extension, was performed
using a web based Self-administered-PASI (SAPASI),
registered by the own patient. This has been shown to
be equivalent to the PASI evaluated by a dermatologist
[6, 18-21].
The emotional state
The current emotional state was measured using the PANAS
questionnaire, a questionnaire widely used for emotional
assessment, which measures both positive and negative
affect. It has 21 Likert-like scales evaluating both positive
(interested, excited, strong, enthusiastic, proud, alert,
inspired, etc.) and negative emotions (distressed, upset,
guilty, scared, hostile, irritable, ashamed, nervous, etc.). It
offers two overall scores of positive and negative affect, as
well as individual scales for each one of the 21 scales, based
on emotions they have felt recently. We decided to use the
PANAS questionnaire because it measures the clinical state
at the moment, which makes it a good instrument to cor-
relate with the state of the skin. It has been used in clinical
and non-clinical populations, showing good psychometric
properties [22, 23]. It has also been shown that the negative
affect scale is well correlated with other questionnaires
used to measure psychopathology [18] so it can be used
to compare the results with previous psychopathological
studies.
Statistical analysis
For the demographic characterization of our sample, we
compared the demographic characteristics of our sample
with a national sample from 123 hospitals across Spain.
Student t test and ␹2 were used to compare the two samples.
The results are presented in table 1.
PASI (extension and severity of psoriatic lesions) results
were obtained along with the BSA (extension) of the skin
lesions as two separate variables. Pearson’s ‘r’ was used
to assess the degree of correlation between emotional state
and skin state and associations between the state of skin
lesions and emotional state were considered significant
when p<0.05. All correlation analyses were performed
controlling for age, sex and demographic status (low, low-
middle, middle-high and high status) included in the online
questionnaire. Factor analyses were performed to resume
the second order factors of emotions following the PANAS
and the PAD models of emotions. We grouped the list of
emotions contained in the PANAS scale into Positive and
Negative emotions respectively, according to the PANAS
model, and obtained two second order factor scores. Then,
we repeated the same procedure grouping the same list
of emotions into the three dimensions of the PAD model:
Pleasure (pleasant and unpleasant), Activation (high
activation and low activation) and Dominance (dominance
and submission) (for example: depression was included in
unpleasant, low activation and submission categories; anger
was included in unpleasant, high activation and dominance
categories). We obtained six categories of second order
factor scores. These factor scores were then correlated with
the PASI scales. SPSS 20 for Windows was used for the
analysis.
EJD, vol. 25, n◦ 4, July-August 2015
Table 1. Descriptive statistics. Age and Sex in our sample compared with the demographic results of a national psoriasis study
from 123 institutions all over Spain [41]. Marital status was not available in the comparison sample. Student t test and ␹2 were
used for the analysis.
Study sample
Descriptive variables Mean (SD) /N (percentage) Median
N 823
Age 45.9 (12.16) 45
Sex
Female 458 (55,7%)
Male 365 (44.3%)
Marital Status
Single 247 (30%)
Married 481 (58.4%)
Divorced 168.72(20.5%)
Widowed 478.99(58.2%)
Results
From the initial 1238, 66.48% of the sample responded
to the online questionnaire. The final sample was formed
by 823 psoriasis-affected people (Mage = 45.9 years;
SD = 12.16). 45.3% were men and 55.7% women. These
results matched previous studies regarding sex and age in
a national sample of patients with psoriasis [41] (table 1).
Marital status was distributed as follows: 481 (58.4%) were
married, 247 (30%) were single, 81 (9.8%) were divorced
and 14 (1.8%) were widowed. The mean age of psoria-
sis onset was 22.9 years (standard deviation 12.72 years).
Regarding the PANAS, the negative affectivity scale had a
mean of Mnegative = 26.74 (SD = 7.52) and the positive affec-
tivity scale had a mean of Mpositive = 20.02 (SD = 7.48).
The severity (PASI) and extension (BSA) means were
MPASI = 16.21 (SD = 12.61) and MBSA = 20.56 (SD = 18.77),
respectively. No differences at the baseline were found
after statistically controlling for the possible influences of
age and gender and marital status. Pearson’s correlations
between emotion scales and both BSA and PASI are shown
in table 2.
We found a different pattern of association with both
the consensual model of emotion and the PAD model of
emotion. Following the consensual model of emotion, the
overall negative affect of the PANAS was correlated both
with extension (BSA; r = 0.222; p = .000) and severity
(PASI; r = 0.236; p = .000). However, we found no relation-
ship between skin lesion involvement and positive emotions
for severity (PASI; r = -0.056; p = .105) or extension (BSA;
r = -0.030; p = .385).
When we performed a correlation analysis with the global
dimensions of emotions according to the PAD classi-
fication (Dominance/Submission, Activating/Deactivating
and Positive/Negative) we also found a different pat-
tern of association for Dominance/Submission and for
Positive/Negative dimensions. Submission and Negative
emotions showed a direct significant relationship of mod-
erate magnitude with skin lesions, both for extension and
severity, while positive and dominant emotions were not
associated with skin lesions. Finally, in relation to the Acti-
vating/Deactivating dimension, direct positive correlation
EJD, vol. 25, n◦ 4, July-August 2015
Nationally representative sample difference
Range Min Max Mean (SD) p
1217
67 14 81 45.11 (13.92) .1862
742 (61%) .5254
475 (39%)
were found for both activating and deactivating emotions
with psoriasis lesions. These results can be found in table 2
as well.
Discussion
Main findings
The aim of this study was to explore the emotional profile
of a large sample of psoriasis patients and its relationship
with the severity and extension of skin lesions measured by
PASI. We found that both the extension and the severity of
the lesions showed a direct significant relationship with neg-
ative emotions but not with positive emotions (i.e. patients
with greater lesion extension or intensity had a higher prob-
ability of having more intense negative emotions and vice
versa), as shown previously [24]. In addition, submissive
emotions were directly correlated with a greater extension
and severity of the lesions, while the opposite was found for
the emotions categorized as dominance emotions. Thus, we
found a different emotional profile associated with psoriasis
lesions.
Related studies
In the literature, both positive and negative affectivity
has been correlated with other instruments measuring
psychopathology [23]. Regarding the different emotions
explored in our sample, the emotional profile that was most
associated with the severity of the lesions were feeling ‘dis-
tressed’, ‘jittery’, ‘depressed’ or ‘upset’. This finding is
consistent with the fact that psoriasis patients usually score
highly in questionnaires focusing on psychopathology,
especially on depression and anxiety [1, 25-28]. Although
more scarce in psychodermatology research, different emo-
tions have been studied in the psoriasis population. Some
previous studies have also found feelings of embarrass-
ment and shame in psoriasis patients [13], worry and anger
[15], fluctuating moods, negativity and loneliness [29]. Oth-
ers found support for the relationship between negative
emotions and the severity of the lesions. Sampogna et al
331
Table 2. Pearson’s correlations between lesion severity index Additional findings
(PASI) and extension of the lesion index (BSA) with the
PANAS scales. Pearson’s correlations between the emotion Another interesting finding, although of low magnitude,
dimensions following the consensual model and the PAD was the positive association between skin lesions and feel-
model of emotion. ings of rejection. It has been shown that psoriasis patients’
levels of distress can be associated with the perception of
BSA p PASI p being stigmatized [31] and the anticipation of rejection and
feelings of guilt and shame [32], all of which are categorized
PANAS Scales
as submissive emotions in the PAD model. In addition to
Positive emotions
this, the fear of negative evaluation has been correlated with
Determined 0.058 .094 0.015 .658 worse quality of life [33]. More recently, these findings have
Active 0.016 .650 -0.003 .927 found support in a study using an experimental face recog-
Attentive -0.017 .616 -0.025 .466 nition paradigm, showing higher brain activity when facing
Strong -0.019 .593 -0.058 .094 rejection in patients with psoriasis [2]. Our results suggest
Interested -0.021 .547 -0.051 .139 that patients with psoriasis show a tendency to experience
Concentrating -0.032 .351 -0.050 .150 submissive emotions such as guilt, fear or depression, as
Delighted -0.043 .218 -0.087 .012 opposed to dominant emotions, such as anger or irritation.
Proud -0.044 .208 -0.041 .243 This opens the debate of personality or individual differ-
Excited -0.055 .112 -0.076 .029 ences in patients with psoriasis that will be discussed later
Inspired -0.087 .012 -0.122 .000 in the discussion.
Negative emotions
Ashamed 0.114 .001 0.102 .003
Hostile 0.120 .000 0.153 .000 Is there a causal relationship?
Scared 0.140 .000 0.135 .000 The causal relationship between skin lesions and emotions
Guilty 0.151 .000 0.129 .000 is still controversial and conflicting positions coexist.
Rejected 0.155 .000 0.179 .000 While some authors defend that (1) the state of the skin
Irritable 0.167 .000 0.178 .000 may impair the emotional state of people with psoriasis
Afraid 0.168 .000 0.152 .000 [32], which is supported by different studies that have
Upset 0.180 .000 0.205 .000 shown that anxiety and depression symptoms improved
Distressed 0.190 .000 0.222 .000 after reducing the skin lesions in patients with psoriasis
Jittery 0.191 .000 0.216 .000 following a dermatological treatment [33-35], others claim
Nervous 0.202 .000 0.199 .000 that (2) there is no such relationship, based on studies that
Depressed 0.236 .000 0.206 .000 have not found any association between negative emotions
Emotion Dimensions
and the duration of the illness [36], skin lesions or general
Consensual model
psychosocial impairment [37]. And finally, other studies
suggest that (3) the emotional state may worsen the skin
Positive -0.030 .385 -0.056 .105
lesions [38], supported by the fact that psychological state
Negative 0.222 .000 0.236 .000
is relatively independent of the state of the skin [9], that
PAD model
depressed psoriasis patients have a higher risk of develop-
Dominance -0.089 .012 -0.135 .000 ing psoriasis lesions [25], that psoriasis patients generally
Submission 0.230 .000 0.217 .000 present higher rates of psychological disorders [34, 35] even
Activating 0.163 .000 0.193 .000 in remission periods [40], and report higher levels of stress
Deactivating 0.206 .000 0.198 .000 prior to the onset of psoriasis (i.e. in some cases, 72% of
Positive -0.022 .533 -0.059 .100 cases [36]).
Negative 0.236 .000 0.237 .000

Study limitations and strengths

found that feelings of shame, anger, worry and difficulties
in daily activities and social life were associated with the
severity of the lesions [15]. However, other studies did not
find this relationship in the case of feelings of worry [27].
In relation to positive or negative emotions, our sample
shows similar levels of negative affect but lower positive
emotions than what has been reported in the general popula-
tion [18], which could indicate that psoriasis patients suffer
subclinical levels of psychopathology. This is in accordance
with a classic study which found that psoriasis patients had
intermediate levels of psychopathology when compared to
depressed patients and healthy subjects [30]. The sugges-
tion of intermediate levels of psychiatric diagnosis could
partly explain why the psychological suffering of patients
with psoriasis can go unnoticed to the healthcare profes-
sionals [8].
Regarding the limitations of our study, a major issue
to be clarified is whether emotional state can influence
the rating of skin lesions, causing an artifactual relation-
ship. We have to admit the possibility that the negative
emotional state may have influenced the perception of
the lesions (i.e. more depressed, worse self-evaluation of
the lesion). However, our findings are compatible with
previous evidence of an association between stress and
skin lesions [11], supported by the relationship between
hypothalamic–pituitary–adrenal axis with the skin [10] and
not just a subjective interpretation of the lesions due to
negative affect [37].
The method for collecting data deserves a brief discussion.
In our study, only patients belonging to the Spanish Associ-
ation of Psoriasis Patients were included. So, patients were
not randomly sampled and may not be representative of the
Spanish population. We also used an online survey as our

332 EJD, vol. 25, n◦ 4, July-August 2015

collection method. There is an ongoing controversy about
the use of the internet to recruit subjects for scientific stud-
ies. Some warn about the potential for selection biases based
on internet access, age, computer skills, etc. These criti-
cisms have to be taken into account, as most patients not
versed in the internet may be excluded. However, in this
study, the variables of age, gender or socioeconomic status
showed no relationship with lesion severity or extension.
Moreover, the results were coherent with previous national
surveys in patients with psoriasis [41], so there are no rea-
sons to expect such bias in the results because of the online
survey. In addition, the exclusive use of Spanish subjects
in the sample could be a limitation when generalizing the
results to other populations.
Our study also has many strengths. The high number of
participants (>800 subjects) reinforces the reliability of
the study, and the fact that data was collected from dif-
ferent geographical locations inside the country increases
the generalization of the results. Other advantages of the
method used in our study are (1) the reduction in the time of
data collection, which may reduce the influence of eventual
maturation of lesions over time or different environmental
influences (season of the year, weekends, vacations) over
the lesions and/or the emotional state, (2) the reduction
of the probability of typing or coding errors, as patients
input their data directly into an electronic database, (3) the
reduction of the amount of missing data, as patients are
notified automatically if the survey is not fully completed
before they can finally send the online questionnaire, and
(4) the reduction of the interference caused by the presence
of the healthcare provider, allowing for a calm situation
for responding and reducing the desirability bias and thus
probably improving the quality of the responses.
Final remarks
As dermatologists assisting patients with psoriasis, we all
have patients in whom the appearance of an outbreak or
worsening of preexisting lesions occurs sometime after
going through difficult life situations that concern them
[39], while in others, this relationship is much less clear. Our
results show an association between the negative and sub-
mission emotions and the severity of the lesions, in a group
of more than 800 subjects, which corroborates this clinical
intuition. But the fact that such association is low probably
means that the relationship is true only in a proportion of
patients and not in others, or that it only occurs on some
occasions and not others within the same patient. That is to
say, the relationship may not be constant or homogeneous.
In this sense, it would be interesting to know what vari-
ables influence this relationship, which sometimes occurs
and sometimes does not. It could depend on the nature of
the stressor or an interaction between the stressor and some
individual characteristic.
An association has been found between personality traits
and early onset of psoriasis, in a study that found that
patients with early-onset psoriasis (<20 years old) were
significantly more anxious and depressed than patients with
late-onset psoriasis [42]. Personality styles have also been
proposed as modulators of the relationship between cer-
tain emotions and psoriasis lesions [6, 40]. Thus, it is
possible that the association between psoriasis lesions and
negative emotions found in our sample is modulated by
EJD, vol. 25, n◦ 4, July-August 2015
personality variables. Further research is required in this
area.
To address the causality question, longitudinal studies are
needed in order to better understand this relationship.
Conclusions
Generally, research in psoriasis has suggested an associ-
ation between different emotions, although studies of a
complete emotional profile and its relationship with skin
lesions are scarce. With that in mind, we have assessed a
wide sample of patients with psoriasis to address the rela-
tionships between psoriasis lesions following two different
models.
Our data supports that the relationship between negative
emotions and skin lesions exists, although with low to
moderate intensity. In addition, we found that submissive
emotions rather than dominance showed a greater correla-
tion with skin lesions. These findings could have important
value for dermatologists and mental health professionals,
researchers and clinicians, as a reminder that this relation-
ship has to be taken into consideration when approaching
the psoriasis patient, while, at the same time, it suggests
some new information that could help manage the doctor-
patient relationship.
This study suggests that two types of emotion (submissive
and negative) are more related to skin lesions in psori-
asis patients. This information may offer some clues to
understanding the mechanisms underlying the complex
relationship between skin lesions and emotions and we hope
that it may help guide health professionals and their patients
in order to better cope with the disease and improve their
quality of life. 
Disclosure. This research was done in close collaboration
with the Spanish association of psoriasis patients Acción
Psoriasis.
Financial support: none. Conflict of interest: none.
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