Psychological stress documentation and subsequent risk of chronic inflammatory skin diseases: a large-scale real-world cohort study
11 affiliations
- 1Dermatology and Venereology Division, Department of Medicine (Solna), Karolinska Institutet
- 2Department of Medical Epidemiology and Biostatistics, Karolinska Institutet
- 3Dermato-Venereology Clinic, Karolinska University Hospital
- 4Lübeck Institute of Experimental Dermatology, University of Lübeck
- 5University of Lübeck
- 6QIMA Life Sciences, QIMA Monasterium GmbH
- 7Gifu University Graduate School of Medicine
- 8Department of Dermatology, Allergology and Venerology, University Medical Center Schleswig-Holstein
- 9Department of Cardiology, University Heart Centre Frankfurt, University Hospital Frankfurt
- 10Department of Psychiatry and Psychotherapy , University Medical Center Schleswig-Holstein
- 11Institute and Comprehensive Center for Inflammation Medicine, University of Lübeck
Abstract
Background: Chronic inflammatory skin diseases (CISD) affect 20-25% of the population. Psychological stress is considered a modifiable risk factor, yet epidemiologic evidence remains inconsistent, partly due to challenges in capturing stress through clinical documentation.
Objective: To investigate whether clinically documented psychological stress is associated with altered risk of incident CISDs.
Methods: Retrospective cohort study. Individuals with ICD-coded psychological stress diagnoses propensity score-matched to controls on demographics, comorbidities, and healthcare utilization. Incident CISD risk was evaluated using Cox proportional hazards models over a median follow-up of 7.1 years. Robustness was assessed through seven sensitivity analyses, positive and negative control outcomes, model triangulation using multivariable Cox models, and quantitative bias analysis for exposure misclassification and empirical calibration of all primary estimates against 22 negative control outcomes.
Results: Among 399, 615 matched pairs, ICD-coded stress showed no consistent association with incident atopic dermatitis, psoriasis vulgaris, vitiligo, lichen planus, alopecia areata, acne vulgaris, or rosacea. A modest association was observed for hidradenitis suppurativa (HR 1.20, 95% CI 1.13-1.27), which did not persist after empirical calibration (calibrated HR 1.17, 95% CI 1.00-1.37, calibrated p=0.049). Negative control outcomes revealed a small systematic upward shift, centred at HR 1.02. Bias analysis showed that incomplete documentation of stress among comparators could not account for the null associations.
Limitations: Incomplete capture of psychological stress in electronic health records, potential diagnostic miscoding, residual unmeasured confounding, differential outcome ascertainment between cohorts, and lack of causal inference.
Conclusion: After empirical calibration, ICD-coded stress diagnoses were not associated with incident CISD in US electronic health records, suggesting that stress documentation may not be a robust population-level predictor of CISD onset.
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BibTeX
@article{curman2026psychological,
title = {{Psychological stress documentation and subsequent risk of chronic inflammatory skin diseases: a large-scale real-world cohort study}},
author = {Philip Curman and Emelie Fischer and Jasmina Golaboska and Kaya Harms and Johanna Borowik and Julica Huckshold and Clara-Elisabeth Löscher and Marjam Nadjmabadi and Ayumi Maeda and Khashayar Pourrahimi and Sören Dräger and Hatim Kerniss and Jan Philipp Klein and Katja Bieber and Ralf J. Ludwig},
journal = {Frontiers in Immunology},
year = {2026},
month = oct,
doi = {10.3389/fimmu.2026.1951015},
url = {https://www.frontiersin.org/articles/10.3389/fimmu.2026.1951015/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Psychological stress documentation and subsequent risk of chronic inflammatory skin diseases: a large-scale real-world cohort study
AU - Philip Curman
AU - Emelie Fischer
AU - Jasmina Golaboska
AU - Kaya Harms
AU - Johanna Borowik
AU - Julica Huckshold
AU - Clara-Elisabeth Löscher
AU - Marjam Nadjmabadi
AU - Ayumi Maeda
AU - Khashayar Pourrahimi
AU - Sören Dräger
AU - Hatim Kerniss
AU - Jan Philipp Klein
AU - Katja Bieber
AU - Ralf J. Ludwig
PY - 2026
DA - 2026/10/13
JO - Frontiers in Immunology
DO - 10.3389/fimmu.2026.1951015
UR - https://www.frontiersin.org/articles/10.3389/fimmu.2026.1951015/full
AB - Background: Chronic inflammatory skin diseases (CISD) affect 20-25% of the population. Psychological stress is considered a modifiable risk factor, yet epidemiologic evidence remains inconsistent, partly due to challenges in capturing stress through clinical documentation. Objective: To investigate whether clinically documented psychological stress is associated with altered risk of incident CISDs. Methods: Retrospective cohort study. Individuals with ICD-coded psychological stress diagnoses propensity score-matched to controls on demographics, comorbidities, and healthcare utilization. Incident CISD risk was evaluated using Cox proportional hazards models over a median follow-up of 7.1 years. Robustness was assessed through seven sensitivity analyses, positive and negative control outcomes, model triangulation using multivariable Cox models, and quantitative bias analysis for exposure misclassification and empirical calibration of all primary estimates against 22 negative control outcomes. Results: Among 399, 615 matched pairs, ICD-coded stress showed no consistent association with incident atopic dermatitis, psoriasis vulgaris, vitiligo, lichen planus, alopecia areata, acne vulgaris, or rosacea. A modest association was observed for hidradenitis suppurativa (HR 1.20, 95% CI 1.13-1.27), which did not persist after empirical calibration (calibrated HR 1.17, 95% CI 1.00-1.37, calibrated p=0.049). Negative control outcomes revealed a small systematic upward shift, centred at HR 1.02. Bias analysis showed that incomplete documentation of stress among comparators could not account for the null associations. Limitations: Incomplete capture of psychological stress in electronic health records, potential diagnostic miscoding, residual unmeasured confounding, differential outcome ascertainment between cohorts, and lack of causal inference. Conclusion: After empirical calibration, ICD-coded stress diagnoses were not associated with incident CISD in US electronic health records, suggesting that stress documentation may not be a robust population-level predictor of CISD onset.
SN - 1664-3224
ER -