Perceived stress in four inflammatory skin diseases: an analysis of data taken from 7273 adult subjects with acne, atopic dermatitis, psoriasis or hidradenitis suppurativa

blood smear, infections viral panel, HIV, HBV, HCV, IgG and IgM for VZV. We dismissed the patient with acyclovir 800 mg every 6 h for 10 days and programmed a control visit. One month later, all examinations prescribed were negative, and IgG for VZV was positive, but IgM was negative. Moreover, a past vaccination for chickenpox was tracked in the patient’s records. Two weeks later, all the cutaneous lesions healed. Still, patients referred that all his family (wife and the two small children) developed a varicelloid eruption 2 days after first patient admission. According to Naranjo scale, we considered probable the diagnosis of ‘Disseminated herpes zoster’ by the SARS-CoV-2 vaccine. The diagnosis remains probable, despite the solid temporal relationship, due to the inability to perform a rechallenge, although rare cases of skin manifestations such as disseminated varicella have been reported in the literature after SARS-CoV-2 vaccine. We already are aware that infections cause immunodepression, and it is known that Zoster disease may appear in patients affected by several forms of COVID-19, but disseminated varicelloid eruption, a typical sign of VZV reactivation in an immunosuppressed host, is doubtful in healthy subjects. We believe that the Pfizer vaccine temporarily reduced or altered the responsiveness of cellular immunity to the VZV, causing a disseminated herpes zoster affection. It is also possible that the initial vaccination for chickenpox was not sufficient and that the virus reinfected the hosts due to the already circulating virus in other family members. However, due to the recorded vaccination, the previous chickenpox infection at a young age and since he was the first family member affected, reinfection appeared quite unlikely. What we know is that the greater the number of people vaccinated, the greater the cutaneous side effects we have observed, which have always self-resolved until now without any sequela.

patient's vaccination record and prescribed a chest X-ray, 2,3 a blood smear, infections viral panel, HIV, HBV, HCV, IgG and IgM for VZV.
We dismissed the patient with acyclovir 800 mg every 6 h for 10 days and programmed a control visit.
One month later, all examinations prescribed were negative, and IgG for VZV was positive, but IgM was negative. Moreover, a past vaccination for chickenpox was tracked in the patient's records. Two weeks later, all the cutaneous lesions healed.
Still, patients referred that all his family (wife and the two small children) developed a varicelloid eruption 2 days after first patient admission.
According to Naranjo scale, 4 we considered probable the diagnosis of 'Disseminated herpes zoster' by the SARS-CoV-2 vaccine.
The diagnosis remains probable, despite the solid temporal relationship, due to the inability to perform a rechallenge, although rare cases of skin manifestations such as disseminated varicella have been reported in the literature after SARS-CoV-2 vaccine. 5, 6 We already are aware that infections cause immunodepression, and it is known that Zoster disease may appear in patients affected by several forms of COVID-19, 1 but disseminated varicelloid eruption, a typical sign of VZV reactivation in an immunosuppressed host, is doubtful in healthy subjects.
We believe that the Pfizer vaccine temporarily reduced or altered the responsiveness of cellular immunity to the VZV, causing a disseminated herpes zoster affection.
It is also possible that the initial vaccination for chickenpox was not sufficient and that the virus reinfected the hosts due to the already circulating virus in other family members. However, due to the recorded vaccination, the previous chickenpox infection at a young age and since he was the first family member affected, reinfection appeared quite unlikely.
What we know is that the greater the number of people vaccinated, the greater the cutaneous side effects we have observed, which have always self-resolved until now without any sequela.

Conflict of interest
The authors have no conflict of interest to declare. Perceived stress in four inflammatory skin diseases: an analysis of data taken from 7273 adult subjects with acne, atopic dermatitis, psoriasis or hidradenitis suppurativa Editor Adult acne (AA), atopic dermatitis (AD), psoriasis (P) and hidradenitis suppurativa (HS) are common and chronic, inflammatory skin diseases with an incidence that has been estimated at almost 15% of the adult population in France. 1 They are often accompanied by increased psychological stress levels. 2 This observational, cross-sectional, non-comparative study conducted by five patient associations in France between October 2020 and February 2021, assessed perceived stress in adults with AA, AD, P or HS, as well as self-perceived disease severity and quality of life (QoL) in a large population using a digital questionnaire. The questionnaire was distributed directly to patient association members or through social networks. The study complied with local legal requirements for the conduct of this type of study and received ethics committee approval (CPP Ile de France X, 2020-A01621-38).
The questionnaire ensured that the target dermatoses had previously been confirmed by a health care professional. Stress was assessed using the validated perceived stress scale (PSS) and QoL using the DLQI. 3,4 The PSS questionnaire measures the degree to which situations in one's life are considered as stressful. Individual scores on the PSS can range from 0 to 40, with higher scores indicating higher perceived stress. Scores ranging from 0 to 13 indicate low perceived stress, scores from 14 to 26 indicate moderate perceived stress and scores from 27 to 40 indicate high perceived stress. A DLQI score above 10 designates an important or very important impact on the patient's QoL. Moreover, patients were asked to assess the severity (mild, moderate or severe) of their dermatosis at the time the study was conducted and to confirm if they had been offered psychological support with regards to their dermatosis.
Overall, 7273 subjects participated in this survey; 1605 subjects had AA, 2538 AD, 2329 P and 801 HS. The average age was 40.6 years; 69.25% were women and 54.37% were employed. The self-assessed disease severity was moderate in 49.73% of subjects.
Stress according to disease is displayed in Letters to the Editor AA, AD and P showed that the more severe the condition, the higher the perceived stress scores. This could not be observed for HS patients. While the level of stress was very high in all groups and especially in those patients with severe disease forms, less than 15% had been offered psychological support and, when such aid was proposed, only two patients out of three had accepted it. This finding requires special attention for future patient-centred care measures to be put in place.
The DLQI score was significantly higher and impacted the QoL of patients with AA, AD and P more, especially when stress scores were above 27, which should encourage health care professionals to develop a different, patient-centred treatment approach; these results paralleled results observed for perceived stress ( Table 2).
The main limitations of our study are that the population may be considered unrepresentative, that there was no control group and that the HS population was potentially too small to detect similar results. Moreover, subjects, as members of patient organizations, may suffer more from their disease and could, therefore, be more stressed. Moreover, the gender distribution is not representative, as a majority of women participated in the survey.
Despite these limits and bias, our study shows that in patients with chronic inflammatory skin diseases, psychological stress is an important issue, requiring specific attention and personalized psychological support. Implementing a patient-centred management in chronic inflammatory skin diseases may reduce psychological stress, and potentially improve treatment adherence and improved treatment outcome.

Conflicts of interest
None.

Funding sources
Project funded by European Market Maintenance Assessment with institutional support from Almirall, Leo-Pharma, Pfizer, Bioderma, Pierre Fabre, Amgen, Sanofi and La Roche Posay.

Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.