Perception, understanding, and association between psychological stress and skin aging: Quantitative surveys of Asian women aged 18–34 years, dermatologists, and psychologists in China and Japan

Skin aging involves a variety of structural and functional changes, under the influence of various factors. Preaging skin is a relatively new concept describing self‐perceived signs of skin aging that appear in the early 20s–30s and may be triggered by psychological stress. However, it is unclear how young women and healthcare professionals (HCP) understand the association between stress and skin aging.


| INTRODUC TI ON
During a person's lifetime, their skin undergoes considerable changes with age, including the appearance of wrinkles, drying, loss of elasticity and firmness, progressive thinning of the skin, and a dull appearance. [1][2][3] These changes could be driven by a multitude of physiological processes and pathological intrinsic and extrinsic factors such as air pollution and sun exposure. However, increased exposure to environmental pollutants, sun (ultraviolet light), and lifestyle factors such as poor sleep, stress, smoking, and nutrition, contributes to increased inflammation, oxidative stress, and DNA damage within the skin also in early life. [4][5][6] Based on this, a new concept, referred to as preaging skin, has emerged that has been described as self-perceived signs of skin aging appearing in the early 20s-30s, mainly among women. 4 Psychological stress is highly prevalent in modern societies, reflecting education, work, financial, and family pressures facing young women. Recent events, including the COVID-19 epidemic, have also had a profound impact on psychological stress, especially in younger adults. 7,8 Psychological stress is a response to external or internal factors that induces a variety of physiological changes through neural and endocrine processes, including inflammation. 9,10 Prolonged activation of these pathways can result in chronic immune dysfunction, increased production of reactive oxygen species, and DNA damage, leading to the aging of skin and other related tissues, a process that has been termed inflammaging. 4,6,[9][10][11] Despite a better understanding of the pathophysiologic processes involved in skin aging, it is currently unclear how young women and healthcare professionals understand the association between stress and aging. Furthermore, it is uncertain whether their perceptions are consistent with the actual pathophysiology of stress-related skin aging or inflammation. We therefore sought to explore these perceptions of stress-related aging skin by performing online surveys of young women (aged 18-34) and healthcare professionals. In this study, we focused on Chinese and Japanese women to provide further insight into our earlier study, in which we found that women in China and Japan perceive preaging to involve skin changes that start in the early 20s. 12 We also considered evidence from other studies showing signs of aging in Japanese women in their 20s that contributed to a perception of aging, 13 age-related changes in facial features in Asian women, 14,15 and the potential for differences in skin care habits. 16 We also performed surveys of dermatologists and psychologists, because these are the frontline healthcare professionals involved in managing patients with skin disorders and psychological stress. We examined the association between the aging skin manifestations using a battery of questions related to signs of skin aging and validated measures of stress and well-being. Using the data from the surveys, we also investigated whether perceived stress-related skin aging manifestations are more frequently reported by women with greater stress levels.

| Ethics
The online surveys were conducted by IQVIA in accordance with the codes of conduct for cross-sectional market research China and Japan. 17 As noninterventional, nonclinical, low-risk consumer research surveys compiling anonymized/unlinkable data, ethics committee approval was not required, consistent with recent studies using a similar design. 18,19 After receiving an introduction to the survey, the participants provided informed consent in the form of a check box. The participants had the right to withdraw at any time.

| Participants
Women (self-identified) aged 18-34 years in China and Japan who were members of an IQVIA online market research panel were invited to participate in this online survey. Participants were eligible if they had no major self-reported illnesses or skin disorders, resided in a major city, and were not affiliated with or had participated in other research on skin products. Age and gender were recorded using screening questions to confirm eligibility.
Dermatologists and psychologists who were members of a healthcare professional online market research panel were invited to participate. Healthcare professionals were eligible if they had ≥3 years of experience, spent ≥75% of the time on direct patient care, had a caseload of ≥30 patients per month (≥10 aged 18-34 years), and resided in a major city.
Participants with unique user IDs were only able to complete the relevant survey once through their online dashboard to prevent multiple entries from a single person. Furthermore, upon completion of data collection, data quality control was performed to detect potential duplicate entries; no duplicate entries were detected in the final sample.

| Survey designs
The online surveys were designed to take approximately 20 min to complete. All surveys were written in English and translated into with validated Chinese and Japanese translations. Both scales were analyzed using the appropriate methods.
The survey for healthcare professionals included up to 21 questions, depending on country and specialty. The design of this survey is presented in File S2. The questions covered patient issues and complaints, stress triggers, inflammation, stress-skin cycle, skin issues, skin-aging connection, stress-aging connection, skin signs and stress, medications/holistic therapies for skin and stress, the impact of COVID-19, and changes in stress among patients.
The surveys of young females and healthcare professionals included a mixture of multiple-choice (single or multiple responses) and free-text responses. To minimize sequence bias, the orders of responses/items were rotated for the questions listed in Files S1 and S2.
The respondents were unable to skip any questions or leave any items blank. If they did not answer any questions, the questionnaires were marked as "incomplete" and the data were not included in the final data set. Information on incomplete questionnaires was not recorded.

| Data analyses
It was planned to enroll 300 women in China and 100 women in Japan aged 18-34 years as well as 30 dermatologists and 30 psychologists in each country. This sample size was deemed sufficient to obtain insight into psychological stress and skin manifestations affecting Asian women as well as the perceptions among healthcare professionals.
The sample sizes were selected to provide an acceptable margin of error in the survey of young women and to provide a minimum quantifiable sample for each specialty of healthcare professionals.
All data were analyzed descriptively in terms of calculating the number (percent) of responses for each question/item.
As an indicator of stress, the sum scores for the seven stress subscale items (1, 6, 8, 11, 12, 14, and 18) were summed and multiplied by 2 to yield a maximum possible range of 0-42. The participants were then divided into two groups by applying a cutoff value of ≥15 to indicate those with mild-extremely severe stress and <15 to indicate those with normal stress. 20 The types of skin issues reported by the young women and their demographic characteristics were compared using χ 2 tests between respondents with normal stress and those with mild-extremely severe stress based on the stress subscale scores.
Multiple logistic regression models were used to examine the unbiased association between each of the skin manifestations and the respondents' stress level with adjustment for age, country, employment status, and education attainment.
For the question "In your opinion, how much is each of the skin signs below associated with stress, that is, is a result of stress/ psychological and emotional pressure?" (Q10, young women; Q12, healthcare professionals), the responses "not at all associated" (1), "somewhat not associated" (2), "maybe associated, maybe not" (3), "somewhat associated" (4), and "very much associated" (5) were recoded as −2, −1, 0, 1, and 2, respectively, in order to analyze the strength and direction of the perceptions on the association between psychological stress and the appearance of various skin signs and compare the perceptions between young females and healthcare professionals. For this, the calculated scores were perceived to be stress-related (score > 0), unrelated to stress (score < 0), or of unclear relationship (score = 0).

| Participants
Valid responses were obtained for 403 young women aged 18-34 years with an expected distribution of 100 (24.8%) in Japan and 303 (75.2%) in China (Table 1). Two-thirds (66.3%) of the respondents were in full-time employment and 79.9% had an undergraduate degree.
Valid responses were obtained from 120 healthcare professionals, which comprised 60 psychologists and 60 dermatologists (30 each from China and Japan). Overall, 75 (62.5%) had >10 years of experience, 39 (32.5%) had 6-10 years of experience, and 6 (5.0%) had 3-5 years of experience.  25-34 (47%) years. There was a trend for the 25-34 age group to report greater stress levels ( Figure 1). When divided into two groups, the stress level was normal (<15) in 212 (52.6%) women and mildextremely severe (≥15) in 191 (47.4%) women. The normal stress group included a greater proportion of women aged 18-24 years (57.4%), whereas the mild-extremely severe stress group comprised a greater proportion of women aged 25-34 years (56.0%) (p = 0.04; Table 2). The mild-extremely severe stress group also included a greater proportion of full-time employees than the normal stress group (70.7% vs 62.3%), although the distribution of employment status did not differ significantly (p = 0.074). The geographic location and education attainment were comparable in both groups.

| Perceptions of young women on the association between stress and skin aging
Based on the question "Thinking of how stress may impact somebody's life, how strong do you think the connection between stress, psychological and emotional pressure and premature skin aging is?" (Q8), 92.3% of the young women reported a moderate-very strong connection. The three skin manifestations that were considered to show the strongest association, based on the responses to the question "how much is each of the skin signs below associated with stress, that is, is a result of stress/psychological and emotional pressure?" (Q10), were "dark eye circles," "slow metabolic rate," and "dull skin" F I G U R E 1 Self-reported stress levels among young women aged 18-24 or 25-34 years based on the DASS-21 stress subscale. The seven stress subscale items (1, 6, 8, 11, 12, 14, and 18) were summed and multiplied by 2 to yield a maximum possible range of 0-42. The scores were divided into normal, mild, moderate, severe, or extremely severe. 20 Although approximately half of the young women had mild stress, the proportion of women with extremely severe stress tended to be greater among those aged 25-34 years than in those aged 18-24 years.  Table 3 indicating that these were the most frequently reported skin manifestations or the manifestations with the greatest differences in frequency between the normal and mild-extremely severe stress groups.

| Perceptions of healthcare professionals on the association between stress and skin aging
The healthcare professionals were asked, "how much is each of the skin signs below associated with stress, that is, can be a result of stress/psychological and emotional pressure, or stress-induced inflammation?" (Q12), and their responses were classified based on whether each manifestation was perceived to be stress-related, unrelated, or of unclear relation. As indicated in Figure 2, healthcare professionals thought that "acne," "dry skin," "skin rash," "wrinkles," "changing skin type (dry or oily)," "dull skin," "clogged pores," "rough skin," "thin skin," "sagging skin/lack of firmness," "poor elasticity," "dark eye circles," and "flat lines around the eyes" were somewhat or very much associated with stress (with scores exceeding 0.5).
The psychologists and dermatologists had similar perceptions of these factors, although small differences were noted. For example, psychologists tended to consider "wrinkles," "thin skin," and "poor skin elasticity" as showing greater associations with stress compared with dermatologists.

| Differences in perceptions of stress and skin aging between healthcare professionals and young women
The healthcare professionals judged many of the manifestations as having a stronger association with stress than did the young women ( Figure 2), although the perceptions were similar for some, including "dark eye circles" and "slow metabolic rate." The young women also considered some skin manifestations to be more important than did the healthcare professionals, including "more reactive to aggressors/less resilient," "yellow/sallow tone," "less translucent," "darker color on the neck than face," and "wrinkle on nasolabial fold," although the scores were broadly neutral.

| Recommendations given by healthcare professionals to individuals with signs of stress
We also evaluated the types of treatments recommended by healthcare professionals to their patients experiencing stress using the questions: "For those of your patients who may be experiencing skin issues due to stress or mental/emotional pressure, do you recommend any of the following to reduce stress?" (dermatologists) or "For your patients suffering from stress or mental/emotional pressure, what do you usually recommend to alleviate the stress?" (psychologists) (Q15.1). Generally, the dermatologists and psychologists made similar recommendations, with "adjusting the sleep pattern," "meditation," "physical exercise/sports," and "taking a holiday/ time off work" being the top four recommendations (Figure 3).
Psychologists more frequently recommended that their patients should "spend more time outdoors" or "re-connect with friends or family." Dermatologists more frequently recommended "apps for meditation/relaxation" and "anti-stress cosmetic products."

| DISCUSS ION
We performed online surveys to elucidate how well young women and healthcare professionals (in this case dermatologists and psychologists) perceived an association between psychological stress and skin aging. We also examined whether young women with TA B L E 3 Comparison of self-reported skin issues (Q10) between young women divided into subgroups according to the level of stress defined using the DASS-21 stress subscale scores a . higher stress levels were more likely to experience skin manifestations typically associated with aging.
Of note, we found that nearly half of the young women had mildextremely severe stress, with DASS-21 stress subscale scores of ≥15.
Furthermore, several skin manifestations, including "rough skin," "slow metabolic rate," "dull skin," "sagging skin/lack of firmness," "more reactive to aggressors/less resilient," "poor skin elasticity," "yellow/sallow tone," and "dry skin" were more frequently reported in the mild-extremely severe stress group than in the normal stress group. In other countries, high levels of stress were also reported to be associated with skin symptoms. For example, in a US study of 422 university students aged 18-30 years, high self-reported stress was significantly associated with various skin symptoms, including pruritus, hair loss, patchy scalp, hyperhidrosis, scaly skin, nail-biting, itchy rash on hands, and hair pulling. 22 Similar results were reported in an Australian study of university students aged 18-30 years 23 and in a survey of 529 medical students aged 18-24 years in Saudi Arabia. 24 Taken together, these findings provide further support for an association between stress and the signs of preaging of skin or other skin symptoms. 9,10 To explore this association between stress and preaging of skin, we evaluated the strength and direction of the perceptions held by young women and healthcare professionals. We found that young women mostly considered "dark eye circles," "slow metabolic rate," and "dull skin" to be associated with stress, although the strengths of these associations were relatively low. By comparison, the healthcare professionals reported much stronger associations between stress and appearance of skin signs, particularly "acne," "dry skin," "skin rash," "wrinkles," "changing skin type (dry or oily)," "dull skin," "clogged pores," "rough skin," "thin skin," "sagging skin/lack of firmness," "poor F I G U R E 2 Strength and direction of the perceptions of young women and healthcare professionals on the association between psychological stress and the appearance of skin signs. The responses to the question "In your opinion, how much is each of the skin signs below associated with stress, that is, is a result of stress/psychological and emotional pressure?" (Q10, young women; Q12, healthcare professionals), "not at all associated" (1), "somewhat not associated" (2), "maybe associated, maybe not" (3), "somewhat associated" (4), and "very much associated" (5) were recoded as −2, −1, 0, 1, and 2, respectively, to analyze the strength and direction of the perceptions on the association between psychological stress and the appearance of various skin signs and compare the perceptions between young women and healthcare professionals. The calculated scores were perceived to be stressrelated (score > 0), unrelated to stress (score < 0), or of unclear relationship (score = 0). Young women and healthcare professionals had differing perceptions regarding the associations between stress and specific skin manifestations of aging. According to young women, the three skin manifestations that showed the strongest association were "dark eye circles," "slow metabolic rate," and "dull skin," whereas "acne," "dry skin," and "skin rash" showed the strongest association based on the healthcare professionals' responses.   The surveys were performed in winter, which is known to have an impact on the levels of stress or depression. 26 Furthermore, the participants could have been less concerned about sun exposure and its impact on signs of skin aging than they might be in summer.
Therefore, further studies might be useful to investigate how the perceptions of skin aging vary with the season.

| Limitations
There are some limitations to discuss. Because this was an online

| CON CLUS IONS
In conclusion, we found that approximately half of the young women

AUTH O R CO NTR I B UTI O N S
All authors substantially contributed to research design, execution, and analysis were involved in manuscript development and approved the final draft. The authors also take accountability for the integrity and accuracy of the data reported in this article.

ACK N OWLED G M ENTS
The authors acknowledge IQVIA for performing the surveys and data analyses. The authors thank Sajita Setia and Nicholas D. Smith (Transform Medical Communications) for medical writing support, which was funded by Johnson & Johnson Pte., Ltd.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data used for this analysis are available upon request from the corresponding author.

E TH I C A L A PPROVA L
The online surveys were conducted by IQVIA in accordance with the codes of conduct for cross-sectional market research in China and Japan. 17 As noninterventional, nonclinical, low-risk consumer research surveys compiling anonymized/unlinkable data, ethics committee approval was not required, consistent with recent studies using a similar design. 18,19

I N FO R M ED CO N S ENT
After receiving an introduction to the survey, all participants provided informed consent in the form of a check box. The participants had the right to withdraw at any time.