Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(3):5249 1 Impact of Psychological Factors on Early vs. Late-Onset Psoriasis: A Comparative Analysis Elif Afacan Yıldırım E1, Muhterem Polat2 1 Demiroglu Bilim University, Faculty of Medicine, Department of Dermatology, Istanbul, Turkey 2 Gazi University, Faculty of Medicine, Department of Dermatology, Ankara, Turkey Key words: Psoriasis, Psychological impact, Stress, Psychodermatology, Early-onset psoriasis Citation: Afacan Yıldırım E, Polat M, et al. Impact of Psychological Factors on Early vs. Late-Onset Psoriasis: A Comparative Analysis. Dermatol Pract Concept. 2025;15(3):5249. DOI: https://doi.org/10.5826/dpc.1503a5249 Accepted: April 3, 2025; Published: July 2025 Copyright: ©2025 Afacan Yıldırım et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Elif Afacan Yıldırım, MD, Demiroglu Bilim University, Faculty of Medicine, Department of Dermatology, Istanbul, Turkey. ORCID ID: 0000-0001-7912-2745. E-mail: eliff_afacan@hotmail.com Introduction: Psoriasis is a chronic inflammatory disease that significantly impacts psychosocial well-being. This study compared the clinical and psychosocial characteristics of early-onset (<40 years) and late-onset (≥40 years) psoriasis. Methods: This cross-sectional study included 190 patients with psoriasis categorized as early-onset (n=135) and late-onset (n=55). Data on demographics, clinical features, comorbidities, and psychoso- cial factors were collected. The Hospital Anxiety and Depression Scale (HADS) and the Dermatology Life Quality Index (DLQI) assessed psychological impact and quality of life. Statistical analyses includ- ed chi-squared tests, t-tests, and correlation analyses. Results: Early-onset patients were more likely to have a family history of psoriasis (43.7% vs. 16.4%, P<0.001), while pustular psoriasis was more common in the late-onset group (27.3% vs. 11.1%, P=0.006). A significant positive correlation was observed between DLQI scores and HADS-Total, HADS-Anxiety, and HADS-Depression scores (P<0.001). Psychological stress was reported as a dis- ease trigger by 63.1% of patients, with a higher proportion in the early-onset group (P=0.025). Al- though initial comparisons revealed no significant difference in DLQI or HAD scores between groups, an additional analysis limited to chronic plaque psoriasis revealed significantly higher anxiety and total HADS scores in the early-onset group (P=0.002 and P=0.035, respectively), suggesting a stronger psychological burden when clinical subtype is controlled. Conclusions: Early-onset psoriasis patients are more likely to report stress as a trigger and have a family history, while late-onset patients exhibit higher rates of pustular psoriasis and increased body mass index. Early-onset patients with chronic plaque psoriasis experience greater psychological bur- den, particularly anxiety. These findings highlight the importance of age of onset in tailoring psycho- social support and treatment strategies in psoriasis care. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(3):5249 Introduction Psoriasis is a common chronic immune-mediated inflam- matory disease characterized by periods of remission and relapse, significantly impacting patients’ quality of life [1]. Psoriasis is traditionally classified into two categories based on age at onset: early-onset (type 1, onset before age 40 years) and late-onset (type 2, onset after 40 years) [2]. According to Henseler and Christophers [2], early-onset psoriasis is asso- ciated with HLA markers, often has a family history, and represents a more severe clinical form. In contrast, late-onset psoriasis shows weaker associations with HLA and family history, following a milder course. Studies have used different threshold ages to define early- and late-onset psoriasis, but generally, early-onset psoriasis is linked to a higher genetic predisposition, a more severe disease course, and greater psychosocial comorbidity [3-5] The chronic nature of psoriasis and its significant impact on quality of life result in a high burden of psychosocial mor- bidity. Psychological stress is a crucial factor, both as a trig- ger and as a consequence of the disease [6]. Studies have shown that patients with psoriasis experience numerous psy- chological challenges, and as a result, they are at increased risk of depression, anxiety, social phobia, suicidal thoughts, and addictions (e.g., smoking, alcohol) [7-9]. In a study in- vestigating the psychological effects of early- and late-onset psoriasis, statistically significant differences were observed in patients’ personality traits, depression, and anxiety scores [4]. While the existing literature provides limited insights into the clinical and psychosocial characteristics that distinguish early-onset from late-onset psoriasis, understanding these differences is essential to optimizing patient management strategies. Objective This study aimed to determine whether there are differences in clinical and psychosocial characteristics of psoriasis pa- tients based on the age at disease onset. By comprehensively examining these variables, we aimed to determine whether early-onset and late-onset psoriasis manifest distinct profiles that could inform differential treatment approaches and en- hance patient care outcomes. Methods Study Design and Participants In this cross-sectional study, a total of 190 patients were re- cruited from the psoriasis treatment center at Gazi University, Department of Dermatology and Venereology. The study was conducted in accordance with the ethical standards described in an appropriate version of the 1975 Declaration of Helsinki, as revised in 2018. The patients were categorized into two groups based on the age at psoriasis onset: early-onset (under age 40 years) and late-onset (40 years and older). Follow- ing informed consent, all patients were assessed by qualified dermatologists. The PASI (Psoriasis Area and Severity Index) scores were calculated for patients with chronic plaque pso- riasis. The patients were asked to complete the scales of the Dermatology Life Quality Index (DLQI) and Hospital Anx- iety and Depression Scale (HADS). The study was approved by the Gazi University Clinical Research Ethics Committee on 21 July 2020, with decision number 512. Measurement Tools The Dermatology Life Quality Index (DLQI) The Dermatology Life Quality Index (DLQI) was the first tool developed specifically for dermatological conditions by Finlay et al. [10] The DLQI consists of 10 questions grouped into five categories, and the total score ranges from 0 to 30. Higher scores indicate a greater impact on quality of life. The validity and reliability study of the Turkish version of the DLQI was conducted by Öztürkcan et al. in 2006 [11]. Hospital Anxiety and Depression Scale (HADS) The Hospital Anxiety and Depression Scale (HADS) was developed by Zigmond and Snaith to identify anxiety and depression in individuals with physical illnesses [12] The va- lidity and reliability study of the Turkish version was con- ducted by Aydemir et al. in 1997 [13]. The HADS is a 14-item scale with a four-point Likert response format, where seven items measure anxiety (HADS-A) and seven items measure depression (HADS-D). The cutoff points for the Turkish ver- sion are 10 for HADS-A and 7 for HADS-D [13]. Statistical Analysis The statistical analyses were conducted using IBM SPSS Statistics Version 23.0 (Statistical Package for Social Sci- ences, SPSS Inc., Armonk, NY, USA). Descriptive statistics are presented as mean, standard deviation, frequency, and percentage. The Pearson chi-squared test was used to com- pare categorical variables. The Kolmogorov-Smirnov test was used to determine the normality of the distribution of variables. For variables not following a normal distribution, the Mann-Whitney U test and Kruskal-Wallis test were ap- plied. Pearson correlation analysis was used for the correla- tion of parametric variables. The significance threshold was set at P<0.05. Results Study Population The study included 190 patients aged 18 and older. Among them, 135 had disease onset before the age of 40 and were Original Article | Dermatol Pract Concept. 2025;15(3):5249 3 classified as the “early-onset psoriasis” group, while 55 had disease onset at age 40 or older and were classified as the “late-onset psoriasis” group. Sociodemographic Characteristics of the Patients The sociodemographic characteristics of the patients are summarized in Table 1. The higher proportion of females in the late-onset group was found to be statistically significant (P=0.023). Clinical and Psychosocial Characteristics of the Patients The features related to family history, clinical presentation, and smoking/alcohol use in early- and late-onset psoriasis patients are shown in Table 2. A family history of psoriasis was significantly more prevalent among early-onset patients (χ²=12.71, P<0.001). On the other hand, pustular forms of psoriasis were observed at a significantly higher rate in the late-onset group (χ²=7.62, P=0.006). In patients with chronic plaque psoriasis, the mean PASI score was found to be 4.23 (ranging from 0 to 49). No significant difference in PASI scores was observed between patients with early-onset and late-onset psoriasis vulgaris (Z=-1.195, P=0.232). The comorbidities associated with early- and late-onset psoriasis patients are shown in Table 3. In early-onset psori- asis patients, the most common comorbidities were obesity (n=30), hypertension (n=21), diabetes mellitus (n=13), and hypo/hyperthyroidism (n=11). In late-onset psoriasis pa- tients, the most common comorbidities were hypertension (n=20), obesity (n=19), and diabetes mellitus (n=9). The distribution of patients based on body mass in- dex (BMI) was as follows: among early-onset psoriasis pa- tients, 3% had a BMI under 18.5 kg/m², 40.3% were in the 18.5-24.9 kg/m² range, 30.6% were in the 25-29.9 kg/m² range, and 26.1% were in the 30-39.9 kg/m² range. In con- trast, among late-onset psoriasis patients, none had a BMI under 18.5 kg/m², 17.0% were in the 18.5-24.9 kg/m² range, 43.4% were in the 25-29.9 kg/m² range, and 39.6% were in the 30-39.9 kg/m² range. Our results indicate that a later age at onset is associated with an increase in BMI (P=0.001). The comorbidities associated with early- and late-onset psoriasis patients were also compared. Hypertension was significantly more common in patients with late-onset psoriasis (χ²=9.99, P=0.001); however, there was no significant difference be- tween the two groups for other comorbidities, including dia- betes, coronary artery disease, hyperlipidemia, inflammatory bowel disease, and hypo/hyperthyroidism. Upon questioning patients about major traumatic life events experienced at the time or just before the onset of psoriatic lesions, 101 patients (53.1%) reported a major traumatic life event that they associated with the beginning of their disease. These events included the death of a loved one, family problems, economic and work-related issues, relocation, military service, and other similar situations. The frequency of major traumatic life events was found to be significantly higher in late-onset patients compared to early-onset patients (χ²=11.90, P=0.001). A comparison of the psychosocial characteristics of early- and late-onset pa- tients is shown in Table 3. The difference in patients report- ing psychological stress as a trigger for their illness between Table 1. The Sociodemographic Characteristics of the Patients. Early-onset psoriasis patients Late-onset psoriasis patients All patients Mean ± SD Mean ± SD Mean ± SD Age 39.39±13.57 55.56±7.56 44.07±14.18 n (%) n (%) n (%) Sex Female 59 (43.7) 34 (61.8) 93 (48.9) Male 76 (56.3) 21 (38.2) 97 (51.1) Marital Status Married 94 (69.6) 47 (85.5) 141 (74.2) Single 39 (28.9) 2 (3.6) 41 (21.6) Divorced/Widowed 2 (1.5) 6 (10.9) 8 (4.2) Education Level Primary education 19 (14.1) 23 (41.8) 42 (22.1) Secondary education 54 (40.0) 20 (36.4) 74 (38.9 University and above 62 (45.9) 12 (21.8) 74 (38.9) Employment Status Employed 62 (45.9) 20 (36.4) 82 (43.2) Unemployed 45 (33.3) 18 (32.7) 63 (33.2) Student 16 (11.8) 0 (0.0) 16 (8.4) Retired 12 (8.9) 17 (30.9) 29 (15.3) 4 Original Article | Dermatol Pract Concept. 2025;15(3):5249 Table 3. A Comparison of the Psychosocial Characteristics of Early- and Late-Onset Patients. Early-onset psoriasis patients Late-onset psoriasis patients All patients Pn (%) n (%) n (%) Traumatic life event at disease onset Yes 61 (45.2) 40 (72.7) 101 (53.2) χ 2=11.90, P=0.001 No 74 (54.8) 15 (27.3) 89 (46.8) Psychological stress as lesion trigger Yes 92 (68.1) 28 (50.9) 120 (63.1) χ 2=4.99, P=0.025 No 43 (31.9) 27 (49.1) 70 (36.9) History of psychiatric consultation Yes 56 (41.5) 19 (34.5) 75 (39.5) χ 2=0.78 P=0.375 No 79 (58.5) 36 (65.5) 115 (60.5) History of psychiatric medication Yes 45 (33.3) 19 (34.5) 64 (33.7) χ 2=0.26 P=0.873 No 90 (66.7) 36 (65.5) 126 (66.3) Mean ± SD Mean ± SD P DLQI 6.50±7.00 6.01±6.98 t=0.43, P=0.668 DLQI: Dermatology Life Quality Index. Table 2. The Features Related to Family History, Clinical Presentation, and Smoking/Alcohol Use in Early- and Late-Onset Psoriasis Patients. Early-onset psoriasis patients Late-onset psoriasis patients All patients Pn (%) n (%) n (%) Family history Yes 59 (43.7) 9 (16.4) 68 (35.8) χ 2=12.71, P=0.000No 76 (56.3) 46 (83.6) 122 (64.2) Type of psoriasis Pustular psoriasis (generalized and/ or palmoplantar pustular) 15 (11.1) 15 (27.3) 30 (15.8) χ 2=7.62, P=0.006 Chronic plaque psoriasis 120 (88.9) 40 (72.7) 160 (84.2) Joint involvement Yes 62 (45.9) 28 (50.9) 90 (47.9) χ 2=0.15 P=0.692No 73 (54.1) 27 (49.1) 100 (52.1) Nail involvement Yes 78 (57.8) 30 (54.5) 108 (56.8) χ 2=0.16 P=0.683No 57 (42.2) 25 (45.5) 82 (43.2) Smoking Yes 69 (51.1) 33 (60.0) 102 (57.7) χ 2=1.43 P=0.231No 66 (49.9) 22 (40.0) 88 (42.3) Alcohol consumption Yes 32 (23.7) 10 (18.2) 42 (22.1) χ 2=0.69 P=0.405No 103 (76.3) 45 (81.8) 148 (77.8) History of hospitalization for psoriasis Yes 35 (25.9) 12 (21.8) 47 (27.7) χ 2=0.35, P=0.552No 100 (74.1) 43 (78.2) 143 (75.3) the early-onset and late-onset groups was found to be statis- tically significant (χ²=4.99, P=0.025). The HADS scores for both groups are shown in Table 4. The total HADS scores were 14.11±7.34 in the early-onset group and 12.51±7.80 in the late-onset group. There was no significant difference in HADS-A and HADS-D scores between the early-onset and late-onset groups (P>0.05). Additionally, patients who identified psychological stress Original Article | Dermatol Pract Concept. 2025;15(3):5249 5 Table 4. Hospital Anxiety and Depression Scale (HADS) Scores in Early- and Late-Onset Psoriasis Groups. HADS n (%) Mean ± SD Early-onset psoriasis patients HADS-A Below threshold 102 (75.6) 7.82±4.21 Above threshold 33 (24.4) HADS-D Below threshold Above threshold 87 (64.4) 6.29±3.80 48 (35.6) Late-onset psoriasis patients HADS-A Below threshold Above threshold 44 (80.0) 6.60±4.66 11 (20.0) HADS-D Below threshold Above threshold 34 (61.8) 5.90±4.01 21 (38.2) HADS-A: HADS-Anxiety, HADS-D: HADS-Depression. Table 5. Subgroup Analysis of Psychological Outcomes in Patients with Chronic Plaque Psoriasis According to Age of Onset. Psychosocial parameters Early-onset chronic plaque psoriasis patients (n=120) Mean ± SD Late-onset chronic plaque psoriasis patients (n=40) Mean ± SD t p DLQI 5.79 ± 6.43 3.97 ± 5.62 1.59 0.112 HAD-A 7.96 ± 4.17 5.55 ± 4.48 3.11 0.002 HAD-D 6.23 ± 3.76 5.75 ± 4.23 0.68 0.496 HAD-T 14.19 ± 7.25 11.30 ± 7.96 2.13 0.035 Abbreviations: DLQI: Dermatology Life Quality Index; Hospital Anxiety and Depression Scale (HADS). as a trigger had significantly higher HADS-Total (P=0.016), HADS-A (P=0.024), and HADS-D (P=0.030) scores com- pared to those who did not identify psychological stress as a trigger. Although DLQI scores were higher in the early- onset group, this difference was not statistically significant (t=0.43, P=0.668). Furthermore, our study found a positive and significant correlation between DLQI and HADS-Total (r=.388, P=0.000), HADS-A (r=.400, P=0.000), and HADS-D (r=.301, P=0.000). To address the heterogeneity introduced by different clin- ical types of psoriasis, a subgroup analysis was conducted including only patients diagnosed with chronic plaque pso- riasis (n=160; early-onset=120, late-onset=40). Patients with early-onset disease had significantly higher HADS-A and HADS-Total scores compared to those with late-onset psoria- sis (P=0.002 and P=0.035, respectively). No significant differ- ences were observed in DLQI or HADS-D scores (P=0.112 and P=0.496, respectively). Detailed results are provided in Table 5. Discussion The age at onset of psoriasis is highly variable, ranging from early infancy to advanced age, with the most common age at onset occurring during puberty [14] Approximately 70% of patients experienced the first symptoms of pso- riasis before the age of 40, most frequently in the second to third decades of life [15] A study reported that in 30% of patients, the disease began before the age of 16 [16]. In our study, the observation that 71% of patients had early-onset psoriasis is consistent with the literature. Addi- tionally, a family history of psoriasis was found in 43.7% of early-onset patients, compared to 16.4% of late-onset patients. This finding aligns with literature reports indicat- ing that a family history is more common in early-onset psoriasis patients [2,17] Our study corroborates findings by Ferrándiz et al.[5], demonstrating a higher prevalence of pustular subtypes in late-onset psoriasis. This aligns with their observation that palmoplantar pustulosis predominantly affects patients with disease onset after 30 years of age [5]. The correlation sug- gests that age-related factors may influence the manifesta- tion of specific psoriasis subtypes. Additionally, the same study found no association between joint involvement and the age at disease onset, which aligns with our findings as we also did not observe such an association. Another parameter associated with late-onset age in our study was an increase 6 Original Article | Dermatol Pract Concept. 2025;15(3):5249 Mizara et al. [19] reported maladaptive psychological behavior patterns specific to the early period in patients with psoriasis and suggested that unmet emotional and develop- mental needs in early life could create vulnerability to psy- chological stress in later years. In line with this, another study noted that children and adolescents often experience stigma- tization and social difficulties due to their illness, suggesting that these negative experiences in childhood can affect per- sonality development and lead to anxiety and depression in adulthood [20]. In our study, the presence of psychological stress as a trigger for psoriatic lesions was significantly more common in the early-onset group compared to the late- onset group. Our findings align with another study, by Raychaudhuri and Gross [16], which compared pediatric- onset (<16 years) and adult-onset (>16 years) psoriasis. They emphasized that disease flare-ups were more frequent in pediatric-onset patients under psychological stress. The au- thors explained this by suggesting that emotional immaturity and lack of insight make younger patients more sensitive to psy- chological stress. In our study, the proportion of patients who associated the onset of psoriasis with a recent traumatic life event was significantly higher in the late-onset group. Several studies in the literature indicate that traumatic experiences may play a crucial role in the development and exacerbation of psoriasis [21,22,23]; however, the relationship with the age at disease onset has not been thoroughly investigated. Kimball et al. [24] proposed the concept of Cumulative Life Course Impairment (CLCI) for psoriasis, which ex- presses the cumulative impact of the disease over a lifetime. According to this model, CLCI in psoriasis results from the complex interaction of external factors such as stigmatiza- tion, physical and psychological comorbidities, coping strat- egies, and the social environment. This lifelong accumulation of physical, psychological, social, and economic burdens in- fluences major life decisions. Warren et al. [25] reported that early-onset psoriasis significantly impacts feelings of shame and stigmatization as well as career choices, continuing edu- cation, and relationships with family and social circles, com- pared to late-onset psoriasis. The significant positive correlation between DLQI and HADS-Total, HADS-A, and HADS-D in our study supports the relationship between quality of life, depression, and anx- iety reported in previous literature [26,27]. In the literature, various studies report that the proportion of patients who associate their disease with psychological stress ranges from 37% to 78% [28]. The role of psychological stress in pso- riasis can be explained by its induction of catecholamines and corticosteroids released from the hypothalamic-pituitary axis, leading to the release of neuropeptides from the skin through neuroendocrine, immune, and cutaneous interac- tions. However, the evidence of a relationship between psy- chosocial stress and psoriasis flare-ups is limited, as most in BMI. This finding is consistent with the results reported by Herédi et al., who found that obesity is more common in patients with late-onset psoriasis compared to those with early-onset psoriasis [18]. This suggests that obesity may be a contributing factor to the development of psoriasis at an older age. Early-onset psoriasis has been associated with higher genetic predisposition, a more severe disease course, and greater psychosocial comorbidity in the literature [3,4,5]. However, different studies have used varying threshold ages to define early- and late-onset psoriasis. In a study by Rem- röd et al. [4] involving 101 patients, psoriasis onset before the age of 20 was considered early-onset, while onset at 20 years and older was considered late-onset. Based on this classification, significant differences were found between early-onset and late-onset psoriasis groups in Spielberger State-Trait Anxiety Inventory scores, Beck Depression Inven- tory scores, and the seven personality types identified by the Swedish Universities Scales of Personality. According to these findings, early-onset patients (onset before 20 years of age) were more anxious and depressed compared to late-onset patients. The same study found no significant relationship between PASI scores and patients’ depression and anxiety scores. Additionally, there was no association between the duration of psoriasis and levels of state-trait anxiety, severity of depression, or personality types [4]. However, in contrast with the study by Remröd et al. [4], our study did not ini- tially find a statistically significant difference in depression and anxiety between early-onset and late-onset psoriasis pa- tient groups. One possible explanation for this could be the different threshold ages used in defining early- and late-onset psoriasis. Another important factor may be clinical hetero- geneity. When we performed an additional analysis limited to patients with chronic plaque psoriasis—the most prev- alent and clinically homogeneous subtype—we found that early-onset patients had significantly higher anxiety scores and total HADS scores compared to those with late-onset disease. These findings suggest that when a clinical sub- type is controlled, the psychological burden associated with early-onset psoriasis becomes more apparent, supporting the hypothesis that younger patients may be more vulnerable to anxiety, regardless of disease duration or severity. In a study involving 137 patients, Gupta et al. high- lighted that early-onset disease (before the age of 40) is associated with difficulties in expressing feelings such as self-confidence and anger compared to late-onset disease (after the age of 40). This personality trait can negatively impact the patients’ capacity to cope with stress [3]. In our study, the threshold age for early and late onset was set at 40 years, similar to the study by Gupta et al., and as first proposed by Henseler and Christophers in 1985 to define early and late psoriasis. Original Article | Dermatol Pract Concept. 2025;15(3):5249 7 should include larger, more diverse populations and employ longitudinal designs to provide a clearer understanding of the temporal relationships and underlying mechanisms. Conclusion Our study elucidates significant clinical and psychosocial distinctions between early- and late-onset psoriasis, em- phasizing the need for age-specific management strategies. The higher prevalence of stress-triggered exacerbations in early-onset patients and the increased occurrence of pus- tular subtypes in late-onset patients underscore the hetero- geneity of psoriasis presentations. Implementing tailored therapeutic approaches that account for the age at onset could enhance patient outcomes. Early-onset patients may benefit from integrated psychosocial support to manage stress effectively, while late-onset patients might require targeted interventions for specific subtypes like pustular psoriasis. Future research should focus on elucidating the underlying mechanisms driving the clinical and psychoso- cial disparities observed in early versus late-onset psoria- sis. Longitudinal studies could provide deeper insights into how age-related factors influence disease progression and response to treatment. Acknowledgment We gratefully acknowledge Dr. Yusuf Ezel Yıldırım for his invaluable contributions to the statistical analyses, which significantly enhanced the rigor and depth of our study. References 1. Boehncke WH, Schön MP. Psoriasis. The Lancet. 2015;386: 983–94. DOI:10.1016/S0140-6736(14)61909-7. PMID: 26025581. 2. Henseler T, Christophers E. Psoriasis of early and late onset: Characterization of two types of psoriasis vulgaris. J Am Acad Dermatol. 1985;13(3):450-456. DOI: 10.1016/s0190-9622(85) 70188-0. PMID: 4056119. 3. Gupta MA, Gupta AK, Watteel GN. Early onset (<40 years age) psoriasis is comorbid with greater psychopathology than late onset psoriasis: A study of 137 patients. Acta Derm Vene- reol. 1996;76(6):464-466. DOI: 10.2340/0001555576464466. PMID: 8982413. 4. Remröd C, Sjöström K, Svensson A. Psychological differences between early- and late-onset psoriasis: A study of person- ality traits, anxiety and depression in psoriasis. Br J Derma- tol. 2013;169(2):344-350. DOI: 10.1111/bjd.12371. PMID: 23565588. 5. Ferrándiz C, Pujol RM, García-Patos V, Bordas X, Smandía JA. Psoriasis of early and late onset: A clinical and epidemiologic study from Spain. J Am Acad Dermatol. 2002;46(6):867-873. DOI: 10.1067/mjd.2002.120470. PMID: 12063483. 6. Dubertret L, Mrowietz U, Ranki A, et al. European patient per- spectives on the impact of psoriasis: The EUROPSO patient data in the literature are based on anecdotal reports or retro- spective studies [29, 30]. In our study, 63.1% of patients reported psychological stress as a trigger factor for psoriatic lesions, and this pro- portion was significantly higher in the early-onset psoriasis group. Our findings align with previous studies that indicate a significant role of stress in exacerbating psoriasis. Ferrán- diz et al. [5] reported in a study involving 1,774 patients that trigger factors were more common in patients whose psoria- sis onset occurred before the age of 30. Malhotra and Mehta [31] reported that stressful life events were noted in 26% of psoriasis vulgaris patients within a year preceding the onset or exacerbation of the disease. In the study by Consoli et al. [32], 54.8% of patients identified various stressful events as triggers for their psoriasis lesions. In the same study, psychi- atric comorbidities of patients were assessed using various scales, and no significant relationship was found between psychiatric comorbidities and identifying stress as a trigger. In contrast, in our study, patients who identified psycho- logical stress as a triggering factor had higher HADS-Total, HADS-A, and HADS-D scores compared to those who did not identify stress as a trigger. The differences in the results may be related to the limitations of evaluating a complex and highly subjective experience like psychological stress us- ing surveys with only one or a few questions. These findings underscore the importance of incorporating comprehensive stress management strategies into psoriasis treatment plans to mitigate the exacerbating effects of psychological stress on the disease and improve overall patient outcomes. Limitations This study has several limitations. The cross-sectional design restricts our ability to establish causality between psoriasis onset age and observed differences. The presence of comor- bid conditions such as hypertension, diabetes, and cardiovas- cular disease, which are more frequently observed in patients with late-onset psoriasis, may have confounded the observed associations between age at onset and psychosocial out- comes. Data regarding disease activity and flare status were not systematically collected. Given that a well-controlled chronic condition may exert less psychological burden than an uncontrolled or newly diagnosed flare-up, the absence of flare status as a variable limits the interpretation of qual- ity of life outcomes. Self-reported data on stress and psy- chosocial factors may introduce recall bias. While validated scales like the HADS and DLQI were used, the complexity and subjective nature of psychological experiences such as stress may not be fully captured by these instruments. More comprehensive psychometric evaluations could provide a deeper understanding of the psychosocial impact of psoria- sis. Additionally, the sample was drawn from a single center, limiting the generalizability of the findings. Future studies 8 Original Article | Dermatol Pract Concept. 2025;15(3):5249 20. Kimball AB, Wu EQ, Guérin A, et al. Risks of developing psy- chiatric disorders in pediatric patients with psoriasis. J Am Acad Dermatol. 2012;67(4):651-657.e2. 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