War is one of the preventable reasons of the life-threatening diseases causing disability and deaths. Wars have continued in the different regions of the world since the onset of history of the mankind
13,14. People have had to emigrate from their own countries to other countries because of the wars. Migrants or refugees are usually called to the people who leave their own country for economic and cultural reasons and settle in the other country with the expectation of a better life
15.
A large number of refugees came to Turkey because of the civil war of Syria started in March 2011. Erdogan et al. reported that more than 1.6 million Syrian refugees have been in Turkey for 3.5 years that 13% of them are living in refugee camps and the others in different cities of Turkey 2.
There are various studies about refugees in the world. Even though health problems of the refugees are particularly associated with traumatic events, there are a few studies about dermatological diseases observed in refugees 16,17. Pavodese et al. have noted the dermatological diseases as the most common disease group in their study conducted on the refugees 18. However, studies demonstrating dermatological problems of Syrian refugees in Turkey are scarce. Most of these studies are about leishmaniasis in the refugees 19-21. Turan et al. compared the socio-demographic and clinic features of Syrian refugees and local people with leishmaniasis. The duration and number of cutaneous leishmaniasis lesions were higher in Syrian refugees than in local people 21.
In the present study, we evaluated the stress-related dermatological diseases such as AV, AA, psoriasis, pruritus, SD and urticaria in the refugees and local people. AV is an inflammatory disease of pilosebaceous unit. Corticotropin-releasing hormone (CRH), the stress hormone, has been shown to increase the lipid synthesis in the sebaceous glands as in vitro and therefore, has been proposed to induce of acne and seborrhea 9. In a study including 304 farmers, Quandt et al. found the acne prevalence of 48.4% in North Carolina 22. Krejci-Manwaring et al. 23 reported the acne prevalence of 24.1% among Latin immigrant farmers.
In our study, the prevalence rates of AV were 1.7% and 10.2% in local people and refugees, respectively.
AA is a cutaneous disease characterized by round, well demarcated bald patches resulting fromrapid loss of hair. AA influences the patients negative psychologically because of cosmetic concerns, even though it does not lead to any physical problems. The rates of psychiatric diseases, especially anxiety disorder, depression, and adjustment disorders, have been found high in the patients with AA 24. Albares et al. reported the AA prevalence of local people and refugees in Spain as 1.2% and 1.4%, respectively 25. In our study, the prevalence of AA was 2.6% in refugees and 0.3% in local people.
Psoriasis is a chronic inflammatory skin disease that is considered to be a psychosomatic disorder. Stress and psychosocial factors play an important role in the onset, as well as exacerbation of psoriasis 26. In the present study, prevalence of the psoriasis was 5.3% in refugees and 0.5% in locals.
Although the pathogenic mechanism of stress on itching is not clear, suppression of hypothalamic-pituitary-adrenal pathway have been proposed to induce itching mediators such as endogenous opioids 10. Albares et al. 25 reported the pruritus prevalence of the refugees and local people in Spain as 1.7% and 1.2%, respectively. In our study, pruritus prevalence was 2.1% in refugees and 0.6% in locals.
SD is a chronic, recurrent, and inflammatory dermatosis affecting especially the sebum rich areas such as eyebrows, scalp, and nasolabial region characterized by yellowish scaly plaques. The vast majority of SD flares are usually seen in the periods of emotional stress and depression 27. In a multicenter study comprising 2159 patients with SD, depression, stress, and fatigue were triggers for SD 28. Misery et al. 29 have noted the stress as the main promoting factor of SD in their study population. In our study, the SD prevalence of refugees (4.3%) was significantly higher than local people (0.3%).
Urticaria is an itchy disease characterized by erythematous, edematous papules, and plaques 30. Emotional stress is a well-known triggering factor of urticaria. Staubach et al. 31 have detected at least one psychosomatic disorder in 48% of the patients with chronic spontaneous urticaria (CSU). Among these disorders, the most common one was anxiety disorder, and it was followed by depression and somatoform disorders. In a study conducted on 30 patients with CSU, 30 patients with AA, and 39 controls, the anxiety and depression scores were significantly higher in the patients with CSU than in the controls 32. Albares et al. 25 found the prevalence of urticaria as 1.3% and 0.7% in the refugees and locals, respectively. In our study, the prevalence of urticaria was 1.0% in the refugees and 0.3% in the locals.
Psychological trauma includes man-performed traumatic events such as wars, terrorist attacks, torture, and sexual assault other than unintentional traumatic events such as natural disasters 33. Gammouh et al. 6 have reported that 35% of the refugees with chronic diseases had depression. The prevalence rates of depression in the refugees have been varied from 22% to 68% in the different studies 34-36. TSSD is a condition including emotional, mental, behavioral, and social impairments that develops in everyone after unusual human experiments 37. Traumatic stress disorders have been known to cause of disability and loss of function. In a study performed by Fazel et al. 38, 9% of the refugees were diagnosed as PTSD and 5% as MD. Alpak et al. 39 found the PTSD prevalence of 33.5% in Syrian refugees. Nora Alghothani et al. noted that several psychiatric diseases such as somatoform disorders, depression, anxiety, PTSD, and smoking was quite common in Syrian refugees 40. In our study, 78 (47%) of the refugees had at least one psychiatric disease. Among these patients, 27 (16%) had MD and 19 (11%) had PTSD. The prevalence of PTSD was significantly higher in refugees (37.5%) than in local people (0.8%). The prevalence rates of MD were almost equal in refugees and locals (16.7% vs. 16.1%).
The limitation of the study was the small number of the participants due to the poor life conditions of the researchers that bullets and shrapnel parts of bombs targeted the hospital for many times.
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