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  The phenomenon of stress is a common human experience frequently blamed for much of the ill health individuals experience. Much focus has been given to the effect of stress on health and wellness. Stress can be physical or psychological, acute or chronic. Stress is often thought of as the human response to a stimulus or more specifically a “stressor” in one’s environment. The response is often based on an individual’s appraisal of the situation, the individual’s coping behaviors, and the resources available to the individual. Lazarus and Folkman¹ specifically define stress as a “relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her wellbeing.” Appraisal and coping are key to this definition and lead to the subjective experience of stress. The degree of perceived threat determines the magnitude of the stress response to the environmental event. When individuals can no longer cope with stressful situations, affective, behavioral, and physiological changes result.² Research demonstrates a strong relationship between psychological stress and health including, but not limited to, alteration in immune system functioning,^3–6 poor surgical outcomes,⁷ alterations in metabolism, increased risk of obesity,^8,9 and increased risk of developing cardiovascular disease.^10,11

  The skin is the largest organ of the human body and is responsible for protection from pathogens, ultraviolet radiation, and mechanical injury. Additionally, the skin provides protection from fluid loss and has an active role in thermoregulation, as well as vitamin D production. The slightly acidic pH of the skin serves as a protective barrier against bacterial and fungal invasions. The skin contains a vast supply of sensory nerves that provide sensory input regarding pain, temperature, pressure, and pleasure.^12,13 Timely wound healing is of utmost importance because of the skin’s vital protective and regulatory functions.

  Wounds of the skin typically progress in a predictable and timely manner. When the normal phases of wound healing are interrupted, chronic wounds develop, which leads to an increased risk of infection, prolonged hospital stays, and decreased quality of life. Chronic wounds account for a significant amount of healthcare spending in the United States, amounting to an estimated $5 to $9 billion each year.¹⁴

  Stress has been shown to have a negative impact on wound healing.^15–17 Although both the direct and indirect mechanisms of stress may be responsible for slowed healing, the most prominent impact is through the effects of stress on cellular immunity. Cellular immunity has an important role in the regulation of wound healing through the production and regulation of pro-inflammatory and anti-inflammatory cytokines.