Psychosocial effects of acne

More Than Skin Deep: The Psychosocial Effects of Acne

Acne vulgaris is one of the most common skin conditions, affecting approximately 85% of young adults ages 12-25 years old.^[1] Despite often being viewed as a relatively “benign” cosmetic ailment, acne and its sequelae (scarring, post-inflammatory hyperpigmentation) can greatly affect an individual’s social and emotional well-being. With its appearance in adolescence and early adulthood, acne can contribute to psychological distress that may manifest as embarrassment, poor self-esteem, negative body image, social avoidance, and anxiety and depression.^[2]

Acne in Adolescence vs. Adulthood

The majority of individuals suffering from acne vulgaris are adolescents.^[3] The adolescent stage is a pivotal moment in the development of a person’s body image, sexuality, self-image, and socialization. Changes in hormone levels during this time can lead to greater psychological vulnerability. A few studies have shown that patients who develop acne earlier in life are at a greater risk for impaired self-esteem and relationships.^[4,5] Adolescents may also be more vulnerable to bullying because their self-image is not fully developed,^[3] as well as also influence an adult’s self-perception. Within this age group, the greatest concerns regarding acne are related to employment and socializing.^6,7

Females Are Disproportionately Affected by the Psychosocial Impacts of Acne

Cultures across the world associate clear skin with beauty and success.^[8] While acne affects males and females more or less equally, it appears to cause more psychosocial distress in females.^[3]

A study conducted in India by Pruthi et al. evaluated the physical and psychosocial effects of acne in women between the ages of 18 and 25 years old with mild to moderate acne.^[7] In the majority of cases, there was a negative impact on physical comfort due to acne.^[7] Individuals reported physical discomfort due to pain, scars, and redness.^[7] The researchers also noted an increased prevalence of anger and depression amongst individuals in their study, leading to social distress.^[7] In the open-ended questionnaire, many of the individuals remarked that physical attractiveness is an important quality to possess when seeking a partner or career, and that they feel their acne may affect these pursuits.^[7]

In the qualitative questionnaire, one patient’s report summed up the overall negative impact acne can have on an individual’s well-being: “The fact is that I cannot be normal, when it hurts and is red. It … hurts to smile, and then I cannot feel happy, even if I want to. Also the marks that get left behind- I feel bad about it because it makes my face ugly looking.”^[7]

Correlations Between Grade and Location of Acne and Quality of Life

One study conducted in India by Hazarika et al. used the dermatology life quality index (DLQI) questionnaire to assess the psychosocial effects of acne and how they relate to the grade and location of the acne lesions as well as the gender identity of the patient.^[2] Thirty-seven percent of patients had a DLQI score in the range of 6-10, which is graded as “moderate effect on quality of life,” and 29% of patients scored 11-20, which is interpreted as “very large effect on quality of life.” The DLQI questions address many ways in which a person’s life may be affected by acne vulgaris, including:

• Physical symptoms like pain, itching, or stinging:^[2] Physical symptoms were reported by 78% of patients in this study, and showed statistical correlation with the grade of acne.

• Embarrassment and self-consciousness:^[2] Eighty-eight percent of patients reported feeling embarrassed and/or self-conscious due to their acne lesions. Not surprisingly, those with more severe acne suffered a greater degree of embarrassment and self-consciousness. Interestingly, there was a statistically significant positive correlation between the degree of embarrassment and acne being present on the face (vs. other areas).

• Effect on daily activities like home duties, shopping, and gardening:^[2] Sixty-nine percent of individuals in this study complained of problems completing their daily activities. The authors speculate that the problems with completing daily activities may be associated with avoidance behavior, anger, and frustration rooted in poor self-esteem.

• Influence on clothing choices:^[2] In this study, 37% of individuals felt that their acne affected their clothing choices. Those with truncal acne were significantly more likely to report an influence on clothing choices, likely in an effort to cover the acne-affected areas.

• Effect on social and leisure activities:^[3] Sixty-eight percent of patients reported a negative effect on their social activities. Females and those with more severe acne were statistically more likely to report an effect on their social lives. Patients reported that they especially avoided social gatherings during an acute acne flare out of fear of other people staring at their lesions.

• Effect on sports:^[2] In this study, 25% of individuals reported having difficulty in sports. However, the kinds of difficulties were not discussed.

• Influence on work and/or study:^[2] Fifty-seven percent reported negative effects on their careers or schooling. Patients cited being distracted by their acne and affected appearance, making it more difficult to concentrate.

• Interpersonal problems:^[2] Seventy-five percent of the patients in this study reported relationship problems with intimate partners, friends, and/or relatives. Patients complained of peers and relatives constantly asking about their acne or making jokes about it. Female patients expressed concerns regarding finding a significant other. There may also be a fear of being perceived as unhygienic or unhealthy.

• Effect on sex life:^[2] Only 5% of patients in this study cited sexual difficulties; however, this may be underreported due to cultural norms. The authors speculated that sexual difficulties may arise due to changes in self-perceived attractiveness or sexual disinterest associated with anxiety.

• Effect on time management:^[2] Forty-five percent of patients reported that treating their acne was time-consuming or inconvenient. They also note that efforts to cover up acne (make-up, hairstyles) took up a significant amount of time.

Depression and Suicide

Patients with acne have been shown to be at an increased risk of depression and suicide.^[3] Among adolescents with severe acne, the risk of suicidal ideation can be 2-3x that of their unaffected peers.^[9] Patients with acne should be assessed for depression and suicidal ideation regularly.

Does Isotretinoin Increase the Risk of Suicide?

Oral isotretinoin, a systemic retinoid is used in severe acne that does not respond well to other systemic and topical treatments.^[10] Isotretinoin has a lesion clearance rate >85%, making it the most effective anti-acne drug. However, clear skin comes with a slew of side effects. Shortly after its release in the 1980s, there were reports of increased depression and suicide amongst isotretinoin users.^[11] However, recent literature suggests that the general population does not experience an increase in depression or suicidal ideation with the use of isotretinoin.^[11,12] It is noted that suicidal tendencies are more prevalent in adolescent populations and are increased by acne.^[12] A couple of studies report that due to its positive impact on physical appearance, isotretinoin actually often decreases depressive symptoms in patients.^[11,13] However, routine screening for depression is still recommended for patients taking this medication.

While many studies have documented the psychosocial impacts of acne vulgaris, this aspect of care often goes ignored or forgotten. Acne treatments are nearly always focused on ridding an individual of the active lesion, scars, and/or post-inflammatory hyperpigmentation; however, it is important to remember that acne is not a purely cosmetic disease—the emotional and social aspects must be addressed as well.

Practical tips

• Acne vulgaris is not just a cosmetic condition – it can have profound psychosocial impacts.
• Remember to check-in with patients about how their acne may be affecting their emotional and social well-being. Questions can be incorporated into the interview or a routine screening questionnaire like the PHQ-9 can be employed.