Acne and its psychological impacts

It is important to take concerns about acne seriously when coming from the patient or their parent and consider a psychiatry referral for those identified as high risk of mental health disease and suicide

ACNE is a common disease that mostly affects adolescents and young adults, and up to 80% of people aged 18–25 years suffer from it (here and here). This is one of the most important stages of life, when identity is formed and social relationships are created. Therefore, prompt treatment of the disease should occur before it causes permanent negative psychological and physical effects.

Scarring from acne prolongs its detrimental effect on emotional and social wellbeing. In addition, acne and its scarring can cause economic hardship and career difficulties (here and here). All patients with acne can suffer from psychological distress as the clinical severity is not always correlated with the distress caused by it. Although acne is not a life-limiting disease, it is not trivial. Treating acne improves patient wellbeing and the therapeutic relationship. Systemic treatment of acne is the most effective treatment for severe acne and has been shown to improve quality of life and reduce depression and anxiety.

The media’s impact on body image

In the modern era, people are increasingly concerned with their physical appearance including having clear skin. Ideas around body image have changed significantly to become unrealistic and harmful with the use of social media, particularly for young adults. Patients face the physical changes of puberty and the social challenges of adolescence when they are least equipped to deal with stressors. Acne is one of those physical changes often fixated on by people and their peers. This can result in feelings of embarrassment, disgust and shame, resulting in poor self-esteem that can continue into adulthood (here and here).

Social media has an additional consequence as there is often misinformation on the platform. This results in an extended period when patients do not seek help from a health professional, delaying proper treatment. A study of 130 people with acne who consulted a medical professional showed that only 31% of people previously used treatments that aligned with national (American) guidelines.

Health practitioners should enquire about previous acne treatments including dietary changes, supplements and cosmetic products to educate patients on evidence-based treatments. Social media may also amplify the judgement and criticism from peers as it is a platform for people to comment harshly on other people’s appearance.

The psychological impact of acne

Acne causes psychological distress in many adolescents today. The effect of social media has been highlighted above and shows that it provokes negative emotions toward oneself contributing to poor mental health. A study of 99 patients with acne in Turkey found that 29.5% of patients were at risk of depression and 26.2% of patients were at risk of anxiety, calculated with the Hospital Anxiety and Depression Scale using the depression and anxiety subscale. This compares with 7.9% (P = 0.0011) and 0% (P = 0.001) respectively for the arm of patients without acne. The study concluded that the risk of depression and anxiety were higher in patients with acne and was not correlated with the clinical severity of the disease.

In New Zealand, a study of 9567 students aged 12–18 years  showed that acne was associated with an increased probability of having depression and anxiety (odds ratio [OR], 2.04 and 1.83 respectively). This study also found an increased incidence of suicide attempts (OR, 1.50) in students with acne. It is important to take concerns about acne seriously when coming from the patient or their parent and consider a psychiatry referral for those identified as high risk of mental health disease and suicide.

Another issue faced by people with acne is bullying. A qualitative study, conducted in Australia, interviewed patients with acne, psoriasis and atopic dermatitis and investigated the themes around facial stigmata and bullying. The most prominent theme was about teasing being malicious, which made those with acne feel embarrassed, humiliated and socially excluded. This is not limited to school-aged people, as bullying occurs throughout all stages of life.

Acne scarring also causes significant anxiety and concern for patients. Scarring can include hypopigmentation, hyperpigmentation, atrophic and hypertrophic scars. These can persist for weeks or be permanent. Scars tend to be worse in Asian and dark-skinned patients as they are at higher risk of keloid scarring and pigment issues. Even after acne has been successfully treated, many patients are left with disfiguring scarring. Treating acne scarring is notoriously difficult and imperfect. Treatments, such as dermabrasion and fractional carbon dioxide laser, are also expensive. Scarring can cause issues with self-acceptance and make people feel unattractive, self-conscious and embarrassed.

Clinicians are often focused on the clinical severity of acne; for example, grading the severity of acne using the Leeds method of classifying acne. However, the patient’s perception of the disease is more important than clinical parameters. Assessing the impact of acne on a patient’s quality of life provides an insight into the psychological impact, detects when psychological support is needed, and can track treatment efficacy. A tool such as the Dermatology Quality of Life Index is a standardised and validated tool that also has a strong correlation with response to treatment. Social functioning is commonly affected by acne as many patients avoid activities where they expose skin. A study of 143 people who viewed images of people with and without acne found that people with acne were considered younger, less mature, and unattractive. The study concluded that people with acne were judged negatively and subsequently disadvantaged in social situations.

The economic impact of acne

An unfortunate consequence of acne is the judgement from people and unconscious biases that people hold (here and here). Aside from the social effect of this, there are also economic consequences. Patients could be discriminated against due to their facial stigmata in a job interview.

A 2012 study assessed the hiring intentions of 171 people when faced with applicants who were facially stigmatised compared with those who had clear skin. It found that people with facial stigmata were disadvantaged despite having equal qualifications. The interviewer’s eyes were drawn to affected regions on the applicant’s face and they recalled less information from the interview. These results were replicated in a 2020 study. These studies show that people with acne are discriminated against in the job hiring process which puts financial pressure on top of the emotional distress that acne can cause.

Sectors of employment such as the defence force have regulations around the medications that employees can use. For example, the Navy does not allow people to work on board if they are using isotretinoin due to concerns around mental health. This hinders the opportunities for people with severe acne to work as they must prioritise either their health or their finances.

Impact of treatment of acne

There are many treatments for acne and the appropriate medication should be determined by considering the severity and previous treatments. Topical treatments such as salicylic acid, benzoyl peroxide, antibiotics and retinoids are recommended for mild to moderate acne (here and here). For moderate to severe acne, systemic treatments may be required. Females can use hormonal treatments including the oral contraceptive pill. Oral antibiotics are also effective including tetracyclines and macrolides. For all of the mentioned treatments, allowing adequate treatment time and promoting medication compliance are essential to carry out before stepping up treatment. Patient preference, adverse events and side effects should also be considered. For example, long term use of doxycycline results in sun sensitivity so patients unable to maintain sun-protective measures should not use it.

For severe cystic acne, isotretinoin is the only effective treatment but its use is highly regulated due to its teratogenic effect.

There is a particular concern in the medical industry about the safety profile of isotretinoin as initial reports suggested it may cause depression and suicidality. A study in 2009 compared the quality of life, depression and anxiety of patients treated with isotretinoin and topical treatments. The isotretinoin group had a greater improvement in quality of life and mental health than the topical treatment group.

A meta-analysis on the use of isotretinoin to treat acne and its relationship with depression found that there was no significant difference between the change in depression for patients using isotretinoin and those using other treatments (standardised mean difference [SMD], –0.334; 95% CI, –0.68 to 0.011). There was a significant decrease in depression among both treatment groups (SMD, –0.335; 95% CI, –0.498 to –0.172). These results have been replicated in numerous additional studies and indicate that treatment of acne, whether through topical or systemic treatment is effective at reducing the burden of mental health in patients.

With the clinical improvement of acne, patient mental health improves and the social and economic burden of the disease is alleviated.

Clinical Associate Professor Kurt Gebauer, from the University of Western Australia, is Director of Fremantle Dermatology.

Lori Zhang is a medical student who is passionate about skin conditions, their treatment and their psychological impact on those affected.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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