Psychological effects of acne

Acne can have profound social and psychological effects. These are not necessarily related to its clinical severity. Even mild acne can be significantly disabling. Acne can affect people of all ages but it predominantly occurs during the teenage years, approximately 85% of people between the ages of 12 and 25 develop acne.

Response to acne

What problems does it cause?

The psychological and social impacts of acne are a huge concern especially because it affects adolescents at a time they are developing their personalities. During this time, peer acceptance is very important to the teenager and unfortunately it has been found that physical appearance and attractiveness is highly linked with peer status.

In recent years, open discussions between patients and medical professionals have revealed the impact acne has on one's psyche. The following are some of the problems that patients with acne may face.

• Self esteem and body image
  • Some embarrassed acne patients avoid eye contact.
  • Some acne sufferers grow their hair long to cover the face. Girls tend to wear heavy make-up to disguise the pimples, even though they know this sometimes aggravates the condition. Boys often comment, acne is not such a problem for girls because they can wear make-up.
  • Truncal acne can reduce participation in sport such as swimming or rugby because of the need to disrobe in public changing rooms.
• Social withdrawal/relationship building
  • Acne, especially when it affects the face, provokes cruel taunts from other teenagers.
  • Some find it hard to form new relationships, especially with the opposite sex.
  • At a time when teenagers are learning to form relationships, those with acne may lack the self-confidence to go out and make these bonds. They become shy and even reclusive. The main concern is a fear of negative appraisal by others. in extreme cases a social phobia can develop.
• Education/work
  • Some refuse to go school leading to poor academic performance and possibly future unemployment.
  • Some take sick days from work, risking their jobs or livelihood.
  • Acne may reduce career choices, ruling out occupations such as modelling that depend upon personal appearance.
  • Acne patients are less successful in job applications; their lack of confidence being as important as the potential employers' reaction to their spotty skin.
  • More people who have acne are unemployed than people who do not have acne are.
  • Many young adults with acne seek medical help as they enter the workforce, where they perceive that acne is unacceptable and that they should have grown out of it by now.

Acne and depression

In some patients the distress of acne may result in depression. This must be recognised and managed. Signs of depression include:

• loss of appetite
• lethargy
• mood disturbance
• behavioral problems
• wakefulness
• spontaneous crying
• feelings of unworthiness.

In teenagers depression may manifest as social withdrawal (retreat to the bedroom or avoidance of peers) or impaired school performance (lower grades or missed assignments). Worse still, severe depression from acne has resulted in attempted suicide and, unfortunately, successful suicide. Worrying statements include I don't want to wake up in the morning; I'd be better off dead; I'm worthless; You'd be better off without me. Parents, friends and school counsellors need to take heed when they start to hear these types of comments.

Rarely, depression can be associated with acne treatment, particularly isotretinoin. There is considerable doubt that the drug has caused the problem and it seems much more likely that it results from the acne and psychological disturbances described above.

Regardless of the cause, depression must be recognised and managed early. If you think you may be depressed, contact your dermatologist or family doctor urgently for advice.

Dysmorphophobic acne

Some patients with only minor acne suffer from disturbed body image. Even in the absence of lesions, they consider they have severe acne and may suffer many of the psychological and social symptoms described above. They are said to have "dysmorphophobic acne". If this is their only abnormal behavioural symptom, they respond well to oral isotretinoin therapy. A low dose of this may be required long term as even slight recurrence of oily skin may unduly concern the patient. Some severe cases of dysmorphophobia have a more global mental disorder similar to anorexia nervosa. They require expert dermatological and psychiatric assistance.

Seeking help

If your acne is interfering significantly with your life, particularly if it is resulting in any of the problems described above, seek help promptly from your family physician or dermatologist.

Tell your doctor all your concerns so that he or she will take your acne seriously. Most cases of acne can be controlled and sometimes cured with treatment, using one or more of the following preparations:

• Over-the-counter topical acne creams, lotions or gels for mild cases
• Prescription medications, both topical and oral, that are available only through a physician

Depression is an illness that can nearly always be treated effectively. See your family doctor for advice and if necessary referral to a health professional specialising in mental illness.

Suitable treatments may include:

• Antidepressant medication.
• Psychological treatments to overcome the negative thinking, anxiety and avoidance that often accompany depression.
• Counselling to help build confidence and rebuild self-esteem.
• Group therapy.

It is important that a teenager's anxiety over their acne is managed appropriately.

Related information

On DermNet NZ:

• Acne treatment

Other websites:

• Internet mental health: A wide range of information on mental disorders.
• Mental health Net: The CenterSite Network of behavioral healthcare websites.
• Grossbart.com : Research-based approaches from a Harvard Med School Psychologist.