Psychological effects of acne

Authors: Dr Amanda Oakley MBChB FRACP, Hamilton, New Zealand; Dr John Collier MBChB MRCPsych FRANZCP, Psychiatrist and Psychotherapist, Hamilton, New Zealand, 1999. Reviewed by Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand; Vanessa Ngan, Staff Writer, February 2014.


Introduction

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 psychosocial problems does acne cause?

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

In recent years, open discussions between patients and medical professionals have revealed the impact acne has on the 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 that this sometimes aggravates their acne. 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 children with acne refuse to go school, leading to poor academic performance.
  • Some people with acne 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.
  • 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".

Assessment of the impact of acne on the individual

Tools that assess the impact of acne on psychosocial factors and quality of life can be used in clinical practice and in clinical trials. They include:

  • APSEA: Assessment of the Psychological and Social Effects of Acne
  • ADI: Acne Disability Index
  • CADI: Cardiff Acne Disability Index
  • AQOL: Acne Quality of Life Scale
  • Acne-QoL: Acne Quality of Life and Acne-Q4

Does acne cause 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
  • Behavioural 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). 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 much controversy about whether the drug causes depression. However, it is clear that depression often results from acne and the psychological disturbances described above.

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

What is 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 because it clears up the spots. A low dose of isotretinoin may be required long-term, as even a 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.

Where do I go for 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 (GP) and/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, for more severe cases

Depression is an illness that can nearly always be treated effectively. See your family doctor for advice and if necessary, you may be referred 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 particularly important that a teenager's anxiety over their acne is managed appropriately.

 

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