Adolescent Acne Vulgaris: The Psychosocial and Psychological Burden
ABSTRACT: Acne is extremely common during adolescence, and it can impose a heavy emotional and psychological weight on teenagers with it. Acne has been associated with a higher incidence of depression, anxiety, suicidal ideation and suicide attempts, poor self-image, poor self-esteem, and social impairment. Accordingly, even though acne might not appear to cause severe morbidity, mortality, or physical disability, it nevertheless must be approached and managed as a serious health condition that can have a significant affect on a person’s quality of life in the teenage years and beyond.
Acne vulgaris is a ubiquitous disease, and its potential to cause significant psychological repercussions was described this way 66 years ago: “There is no single disease which causes more psychic trauma, more maladjustment between parents and children, more general insecurity and feelings of inferiority and greater sums of psychic suffering than does acne vulgaris.”1
Acne is the leading cause for visits to a dermatologist.2 Most cases develop in adolescence, with a 70% to 87% prevalence, and the condition frequently continues into adulthood.3,4 Despite its apparent cosmetic nature, the effects of acne can go far deeper than the surface of the skin and can place a heavy emotional and psychological burden on pediatric patients that may be far worse than its physical impact.
Adolescents are psychologically vulnerable. They are sensitive to modifications in their bodies and appearance. Acne commonly affects young people at a time when they are undergoing maximum psychological, social, and physical change. Using the numerous available rating scales for quantifying quality of life (QoL) in patients with acne,5 studies have shown that the burden of acne diminishes adolescents’ QoL and impacts their global self-esteem.5,6 Between 30% and 50% of adolescents experience psychological difficulties associated with their acne,6 and although the interaction is complex, it can be associated with developmental issues of body image, socialization, and sexuality. Some adolescents are severely affected and require more than medical therapy alone.7
Unlike most other dermatologic diseases that may be limited to areas that are covered by clothing, acne often is visible on the face, heightening issues of body image and socialization. Therefore, it is not surprising that a susceptible person with facial acne might develop significant psychosocial disability. Many people with acne experience problems with self-image and interpersonal relationships. The effects of acne are aggravated by teasing or taunting, by others’ scrutiny, and by the feeling of being on display.8
Often, embarrassment is a prominent response in young people with acne, since embarrassment might be easier for them to articulate than dysphoria, depression, or anxiety. They frequently experience social anxiety and generally avoid activities that bring attention to their condition.9 These feelings often relate to fear of having their faces scrutinized by others; and the societal ideal of perfect skin makes appearance the most important factor.8
Adolescents with acne can feel uncomfortable, avoid eye contact, and grow their hair long enough to cover the face; girls often use makeup to minimize the appearance of acne lesions.10 Studies have shown that acne can significantly affect even the choice of clothing and dressing style of adolescents with the condition.11,12
Impact of Acne and Severity
The relationship between the severity of acne and emotional distress is poorly understood.13 A small study of students at one California university found that those with acne experienced a worsening of their disease during examinations, and that increased acne severity was significantly associated with increased stress levels (P < .01).14 A recent questionnaire-based study among 1,531 adolescents in Greece also found a positive correlation between acne and self-reported stress (P < .0001).11
The clinical severity of acne and the impairment of QoL generally are considered to have a linear relationship. However, the level of impairment also depends on a person’s coping ability, and some individuals with little objective evidence of acne might endure severe subjective impairment, greatly affecting their QoL.15 Thus acne can have a great impact on a patient’s life, often independently of the severity of the condition.16
Severe acne is associated with increased depression, anxiety, suicidal ideation, poor self-image, and poor self-esteem.17 Psychiatric symptoms are more common in more severe acne and in the later stages of puberty.18
Acne, Depression, and Suicide
A number of large studies have shown frequent depressive symptoms in adolescents with acne.18-20 Kilkenny and colleagues18 conducted a computerized questionnaire survey of 2,491 Australian high school students and found self-rated moderate acne to be associated with an increasing frequency of psychiatric symptoms; moreover, acne was more likely to be reported in the later stages of puberty. Still, few published population-based studies have compared the incidence of suicide and suicidal ideation in adolescents with acne to those without it.21
A cross-sectional study of 9,567 secondary school students in New Zealand19 found that 14.1% of students reported “problem acne,” which was associated with an increased risk of depressive symptoms (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.70-2.45) and anxiety (OR, 2.3; 95% CI, 1.74-3.00). Symptoms of clinically relevant depression and anxiety were reported by 14.1% and 4.8% of students, respectively. Problem acne was associated with an increase in frequency of suicidal thoughts and suicide attempts. The association of problem acne with suicide attempts remained after controlling for depressive symptoms and anxiety (OR, 1.5; 95% CI, 1.21-1.86).19
One study in Italy estimated that the prevalence of suicidal ideation in teenagers with acne was 7.1%.22 However, psychiatric comorbidity might occur even with milder acne. A study conducted in Turkey found that patients with acne were at increased risk for anxiety and depression compared with the population without acne, irrespective of gender or the degree of severity.23 The risk of anxiety and depression were 26.2% and 29.5%, respectively, compared with 0% and 7.9% in the control group.23 One study reported that 15% of more than 350 Serbian schoolchildren with acne felt “very depressed and miserable” because of their acne.24
It has been suggested that patients with moderate to severe acne have poor body image and low self-esteem and experience social isolation and constriction of activities. As part of the emotional impact, increased levels of anxiety, anger, depression, and frustration also have been observed in adolescents with acne.25 In a study of 615 Turkish school children with acne, for example, adolescent girls were found to be more vulnerable than boys to the negative psychological effects of acne, and anxiety levels were higher in girls than in boys.25 Given that it causes psychological suffering, acne can affect the social, vocational, and academic performance of teenagers.
Additionally, suicidal ideation (found by one group of authors to be present in 6% to 7% of persons with acne26) and suicide attempts related to the negative psychosocial impacts of acne have been documented.27,28 A study involving 480 patients with various dermatoses found the highest incidence of depression and suicidal ideation in patients with severe forms of acne and severe psoriasis, while patients with mild and moderate acne had the same level of depression and suicidal ideation as those with atopic dermatitis, moderately severe psoriasis, and alopecia areata.26
Halvorsen and colleagues21 surveyed 3,755 adolescents aged 18 to 19 years in Oslo, Norway. Overall, 13.5% of the adolescents reported having substantial acne, with a slightly higher prevalence in boys. Suicidal ideation was reported by 10.9% of all interviewed teenagers, with the incidence increasing with the severity of acne (P < .01); 9.5% of those with little or no acne, 18.6% of those with moderate acne, and 24.1% of those with substantial acne reported suicidal ideation (adjusted OR, 1.80; 95% CI, 1.30-2.50). The differences were greater in boys than in girls. Moreover, study participants with substantial acne were significantly more likely to report mental health problems than those with less acne (adjusted OR, 2.25; 95% CI, 1.69-3.00). Social impairment was more common with increasing acne (P < .01). Adolescents with substantial acne reported lower attachment to family and friends (mainly boys), not thriving at school (mainly girls), and less experience with romantic relationships and sexual intercourse (mainly boys). The authors concluded that because these relationships are important for many adolescents, the findings further strengthen the view that acne is an independent risk factor for suicidal ideation.21
Acne negatively affects QoL, and its severity does not always correlate with its impact on QoL. The magnitude of anxiety and depression is proportional to the degree of impairment of QoL due to acne.23 Persons with acne who also have greater social sensitivity have been noted to experience poorer QoL compared with other persons with the same degree of severity of acne.28 Anger, similarly, is associated with poorer QoL and less satisfaction with treatment, independent of other variables.29
Acne’s Psychosocial Impact
A number of authors23,25,30-33 have characterized the relationship between acne and adverse outcomes such as anxiety, depression, embarrassment, lack of self-confidence, social dysfunction, and unemployment.
Studies on the psychosocial impact of acne have documented dissatisfaction with appearance, embarrassment, self-consciousness, and a lack of self-confidence in persons with acne. Social dysfunction has also been observed, including concerns about social interactions with the opposite gender, appearances in public, interaction with strangers, and reduced employment opportunities.18,30,34 Furthermore, acne is associated with lower body satisfaction (with boys generally showing lower self-attitude and girls generally showing lower self-worth, independent of weight problems or depressive symptoms).35
Acne has been shown to be negatively associated with participation in sports and exercise, perhaps as a result of how acne patients perceive their skin to be evaluated by others.11 In a study among Scottish schoolchildren, 10% avoided swimming and other sports because of embarrassment with their acne.15 Acne also has been shown to negatively affect schoolwork and activities while on vacation.11,15 Self-esteem issues also might be a factor in the higher rates of unemployment in persons with acne; moreover, a bias also exists whereby persons with acne are more likely to be passed over by prospective employers.36
Other studies have reported that as many as 20% of adolescents with acne had problems in relationship building due to their acne. The depression, social withdrawal, and anger often seen in persons with acne are hypothesized to be related to the damaging effects of facial appearance on self-concept.33,37
Acne can create a vicious cycle: Not only does it result in emotional distress, but also the anxiety provoked by having acne can aggravate the skin condition itself at a time when persons with it are least capable of coping with the additional stress.38
The psychological affect of acne on teenagers can be considerable. It can have profound psychosocial consequences, and the severity of disease determines the extent of embarrassment and lack of enjoyment and participation in social activities and can leave permanent scarring,39,40 with lifelong consequences.41
Girls and boys with acne generally have lower self-attitude, more feelings of uselessness, fewer feelings of pride, lower self-worth, and lower body satisfaction than do those without acne. In a study using a regression model for body mass index and depressive symptoms, the presence of acne explained a significantly lower self-attitude for boys and poor self-worth for girls in Norway.35
During adolescence, the frequency of acne increases with age and pubertal development. In girls, the commencement of menstruation is associated with increased frequency of acne.24
The only correlation between sex and acne that appears supported in the literature is that of a decreased QoL and sexual satisfaction among women who suffer from polycystic ovary syndrome and acne.42
The impact of acne on a particular person is not always easy to judge clinically. People of both sexes reportedly find the effects of acne on appearance to be the most bothersome aspect of their disease, and the negative effects of acne occur in older and younger patients alike.43 Even mild acne can pose a significant problem for some persons, diminishing their QoL and, in some cases, their social functioning.
The severe burden of acne
Acne is not a trivial disease in comparison with other chronic conditions.44 Even if acne is not associated with severe morbidity, mortality, or physical disability, it nevertheless can have considerable psychological and social consequences for a teenager with it.45
Reducing the psychosocial impact of acne is one of the guiding principles of its clinical management, and it is important to measure and evaluate this impact on young patients.
The social, psychological, and emotional impairment that can result from acne, especially in more severe forms, has been reported to be similar to that associated with epilepsy, asthma, diabetes, back pain, and arthritis.12,35,39,44-48 Adolescents with acne might be more prone to depression, anxiety, social withdrawal, and anger; scarring can lead to lifelong problems with self-esteem.49 Effective and safe therapies for acne are available, yet many people do not consider the condition a problem worth treating.50
The severe burden of acne is strong justification for effective acne treatment and psychiatric screening for patients with the condition. Improvements in acne after appropriate treatment have been shown to result in enhanced self-esteem, body image, and social functioning.n
Richard G. Fried, MD, PhD, is a psychologist and dermatologist and is the clinical director of Yardley Dermatology Associates in Yardley, Pennsylvania.
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Brian Bulley, MSc (Inergy Limited, UK), assisted with the preparation of the manuscript.