Acne can have effects on both the skin and the psyche. Although considerable numbers of young people with acne report adverse emotional and depressive symptoms, most adolescents cope well. This article examines the evidence for the association of acne with depression and draws on current concepts of resilience from adolescent medicine to suggest that by treating acne and building resilience within young people the impact of acne could be greatly reduced.
The picture of acne painted in the medical literature is largely negative, with a focus on severe disease, adverse psychological outcomes and impaired quality of life. During adolescence acne affects most of the population and is often considered a normal part of the teenage years. In reality, acne is only a minor inconvenience for most adolescents and it is not uncommon to see even severely affected patients who are largely unconcerned by it. Conversely, for others acne has a tremendous impact on their psychological well-being, and the degree of this impact does not seem to be related to the objective severity of their skin disease. So what are the psychological effects of acne in adolescence? And what allows some teenagers to deal with acne successfully, while others suffer what may be lasting psychological damage?
Adolescence can be a challenging time. It is the phase of transition from the dependence of childhood into the independence of adulthood. During this time young people begin to forge meaningful bonds outside the family circle and form emotional and sexual relationships with others. It is also a time of cognitive, moral and social development. The development of self-concept is part of this. Physical appearance plays an important role in self-awareness, particularly in early adolescence, and it is normal for young people to both scrutinize themselves and feel under scrutiny by others. Body image is important in the development of self-image and self-esteem. Skin disorders, as well as other aspects of appearance such as body size and shape, can play into this Citation[1].
Psychiatric illness in young people is an issue of concern. The point prevalence of depression in adolescents is between 0.4 and 8.3%, with a lifetime prevalence of 15–20% Citation[2]. Depression was ranked fourth in the estimate of disease burden in 1990 by the WHO’s Global Burden of Disease study, ahead of ischemic heart disease, cerebrovascular disease and tuberculosis, and is projected to be second by the year 2020 Citation[3]. Youth suicide is also a matter of importance, with rates in some countries as high as 40 per 100,000 Citation[4].
The relationship of acne and disorders of mood is the subject of an increasing body of medical literature. Much of this focuses on the question of the potential association of isotretinoin with depression and suicide: understandably an issue of considerable concern to those prescribing the drug. However the question of the effect of acne on psychological and emotional well-being during adolescence, independent of treatment, should also be relevant to those treating young people with skin disease.
Young people with acne report a number of adverse emotional, psychological and social effects of skin disease. These include shame, embarrassment, lack of confidence, anger, impaired self-image and low self-esteem. Such feelings may result in withdrawal from social activities such as sports and dating Citation[5]. In addition, reduced employment opportunities have been reported Citation[6].
A number of studies have linked acne with an increased risk of depression and anxiety. It has been demonstrated that subjects with acne have rates of depressive symptoms as high as 24–29% and anxiety symptoms between 9 and 26% Citation[7–9]. These rates are significantly higher than control groups and population norms. Suicidal thoughts and behaviors are also reported more frequently by those with acne Citation[7,9]. Interestingly, no relationship has been found between objective acne severity and symptoms of depression and anxiety Citation[10,11]. However, it is worth noting that studies have used screening tools for depression and anxiety. These are designed to detect those at risk of a mood disorder and will overestimate the true prevalence.
One small study that looked more closely at those patients considered at-risk for depression found the rate of clinical depression to be much lower Citation[12]. The study investigated mood changes in 101 adolescents with moderate-to-severe acne treated with isotretinoin or conservative methods. Those with suicidal ideation or scores of greater than 17 on the Center for Epidemiologic Studies Depression Scale (CES-D) were interviewed, based on the mood disorders section of the Structured Clinical Interview for DSM-IV Axis 1 Disorders, and screened for other risk factors for depression such as medications, substance abuse, general medical conditions and bereavement. Of the 26 patients considered at risk for depression or suicide, only two were considered to require referral for psychiatric evaluation after further interview. Another study of 26 acne patients seen in primary care who underwent semistructured interviews to gain qualitative data on psychological sequelae, found that although many had depression and anxiety symptoms, these were often fleeting Citation[13]. None met Diagnostic and Statistical Manual of Mental Disorders criteria for diagnosis of a mood disorder. Therefore, although depressive symptoms are reported by approximately a quarter of patients with acne, these symptoms are often transient, and considerably fewer experience the pervasive low mood and loss of pleasure lasting weeks that is characteristic of clinical depression.
The good news is that treatment of acne seems to result in improvement of mood symptoms. Studies looking at the effect of treatment with topical agents, systemic antibiotics and isotretinoin have found that many patients show an improvement in mood that follows the improvement in their skin Citation[14–16]. However, isotretinoin has received considerable media coverage regarding a postulated link with depression and suicide, causing concern among patients, families and prescribers alike. There are reports of depression occurring in patients prescribed isotretinoin shortly after beginning treatment, resolving on stopping treatment and recurring on rechallenge. Suicidal thoughts, attempts and completed suicides have also been reported, and isotretinoin is the only nonpsychotropic medication in the top 10 ranked drugs for suicide attempts by the US FDA Citation[17]. Some have suggested that acute depression is an idiosyncratic reaction affecting about 1% of those treated with isotretinoin Citation[18]. Conversely several large, retrospective studies have not demonstrated an association between isotretinoin and depression, and the few prospective studies performed have been insufficiently powered to identify or rule out an association Citation[19]. Large, prospective randomized controlled studies could possibly answer this question but would have the disadvantage of denying some participants a treatment that is known to be effective. Certainly many patients, including those with depression, have been safely treated with isotretinoin and there seems little reason to deny adolescents effective treatment for their acne provided that adequate monitoring and support is in place.
Nevertheless, it seems simplistic to think that acne as a single factor alone is responsible for depression. Depressive illness is the result of a complex interaction between predisposing and precipitating factors from biological, psychological and social arenas. It has been shown that there is a linear relationship between the number of adverse factors experienced in childhood (e.g., poverty, parental conflict, poor parent–child relations) and psychological problems in adolescence Citation[20]. Risk factors build on each other and interact to have a much greater effect than each would alone. Therefore, acne may act as yet another risk factor pushing an individual towards depression. However just as risk factors are thought to underpin a negative chain of events resulting in a poor outcome, it is proposed that protective factors, such as a positive temperament, could also interact to create a positive chain reaction resulting in a positive outcome Citation[21]. Exploring the possibilities for developing this positive chain reaction is the basis for the growing literature on resilience.
Resilience is the ability to cope with or adjust to adverse circumstances while maintaining good psychological well-being and functionality Citation[21]. Despite the various negative emotional and psychological symptoms reported by young people with acne, many, even severely affected, patients maintain a healthy outlook. Presumably these young people who cope well with acne are more resilient than those who do not. Resilience has been shown to be associated with a number of factors, related to the individual, their family and society. One’s resilience is strengthened by factors such as good self-esteem, a sense of being lovable, a feeling of control over events in one’s life and hope for the future. Close and trusting relationships within the family are important, as are emotional supports outside of the family. A sense of connectedness to school and community, success at school and religion have also been shown to be valuable. Fostering resilience in young people and teaching them adaptive coping skills is a popular target for youth health programs. Strategies that improve resilience in young people may also be of benefit in helping them cope with the adverse effects of acne.
So what can clinicians do to improve the mental health of their adolescent acne patients? On an individual level it is important to build a relationship with the young person that will allow them to talk about emotional and psychological issues. Unfortunately this may be difficult in a busy clinic. Often the young person comes unprepared to be asked about issues other than their skin and may be accompanied by a parent in front of whom they do not feel they can talk freely. The use of waiting room surveys can be helpful as these are often perceived as less confrontational and may aid the identification of those at greater risk of significant psychological difficulty. Spending part of the consultation with the adolescent apart from their parent may help them talk more easily about sensitive personal subjects; this includes use of contraception and illicit drugs as well as psychological issues. It is important that suicide and self-harm are asked about directly, as screening for mood disorders, such as depression and anxiety, may not detect all of those at risk Citation[7]. On a population level, addressing some of the issues which result in the adverse impact of acne is even more challenging. Strategies that improve resilience among young people generally will assist them in dealing with negative emotions related to acne as well as other life challenges. Advancing community knowledge about acne and available treatments could empower young people to take a degree of control over their own skin care and potentially prevent some of the more severe cosmetic consequences through early use of treatments. However, the increasing focus that society places on appearance, and the frequently unrealistic images held up as ideal, means that young people often feel they fall short of expectations about how they should look, no matter how attractive they may be. Changing this focus would require a major shift in media, marketing and social attitudes.
In summary, acne can have effects on both the skin and the psyche. Although considerable numbers of young people with acne report adverse emotional and depressive symptoms, most adolescents cope well. Dermatologists have the potential to reduce the psychological impact of acne, not only through appropriate use of acne treatments, but by working with other professionals to identify and strengthen resilience factors in young people.
Financial & competing interests disclosure
Diana Purvis is supported by a research grant from the Starship Foundation which is a non-profit organisation supporting the health of children in Auckland. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.
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