Quality of Life in Acne

Zits. Jerry Scott and Jim Borgman’s title comic with the same name adds some humor to the pleasantries of coming of age. However, the annoyance of zits, often signaling the transition to puberty, can be more of a nuisance, and even become a bane of existence. Acne is one of the most common skin conditions that features blackheads, whiteheads, and pimples with or without pus.^[1] The blackheads and whiteheads commonly appear on skin as a result of excess sebum (oil-like substance) plugging hair follicles and the larger inflamed pimples are usually due to skin bacteria overgrowth.^[1]

Acne is common, affects 85% percent of teenagers and also continues into adulthood.^[2,3] It most commonly pops up on the body between the age of 16-20, but can also affect adults over age 25 and continue through age 40 to 50.^[4,5] However, over the age of 20, women are affected at higher rates than men.^[4]  

The Role of Stress in Acne

Several factors can affect acne severity, but one common factor is stress. In student studies, acne worsened around the time of examinations and became more prevalent around other stressful times, especially in males.^[6] When oil gland production was examined during high and low times of stress in the same individuals, researchers found no differences in production, suggesting that the increase in acne around stressful times is not simply a matter of producing more or less oil, but other factors are involved too.^[7]

As acne can be stressful, be assured that acne is not due to poor hygiene and cannot be easily fixed by increased washing.^[8] Additionally, even when you start on treatment regimens, you may not see any improvements for 1-2 months, and the acne may even worsen during the initial treatment stage.^[8]

Psychological Stress of Acne

Often, a patient’s perception of acne can be quite different than that of his or her care provider.^[9] The profound psychological effect of acne was initially mentioned in the 1940s, “there is probably no single disease which causes more psychic trauma, more maladjustment between parents and children, more general insecurity and feeling of inferiority and greater sums of psychic suffering than does acne vulgaris.”^[10] Given the psychological impact of acne, a patient’s mental health should be taken into account when treating acne.^[11,12] 

Depression and anxiety are reported in approximately 18% to 44% of acne patients and 6% of acne patients have suicidal tendencies.^[13] As acne is associated with significant mental health morbidity, treatment is crucial for appearance’s sake as well as mental well-being.  A patient who feels anxious or depressed, especially about their acne, should seek to find a care provider that they feel comfortable and honest telling him or her about their feelings. Conversely, it is important for practitioners to have an open conversation about the psychological effects of acne.

Interdisciplinary therapy to help with not only acne but also the mental health struggles as well will be important.^[14] A start to the treatment plan often includes education about the mind-skin connection; helping reduce stress on the mind can help reduce the inflammation on the skin.^[6,15] The feelings of anger and frustration about acne are common, and a care provider can help develop a treatment plan that suits the patient's needs and achieves their goals.^[16]

Psychological Effects of Acne in Those with Darker Skin

In individuals with skin of color, post-inflammatory hyperpigmentation and keloid scarring are more common as potential complications of acne than lighter skinned patients.^[17] In African American, Latino, Asian, and Arab-American populations, acne was often reported as the most common skin condition.^[18-20] On a microscopic level, acne on darker skin presents slightly differently than on Caucasian skin, which may be likely why acne on ethnic skin leaves darker areas of pigmentation called post-inflammatory hyperpigmentation.^[21] 

In those with darker skin, the acne scarring and discoloration may distress them more than the actual acne.^[20] The hyperpigmentation can be present for much longer than the original acne and can affect self-esteem and confidence.^[20] In the treatment of ethnic skin acne, it is important to utilize therapies that may reduce or prevent the inflammation that causes this post-inflammatory hyperpigmentation.^[21] Care providers can work with the patient to develop a treatment plan that addresses the acne to prevent scarring and treat the discoloration. Some examples of medications that can treat both acne and dyspigmentation include topicals like azelaic acid and tretinoin.^[22,23]

Treatments to Improve Quality of Life

While treating acne can improve the disease, other treatment modalities and options are available to patients to specifically improve their quality of life. Health practitioners can advise creams, pills, and medicated body washes to help with the acne, as well as other therapies such as exclusion diets and yoga to help improve the psychological aspects of the disease.^[24] Yoga, in particular, helps reduce stress and is another potential option to help manage tension and anxiety related to acne.^[25] One study performed on college campuses, where many of the participants included students within the acne age range, showed that yoga may help reduce symptoms of stress and worry.^[26]