The Interaction Between Acne Vulgaris and the Psyche Hilary E. Baldwin, MD Acne is the most common problem that presents psychosocial counseling also may be an integral to dermatologists. Because it causes visible dis- part of therapy. figuring of the face, it produces a great deal of According to R. Fried (written communication, embarrassment, frustration, anger, and depres- October 1998), there are 5 general ways in which sion in patients. In addition, acne is most com- acne and the psyche interact: (1) acne can cause mon in adolescence and young adulthood, a time mental disturbances such as anger, depression, and when patients are least capable of coping with frustration; (2) acne may worsen emotional factors additional stress. As a result, it is virtually in a patient’s life; (3) acneform lesions can be a impossible to separate acne from psychiatric manifestation of mental disorders; (4) acne can disturbances. Some patients are severely decrease a patient’s psychologic functioning and affected and require more than just acne ther- quality of life; and (5) acne medications may have apy. Dermatologists need to become more adept psychiatric side effects. One difficulty in quantify- at diagnosing and treating causative, concomi- ing the significance of acne on quality of life is tant, and resultant psychiatric disturbances in determining which is the chicken and which the patients with acne. This article is intended to egg—does acne cause the psychiatric distress, or highlight the scope of the problem, identify at- does the stress of adolescence and other life changes risk patients, and help dermatologists assist exacerbate the acne? patients with both their acne and their psycho- logic response to it. Effects of Acne on the Mental State The impact of acne on the mental state of the cne is the single most common skin problem patient has been recognized since at least 1948, in the United States, affecting 40 million when it was noted that “there is no single disease A adolescents and 25 million adults.1 There that causes more psychic trauma, more maladjust- are many opportunities for this condition to inter- ment between parents and children, more general face with the psychologic functioning of the insecurity and feelings of inferiority, and greater patient. Although generally mild in severity, the sums of psychic suffering than does acne vulgaris.”2 coexisting psychologic abnormalities can be serious Since then, many studies have been performed that and even life threatening. This is not surprising detail the detrimental effect of acne on the psyche.3-11 because acne most often involves the face, which is Despite the abundance of these data, few practi- visible to all. Also, it is most common during the tioners spend adequate efforts evaluating the inter- time of life when patients are developing their actions between acne and the psyche. sense of self and social skills. In many patients, The psychiatric effects of acne can be influenced acne is a disease in which the psychosocial conse- by patient age and gender, baseline self-esteem quences are more significant than the medical issues, severity of the disease, response and support issues. We are well aware that successful acne treat- of friends and family, personality, and coping mech- ment relies on the appropriate choice of therapeu- anisms. Its effects also can be influenced by under- tic agents. We are less cognizant of the fact that lying psychiatric disorders that may predate the onset of acne. Adolescents are at the highest risk for mental From the Department of Dermatology, State University of disturbances from acne. Physical and emotional New York at Brooklyn. Reprints: Hilary E. Baldwin, MD, State University of New York at upheavals, which naturally occur at this time of Brooklyn, 450 Clarkson Ave, Brooklyn, NY 11203 life, can magnify the consequences of acne lesions. (e-mail: [email protected]). Hormonal volatility, issues relating to body image, VOLUME 70, AUGUST 2002 133 Acne Vulgaris and the Psyche sexuality, and dating can blow out of proportion even The relationship between stress and acne is likely relatively minor acne lesions, resulting in long-term to be highly variable, depending in part on the abil- emotional and functional consequences. Studies ity of individuals to handle the stresses in their lives. have shown that 30% to 50% of adolescents have Additionally, potential reductions in medication psychiatric disturbances related to their acne.3-8 compliance during times of stress must be consid- Adult women may experience a resurgence or ered. Stressful situations are not conducive to the new onset acne vulgaris. Coupled with issues com- use of any medication, and topical acne preparations mon to this age group, such as motherhood, sexual- may be the first to be discontinued. ity, and occupational competence, these patients can experience psyche disturbances. Wu et al10 Effect of Acne on Functional Status found that adult women who either had or per- It is clear that acne has profound effects on the ceived themselves to have severe acne showed functional status of patients. Do the emotional higher levels of anxiety and anger. Kellett and changes result in decreased social, vocational, and colleague9 found that 44% of adult patients with academic functioning? Studies have shown that acne also had clinically significant anxiety, and acne interferes with social activities such as dating 18% reported depression. Women were more debil- and sports.13,23 The severity of acne in both males itated by acne than men.9 and females is related to their lack of participation Studies have shown that these patients have in and enjoyment of social activities.11 Patients increased anxiety and anger, in addition to docu- with severe acne show poorer academic perfor- mentably poor self-image.8 Some studies show a link mance4 and higher unemployment rates than adults between acne severity and clinical depression.10,11 without acne (16.2% vs 9.2%).24 However, even patients with mild to moderate acne Adults with acne may be even more impaired vulgaris show significant psychiatric disturbances.12-14 functionally. Lasek and Chren25 found that adults Gupta et al12 showed that 3 of 10 patients with acne with acne are more severely affected with emo- were clinically depressed. Treatment of acne in tional symptoms than are adolescents. these studies resulted in amelioration of psychiatric disturbances, with the best response seen in Acneform Lesions Manifest Underlying patients with the best clinical improvement.12,15,16 Psychiatric Disorders Treatment of acne scarring also may improve the Manipulation of the skin can result in lesions that psychiatric functioning of patients.17 resemble acne but are actually the results of self- mutilation. Such manipulations can be purposeful, Effects of Emotional Factors on Acne as in delusions of parasitosis and acne excoriate, or The relationship between stress levels and acne is largely unconscious. The severity of acne does not firmly entrenched in the patients’ belief system. Our necessarily correlate with self-excoriating behavior, colleagues, who frequently blame all types of skin as shown in a study of 56 women with mild to mod- ailments on stress, perpetuate this belief. This topic erate facial acne.26 In this study, the authors found has been poorly and insufficiently explored.17 The that poor self-concept and compulsive and perfec- relationship is at least theoretically possible. Stress tionistic personality traits were more highly predic- results in an increase in glucocorticoids and andro- tive of patients who picked at their acne than was gens, which could result in an acne flare. Schulpis et the severity of the acne at which they picked. al18 showed an association between psychologic Other manifestations of underlying psychiatric states and sympathoadrenal status in patients with disorders can be very subtle, such as noncompli- acne. Griesemer19 found that patients with acne ance with medication. The most common disorders reported a lag time of 2 days between a stressful to present in this fashion include anxiety disorders episode and the exacerbation of acne. Lorenz et al20 such as obsessive-compulsive disorder (OCD), per- found that intense anger also may aggravate acne sonality disorders such as borderline personalities, severity. Acne improvement has been shown to be depressive disorders, and body dysmorphic disor- related to a reduction in both depression and anxi- der.26 Patients with body dysmorphic disorder may ety, as well as to an increase in body image.12 perceive their acne as worse than it is, and their Studies of stress-relief biofeedback techniques level of psychologic dysfunction is more related to have shown improvement in acne severity.21 Subse- their perception than reality. Wu et al10 showed quent discontinuation of the techniques resulted in that patients who self-rated their acne as moderate clinical worsening. Insight-oriented psychotherapy or severe exhibited greater anxiety and anger than was shown to improve inflammatory dermatoses in patients who believed their acne was mild. The 4 patients with recalcitrant disease.22 true clinical severity, as graded by the observing 134 CUTIS® Acne Vulgaris and the Psyche dermatologist, did not necessarily agree with that evaluate the patient at each visit using specific which was perceived by the patient. Van der queries for symptoms of depression. Meeren et al27 found that patients with severe acne were more focused on bodily functions, had a more Identifying Patients at High Risk for self-defensive attitude, and were more neurotic Acne-Related Psychiatric Problems than patients without acne. Now that we know to be clinically suspicious, how do we recognize these impaired patients, especially Psychiatric Problems Caused by with our limited knowledge of clinical psychology Acne Medications and the patient visit time frames imposed by health Isotretinoin has been reported by the manufactur- maintenance organizations? We must be able to ers to be associated with a less than 1% incidence rapidly identify the patients with acne who need of depression, psychosis, suicidal ideations, suicide more than just prescriptions.