The effect of acne upon the psychological state of the patient is a compelling component of the overall morbidity associated with acne; it can be a critical factor in both treatment and management. In fact, for those patients with mild to moderate acne vulgaris, the psychological effects of acne as well as psychosocial may constitute the most prominent morbidity.
The severity of acne does not necessarily reflect the degree of overall psychosocial disability experienced by the patient; those with mild to moderate acne sometimes report the same degree of psychosocial distress as their more severely affected counterparts. Teenagers are particularly vulnerable to the negative psychological effects of acne, because their self-esteem, confidence in social interactions, and identity are often in a precarious, formative stage.
Acne can be classified as a cutaneous disorder with a primary dermatopathological basis that can (a) be influenced by psychosomatic factors, such as in the case of psychological stress exacerbating acne, and (b) result in an emotional reaction primarily as a result of the cosmetic disfigurement and/or the social impact of the disorder. This latter factor is the most important basis for the psychological morbidity that is associated with acne. The relatively high prevalence of psychiatric comorbidity with acne may in part be a reflection of the fact that the prevalence of acne is about 40 percent among adolescents, who are at a life stage that is also associated with a high incidence of depressive illness and body-image disorders. As a result, among some patients, the acne may not be the sole basis for the psychological symptoms, such as depression, but may end up being the focus of attention for both the patient and his or her family, who may find it “easier” to focus on the acne rather than the complex individual and family dynamics that can be associated with teenage depression.
STRESS AND ACNE
It is a commonly held clinical impression that psychological stress exacerbates acne. Conversely, the relatively profound effect of acne upon the quality of life can conceivably lead to psychological stress. It has been proposed by some that the rising incidence of acne among adult women is related to the multiple life stresses that women face, for example, the stresses of family and career. The effect of stress on the neuroendocrine response, especially cortisol and androgen secretion and their effect on sebum secretion, has been implicated as a possible contributory factor.
PSYCHIATRIC DISORDERS ASSOCIATED WITH ACNE
Acne has been associated with a range of psychopathological reactions that are not always related to the clinical severity of acne. One study involving psychiatric examinations of 55 acne patients with cystic acne revealed that only 1 of the 55 patients met the standard American Psychiatric Association diagnostic criteria (Diagnostic and Statistical Manual of Mental Disorders, or DSM) for a major depressive episode and that only 4 of the 55 patients met the criteria for a past history of a mood disorder. In contrast, another study involving 10 patients with only mild to moderate facial acne vulgaris observed that 3 of the 10 patients met the current DSM criteria for a major depressive disorder and that 7 of the 10 met the criteria for a past history of a mood disorder, according to the clinical psychiatric examination.
Increased levels of anxiety and depression have been observed among both patients with severe cystic acne and patients with mild to moderate noncystic acne when psychological rating scales were used. While high scores on rating scales do not necessarily indicate the presence of major depressive disorders that will be responsive to antidepressant drugs, they do indicate the presence of psychological morbidity among acne patients. It is important to note that even a full depressive syndrome that meets the DSM diagnostic criteria for a major depressive disorder can improve with the improvement of the acne alone and without antidepressant medications, in some cases. This finding highlights the profound impact that acne can have upon the mental state of the patient, most likely as a result of the cosmetic disfigurement and self-consciousness caused by acne.
Depressive illness can be associated with suicide risk. In a recent report, Cotterill and Cunliffe described 16 cases of completed suicide among dermatologic patients. Seven of the patients had acne, a finding that highlights the importance of recognizing depressive illness and other major psychiatric disorders that can increase the risk for suicide among acne patients.
In the adolescent population, depressive disease can manifest as behavioral problems, a substance-abuse disorder, or academic problems, rather than a complaint of a depressed mood by the adolescent patient. As a general guideline, when assessing an acne patient, the clinician should consider the most-current diagnostic criteria set by the American Psychiatric Association, as follows: The essential feature of a major depressive episode is a period of at least two weeks during which the patient reports a depressed mood or the loss of interest or pleasure in nearly all activities. Among children and adolescents, the mood may be irritable rather than sad or depressed. To meet the diagnostic criteria for a major depressive episode, the patient must also experience—in addition to the essential mood symptom—at least four other symptoms from the following list of seven symptoms:
- Changes in appetite or weight. There may be weight loss in the absence of dieting or increased or erratic eating and weight gain. This symptom in children may manifest mainly as failure to make expected weight gains.
- Difficulties with initiating or maintaining sleep or increased need for sleep nearly every day. The patient may complain of increased daytime sleepiness.
- Psychomotor agitation—for example, manifesting as pacing, inability to sit still, and pulling and rubbing of the skin—or psychomotor retardation—for example, manifesting as slowed speech and slowed body movements severe enough to be observable by others.
- Decreased energy almost every day. Even relatively minor tasks, such as dressing in the morning, may require substantial effort.
- Sense of worthlessness and excessive or inappropriate guilt nearly every day.
- Impaired ability to concentrate, think, or make decisions. The patient may appear easily distracted and complain of memory difficulties. In children and adolescents, this is seen as a decline in their academic performance.
- Thoughts of death, suicidal ideation, or suicide attempts.
In a study involving 13 men with mild to moderate facial acne vulgaris, it was observed that coexisting depression or an anxiety disorder was associated with an increased tendency for the patient to pick his acne lesions. This self-excoriating behavior can in turn exacerbate the acne and may be the manifestation of psychomotor agitation or self-mutilating behavior in the depressed acne patient.
DRUS SIDE EFFECTS AND INTERACTIONS
Isotretinoin is used to treat severe cystic acne and recalcitrant acne. There have been reports of “insomnia and minor depression,” psychotic reactions, and the development of a major depressive syndrome in association with oral isotretinoin therapy. A review of the literature indicates that the onset of depression or psychotic reaction was sporadic and not related to the dosage or duration of treatment with isotretenoin, reflecting an idiosyncratic rather than a predictable side effect of isotretinoin.
Lithium, a mood-stabilizing agent, is classically used to treat manic-depressive illness and recurrent depression. It has been associated with a wide range of dermatologic reactions, including acneiforme eruptions. Lithium-induced acne tends to be pustular with an erythematous base and is often dose-dependent. It should alert the clinician to a possible underlying state of lithium toxicity, which has been reported as a result of combining lithium with tetracycline, a standard acne therapy that sometimes has a nephrotoxic effect. Erythromycin, one of the standard treatments for acne, can interact with carbamazepine, an antiseizure medication that is also used as a mood stabilizer in manic-depressive disease, and result in elevated blood levels of carbamazepine in some patients.
ACNE AND BODY IMAGE
For the adolescent with acne, it is important to evaluate the impact of even mild acne upon the patient’s body image. Acne can have a profound effect upon the self-image and body image of the patient, and this in turn can lead to social isolation and even a depressive reaction. Several investigators have shown that the degree of body-image concern in the acne patient is not always related to the clinical severity of the acne. In some cases, concerns about cutaneous body image resulting from acne can generalize to concerns about overall body image that are not necessarily related to the skin, such as concerns about body weight and shape. The patient may attempt to “control” this aspect of body image by excessive dieting and may eventually develop an eating disorder such as anorexia nervosa or bulimia nervosa.
Acne excoriee des jeunes filles is a relatively rare syndrome that is observed among young girls with an immature personality constellation and body-image problems. In this syndrome, the patients express excessive concerns about very minimal acne and present with deeply excoriated lesions. The repetitive self-excoriation can exacerbate the deeper inflammatory process in acne, and this in turn can prolong the course of acne and contribute to permanent scarring. These patients often focus on the self-excoriated lesions, which can sometimes serve as an “excuse” to isolate socially when the patient is having difficulty coping with the social and emotional demands of adolescence and adulthood. It has been observed that some adult women with acne excoriee comprise a subgroup that often do not recover with dermatologic therapies alone, as the excuse for social isolation becomes a maladaptive “coping mechanism” for the patient. Such patients, who are often very socially dysfunctional, may require psychiatric interventions to enable them to develop more-adaptive coping mechanisms.
ACNE AND QUALITY OF LIFE
“Quality of life” is defined as one’s perception of one’s psychological state, social interaction, physical and occupational functioning, and somatic sensation. The areas of quality of life that are most affected by acne include the patient’s psychological, social, and vocational functioning. The impact of acne upon the quality of life is an important component of the overall morbidity that is associated with acne, and it is often the primary consideration in deciding whether to institute therapies, especially for patients with mild to moderate acne vulgaris.
Some patients who report a significant impairment of their educational and/or occupational functioning as a result of their acne may in fact be suffering from more-severe psychopathology, such as depressive disease. As noted earlier, both acne and major depressive disorder have a peak incidence in adolescence, and this may in part be the basis for their comorbidity. Therefore, it is important to consider that psychosocial morbidity may not be secondary to the acne, but may represent a primary psychiatric disorder, such as depressive disease, which in turn can make the patient more vulnerable to the psychosocial impact of the acne.
It is important to evaluate the effect of even mild acne on the patient’s mental state, body image, and social and vocational functioning. The psychopathological states that are observed in the acne patient may be secondary to the acne or may represent a primary psychiatric disorder, especially in the adolescent patient. Some patients who attribute their vocationally related problems, such as impairment in their academic functioning, primarily to their acne may have an underlying depressive illness that may be more important.
Dr. Gupta is Professor of Psychiatry at the University of Western Ontario, London, Ontario, Canada. She has published many original papers in the field of psychodermatology.