The Link Between Acne and Mental Health

I want to dedicate this blog post to discussing the link between mental health and acne. Although it is becoming well-recognised that acne can affect mental health (and vice versa), there is a long way to go before we see the right amount of support offered to people that have acne.

How does acne affect mental health and vice versa?

Acne negatively affects quality of life and has considerable psychological, social and emotional impact. The following research findings highlight the connection between acne and mental health.
• The psychological impact of acne affects several aspects of daily life, including ability to socialise, and occupational opportunities.
• People with acne can show symptoms of depression and anxiety (e.g. anger, low self-esteem). Other effects are embarrassment (females affected more than males), body dissatisfaction,
poor emotional health, anxiety and depression, social phobia, and thoughts about suicide.
• 1/5 acne patients are reported to have psychiatric disorders in one study.
• Older people with acne (>20-years-old) have more appearance-related concerns than younger acne patients.
• Women with acne are more self-conscious about it than men, they also feel worse about themselves.
• Adult acne is associated with anxiety, depression, stress and thoughts about suicide in women.
• Longer duration of acne (>5-years) and older age of onset has more impact on quality of life in women.
• Acne on the body makes people more self-conscious when entering intimate/physical relationships.
• The severity of acne does not necessarily correlate with impact on quality of life, some people with mild acne report a large negative effect. However, more severe acne has been associated with an increased risk of anxiety, depression and thoughts about suicide.

If I have acne, why should I see a psychodermatologist?

Psychodermatology is the part of dermatology that considers both the mind and the skin together when seeing a person with a skin problem. I am a medically qualified doctor, specializing in skin disease (a ‘Dermatologist’), and I have an interest in treating the mental health burden that accompanies many skin conditions (a ‘Psychodermatologist’). I know that people with skin conditions are at higher risk of developing poor psychological health, meaning they are more likely to feel embarrassed, low, anxious, have body image issues and feel socially isolated. These feelings can then impact their skin and it can turn into a vicious cycle. In psychodermatology we recognize this link and treat not only the skin condition, but also the psychological impact is having. For example, someone with acne may be feeling anxious about being in a social environment because of their skin, so in addition to treating their acne, I will discuss techniques they can use to overcome these feelings and empower them to do the things they want. I also assess the person as a whole, we talk at length about their lifestyle, skincare regimes, work/study environment and relationships. Very few people realise how reactive their skin is to lifestyle choices.
Typically, a psychodermatology appointment is longer (45-60mins), this is to allow me enough time to assess both the physical and psychological health of the patient, as well as spend adequate time discussing treatment options.

How can I manage the emotional distress created by having acne?

Most important is to first have the correct diagnosis made and following that, appropriate treatment. People with acne and emotional symptoms can see improvement of these when their skin is treated. Relaxation and breathing exercises are some of the simplest forms of therapies I suggest, in addition to medical treatment, these are particularly helpful for symptoms of anxiety. More structured psychological interventions that are based on cognitive behavioural therapy can also be used to manage emotional distress. It is not uncommon for me to treat patients with mood or anxiety-managing medications, but this is on a case-by-case basis. It is helpful to discuss with your GP or dermatologist how you are feeling so these issues can be recognised early. Not all symptoms of low mood need medicine, talking therapies can also help. Your GP is ideal to refer to these organisations, or sometimes you can self-refer. Putting treatment or assessment of mental health issues on hold is not ideal, as they can be implicated in causing or aggravating skin problems, as well as negatively affect treatment outcomes. The best way forward is to treat both the mind and skin together.

I feel embarrassed to ask for help, lots of people just say I will grow out of my acne/it’s my hormones/diet.

Please do not allow your skin condition to be trivialized by others. Speak up and ask to be seen by an expert. The severity of your skin condition does not dictate how you feel, for example, having only a few spots can be devastating to some people, which is something we are trained to deal with in psychodermatology. Psychological health is as important as physical health.

I have heard about a treatment called ‘Roaccutane’/Isotretinoin, but I got put off because it causes depression.

The evidence in this area is inconsistent as different studies report different things. A review of 17 studies showed that use of Roaccutane improved depressive symptoms in acne patients. There are however some studies that suggest an increased risk of depressive symptoms in patients that take Roaccutane. This is why the evidence is conflicting. A dermatologist will prescribe this medication after taking a thorough assessment and will counsel you on the potential side effects. I usually advise that if you are worried about the mental health effects of Roaccutane, you can be monitored closely throughout treatment (approximately every 4 weeks).

My acne got better, but the scars are permanent. How do I overcome this?

I suggest speaking to your GP or dermatologist about how you are feeling. Treatment options for acne scars can be limited on the NHS, but it is good to get appropriate advice on what type of scarring you have and what treatment have been shown to work. Most important is treating any ongoing acne activity as this can cause further scarring. Treatment options for acne scars include creams or gels, or physical treatments such as micro-needling, steroid injection, chemical acid application or surgical excision of certain types of scar. Again, coping is important, and looking into strategies or interventions to enhance this is also helpful. For example, cognitive behavioural therapy-based interventions can help deal with negative thoughts associated with acne or acne scarring. People with acne also have a higher chance of body dissatisfaction, identifying and treating this can be beneficial. Acne scars (or any scars) do not need to be viewed negatively. Your skin tells its own story that is personal to you. Chasing the concept of flawless skin or removing signs of skin injury can also be emotionally distressing. Learning to cope with your skin may be more helpful than engaging in treatments that may have little benefit. The skin positivity movement is extremely important in encouraging people to accept their skin and remove negativity associated with skin imperfections. Changes in skin are NORMAL and happen to EVERYONE.

How do I see a psychodermatologist? I can’t afford a private consultation.

The usual NHS pathway for a patient with acne is to see your GP, who can then refer you to a general dermatologist or psychodermatologist if needed. A psychodermatologist, like me, is a medically qualified doctor with expertise in dermatology, who is also able to manage mental health issues. There is no harm in being asked to be directly referred to psychodermatology if possible. Your GP or dermatologist can refer to the nearest psychodermatology clinic, but this may be outside of your immediate area. A recent survey showed that 45% of dermatologists had to refer patients outside of their region. Current psychodermatology clinics that accept referrals from any area are (to my knowledge):
1. Royal London Hospital, Whitechapel, London, U.K.
2. King Edward VII Hospital, Windsor, U.K.
3. Solihull Hospital, West Midlands, U.K.
It is worth asking your local dermatology department if they know of a nearby specialist. You can also see a psychodermatologist privately if able. Please do check the credentials of the specialist before making an appointment.
I would encourage anyone with symptoms of psychological distress associated with having a skin condition to seek appropriate support via their GP, dermatologist or psychodermatologist.

I work in both the NHS and private sector. The NHS trusts I work for are Frimley Health NHS Foundation Trust and Barts Health NHS Trust, your GP is welcome to refer to me directly.

To book a private consultation: https://thepsychodermatologist.com/contact-us/

Please follow me on IG! You can also access my videos and interviews on my profile:

@the_psychodermatologist

Websites

1. skinsupport
2. changingfaces

References

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2.Del Rosso JQ, Harper JC, Graber EM, et al. Status report from the American Acne & Rosacea Society on medical management of acne in adult women, part 1: overview, clinical characteristics, and laboratory evaluation. Cutis. 2015;96(6):376–382.

3.Kellett SC, Gawkrodger DJ. The psychological and emotional impact of acne and the effect of treatment with isotretinoin. Br J Dermatol. 1999;140(2):273–282.
Martin AR, Lookingbill DP, Batek A, Light J, Thiboutot D, Girman CJ. Health-related quality of life among patients with facial acne – assessment of a new acne-specific questionnaire. Clin Exp Dermatol. 2001;26(5):380–385.

4.Misery L. Consequences of psychological distress in adolescents with acne. Journal of Investigative Dermatology 2011;131(2):290-292.

5.Rapp DA, Brenes GA, Feldman SR, et al. Anger and acne: implications for quality of life, patient satisfaction and clinical care. Br J Dermatol. 2004;151(1):183–189.

6.Rocha M, Sanudo A, Bagatin E. The effect on acne quality of life of topical azelaic acid 15% gel versus a combined oral contraceptive in adult female acne: a randomized trial. Dermatoendocrinol. Epub 2017 Oct 13.

7.Rocha M, Sanudo A, Bagatin E. The effect on acne quality of life of topical azelaic acid 15% gel versus a combined oral contraceptive in adult female acne: a randomized trial. Dermatoendocrinol. Epub 2017 Oct 13.

8.Saitta P., Keehan P., Yousif J., Way B. V., Grekin S. & Brancaccio R. An update on the presence of psychiatric comorbidities in acne patients, Part 2: Depression, anxiety, and suicide. Cutis 2011;88(2):92-7.

9.Tan JK, Li Y, Fung K, et al. Divergence of demographic factors associated with clinical severity compared with quality of life impact in acne. J Cutan Med Surg. 2008;12(5):235–242.