Acne and Adolescent Mental Health

Co-authored by Srisindhu Medukonduru and Eunice Y. Yuen, M.D., Ph.D.

Acne is a common, worldwide skin condition with a global prevalence of 9.4%. Interestingly, it is more prevalent in high-income or developed countries than in poorer regions. The issue typically develops during the teen years, affecting 85% of adolescents regardless of gender, and can continue into adulthood as a chronic disease. The problem of acne goes beyond just changing a person's physical appearance. In truth, it can inflict lifelong economic, social, and psychiatric consequences, such as unemployment, lack of social life, and self-esteem or body image issues co-morbid with depression and anxiety.

It is not surprising acne can hit hard on vulnerable teens. In a study analyzing how teenagers see and feel about themselves and how others respond to their skin, teenagers with acne were perceived most often by other people as being shy, stressed, lonely, boring, unhealthy, or rebellious. 64% of teenagers in the study with acne felt embarrassed by it, 71% of teenagers with acne reported lower self-confidence or shyness, and 43% mentioned having difficulty finding dates or making friends. Overall, these results show that acne has a negative effect on the way people are perceived by others and themselves, and thus a huge mental health concern.

Medical Causes of Acne

Acne can present differently depending on severity, ranging from clogged hair follicles with oil and dead skin cells, to severe lesions followed by scars, skin redness, and hyperpigmentation. It can localize mainly on the face, chest, and back of adolescents and young adults. According to a systematic review, onset of puberty, family history, oily skin type, and high body mass index (BMI) have the strongest association with acne presentation. These genetic and hormonal factors change the production of sebum, an oily substance released to maintain skin moisture. Unfortunately, skin with high sebum levels can attract bacteria associated with acne formation and inflammation—Propionibacterium acnes. Dietary factors such as dairy, high fat intake, high glycemic load, and spicy food can increase the risk of acne, while high intake of fruit, vegetables, and fish can be protective against it. Personal factors such as lack of sleep, high stress, and cosmetic usage are associated with increased acne presentation, and frequent face washing may lower the risk.

Teen Mental Health Issues

Adolescence is a developmental stage associated with rapid physical and hormonal changes. One of the most prominent pubertal hallmarks is acne, alongside external factors exacerbating the breakouts such as academic struggles, fear of failure, and social pressures. Acne is associated with higher rates in mental illnesses such as depression, anxiety, and even suicide among teens. Subclinical conditions including low self-esteem, embarrassment, sorrow, and social isolation can be pervasive. It is the fact that acne makes teens more vulnerable to mental health concerns when physical appearance takes on heightened significance for youth’s self-worth and peer acceptance. Having acne in visible areas may receive negative messages and even bullying from peers. Moreover, severe acne can leave permanent facial scarring. The degree of acne severity has a strong correlation not only to teens’ psychological well-being, but also to overall quality of life, and accumulative life-course risks in psychiatric disorders persisted into adulthood.

Although acne affects most teenagers, the psychological impacts can be more significant on teenage girls, racial/ethnic minorities, and sexual and gender minority (SGM) populations. Studies have found women with acne have increased self-consciousness and negative self-concepts than men, and are more likely to be perceived by peers as shy, stressed, and introverted. A nationwide cross-sectional study found there was no difference in mental health outcomes between white and minority acne patients. However, we should be aware of the potential of hidden pains as minority teens may be less likely to see a dermatologist and receive proper acne treatments. The SGM youths have a higher baseline of mental health risks than their peers. The psychosocial effects of acne can be further compounded along with or without the discussion of gender-related treatments. Let us be more compassionate and support these vulnerable youths as family members, providers, and communities.

What can we do to help teens with acne?

Although more work is needed to address adolescent mental health and acne care, a few interesting programs exist. Multidisciplinary integrated acne care across mental health services, primary care, and dermatology services exist to address mental health concerns in teens with acne. Other innovative web-based interventions to support self-management for appropriate use of acne topical treatments are suggested to be feasible. Medical and mental health providers should work collaboratively for appropriate referrals.

For Teens:

• Emotional stress can be a major factor leading to facial acne, which may further strain a teen’s mental health. Stress management is crucial.
• Creating a daily and weekly routine schedule, such as a regular sleep-wake cycle and mealtime, would be helpful in minimizing unexpected stressful events in a teen’s life.
• Designing creative coping strategies such as fun extracurriculars or hobbies to get you away from academic stress could be valuable.
• Identify helpful individuals at school such as counselors, teachers, or coaches to talk about your feelings and what you can do to improve your situation.

For Parents:

• Sometimes teens may feel ashamed and even stigmatized by their appearance that they do not seek help and become isolated. Parents can provide support in many ways.
• Offer supportive space through active listening and understanding for teens to communicate their self-esteem and self-image issues associated with skin conditions. It would be helpful for parents to focus on what teenagers are doing right, rather than commenting on their doing wrong.
• If possible and affordable, take the teen to a pediatrician who can accurately assess their skin condition and possibly refer them to a dermatologist. In some cases, the time to be able to see a dermatologist may take a few months and sometimes is not realistic for some families.
• When teens experience bullying, social ostracism, or other emotional difficulties because of their skin conditions, they are left unsupported and the growing mental health problems go unattended. In this case, parents should make appropriate reports to the school or related authority sources.

Acne is a prevalent dermatological condition amongst adolescents, and it is most usually caused by stress, unhealthy eating, genetics, or hormonal changes. These changes to the teens’ appearance can be detrimental to their mental health and well-being because they see themselves as less attractive and may be prone to encounter hurtful comments from their peers. When teens’ skin conditions become a psychological distress with concerns of depression and anxiety, parents may consider getting help from counseling and mental health services. It is important that youth receive support from their parents and seek appropriate treatment from medical and mental health help.

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Srisindhu Medukonduru is a rising senior at Independence High School, Frisco, Texas, who is aspiring to study public health in hopes of becoming a health care policy analyst in efforts to address global health disparities.