Acne vulgaris: More than skin deep
1. Dalhousie University Medical School Halifax, Nova Scotia, Canada 2. Division of Dermatology, QEII Health Sciences Centre Halifax, Nova Scotia, Canada. email@example.com
Acne vulgaris is a common skin disorder affecting at least 85 percent of adolescents and young adults. This disorder is often dismissed by the medical community and general population as a superficial affliction associated with growing up, however scientific evidence has illustrated that the effects of this condition are far more than skin deep. This brief review of relevant scientific literature discusses the potential effect of acne beyond its dermatological manifestations. These include effects on psychiatric health, psychological well-being, and quality of life.
Acne vulgaris, more commonly referred to simply as acne, is a chronic inflammatory disorder of the pilocebaceous unit that affects at least 85 percent of adolescents and young adults.[1, 2] Acne has been implicated in psychiatric and psychological processes more than most other dermatological conditions. There are many aspects of this disease that contribute to its nondermatological effects including predominant adolescent prevalence, anatomical distribution of lesions, misperceptions regarding etiology, and social pressures. Adolescence is a time of significant physical, emotional, and social development, which may predispose individuals to psychiatric or psychosocial complications. Distribution of acne lesions is limited to areas with well-developed sebaceous glands including the face, back, chest, and upper arms. Unlike other dermatological conditions, which may be limited to areas covered by clothing, acne is apparent. Individual and social perceptions of acne can affect the effect of the condition. In a study of acne patients in a dermatologists care, almost 30 percent believed that poor skin hygiene was a causative factor of acne. If this belief exists among a patient population who has had some degree of education by their physicians, similar beliefs must also exist in the general population. Beliefs similar to this one create a stigma that can lead to feelings of embarrassment, shame, and guilt in the afflicted. Finally, Western society places a great emphasis on physical appearance. It is not surprising that, when patients were asked in what way their acne bothered them, the most common response was appearance. Acne vulgaris can have significant nondermatological effects because of the specific population affected, distribution of lesions, misperceptions regarding etiology of the condition, and the strong emphasis placed on physical appearance.
Psychiatric and psychological implications
Psychiatric disorders can develop secondary to acne vulgaris. [5, 6, 7, 8, 10] Clinical depression, social phobia, and certain anxiety disorders have been associated with acne. Acne patients report greater levels of anxiety and depression than other medical populations, including cancer patients and other dermatology patients. The prevalence of depression and suicidal ideation was measured in 480 patients with potentially disfiguring dermatological conditions. Clinical depression and suicidal ideation occurred at a significantly greater incidence in the group with acne than in groups with alopecia areata, atopic dermatitis, and mild-to-moderate psoriasis. The only group, that surpassed acne with incidence of clinical depression and suicidal ideation were inpatients with severe psoriasis (with a mean total affected body surface of 52 +/- 23.4%). This study used a group of patients with mild-to-moderate acne. Patients with severe acne may in fact be at similar or greater risk of developing such complications. These findings illustrate the importance of recognizing psychiatric comorbidity in patients with acne.
Suicide is rare in dermatological patients. A study reported sixteen cases of suicide in patients with dermatological conditions. Acne without primary psychiatric illness was the presenting diagnosis in seven of sixteen cases of suicide. All these patients had acne scarring and six of seven had poor response to treatment. Although these observations are clinically relevant, the population size was too small to be statistically significant. The remaining five of sixteen patients had primary psychiatric illness, two of sixteen had chronic and debilitating skin disease and two of sixteen had extenuating social circumstances. This breakdown clearly illustrates that acne can have serious psychiatric sequellae. The authors suggest that a simple psychological screening inventory can help identify patients with severe depressive features. This paper also illustrates the distinction between reactive or secondary depression and primary psychiatric illness, which can present with a complaint that is focused on acne. Such primary psychiatric disorders include obsessive-compulsive disorder and psychosis.
Acne negatively affects psychological health and psychosocial functioning. These characteristics are more subjective than psychiatric conditions, and they lack specific clinical definitions. Studies have found significant impairment in self-image and self-esteem,  impairment in psychological well-being,  dissatisfaction with appearance, [9, 11] and inhibition of social interactions in acne patients.  Finally, acne is a psychophysiologic condition as its physical pathology can probably be exacerbated by psychological stress.
Quality of life
Quality of life is the degree of enjoyment or satisfaction experienced in everyday life. Several studies using validated instruments that are either generic or disease specific, have been completed evaluating the quality of life in patients with acne. Generic instruments are beneficial because they allow direct comparison to other populations, but they are limited by lack of disease specificity and great length, which can lead to logistical difficulties. Disease specific instruments measure variables relevant to people with skin conditions and may be more sensitive, but they do not allow comparison with nondermatological populations. One study compared health-related quality of life in patients with acne using both generic and disease-specific instruments. Both instruments show a significant deficit in health-related quality of life before treatment when compared with a population sample. However, the disease-specific instrument was more responsive to change after treatment, presumably because this measures variables relevant to individuals with dermatological conditions.
A study using only generic instruments to measure quality of life found substantial deficits reported by acne patients. The deficits in quality of life are as great as those reported by patients with chronic disabling asthma, epilepsy, diabetes, or arthritis. The deficits in quality of life are significant enough to be detected by an instrument not designed with skin in mind. Therefore, greater deficits may be found using a disease-specific measure.
A study using a disease-specific validated instrument also found that acne vulgaris significantly affects quality of life. In addition this measure determined that regardless of acne severity, older adults with acne reported greater deficits in quality of life than their younger counterparts. This finding may reflect the duration of disease, poor response to treatment, social implications of acne in an adult population, or a small sample size. Further study is indicated to evaluate the impact of acne on quality of life in different age groups.
According to the Canadian Consensus Guidelines for the Treatment of Acne Vulgaris and Prevention of Acne Scarring, treatment encompasses terminating the active disease process and preventing further scarring, and recognizing psychological and social impairment associated with the disease. Currently, many effective therapies are available for the treatment of acne vulgaris. These include topical therapies such as retinoids, benzoyl peroxide, and antibiotics. Oral antibiotics and hormonal therapies including oral contraceptives are also be used effectively. Finally, Isotretinoin (Accutane) is the only agent to induce long-term drug-free remission and potential cure. However, the teratogenicity and the considerable controversy regarding suicide risk with isotretinoin have made its use problematic. However there is no evidence to support a causal connection between isotretinoin and major depressive episode or suicide.[17, 18]
There are many factors that influence a physician's choice of treatment. The grade of acne is considered, which is determined by predominant lesions present, which include microcomedones, papules, pustules, and nodules. A positive correlation was noted between the facial grade of acne and the resultant psychological and social disabilities.[12, 19] Duration and scarring of the condition is another consideration. A study designed to assess the psychological and social effects of acne found that individuals with persistent acne (10 years or more) demonstrated significant psychological disability compared to controls. Another study found that 74 percent of patients waited over 1 year before seeking medical attention. This delay is concerning as duration of active acne is extended and the chance of scarring is increased. It is imperative to select a treatment that can prevent scarring because it is a permanent physical complication of acne. Finally the psychological and psychiatric health of an individual and their health-related quality of life should be a consideration.
The psychological and emotional impact of acne was evaluated in a sample population beginning treatment with isotretinoin. Treatment produced significant improvements across a wide variety of psychological parameters including attitudes about appearance, self-consciousness, and obsessive-compulsive behaviors. The emotional status of these patients appeared to be more resistant to change. It is proposed that this is a result of time lag and inadequate study duration to evaluate a more gradual emotional transition. A similar study reported an improved level of morbidity and mood after treatment with isotretinoin. A third study evaluated 111 patients before and after treatment with a variety of modalities including topical treatments, oral antibiotics, hormonal therapy, and isotretinoin.  Substantial improvement in measurements of quality of life and self-esteem was documented with treatment. The findings of all three studies provide concrete evidence of the psychological benefits of isotretinoin treatment for patients with acne.
In addition, the above study by Newton et al. compared the effectiveness of isotretinoin with the other antibiotic, hormonal, physical and topical treatments in terms of both clinical disease and nondermatological sequelae. Clinical and patient assessed outcomes of physical and psychological measures were significantly better with isotretinoin treatment. A similar study compared isotretinoin with oral antibiotics using patient assessment of psychological and social effects of acne. This study demonstrated a significant improvement in assessment with isotretinoin after therapy. No significant difference was found between the two groups during treatment, which likely reflects the ongoing side-effects of retinoid treatment. However, both studies illustrate that isotretinoin has a superior efficacy for reducing both the dermatological disease and the psychological complications.
Although the primary goal of treatment is to terminate the active disease process, it is important for the treating physician to consider the psychiatric health and psychological well-being of the patient with respect to their acne. Patients with severe psychiatric or psychological comorbidities or any evidence of scarring warrant more aggressive initial therapies. Despite the side-effects of isotretinoin, it offers rapid improvement of acne with potential long-term improvement or cure, and it facilitates psychosocial and psychiatric improvement in patients. Factors to be included in treatment selection are duration, distribution, and grade of disease as well as psychological state, psychiatric comorbidity, quality of life, and social disability caused by acne.
Acne vulgaris has the potential to cause significant psychiatric and psychological complications, while negatively affects quality of life. Many factors influence the nondermatological aspects of acne including personality, perceptions, age, and social and cultural factors, as well as disease characteristics (duration, severity, scarring). It is important to note that not all patients who develop acne experience psychiatric or psychological complications or any alteration in quality of life. However, the scientific literature clearly illustrates that these complications occur more frequently in patients suffering from acne vulgaris. The treating physician should consider these factors when selecting an appropriate treatment. Addressing nondermatological effects of acne allows the physician to treat the whole patient and not solely the skin condition. Acne vulgaris is a common skin disease with potential complications that are more than skin deep.
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