A look at the psychological implications of acne in teenagers and adults.
Casey Butrus, PharmD: It’s very common to see acne in the adolescent population. Hillary,…there are a lot of changes going on at that time in their life. How do you think acne impacts mental health and self-esteem for those patients who maybe have this body image concern at such a young age?
Hilary Baldwin, MD: It’s a devastating time of life. It couldn’t happen at a worse moment. There’s so much psychological overlay due to a bunch of factors. The first is that teenage is the time for the development of the sense of self. If your sense of self is somebody ravaged by acne, how can that possibly not affect your quality of life? It’s a very difficult time. Teenagers are easily derailed, and they have a tenuous grasp on their sense of self-worth and self-esteem. It can be extremely difficult for patients.
Additionally, acne is on the face. Too bad it’s not on the butt or something because you can’t hide this. You can’t cover it up. You can’t wear a paper bag. It’s also prime time for bullying, in middle school and high school. I have patients telling me that their friends are calling them pizza-face and making fun of them. It’s a perfect storm. One of my favorite papers was in 1997, and I still quote it practically daily. It’s by Alison Layton. The paper was called “Scarred for Life.” She found that even when acne is completely gone, and there are no physical scars—in those lucky patients who didn’t scar—the emotional scars of what it felt like to have acne in their teenage years lasted a lifetime. It’s almost like PTSD [post-traumatic stress disorder]. The psychological overlay can’t be downplayed. It needs to be considered with every patient we see.
Casey Butrus, PharmD: I agree. That should definitely be a consideration. Often we consider those costs not to be direct or indirect. From the managed care perspective, how do you measure quality of life? How do you manage the burden? How do you assess that for a patient? You can’t put a financial number on it.
Arash Mostaghimi, MD, MPH, FAAD: It’s cumulative, in the same way Hilary was mentioning. There’s a lifetime of psychological impact. There’s a cumulative burden. If it begins, let’s say that I don’t want to speak in front of a class because I have acne. I don’t want to ask a girl out. I don’t feel comfortable in my interview, so I don’t do well in that interview. Over time, there’s a cumulative lifetime impact where you have a disease that makes you more socially anxious or a little more awkward or less confident in those settings. It may not be that that 1 presentation in class matters or that you didn’t go to that dance. That 1 event may not be that substantial. But if you look at somebody and how it can build up or add up over the course of one’s life, particularly for individuals who are young and in their prime formative years. You get acne at lots of ages. It can go on for quite a while. Thinking about those who are younger and have less self-confidence and sense of self, the lifetime burden and impact indirectly can be substantial.
Hilary Baldwin, MD: I had several patients who were swimmers. Some had been given college scholarships, for example, and they had to quit the team and give up their scholarship because of the acne on their trunks. They refused to take off their shirt, but they had to. That’s the end of that. If soccer and football players get hit and their pimples pop, they get bloody uniforms, and then the mothers of the other kids are worried about transmissible diseases. The cumulative effect of that goes on and on.
Casey Butrus, PharmD: We commonly think of acne being on the face, but as you mentioned, it can happen on other body parts. For truncal acne, how do you manage that differently from facial acne?
Hilary Baldwin, MD: The trunk is very difficult. Steve, you’re good at this stuff. The psychological effect and the treatment of truncal acne. Why don’t you take this 1?
Steven Feldman, MD, PhD: We need to address truncal acne in part because it’s scarring. Hilary, I don’t think anybody could make a clear description based on your past experience of why it’s so important to deal with. Truncal acne is 1 of those misconceptions individuals have about acne. Some think of acne as being the face, but it involves the trunk too. When it does, it can cause scarring and affect patients. The psychological effects of acne aren’t just in teenagers, as much as that’s a perfect storm. It’s normal to have acne as a teenager. Acne is also common as you get older, and it’s not as easily accepted by others because it’s no longer the norm. The toll on psychology, unemployment, and things like that can be just as bad in patients as they get older.
Hilary Baldwin, MD: I agree.
Arash Mostaghimi, MD, MPH, FAAD: One of my patients told me they wanted useful skin. That’s not the way they intended when they got more acne. Particularly as you get older, a lot of the stigma comes from patients who think you’re just not taking care of yourself. [They think] this individual is not washing her face enough or is a little dirty. “Why doesn’t she manage that? Why doesn’t she take care of it?” In that way, it’s part of how you’re perceived as an individual, unfortunately. There’s a lot of stigma associated with it. We recently did a study that examined the stigma and evaluated that, everything ranging from your likelihood to get employed to wanting others to go on a date with you, all are directly impacted as a function of the severity of your acne.
Hilary Baldwin, MD: Not just that, but your ability to do those things. You’re less likely to be in a position of authority, less fun, less intelligent. With those digital surveys of acne and nonacne photographs. I guess the individual is less intelligent because they didn’t get treatment. Why wouldn’t you? Is that the concept there?
Arash Mostaghimi, MD, MPH, FAAD: You end up blaming the individual for something that’s obviously not their fault, even though they may be trying very hard. It’s the interplay between the medical illness part and the social conception of it. If you break your arm, nobody blames you directly. “Look at that guy with his broken arm and how clumsy he is.” Nobody says that. They express sympathy toward him. It’s not just acne, but all dermatologic conditions have that deep component of not only shame but also stigma.
Casey Butrus, PharmD: More so than not, dermatologic conditions—especially acne—are treated as cosmetic. But it’s an underlying medical condition that could respond to treatment and might persist throughout adulthood and be chronic for some patients.
Transcript edited for clarity.