Emotional impact of acne

Acne often makes patients feel unattractive, embarrassed, self-conscious, and uncomfortable in social situations. They tend to be more depressed than patients without acne. It has been shown that suicidal ideation is more prevalent in acne patients than in patients with other skin diseases. Emotional distress probably is an aggravating factor for acne. Under stress, our adrenal glands are stimulated to produce more hormones. One of these hormones (dehydroepiandrosterone) is well known to stimulate the skin's sebaceous glands, and this can lead to aggravation of acne. So it could be in that way a bit of a vicious cycle if the acne itself were the cause of the stress, the stress then being a factor in aggravating the acne.
Cost would be one [reason patients don't seek care], particularly if a person has no insurance or if insurance is not sufficient to cover medication as well as a visit to a doctor's office. Inertia or denial could be two other reasons. There is no question that if a young person, or a person of any age, comes to see a physician for a problem, that problem, no matter what it may be, is a serious problem. It needs to be addressed seriously. Certainly there is never a circumstance where a physician should trivialize a patient's complaint.
Our mission is to treat the acne, and, once it is improved, the emotional conflict over it is also improved, usually dramatically.
In general, there is very little a physician can do with a patient who is not compliant. Certainly you can't apply their medication for them. The best we can do is design a reasonable, preferably simple, treatment plan and to explain it carefully and clearly. Systemic retinoids, in the form of isotretinoin, came on the market in September 1982 and ever since have made a huge difference to patients with severe acne, acne that scars, and inflammatory acne that is unresponsive to other measures. When I prescribe a tretinoin preparation (such as Retin-A®), I ask the patient to apply it at bedtime and a benzoyl peroxide preparation in the morning. When I use Differin® gel (adapalene), I tell them it doesn't matter and they can put whatever they prefer on in the morning and the other at night. Most people would like to get better quickly, and that is the … challenge in explaining expectations for therapy. I tell them it is going to take months for us to see the optimal effects of these treatments and so I usually make their first follow-up visit in two months.
Manifestations of Psychologic Distress
o Acne has long been recognized by the medical profession as a possible cause of psychologic distress to patients.
o Responses to quality-of-life questionnaires correlate with the severity of the acne.
o Acne patients tend to have negative perceptions of themselves because of their acne. Depression and even suicidal ideation is more prevalent in this group.
o These responses are found across the age spectrum.
o Disruptions in family life can be instigated by acne sufferers, leading even to marital strain.
o Emotional distress probably is an aggravating factor for acne, and thus can set up a vicious circle.
o Physicians need to be alert to signs indicating depression on the part of patients.
Evaluation and Treatment
o Quality-of-life questionnaires can be used to evaluate a patient's emotional health, which is something physicians should consider more seriously.
o A physician should never trivialize a patient's complaint about acne.
o Emotional improvement generally follows improvement in the physical manifestations of acne.
o Benzoyl peroxide preparations are the most helpful over-the counter medications in acne cases.
o Patients experience an overwhelming temptation to squeeze their lesions because they believe this is the quickest way to cure acne.
o Patients sometimes are noncompliant, perhaps for psychologic reasons, but there are limits to what the physician can do in such cases. Ultimately, compliance is the patient's responsibility.