Acne can create a significant burden for people of all ages. However, the psychological consequences might often be overlooked. This review comments on recent evidence in the field of psychodermatology, to highlight the importance of considering a person’s mental health in the treatment of acne. A range of presenting issues are discussed, and cases of underserved patients needing additional considerations are highlighted. This article considers how the psychological sequelae can contribute to the pathogenesis of acne, and discusses how psychotherapeutic approaches can be of benefit to people experiencing appearance-related distress. Importantly, attention is paid to the need for clinicians to assess a patient’s wellbeing alongside their physical symptoms. In doing this, early intervention can be facilitated if psychological comorbidities are present, with referral to appropriate specialist services, where available. To improve treatment outcomes, the skin and the mind must be addressed together in a multidisciplinary approach to dermatology care.
Our skin is the largest and most visible part of us.1,2 It protects us, it represents us and it can play a role in defining who we are as individuals.3 Importantly, our skin facilitates a bidirectional relationship between our outer world and our inner experiences.1,2 The interactions between a person’s environment, emotions, biologic mechanisms and skin disease are closely linked, and there is a need to address the skin and the mind together.
Psychodermatology is a subspecialty of dermatology that focuses on the relationships between the brain, immune system, cutaneous nerves, and the skin.4 The field combines dermatology with psychology and psychiatry in the management of two areas: (i) patients presenting with primary psychiatric conditions experiencing skin symptoms (e.g. delusional infestation); and (ii) patients presenting with primary skin disease experiencing psychosocial comorbidity (e.g. acne).4 The establishment of psychodermatology as a discipline has led to the introduction of specialized clinics offering tailored psychological support interventions to patients. Where available, these services involve dermatology healthcare professionals working in collaboration with a clinical psychologist or psychiatrist, and will either refer patients to the onsite mental health practitioner or have them participate in consultations.
Our skin is the largest and most visible part of us.1,2 It protects us, it represents us and it can play a role in defining who we are as individuals.3 Importantly, our skin facilitates a bidirectional relationship between our outer world and our inner experiences.1,2 The interactions between a person’s environment, emotions, biologic mechanisms and skin disease are closely linked, and there is a need to address the skin and the mind together.
Psychodermatology is a subspecialty of dermatology that focuses on the relationships between the brain, immune system, cutaneous nerves, and the skin.4 The field combines dermatology with psychology and psychiatry in the management of two areas: (i) patients presenting with primary psychiatric conditions experiencing skin symptoms (e.g. delusional infestation); and (ii) patients presenting with primary skin disease experiencing psychosocial comorbidity (e.g. acne). The establishment of psychodermatology as a discipline has led to the introduction of specialized clinics offering tailored psychological support interventions to patients. Where available, these services involve dermatology healthcare professionals working in collaboration with a clinical psychologist or psychiatrist, and will either refer patients to the onsite mental health practitioner or have them participate in consultations.
The relevance of psychodermatology to clinical practice is shown by the significant psychosocial burden experienced by many people living with skin conditions.5 For primary skin diseases propagated by inflammatory pathways, such as acne, heightened levels of perceived stress can result in adverse effects.6 Acne is estimated to be the most common inflammatory condition treated worldwide,7 and was one of the most prevalent skin diseases in a population-based study of 44 689 people across 27 European countries (5.4%).8 Acne is characterized by lesions on the body, affecting the face, neck, back and chest/torso.7 The condition presents with comedones, papules, pustules and nodules, and – in some cases – cysts, macular erythema, excoriation and changes in pigmentation, all of which can lead to scarring.
The primary skin lesions caused by acne can cause pain and discomfort, but the impact of the condition extends beyond physical symptoms, and there can be psychological consequences. Having visibly different skin can be difficult, and there is wide-reaching societal pressure to conform to idealized images of ‘beauty’ advertised through the media.9 Exposure to appearance ideals in outlets including magazines might contribute to a process of internalization, whereby a person’s value and desire for social rewards are assigned to achieving a level of ‘attractiveness’.10 This could lead to a sense of ‘failure’ being experienced by people with skin conditions, if they cannot meet unrealistic standards of having a flawless appearance.
Engagement with online content has also been associated with lower appearance satisfaction.9,11 Most recently, Adkins et al.12 investigated social media use in adults with acne, and found that, out of 650 people, there was a correlation between individuals who spent more time on photo activities on Facebook and higher levels of stigmatization, mediated by ‘upward’ appearance comparisons (to people deemed to be ‘superior’).12 However, this was not consistent across all platforms (e.g. using Facebook only, or Instagram) and requires further investigation to understand how variations in the use of social media could influence the processes involved in making social comparisons.