Psychological factors
Psychological factors in acne, as in many skin diseases, stress has been incriminated as a causative factor (see below). There is no doubt that anxiety and depression, secondary to the ievelopment and persistence of the lesions, are commonly experienced and may render the patient a social outcast.
A questionnaire was presented to 2,000 18-19 year old military recruitment candidates to assess antipathy .wards patients with severe acne vulgaris, the occupational handicap associated with severe acne and subjecuve inhibitions in acne patients.40 In addition, these subjects were examined clinically with regard to presence of acne vulgaris. This investigation demonstrated that severe acne has an appreciable disease rating, resulting in social, occupational and psychological problems for the acne patient. This disease rating appears to be objectively greater the lower the level of education of the acne patient, but does not appear to be entirely clear to the acne patient with a low level of education.
For the majority of patients with acne the actual appearance of their skin and the consequent lack of self-esteem are the most important considerations, as the following quotations suggest: 'very embarrassing', not nice to look at', 'very self-conscious'.41 Patients also refer to the amount of time taken up with concealing their acne. Lack of understanding of the problem is common; other people often do not realize the physical and emotional suffering that acne can cause. One man was refused time off work for his 'trivial' hospital appointments, for example.
Interpersonal difficulties are common. Patients can be hurt by the insensitivity of their workmates as is illustrated by the young man who was told, 'If a girl was to kiss you she'd suck the pus out.' A lowering of self-confidence and the implications of this for both personal relationships and professional success are recurring themes. A typical comment might be, 'The worst thing is not being able to communicate. I couldn't look people straight in the eye. I didn't like to go shopping when everyone was looking'. A bank clerk described how, on her first day at work, her skin had erupted and she had developed boils, so she felt that others regarded her as strange. Interviews are frequently mentioned as a source of concern by acne sufferers. One girl spoke of her feeling that 'they might be looking for somebody smart, not a handicapped person'.
Unemployment can result from severe acne. The appearance of the skin can also be a limiting factor in employment, as with the young woman who had hairdressing aspirations and the young man who would have liked to work in a fashion store. When were you last served by a spotty youth in a fashionable city shop? Probably never. them explained, 'I forced myself to go swimming. It was silly but I felt so self-conscious'.
A study by Rubinow et al evaluated the psychiatric morbidity and mood characteristics of seventy-two patients with cystic acne before and after treatment with one of three dosage schedules of isotretinoin.43 No excess psychiatric morbidity was observed but substantial evidence of psychological distress was noted before treatment. After treatment significant reductions in anxiety were observed, with greatest mitigation of anxiety and depression in those patients with the greatest dermatological improvement with isotretinoin.
The social impact of acne is clear, contradicting the common tendency to regard this condition as trivial. In the management of acne, the physician must address the psychological aspects, thus reassuring the patient that his social and emotional problems are appreciated.
Anxiety is also common, especially worry about scarring. Depression is also a feature, fuelled by concern about appearance. One woman with acne said, 'It really depresses me very much. I spend hours looking at myself.
Social life is often affected. Over half of acne sufferers interviewed reported that people had been unpleasant to or made fun of them because of their acne. Most of the females had tried to conceal their acne lesions with make-up, but there was a general consensus that this was largely unsuccessful. Of those with acne, a quarter felt socially restricted. Three people spoke of 'not letting it get to you'.
