Consider the mental health issues in teens with acne

Acne can be considered a rite of passage in the teenage years, affecting around 85% of all teenagers at some point.1 However, more recent reports suggest that the psychological effects of this inflammatory skin disease may be underestimated and deserve more attention in treatment plans.

Multiple studies over the past few years have highlighted the impact of acne on adolescent mental health—especially since adolescence is already a time of intense transition. Self-esteem, social relationships, anxiety and depression can lead to the effects of chronic acne in the teenage years, according to researchers.1,2,3

Mohammad Jafferani, MD, clinical professor of psychodermatology and psychiatry at Central Michigan University in Saginaw, and a board-certified psychiatrist who co-authored a 2020 report on the psychodermatology of acne, said there are many things at play when it comes to the psychological impact of acne.

Acne is the most common inflammatory skin condition, he said, adding that hormones and stress in the teenage years can increase the prevalence. The fact that acne usually occurs mostly on the face doesn’t help, because it can be difficult to cover up or disguise severe papules and comedones.

“They end up feeling very stigmatized,” Jafferani continued. “Their self-esteem is very, very low and very bad, and psychological conditions often develop at the same time [as acne appears].”

In addition to stressing about their appearance and how acne can affect their social relationships, teens can also easily become frustrated by mixed messages about acne treatment, he explained.

Acne treatment should be holistic and multidisciplinary, he added, with diet, hormonal considerations and psychological impact factored into the overall clinical plan. Many teens turn to friends or social media for help dealing with early acne and then become frustrated when certain treatments don’t work. Without proper treatment early in the process, acne — and its psychological impact — usually gets worse, Jafferani continued. Teens with severe acne often stop going out with friends and socializing with others, and studies show that suicide rates are higher among teens with acne than those with clear skin.

The American Academy of Dermatology (AAD) clinical guidelines for acne treatment only briefly mention the psychological impact of acne on teenagers or the risk of increased depression or suicidal thoughts with certain treatment regimens.4

Oral isotretinoin is recommended in the AAD treatment guidelines for severe nodular acne. A number of studies in recent years have examined the relationship between this popular drug and suicidality, but the strength of the link between isotretinoin use and suicide risk remains in question. A 2020 report suggests that there does not appear to be a definite risk and that isotretinoin should not be avoided altogether in depressed teenagers.5 but the American Academy of Pediatrics suggests that the drug be used “with caution” in adolescent patients with depression and that they be monitored during therapy by both a dermatologist and a psychiatrist.6

Jafferany agreed with this recommendation, noting that it is not uncommon for clinicians to refer teenagers for psychiatric screening before prescribing isotretinoin.

There are other treatment options besides isotretinoin, with the full guidelines for AAD available here.

Topical treatments include:

  • Benzoyl peroxide alone or with other topical treatments for mild acne
  • Benzoyl peroxide plus topical retinoids or systemic antibiotics for moderate to severe acne
  • Only retinoids for primary comedonal acne
  • Retinoids plus oral or topical antimicrobials for mixed/primary inflammatory acne
  • Topical dapsone 5% gel for inflammatory acne
  • Azelaic acid for post-inflammatory pigmentation problems

Hormonal treatments and antibiotics may also be considered, as well as complementary and alternative treatments, which include:

  • Tea tree oil
  • Topical and Oral Ayurvedic Compounds
  • Oral barberry extract
  • Gluconolactone solution
  • Diet and nutrition counseling

There is limited evidence of the benefit of physical therapy methods and therapies, although some options include things like:

  • Comedo removal
  • Pulsed dye laser
  • Potassium titanyl phosphate laser
  • Fractional and non-fractional infrared lasers
  • Fractional CO2 laser
  • Photodynamic therapy
  • Peeling with glycolic acid
  • Peeling with salicylic acid
  • Intralesional corticosteroid injections for larger individual acne nodules

References

  1. Natsuaki MN, Yates TM. Adolescent acne and mental health disparities. Prospects for child development. 2021; 15 (1): 37-43. doi: 10.1111/cdep.12397.
  2. Layton AM, Thiboutat D, Tan J. Overview of the global burden of acne: how can we improve care to reduce the burden? BJD. 2021; 184 (2): 219-225. doi: 10.1111/bjd.19477.
  3. Stamu-O’Brien C, Jafferany M, Carniciu S, Abdelmaksoud A. Psychodermatology of acne: psychological aspects and effects of acne vulgaris. JCD. 2021; 20 (4): 1080-1083. doi: 10.1111/jocd.13765.
  4. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines for the care and treatment of acne vulgaris. JAAD. 2016;74(5):945-973. doi: 10.1016/j.jaad.2015.12.037.
  5. Gieler U, Gieler T. Suicidal risk with isotretinoin treatment – a never ending story. JEADV. 2020;34(6):1131-1133. doi:10.1111/jdv.16005.
  6. Teens and acne treatment. HealthChildren.org Updated November 27, 2013. Accessed July 1, 2022.
    https://www.healthychildren.org/English/ages-stages/teen/Pages/Teens-and-Acne.aspx

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