Have you ever had a big pimple on your forehead or chin? Almost everyone has, especially during those acne-prone teenage years. In reality, no one else probably notices that pimple, but to you it's like a huge neon sign flashing ZIT…ZIT…ZIT.
With severe acne, that neon sign doesn't just flash once in a while. It happens all the time. Some people get so worried that everyone is staring at their pimples that they don't want to leave the house.
Though acne itself isn't a serious health condition, living with long-term acne can be every bit as devastating as having a chronic disease like diabetes or epilepsy. The shame and embarrassment of regular breakouts can be overwhelming enough to cause depression. Some people with severe acne even try to commit suicide. And the emotional scars can linger long after the pimples have faded.
Jennifer Liston (her name has been changed to protect her privacy), a consultant from Darien, Conn., started getting breakouts when she was 15 years old. By the time she'd reached her 20s, her acne had gotten so bad that it was having a real impact on her social life.
"It definitely made me more insecure in the dating world," she says. Thinking men didn't want to go out with her because of her acne, Liston closed herself off to relationships.
The stress of her acne made her breakouts even worse. "I feel that the emotions came out through more acne," Liston, who is now 38, recalls. "It was a vicious cycle and it kept getting worse and worse."
Physical and Emotional Scars
Liston's situation isn't unique. Steven R. Feldman, MD, PhD, says he's seen many patients whose acne is so distressing that they don't want to venture out of the house because of it.
Acne is particularly troubling because of its visibility and its intimate relationship with our self-esteem. "The skin in general, and particularly the skin of the face, is the way we see ourselves. It's the way others see us, and most importantly, it's the way we think others see us," explains Feldman, who is a professor of dermatology in the Wake Forest University School of Medicine and author of the book Compartments.
Severe acne can ignite a number of different emotional reactions, according to Ted Grossbart, PhD, a licensed clinical psychologist in Boston and assistant clinical professor of psychology at Harvard Medical School. It can make people feel ugly and unloved enough to get angry at themselves or at the world. And, just as Liston experienced, acne can lead to a sense of loneliness and isolation. "People withdraw and see themselves as uniquely afflicted in a way other people can't understand," says Grossbart, who also authored the book, Skin Deep: A Mind/Body Program for Healthy Skin.
Adolescence, when acne is most common, is already a turbulent time of life. Having severe acne just adds to the intense emotions teens are feeling. When Feldman and his colleagues reviewed several studies of teens with "problem acne," they found that 14% reported feeling depressed. More than 23% of the kids said they'd thought about committing suicide, and nearly 8% had tried to take their own lives.
Acne -- and its emotional effects -- don't end at age 18, either. "In the teenage years it's expected and it's within the norm to have acne," Feldman says. "You get to be 30 or 40 and you may still have acne and it's no longer the norm, so it becomes an issue socially and psychologically.
That may be why depression is two to three times more common in adults with acne than in the general population. Women are particularly vulnerable to self-consciousness and a loss of self-esteem from acne, studies find.
Grossbart often sees patients who turn their loathing of themselves and their acne inward by picking at their skin. "I've seen people with minor acne whose skin would be perfectly fine if they weren't attacking it," he says. "Some people do serious damage." Constantly popping and picking at pimples can turn a minor breakout into a permanent scar.
Acne and depression can quickly turn into a vicious spiral. Stress and anxiety fuel acne outbreaks. Depression can magnify skin problems, making acne seem far worse than it actually is. "Sometimes people will blame their skin for everything that's wrong with their lives," Grossbart says.
Complicating the issue, one of the most potent drugs used to treat acne, isotretinoin, has depression as one of its side effects. Not every study agrees that isotretinoin increases the risk of depression, but dermatologists still use caution when they prescribe this drug, and they carefully monitor patients for depression symptoms while taking isotretinoin.
Coping With Acne
Having severe acne can seem like a huge burden to carry, but it's not a lifelong sentence now that so many effective acne treatments are available. "We can control just about anybody's acne, no matter how severe," says Feldman.
Acne treatments attack pimples on two fronts. Dermatologists prescribe a number of different acne medications, including retinoids, antibiotics, and benzoyl peroxide, to clear the skin. Meanwhile, psychologists help patients deal with the emotional effects of skin problems. "There are a range of psychological techniques you can use to intervene. I use relaxation, imaging, focused psychotherapy, and hypnosis or self-hypnosis," Grossbart says.
Both experts stress the importance of following whatever acne treatment your doctor prescribes. "Medicines don't work if you don't use them," Feldman says. That may sound obvious, but just as depression causes people to lose interest in life, it can also make them ambivalent about using the very treatments that can relieve their acne -- and with it, their depression.
Therapy worked for Liston, who began seeing Grossbart when she was 28. Soon, she was able to make acne less of a focus in her life. Within six months, she was seeing real improvements in her skin. "By a year it was pretty much gone," she says. "It's great. I haven't had any acne or skin problems in eight or nine years."
Now that her skin is clear, Liston can focus her attention on more important things, like her career, her family, and her renewed sense of self-confidence.