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                                        DISCUSSION PAPER

Understanding The Psyche Of The Acne Patient

Andrew J.M. Sun* MBBS(HK), Dip. Derm. (Lond.)                        Emotion And Acne

                                                                          It is generally accepted that acne cannot be
Introduction                                                         primarily produced through psychological stress4.
                                                                     Nevertheless, emotional stress can exert a
                                                                     deleterious effect on pre-existing acne. An increase
      While significant recent advances in medical                   in free fatty acid and acne lesions cutaneously has
therapeutics for acne vulgaris have been made,                       been recorded in acne patients while undergoing
it is often assumed that the psychological aspects                   stressful academic examinations.         Increase in
of this common         "conspicuous" disease are                     pustular formation and sebum output can be
thoroughly understood and, as such, require no                       demonstrated by experimentally-induced anger in
detailed elaboration or discussion. In reality,                      acne patients5. Clinically, severe exacerbation of
however, we would do well to further examine                         facial acne has been noted anecdotally following
the psychological aspects of acne in the light of                    encephalitis or head injury5. It has thus been
effecting a truly holistic management of the acne                    speculated that the effect on the facial vasculature
patient.                                                             or direct nervous control in the sebaceous glands,
                                                                     alone or in combination, may be responsible.
                                                                     Alternatively, it can be that the psyche, through its
Doctor-Patient           Relationship           In    Acne           influence on the pituitary, causes hormonal changes
                                                                     that upset pre-existing acne6.
Therapy

      At least two studies reveal that the                           Adverse Psychological Effects Of Acne
relationship between physicians and patients with
acne have been far from satisfactory1'2. Acne                             Emotional reactions to acne can be grouped
patients are of the opinion that the medical                         into two distinct, yet inter-related parts: the
profession, through its organized behaviour, does                    psychological effects of the disease on the acne
little to relieve their frustration and anxiety, that                sufferer, and the effects on the acne observer,
their physicians fail to notice or regard their                      namely the physician, family and friends.
feelings of rejection and/or isolation.            In
addition, it has been shown that acne patients                            The psychological response of the acne sufferer
are frequently bombarded with false and                              is much dependent on the severity of the symptoms
misleading information from various sources3.                        and signs7. The skin with acne deviates from the
The former, through recognition, can be                              concept of beauty and especially in teenage patients
ameliorated by the caring clinician. The latter,                     may lead to embarrassment, reduced self esteem,
on the other hand, can be effectively addressed                      social isolation, guilt, anger, and even frank anxiety
through the dissemination of factual information                     and depression. Generally the more disfigurement
and guidance.                                                        accompanying the acne the higher the anxiety levels

* Address for correspondence: 306B, Electric Road, G/F, North Point, Hong Kong.

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                                                             Hong Kong Practitioner 14 (2) February 1992


 observed (Figure 1). Such disease rating tends to       education believed acne was contagious as
            the lower the educational standard of the    compared to 28% of persons with higher levels of
      patient8. On the other hand, minimal difficulty    education. This is of some sociological importance
in psychological adjustment is noted in otherwise        in terms of potential to produce significant social
 Well-adjusted patients having milder forms of acne.     and occupational disadvantages for the acne
 Yet, however, neurotic personalities often maladjust    sufferer. Indeed, it has been observed that a
to their acne: the acne is the trigger that causes the   possible correlation exists between severe acne and
           to become evident clinically. A pre-          unemployment 10 .
               with the skin involving frequent
             pinching and excessive applications of
           medications, eventually resulting in          Establishing Compliance With The Acne
 aggravation of the acne, is described in the            Patient
             of "acne excoriee des jeunes filles"
           in French: excoriated acne in young
                                                              Patient compliance is undoubtedly the most
                                                         important factor in successful acne treatment. In
                                                         order to obtain reasonable compliance from our
                                                         acne patients, we need to find out as much as
        1: This Young Man With Severe Cystic
                                                         possible about the effects of acne on their lives.
           Acne On The Back Was Reluctant To
                                                         Once a therapeutic relationship is established, a
           Go Swimming
                                                         feeling of harmony with the doctor reduces the
                                                         patient's feelings of isolation and despair. The first
                                                         encounter is of utmost importance, whereupon the
                                                         particular reason why the patient has come for
                                                         medical help for his/her acne problem must be
                                                         sought.

                                                              To illustrate, patients with a previous history of
                                                         severe acne during their teens may be somewhat
                                                         over-concerned about the few pimples on the face
                                                         of their son or daughter. Age, too, is a significant
                                                         factor. An infant may present with acne, in which
                                                         case responsibility for compliance would rest
                                                         entirely upon the parent(s). The adolescent girl, on
                                                         the other hand, is often afraid of losing her
     In terms of the psychological effect of acne on     popularity because of the "ugly" comedones and
the observer, a study of over 2,000 male acne            boils on her face, and would be too eager to rid
          and non-sufferers found a high potential       them off by any means. Whereas, the adolescent
for rejection of the acne sufferer by acne-free          boy, accompanied by his sensitive mother, may lake
persons5: 88% found acne repulsive, 65% regarded         a "couldn't-care-less" attitude towards his acne, in
acne as intolerable in a job dealing directly with       which case parental concern is used as a tool to
customers, and 32% did not want a severe acne            obtain family privileges. With understanding and
sufferer as a colleague. It was further noted that       awareness of the real reason as to why the patient
36% of the questioned group of acne-free persons         has come for therapy, the practitioner would be
               acne as a contagious disease.             able to determine the explanation, counselling and
Interestingly, again, this finding was education-        appropriate medication to be used for achieving
            in that 50% of those with lower levels of    reasonable patient compliance.

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     In contrast, a different attitude relates to the   aspects of body image including those that are
patient with a recurrent acne problem. Here,            generally unrelated to the appearance of the skin,
attempts must be made to find out the reasons for       namely body shape and weight11'12. This emphasizes
previous lack of therapeutic success. This requires     the profound effect of the appearance of the skin
a thorough knowledge of the previous therapies          upon the patient's overall body image (Figure 3).
employed, the number of physicians seen, and the
explanations given about the disease to the patient.
                                                        Figure 3: A Schematic Summary Of The Acne-
     The chic, mature woman in her 30's with a few                emotion Relationship
deep acne cysts on her chin presents yet another
problem (Figure 2). The drying effect of the acne
treatment frequently conflicts with the deep-seated
concept that dryness and wrinkles go together.
Only a detailed explanation will correct the fears of
such a patient, stop the use of oily cosmetics and
                                                               Relax. Response                                Stress, Treatment
promote the appropriate use of acne medications.               to Treatment                                   Non-compliance


                                                                 Improved Acne                        More Severe Acne


        Figure 2: Pustular Acne On Chin




                                                                      Improved                        Embarrassment,
                                                                      Body Image                      Social Isolation,
                                                                                                      Depression




                                                             In essence, by supplementing the appropriate
                                                        pharmacological therapy with facts to correct
                                                        misconceptions, guidance, and understanding of the
                                                        psychological aspects of acne and its effects on the
                                                        patient, an optimal management scheme to the acne
                                                        patient could be applied.                Hi
Conclusion
                                                        References
     The effective therapies available today to treat
acne, especially if initiated promptly, can go a long
                                                        1.   Ryan T.. Jowett S. Dermatology patients and their doctors. Clin. Exp.
way to prevent or ameliorate the psychological               Dermatol. 1985; 10: 246-254.
problems associated with the disease.         Formal    2.   Korczak D. Acne patients: their mental situation, behaviour and attitude.
                                    5                        In: Treating the acne patient: the skin and the psyche. Bollington: Pennine
psychotherapy is seldom indicated . Recent studies           Press 1989; 9-12.
have shown that the improvement of acne of              3.   Rasmussen J., Smith S. Patient concepts and misconceptions about acne.
                                                             Arch. Dermatol. 1983; 119: 570-572.
whatever grade of severity is associated with           4.   Kenyon K. E. Psychosomatic effects of acne: a controlled study. Br. J.
decreased anxiety and greater satisfaction with              Dermatol. 1966; 78: 344-351.


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                                                                                               (Continued on page




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Acne


       Albers H. J. Psychological dilemma and management of the acne patient.            Sneddon I., Sneddon J. Acne excoriee: a protective device. Br. J. Dermatol.
       In: Focus on Acne Vulgaris, edited by Cullen S. I. Oxford University Press.       1981; 105(Suppl.). 19: 29-31.
       Oxford 1985: 38-44.                                                               Cunliffe W. J. Acne and unemployment. Br. J. Dermatol. 1983; 119: 570-
       Pochi P. E.. Strauss J. S. Endocrinologic control of the development and          572.
       activity of the human sebaceous gland. J. Invest. Dermatol. 1974; 62: 191.        Rubinow D. R., Perk G. L. Squillace K. M., Gantz G. G. Reduced anxiety
       Wu S. F., Kinder B. N.. Trunnel T. N., Fulton J. E. Role of anxiety and           and depression in cystic acne after successful treatment with oral tretinoin.
       anger in acne patients: a relationship with the seventy of the disorder. J,       J. Am. Acad. Dermatol. 1987; 17: 25-32.
       Am. Acad. Dermatol. 1988: 18: 325-333.                                            Gupta M. A.. Gupta A. K., Schork N. J. Psychiatric aspects of the
       Finlay A. Y. Psychological aspects of acne — an overview. In: treating the        treatment of mild to moderate facial acne: some preliminary observations.
       acne patient: the skin and the psyche. Bollington; Pennine Press 1989: 6-8.       Int. J. Dermatol. 1990; 29(10): 719-721.




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