Cause

and Effect:
The
Relationship
Between
Acne and
Self-Esteem
in the Adolescent
Years

Sandra L. Hedden, Susan Davidson, and Christine B. Smith

ABSTRACT

The documented negative psychosocial effects of acne on self-esteem are significant.Acne

is a common complaint among adolescents who present to family practice. Family nurse
practitioners play a major role in the identification of acne, its effect on self-esteem, and
proper treatment and referral. Both the adolescent and health care provider need to be aware
that acne is a treatable skin condition. It is therefore essential that health care providers recog-
nize and assess for the effects of acne on self-esteem and initiate treatment that could prevent
permanent scarring—inside and out.

Keywords: Acne, adolescent acne, psychosocial effects, quality of life, self-esteem

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T
he adolescent years are a time of significant
physical, psychological, and social change.This is
the period when the adolescent begins to form
a sense of identity that is influenced by family, friends,
and societal norms.1 Self-esteem plays a major role in this
transition, both psychologically and socially. It is during
this period of identity formation that positive or nega-
tive influences upon self-esteem can have long-term
effects. One such negative influence with which adoles-
cents are often faced is acne.
Acne is a disorder of the sebaceous glands and hair
follicles. Acne results when these follicles become
plugged by excess oil, allowing bacteria that is com-
mon to the skin to grow, resulting in the non-inflam-
matory and inflammatory lesions associated with acne.2
The exact cause is unclear, but it is believed to result
from the combination of several factors, including hor-
mone activity, heredity, oily substances, and certain
medications.2
Nearly 100% of teenagers experience the occasional
pimple.3 As a result of acne, adolescents experience
symptoms of embarrassment, anger, shame, and depres-
sion.4,5 For most, acne is temporary and resolves by the
mid-20s; however, the more severe cases of acne often
take longer to resolve.3 The more severe the acne, the
greater the negative impact on quality of life (QOL).6
The outward appearance of skin disease has been
shown to negatively influence quality of life as much as,
if not more than, some chronic childhood diseases.7
There are a number of QOL assessment tools that have
been utilized to identify and examine the psychological
and social effects of acne. QOL assessment tools specific
to skin disease include the Dermatology Life Quality
Index (DLQI), the acne-specific QOL index, Skindex,
the Acne Disability Index, and the Cardiff Acne Disabil-
ity Index (CADI).Through utilization of these tools,
health care providers can gain a better understanding of
the psychosocial effects of acne on the individual and
gear treatment for optimal results.
Research has shown that acne can have considerable
negative psychological and social effects, with one effect
being a lowered self-esteem.8 During the adolescent
years, when the effects of puberty are taking their toll
and social interaction and independence are of utmost
priority, a lowered self-esteem can lead to social with-
drawal, anger and frustration, and interfere with school
and/or job performance.5 Both the adolescent and
596 The Journal for Nurse Practitioners - JNP
health care provider need to be aware that while acne is
common, it is also treatable.
It is essential that providers recognize the effects of
acne on self-esteem, so that treatment can be initiated to
prevent permanent scarring—not only on the outside,
but on the inside as well.
LITERATURE RELATED TO WHAT TEENAGERS BELIEVE
CAUSES ACNE
Despite years of research on the pathogenesis of acne,
there is still some debate as to what causes acne. Most
experts agree, however, that a combination of factors
influence acne, specifically androgen secretion, increased
sebum production by the oil glands, colonization of bac-
teria, and plugging of the follice.9-11 Genetics may also
play a role in acne development.10,12 The connection
between diet and acne, however, is still controversial.The
American Academy of Dermatology reports that acne is
not related to diet, but also mentions that if an individual
feels that certain foods flare the acne, these foods should
be avoided.13 Other studies have concluded that diet does
play a role in acne formation.14,15 The following studies
depict what teenagers believe causes acne.
Smithard et al16 examined what adolescents know
about acne. Of the 317 participants, age 14 to 16, 50%
were assessed as having no acne, 22% very mild acne, 17%
mild acne, and 11% with moderate or severe acne. Using
an acne management questionnaire developed for this
study, the purpose was to determine the participants’
knowledge about acne, skin health, treatments, and
sources of help.
Data analysis of the results suggested that 25% of the
participants believed lack of cleanliness was the main
cause of acne, 11% identified greasy food as the cause,
and 10% did not identify a main cause.The majority of
participants (82%) believed that management of acne
included increased face washing, while 50% increased
their water intake, 21% changed their diet, 35% covered
it up with makeup, and 9% treated with over-the-counter
products; only 3% had used prescribed medications. For
help on the topic of acne, 45% consulted their parents,
44% talked with friends, 22% with a physician, and 5%
with a pharmacist.Those with more severe acne were
more likely to seek the help of a physician (P < 0.03).
A study conducted by Magin et al8 examined patient
perceptions of acne causation and their implications for
acne care.This qualitative study explored patient beliefs
September 2008
and practices regarding the association between diet, Participants were also questioned about sources for
hygiene, sun exposure, and acne. General themes for the acne information.The majority (75.5%) of respondents
questions included acne causation (including what in this study cited teenage magazines as their source for
makes it better or worse), diet and acne, and manage- acne knowledge.This was followed by obtaining infor-
ment of acne. mation from doctors (58.9%), parents (53.6%), and
Themes that developed from the interviews regard- school (23.2%).
ing acne causation included genetics and hormonal Another study was conducted by Rigopoulos et al18
causes, stress, diet, and hygiene. Results from the inter- to evaluate the believed causes of acne in adolescents.
views indicated that diet and hygiene were implicated Students aged 13 to 18 from 4 Greek high schools
in acne causation more than genetics, hormones, or (n = 316) were asked to complete a self-reported ques-
stress.These beliefs, in turn, effect how acne is then tionnaire. Questions were designed to answer the main
managed. All participants in this study had changed objectives of the study, which included students’ percep-
their diet to one degree or another in hopes of clearing tions of acne causation and exacerbating factors, sources
their acne. Additionally, many of the participants used for information, and how acne affects daily life and
believed that increased frequency of face washing, and school performance.
sun exposure, improved acne. Results of this study indicated that over half of partici-
Reich et al17 examined teenagers’ views on acne. pants (62.3%), with and without acne, believed diet
The purpose of this quantitative nonexperimental study caused or worsened acne symptoms.This belief was held
was to evaluate the level of knowledge about acne. more by girls and older students, with the most implicated
Teenagers from 14 to 17 years (n =151) from one food reported to be chocolate (66%). Diet was followed
school in lower Poland were included in the study. Of by 55.1% of participants reporting hormones as a cause,
the participants, 53% had mild to severe acne and 47% 42.4% reporting poor hygiene, 31.9% reporting stress,
had no acne lesions. 14.9% reporting infection, and 5.7% reporting genetics.
Results of this study indicated that almost half of the A second objective of the study was to determine
participants (47.7%) considered acne a temporary prob- sources of help used for acne knowledge. Parents were
lem not requiring treatment, with significantly more girls the most reported source of knowledge by 31.6% of
holding this belief than boys (P = 0.03). For factors that participants, followed by dermatologists (26.7%) and
worsen acne, females were more likely than males to media (17.5%). Additionally, over half of participants
blame poor hygiene (80.2% vs 42.9%; P < 0.001), eating (52%) considered the information received as inade-
chocolate (24.7% vs 11.4%, P < quate.This inadequate informa-
0.001), and poor diet (33.3% vs tion is apparent in the results of
17.1%, P < 0.01). Females also reported improvement meth-
Themes that
believed more than males’ acne ods.These included increased
would improve through frequent developed from the cleansing (80.7%), sunbathing
face washing (P = 0.02) and interviews regarding (38.6%), and getting adequate
drinking of mineral water acne causation sleep (32%).
(P = 0.03). Participants, both The study also examined
males and females with acne,
included genetics the effects of acne on daily life
more often believed that sun- and hormonal causes, and school performance. No
bathing helped clear acne stress, diet, and significant differences were
(P < 0.001). Regarding cosmet- hygiene. found between participants in
ics, participants without acne reference to smoking habits,
believed cosmetics worsened amount and quality of sleep,
acne more often than participants with acne (40.9% vs school performance, and stress levels. Results of this
20%, P = 0.03), while participants with a positive family study indicated that 48.6% of participants believed acne
history of acne more often believed that cosmetics did was effecting their interpersonal relations, and 64.4%
not affect acne (27.3% vs 12.9%, P < 0.01). believed acne was affecting their self-image.

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 In conclusion, the preceding studies demonstrate a tion of acne on the body affected the individual.The par-
general lack of knowledge and inadequate help-seeking ticipants with acne were separated into 1 of 3 experimen-
behaviors by adolescents on the topic of acne. Sugges- tal groups depending on the body location of their acne:
tions to improve acne knowledge included improved the facial acne group—only the face affected by acne, the
awareness on the causes, treatments and duration of trunkal acne group—only the trunk and not the face
acne through the use of media, schools, and by physi- affected by acne, and the facial/trunkal acne group—acne
cians. It is also suggested that greater knowledge by affected the face and the trunk.The acne experimental
adolescents on the topic of acne would help to promote groups were randomly matched for sex and age with par-
identification of acne and early treatment and decrease ticipants without acne but who had a chronic or tempo-
the negative psychosocial effects of this disease. rary physical disability.
Instruments used for this study included the Cooper-
LITERATURE RELATED TO THE PSYCHOSOCIAL EFFECTS smith Self-Esteem Inventory (SEI) and the Situation
OF ACNE Inventory of Body Image Dysphoria Questionnaire
Aktan et al19 conducted a cross sectional non-experi- (SIBID). Demographic questions included sex, age, and for
mental study to determine if there is an increased inci- those with acne, how long they have had the condition,
dence of anxiety and depression among adolescents body location, and how severe they felt their acne was.
with acne. High school students Participants without acne
between the ages of 14 and 20 were asked onset of injury,
(n = 2657) were examined for body location, and severity of
presence of acne and separated A study conducted by the injury.The SEI is a 25-item
into either an acne group or a Papadopoulos et al 20 questionnaire that assesses
control group. Six hundred fif- “feelings of competency and
teen participants were deter-
examined the self-acceptance” (p. 434).20 The
mined to have acne; 281 were psychosocial effects SIBID measures feelings about
assessed as having mild acne, 321 of acne, particularly physical appearance.
with moderate acne, 12 with how the location of The study found that par-
severe acne, and 1 with very ticipants with acne had signifi-
severe acne.
acne on the body cantly lower self-esteem and
The instrument used to affected the body image than participants
measure anxiety and depression individual. without acne (P < 0.000 and P
was the Hospital Anxiety and < 0.000, respectively). Addi-
Depression (HAD) scale, which tionally, the study found that
is valid and reliable both in the hospital and in primary participants with facial acne had significantly lower
care setting. A total of 308 participants with acne and self-esteem and body image than participants with
308 sex-matched participants without acne (control trunkal acne only (P = 0.010 and P = 0.007, respec-
group) were interviewed.The mean HAD scores tively).This suggests that the visibility of the acne
between the acne and control groups were not signifi- causes even greater psychological effects.
cant for anxiety (P = 0.276) nor for depression (P = In a similar study, Purvis et al21 examined the effects
0.436). However, when the HAD scores for anxiety of acne on the levels of anxiety and depression, but
were examined among the acne group, girls with acne look also at risk of suicide associated with these
had significantly higher anxiety levels than boys with increased levels.This study was a secondary analysis of
acne (P = 0.041).There was no significant difference in data collected in a national survey of 9567 New
HAD depression scores found between boys and girls Zealand students who were randomly selected using a
with acne. Overall, the HAD scores between girls and clustered sample design and asked to complete a self-
boys in both groups was not statistically significant. reported questionnaire via a laptop computer.
A study conducted by Papadopoulos et al20 examined Instruments used for the study included the Reynolds
the psychosocial effects of acne, particularly how the loca- Adolescent Depression Scale (RADS), a measure for

598 The Journal for Nurse Practitioners - JNP September 2008

depressive symptoms in adolescents, and the Anxiety Dis- (p. 123).6 The negative social impact of acne was meas-
order Index (ADI), which measures anxiety in children ured in 3 ways, including questions about general social
and adolescents. Suicide risk was assessed by the addition concerns related to presence of acne, intimate social con-
of 2 questions:“In the last 12 cerns, and social interference
months, have you thought about related to acne.These questions
killing yourself (attempting sui- were graded on a scale of 1
Research on acne
cide)?” and “In last 12 months, (“not at all”) to 7 (“extremely”).
have you ever tried to kill yourself in adolescents Additionally, demographics,
(attempted suicide)?” (p. 794).21 demonstrates that including age, gender, education
The study found 14.1% of the adolescents have a level, marital status, race, health
total participants to have “prob- status, and acne duration, were
lem acne” (p. 794),21 with these
general lack of examined. QOL was measured
participants reporting more knowledge on acne, using the Global QOL scale,
depression and anxiety symptoms its causes, which has an internal consis-
than those without acne.The and treatment. tency of 0.91, the dermatology-
depressive symptoms increased as specific QOL Skindex, which
the severity of acne increased. has an internal consistency of >.
There was also a reported increased rate of suicidal 0.86, and the Acne-Quality of Life Index, which has been
thoughts and attempts associated with problem acne, shown to be valid and reliable.
which persisted even after controlling for depressive The results of this study concluded that greater acne
symptoms and anxiety (odds ratio = 1.50, 95% CI = severity was significantly associated with poorer social
1.21–1.86). outcomes and quality of life (P < 0.05). General results of
In conclusion, the results of this study emphasize the social sensitivity showed no significant differences related
importance of assessing the psychosocial effects of acne in to age, race, marital status, or education level (all P > 0.05).
patients presenting for treatment.The importance of this Additionally, it was found that individuals with higher
is reflected in the studies results that indicated that social sensitivity reported a poorer global quality of life
“approximately a third will have thoughts of suicide, a (P = 0.0007), skin-specific QOL (P = 0.0008), and acne-
quarter will have clinically significant symptoms of specific QOL (P = 0.0001) than individuals with lower
depression, a tenth will have high levels of anxiety and a social sensitivity.The significant effects of acne on QOL
tenth will have attempted suicide” (p. 795).21 The authors were demonstrated by increased negative social outcomes
indicate that the rates of suicidal thoughts and attempts across the board as acne severity increased in males
reported in this study correlate with lifetime rates at age (all, P < 0.0001) and females (all, P < 0.0001).
18 reported in New Zealand, but admit these rates are In conclusion, the preceding studies on the psychoso-
higher than rates reported in other countries. cial effects of acne demonstrate the negative effects of
A study conducted by Krejci-Manwaring et al6 exam- acne on self-esteem and QOL.The studies also suggested
ined the role that individual personality, specifically social that gender, acne severity, and an individual’s “social sensi-
sensitivity, plays in the negative effects of acne on quality tivity” level may compound the psychosocial effects that
of life. Four hundred seventy-nine participants, age 16 to acne has already been shown to cause.The studies
62, completed a self-reported survey. Participants were reviewed emphasized the need to assess individuals pre-
asked to grade the severity of their acne, which was then senting for acne treatment for these psychosocial effects.
defined by the mean score of a 1 to 7 rating scale.The
median split of the mean score was then used to grade SUMMARY
acne, with “High Severity” defined as greater than 2.5 Research on acne in adolescents demonstrates that ado-
and “Low Severity” defined as less than 2.5 (p. 123).6 lescents have a general lack of knowledge on acne, its
To assess for individual social sensitivity, participants causes, and treatment.This supports the need for
were asked to complete a 16-item questionnaire and were improved education within schools, by media, and by
graded as having “High Sensitivity” or “Low Sensitivity” health care providers.The documented psychosocial

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effects of acne are significant, especially during the ado-
lescent years, when identity formation may be directly
influenced by a lowered self-esteem or poor body image.
The benefits of assessing acne patients for effects on qual-
ity of life include selection of more appropriate treatment
options, improved assessment of effective or ineffective
treatment, and better overall patient satisfaction.Adequate
treatment of any disease should encompass not only treat-
ment of the disease, but the effects that disease has on the
individual psychologically and socially.
References
Sandra L. Hedden, MSN(c), RN, FNP-BC, is a family nurse
practitioner at the Primary Health Care Center in Trenton,
GA. She can be reached at Sandra-Hedden@utc.edu. Susan
Davidson, EdD, RN, is an associate professor and Christine B.
Smith, PhD,APRN-BC, FNP, is the director of nursing at the
University of Tennessee at Chattanooga School of Nursing. In
compliance with national ethical guidelines, the authors report no
relationships with business or industry that would pose a conflict
of interest.
1555-4155/$ see front matter
© 2008 American College of Nurse Practitioners
doi:10.1016/j.nurpra.2008.01.021

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