Enfermería Clínica 31 (2021) S326---S329

www.elsevier.es/enfermeriaclinica

Body image perception is related to self-esteem

of the adolescents with acne vulgaris夽
Riszky Pertiwi Ramadhanty, Achir Yani S. Hamid ∗

Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia

Received 15 September 2020; accepted 21 September 2020

KEYWORDS Abstract Having acne vulgaris may affect the way adolescents perceive themselves. The
Adolescents; objective of this study was to examine the relationship between the body image perception and
Acne vulgaris; self-esteem of adolescents with acne vulgaris. A cross-sectional descriptive-correlative study
Body image; was conducted in 173 high school students in a subdistrict in Indonesia. The relationship between
Self-esteem body image and self-esteem was analyzed using Chi-square test. The results of this study showed
there was a significant relationship between body image perception and self-esteem of adoles-
cents with acne vulgaris in this study (p = 0.000). Body image perception of adolescents with
acne vulgaris is associated with their self-esteem. Nurses should deliver health education con-
taining the major concerns of adolescents, such as acne vulgaris, to promote positive body
image and self-esteem among adolescents.
© 2020 Elsevier España, S.L.U. All rights reserved.

Introduction certain set of perspectives that is largely influenced by their

Adolescents experience a period of puberty marked by
the substantial changes in the physical, cognitive, social,
spiritual, and moral aspects.1 In Erikson’s psychosocial
development theory, adolescence is described as a stage of
self-identity versus role confusion.1,2 In this developmental
stage, adolescents start to shape their identity to achieve a
夽 Peer-review under responsibility of the scientific committee of
the 4th International Conference for Global Health (ICGH) in con-
junction with the 7th Asian International Conference in Humanized
Health Care (AIC-HHC). Full-text and the content of it is under
responsibility of authors of the article.
∗ Corresponding author.
E-mail address: achir@ui.ac.id (A.Y.S. Hamid).
peers and social environment.2
The perspectives aimed by adolescents may incline
towards physical appearance.3 This explains why most ado-
lescents are concerned about their skin appearance, as it
is the most visible part of the body and can play an impor-
tant role in the way people perceive themselves or others
in the social interaction.4 The negative reaction on the skin
problems coming from the adolescent’ social circle may lead
to the negative stigma that affects the body image of the
respective adolescent.4
Body image is a part of an individual’s self-concept. It
is defined as a person’s conscious and unconscious percep-
tion of his/her physical body, encompassing the current and
past views on the body size, function, appearance, and
potential.2 The perception can be formed and influenced
by the puberty-related physical changes.5

https://doi.org/10.1016/j.enfcli.2020.09.021
1130-8621/© 2020 Elsevier España, S.L.U. All rights reserved.
 Enfermería Clínica 31 (2021) S326---S329
A common consequence of the hormonal dynamics during
puberty is acne vulgaris, a dermatological illness in the form
of papules or cysts which can be inflamed with pustules or
abscess and leaves lesions.5 As acne vulgaris predominantly
occurs in the face, it could be an apparent disturbance of
the adolescents’ body Image.5 In fact, acne vulgaris happens
in around 85% of adolescents worldwide.6 According to the
Global Burden of Disease Project, acne vulgaris is the 8th
most prevalent illness in the world, occurring in 9.4% global
population.7
Previous studies reported that individuals with acne
vulgaris experienced body image disturbance, feelings of
shame, and lack of self-confidence, as well as a higher
chance of depression, anxiety, and psychosomatic symp-
toms, all of which may lead to social isolation.8 The
adolescents with acne vulgaris may feel a heightened social
pressure with regards to their facial appearance, thus having
acne can cause anxiety, mood alteration, and low self-
esteem.8
Given the potentially extensive impacts of acne vulgaris
in adolescents, it is deemed important to investigate the
body image perception and self-esteem among Indonesian
adolescents who have this skin problem. This study can
provide the data of the adolescents’ body image and self-
esteem problems related to acne vulgaris. Such data can
inform health care professionals, especially nurses, as well
as parents and teachers, in addressing the problems and
supporting adolescents to form a positive body image.
Methods
A cross-sectional descriptive-correlative design was used
in this study. Using a purposive sampling technique, we
recruited 173 students through screening at a public high
school in Cibinong, West Java province, Indonesia. All grade
X students (n = 391) were screened for having acne vulgaris
problem, feeling disturbed by the acne vulgaris, or feeling
not confident with their appearance because of acne prob-
lem. The screening and recruitment processes were done by
the first author, accompanied by the teachers.
The body image of the participants was measured with
the Multidimensional Body-Self Relations Questionnaire-
Appearance Scale.9 This questionnaire consists of two
components of appearance evaluation and has 14 question
Table 1 Body image and self-esteem of the adolescents with acne vulgaris (n = 173).
Body image
Positive (%) Negative (%)
Overall 48.6 51.4
Age
14 20.0 80.0
15 46.3 53.7
16 52.3 47.7
Gender
Male 53.1 46.9
Female 45.9 54.1
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items. The validity and reliability tests demonstrated that
this questionnaire is both valid and reliable. The validity
score was 0.409---0.953 and the Cronbach alpha was 0.946.9
While the self-esteem of the participants was mea-
sured with the Coppersmith Self-Esteem Inventory.10 This
50-item inventory covers four dimensions of self-esteem,
i.e., the general self, social self-peers, home-parents,
and school academic. This tool was also found to be
valid and reliable (validity score = 0.362---0.729; Cronbach
alpha = 0.942).10 Data were then analyzed using univari-
ate (central tendency, frequency, proportion) and bivariate
analyses (chi-square).
We applied the ethical principles in the study conduct,
including respecting participants’ dignity, privacy and con-
fidentiality. We obtained ethical clearance from the Ethical
Committee of the Faculty of Nursing Universitas Indonesia
(No.132/UN2.F12.D/HKP.02.04/2019).
Results
The mean age of the adolescents in this study was
15.48 years (range = 14---16 years). Most of the participants
were female (63%, 109 out of 173 participants).
With regard to the body image, we used mean value as
the cut-off point to determine the positive and negative
body image. The mean value of the participants’ body image
was 50.22, while the minimum and maximum scores of the
body image were 14 and 84. The results showed that a little
higher percentage of the participants (51.4%) had a negative
body image versus 48.6% of the participants who reported a
positive body image (Table 1). More adolescents in the age
bracket of 14-year-old (80%) had a negative body image.
A negative body image was also slightly higher in female
adolescents (54.1%) compared to their male counterparts.
The mean score of the adolescents’ self-esteem was
30.66 (range = 0---50), which was also used as the cut-off
point of the higher and lower self-esteem. A somewhat
higher proportion of adolescents with acne vulgaris (52%)
scored lower self-esteem. Similar to the case of body image,
more adolescents aged 14 (80%) reported lower self-esteem
compared to the 15 and 16 age group. Lower self-esteem was
also reported by more female adolescents than the males
(56% and 45.3%, respectively). Table 1 summarizes the body
Self-esteem
Mean Higher (%) Lower (%) Mean
50.2 48.0 52.0 30.6
44.8 20.0 80.0 29.2
50.2 47.5 52.5 30.1
50.5 50.0 50.0 31.2
50.5 54.7 45.3 31.6
50.1 44.0 56.0 30.1
 R.P. Ramadhanty and A.Y.S. Hamid
Table 2 The relationship between the body image and self-esteem of the adolescents with acne vulgaris.
Body image Self-esteem
Lower
n % n %
Positive 71 84.5 13
Negative 12 13.5 77
n 83 48.0 90
image and self-esteem data of the adolescents with acne
vulgaris.
Our chi-square analysis showed a statistically significant
relationship of the positive and negative body image with
the higher and lower self-esteem (p = 0.000). There were
more adolescents with acne vulgaris having positive body
image had a higher self-esteem, and vice versa (Table 2).
Discussion
The majority of the adolescents with acne vulgaris are in
the mid-adolescents age group (14---16 years); as shown in
the present study and is consistent with the previous study
results.6,11 In a previous study, it was also found that 713
out of 1.167 people having acne vulgaris problems were
adolescents.12 A higher incidence of acne vulgaris was also
found in the female population.12
We found that more adolescents with acne vulgaris had
a negative body image. Literature supports this finding and
explains that alteration in facial skin appearance, such as
acne vulgaris on the face, can have a direct negative effect
on the individual perception on his/her own body.13 The
perception of other people can also be influenced by the
facial appearance so that it worsens the individual’s body
Image.13 According to prior studies, a person with acne vul-
garis problem tended to have negative body image, and even
depression, anxiety, and social isolation.8 While the adoles-
cents are in the stage of psychosocial development that are
more vulnerable to physical changes.1 Therefore, failure to
adapt to their puberty-related physical changes can have a
deeper impact on their psychological and social life.5 Peo-
ple with acne prone skin who have negative body image also
tend to have a low quality of life.11
Furthermore, our study had more female adolescents
reported negative body image and self-esteem, which is in
line with the findings of some prior studies.14,15 Women are
more likely to have negative body image and self-esteem
than men because women tend to internalize their bodies
more often, be more sensitive about people’s perception
of their bodies, and have higher body awareness than men
do.16 Men tend to take the negativity related to their bod-
ies more easily; they also seek less care of their body
problems.16 A large study of 985.937 participants found that
men consistently had a higher self-esteem than women.17
Nevertheless, many factors such as personality and social
support, can affect a person’s mental image of the body.18
The closest environment of the adolescents, i.e., family
and peers can bring positive influence to the formation of
their body Image.2 Such influencing factors were beyond the
Total p Value
Higher N %
15.5 84 100 0.000
86.5 89 100
52.0 173 100
scope of this study, yet it could be noteworthy for nurses to
help promote adolescents’ mental health.
In this study, the number of adolescents with acne vul-
garis who reported a low self-esteem was slightly higher than
those that reported higher self-esteem (52% versus 48%).
Former studies also found that adolescents with chronic skin
conditions such as acne and psoriasis tend to have low self-
esteem,14 depending on the severity of the acne problem.19
A similar result was found in another study in Singapore that
examined 429 students with acne prone skin conditions.20
The younger adolescents (i.e. 14 years old) made up the
largest proportion of adolescent age group who reported
lower self-esteem and negative body image in the present
study. That the self-esteem and body image tend to increase
with age was demonstrated in previous studies.15,17
Our analysis results demonstrated a significant rela-
tionship between the body image perception and the
self-esteem of the adolescents with acne vulgaris. This is in
line with the results of the prior studies.14,19 Theories also
posit that body image of the adolescents can determines
their self-esteem.18 A person with a negative body image is
more likely to have a lower self-esteem as well.14
Conclusion
We can conclude from our findings that the body image
perception of the adolescents with acne vulgaris is asso-
ciated with their self-esteem. Future studies should be
done with a more representative sample of adolescents,
and underpinned on a strong theoretical framework of ado-
lescent’s psychosocial development. Nurses should deliver
health education containing the major concerns of adoles-
cents, such as acne vulgaris, to promote positive body image
and self-esteem among adolescents. Nurses should also col-
laborate with the parents to help adolescents nurture higher
self-esteem in this dynamic period of their maturation.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
This work is supported by Hibah PITTA B 2019
funded by DRPM Universitas Indonesia No. NKB-
0481/UN2.R3.1/HKP.05.00/2019.
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 Enfermería Clínica 31 (2021) S326---S329
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