Depression, mood change and self-esteem among adolescents aged 12-25 years with acne vulgaris in India

Introduction: Acne vulgaris is a medical condition of serious concern among adolescents. This study was conducted with the aim to compare psychosocial factors such as depression, self-esteem, and social impairments between females who had acne vulgaris and those who did not have acne vulgaris. Materials and Methods: Fifty (50) female acne cases and 100 controls (hereafter nonacne participants) in the age group of 12-25 years who were seeking treatment at the Dermatology Outpatient Department (OPD) of Saveetha Medical College, were enrolled in the study. Information about sociodemographic profiles, disease management, and normative perception was gathered. Further assessment of self-esteem, cognitive and behavioral factors, and self-efficacy was done. Results: Seventy-four percent (74%) of the acne cases were overwhelmed by their skin condition, and this was found to be statistically significant (P < .0001). More than half (58%; P < .0001) of the acne cases experienced anger while thinking of their skin conditions. Half of the number of acne cases (52%) felt that people perceived them as being dirty due to their skin condition and that it hindered them from interacting with the opposite sex. Conclusion: Adolescent females who had acne reported difficulties in overcoming the emotional disturbances occurring due to acne vulgaris.

Keywords: Acne vulgaris, adolescent females, depression, emotional disturbances, self-esteem, social impairments

Acne vulgaris is a common dermal disease characterized by chronic inflammation of the pilosebaceous units. ^[1],[2] Predominantly it occurs in the adolescent population, affecting the face and the upper part of the trunk. ^[2] Clinically it is characterized by seborrhea, comedones, papules, nodules, pustules, and scarring. ^[3]

The prevalence of acne is about 80%, affecting both adolescents and adults. ^[4] Nearly all adolescents are affected by varying degrees of acne in their lifetime, and among them 10-20% of acne cases are in the moderate-to-severe category. ^[5] The Global Burden of Disease study 2010 showed a 22% rise in disability-adjusted life years (DALYs) due to acne vulgaris since 1990. ^[6] Previous studies had reported 0.38-8% prevalence of acne vulgaris in India. ^[7],[8],[9]

Previous studies have shown a relatively high degree of psychosocial problems among individuals having acne vulgaris. ^{[1],[5],[7],[10],[11]} One of those studies reported a strong association between the incidence of acne and elevated anger, depression, frustration, poor self-image, suicidal ideation, mental health problems, and social impairment among adolescents. ^[5] An estimated prevalence of 10.9% for suicidal ideation was seen in the same study. ^[5] Adolescents with severe forms of acne were found to be more likely to develop mental problems and were at risk of attempted suicide. ^[5],[12] One study showed clinical anxiety among 68% of acne cases and depression among 26% of the cases. ^[2] Another older study had shown social inhibition in 21%, followed by anxiety in 17% and depression in 9% of the individuals with acne. ^[10] A study by Bashir et al. showed a slightly higher prevalence (34%) of depression among acne patients. ^[13] Acne had a significant influence on social interaction, health-related quality of life, and self-image. ^[14] In an earlier study, severe acne among boys was more correlated with low attachments to peers, family, and the opposite sex, but in girls poor academic performance was more evident. ^[15]

Older studies have stressed the importance of psychosocial treatment along with physical treatment. ^[5],[11] Thus, taking into consideration the results of previous studies, we conducted this study to compare psychosocial factors such as depression, self-esteem, and social impairments between females who had acne vulgaris with those who did not have acne vulgaris.

An exploratory cross-sectional study was conducted in Chennai, a metropolitan city in South India, from August to November, 2013. Fifty (50) female acne cases and 100 controls (hereafter nonacne participants) in the age group of 12-25 years who were seeking treatment from the dermatology outpatient department (OPD) of Saveetha Medical College were enrolled in the study. The numbers are for a month, 140-150 patients visit the Dermatology OPD. In total, 90 acne cases were approached and enrolment was done until the desired sample of 50 participants was achieved. Nonacne participants were matched for age and location. Diagnosis of acne cases was made by a qualified dermatologist. Individuals who agreed to participate and signed the consent form were included in the study. Individuals with anxiety nervosa or binge eating, those with any preexisting psychological morbidity, those with any mental and/or physical challenges making it too difficult to participate, and/or those involved in other clinical trials were excluded from the study.

The study was approved by the Institutional Review Board of the Foundation of Healthcare Technologies Society, New Delhi (IRB#FHTS/011/2013) and conforms with the provisions of the Declaration of Helsinki (as revised in Seoul, 2008).

Data collection

Information on the following variables was gathered:

1. Sociodemographic characteristics: Information was gathered about age (years), educational status (Grade 1-5, Grade 6-8, Grade 9-10, Grade 11-12, Graduate or above, or no education), marital status (single, married, divorced or separated, or widow), annual household income, household location (rural or urban), type of family (joint, nuclear, broken, or extended), family size, and occupational status (semiprofessional to professional, skilled worker, unskilled, unemployed, or student). ^[16]
2. Disease-related information: Information was gathered on:
   1. Information-seeking for acne management,
   2. Source of information, and
   3. Discomfort due to this condition (itching, scarring, pain, redness, swelling, bleeding). Additional information was gathered on the frequency and type of products used by the participants while washing their face. ^[14]
3. Self-esteem, cognitive and behavioral assessment: Information was gathered by using the pretested semistructured 14-item questionnaire, which included the categories:
   1. Excessively concerned about the face,
   2. Looking too much at one’s own face in the mirror,
   3. Feeling overwhelmed by the skin condition,
   4. Anger while thinking of acne,
   5. Fear of living with acne,
   6. Opinion about self-appearance in absence of acne,
   7. Worrying about the future and complications,
   8. Participation in school/college recreational activities,
   9. Deprivation from employment opportunities,
   10. Skin condition as a barrier in making new friends,
   11. Confidence in self,
   12. Obtaining treatment for skin condition,
   13. Satisfaction toward treatment plan, and
   14. Anxiety about harmful consequences of skin treatment. ^{[1],[2],[5],[11]}
4. Normative perception: A three-item questionnaire was used to gather information on:
   1. Whether they thought their skin condition is the first thing noticed by others,
   2. Uneasiness while interacting with the opposite sex, and
   3. Whether they thought that people perceived them as dirty because of their skin condition. ^[11]
5. Self-efficacy assessment: Information was gathered by using a five-item questionnaire, which included problems faced while performing day-to-day chores such as:
   1. Bathing,
   2. Cleaning of home, and
   3. Shaking of hands. Additional information was gathered on whether the subjects could easily get rid of the scars and the ability to control emotions resulting from skin conditions. ^[2],[7],[14]

Statistical analysis

Quantitative descriptive analysis was performed using univariate statistics to report means and standard deviations for the continuous variables and frequency distribution for the categorical variables. Chi-square and Fisher’s exact tests were done to compare the frequency of categorical variables. All analysis was performed in SPSS version 16 (SPSS Inc., Chicago, USA).

The median age of participants was 19 years. A slight preponderance toward the urban setting (67%, n = 100) was seen in the study. The majority of the participants were students (78%, n = 117) with an identical or less than intermediate (43%, n = 65) level of education. Their average annual household income was around 364266 INR (approx. 6071 USD) [Table 1].

The frequency of face-washing was higher among acne cases (54%) as compared to nonacne participants (34%). All of the participants used either soap or facewash for washing their face. Twenty-four percent (24%) of the acne cases reported pain, 18% of them reported redness, and 12% reported bleeding as a result of acne. Twenty percent (20%) of the acne cases reported scar formation, 10% reported swelling, and 18% reported itching due to acne. More than half of the acne cases (64%) sought information regarding acne management [Figure 1]. Twenty-two percent (22%) of the acne cases reported healthcare professionals to be the most preferred source of information, followed by the Internet (18%), books (16%), and television (8%). Uncertainty about reliability (6%) and usability (8%) were the two main reasons for not seeking information on acne management. Six percent (6%) of them were not able to seek information due to the lack of opportunities and 10% of them were not interested in seeking any information.

Concern about the face was higher among acne cases (92%), compared to nonacne participants (65%). Seventy-eight percent (78%) of the cases spent too much time looking at the mirror. Seventy-four percent (74%) of the acne cases were overwhelmed by their skin condition and this was found to be statistically significant (P < .0001). More than half (58%; P < .0001) of the acne cases experienced anger while thinking of their skin conditions. Fear of living with acne was higher among acne cases than among nonacne participants (52% vs 27%; P = .003). Forty-four percent (44%) of the acne cases worried about their future and the possibility of complications, yet the majority of them had confidence (82%) in themselves. The majority of acne cases (86%) felt that their appearance would have been better if they did not have this condition. Half of the acne cases (52%) reported participation in school/college recreational activities despite having acne. Thirty-eight percent (38%) of the acne cases believed that their skin condition could affect them in terms of employment opportunities. Thirty-two percent (32%) of the acne cases believed that their skin condition was a limitation against making new friends (P < .0001). The majority of the acne cases had received treatment from a healthcare professional in the past (80%; P < .0001). Forty-eight percent (48%) of the acne cases were not satisfied with their treatment plan. The proportion of individuals who felt that skin treatment might harm their general health was higher among the acne cases as than among the nonacne participants (28% vs 7%; P = .001) [Table 2].

The results showed that 46% of the acne cases felt that the first thing noticed by people while looking at them was their skin. Half of the acne cases (52%) felt that people perceived them as dirty due to their skin condition and that it hindered them from interacting with the opposite sex. All of the normative perception variables showed statistically significant differences between acne cases and nonacne participants [Table 3].

More than half of the acne cases reported that they could take baths properly (70%) and keep their homes clean (78%) despite their prevailing skin conditions. Seventy-six percent (76%) of the acne cases did not feel any hesitation about shaking hands. More than half of the acne cases reported inability to control emotions (54%) from rising due to their skin conditions, and 64% of them reported inability to clear scars [Table 4].

Adolescent and early adulthood comprise the phase of life when people undergo various physical, social, and mental changes. Acne vulgaris is a common skin problem among the adolescent and adult population. Past studies have shown that acne has physical as well as psychosocial impact. ^[11] This study was conducted to compare psychosocial factors such as depression, low self-esteem, and social impairments between females with acne vulgaris and nonacne controls.

The results of the study showed that the majority of the acne cases were overwhelmed by their skin conditions and spent a lot of time looking at mirrors. This may lead to decreased social interaction and lifetime productivity of an individual. ^[17] In the present study, 32% of the acne cases believed that their skin condition limited them in terms of making new friends. This result is quite similar to a study among adolescents in Greece, which reported 20% of acne adolescents with problems in relationship-building due to their acne lesions. ^[4] Thirty-eight percent (38%) of the acne cases felt that acne was a barrier in achieving career opportunities. Forty-four percent (44%) of them were worried about their future, but most had confidence (82%) in themselves.

The majority of the acne cases had received treatment from a healthcare professional, but satisfaction with treatment plans was acknowledged by only half of the acne cases (52%). Previous studies have shown a significant improvement in quality of life due to strategic treatment of acne. ^[14] However, in our study, 28% of the cases felt that skin treatment might cause a catastrophic impact on health.

In the present study, 52% of the acne cases felt that people perceived them as dirty because of their skin conditions, and this was statistically significant (P < .0001). This finding was similar to a previous study that had shown that acne cases were uncomfortable about being judged as unappealing and worthless. ^[18] Acne-related self-image has negative impact on the self-esteem of the individual. ^[18] One of the critical reasons behind such negative thinking is the advertisements shown on electronic and print mass media. ^[18] These advertisements present idealistic images of skin, which in turn create the pressure of needing to achieve clear skin among acne cases. ^[18] Our study has shown that 54% of acne cases were unable to overcome the emotional disturbances that had risen due to acne. A previous study had shown that acne was associated with psychological morbidity and its treatment helps in improving of associated psychological morbidities. ^[18]

In our study, more than half of the acne cases sought information for acne management, and healthcare professionals were considered the most preferred source of information. In developing countries such as India, the majority of acne patients consult a primary-level healthcare professional before approaching a dermatologist. Thus there is a need for initiating psychotherapy along with acne treatment at the primary healthcare professional level.

Our study had certain limitations. First, it included a smaller sample size and cross-sectional study design. This limits the possibility of establishing temporality. Second, the study was limited to one geographical location, so the results of the study cannot be generalized. Third, the study included only females, therefore the findings of our study may not be applicable to males. Fourth, we were not able to study confounding variables such as parents’ education and occupation, seasonal variations, duration with acne, and treatment compliance.

Future study is warranted to assess the impact of implementing psychotherapy for acne cases in the primary healthcare setting.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.168712

[Figure 1]

[Table 1], [Table 2], [Table 3], [Table 4]