Abstract
Acne vulgaris is one of the most common dermatologic complaints. Although dermatologists are skilled at treating acne, invisible psychological scars can be left by the disease. We review 13 articles that examined the effect of acne vulgaris on patients’ self-esteem. Overall, these studies demonstrated that acne has a negative effect on self-esteem among patients of all age groups. These effects most strongly affect women and those with severe acne (both subjectively and objectively). Despite the impact on self-esteem, only a minority of patients seek medical treatment, and even fewer seek treatment from a dermatologist. As dermatologists, we are trained in managing acne. We can provide early and effective treatment that improves both the physical and psychological effects. It is up to us to bridge the gap between those suffering from acne and their access to medical treatment.
Keywords: acne vulgaris, self-esteem, acne, isotretinoin, quality of life
Introduction
Acne vulgaris (AV), which was first described in the 6th century AD, is one of the most common dermatologic conditions. Prevalence varies based on age and ethnicity, but up to 85% of adolescents and up to two-thirds of patients over the age 18 of years may be afflicted with acne (White, 1998, Zaenglein and Thiboutot, 2012). Despite how commonplace AV is, its negative effects on psychosocial functioning are profound. Acne has been associated with higher rates of depression, anxiety, failure to thrive at school and in social environments, suicidal ideation, and suicidal attempts (Halvorsen et al., 2011, Picardi et al., 2006, Purvis et al., 2006, Yentzer et al., 2010). This psychological impact is rooted in real-world implications because patients with AV have been found to have higher rates of unemployment compared to their unaffected counterparts (Cunliffe, 1986). Additionally, attractiveness, which in many cultures includes unblemished skin, has been linked to election results (Little and Roberts, 2012).
In addition to the psychological and occupational impairments listed, AV can have a major impact on self-esteem and self-image. Self-esteem is defined as “the reasonable or justifiable sense of one’s worth or importance” (Merriam-Webster, 2017). The development of self-esteem and personal identity is critical in young adults. A visible and potentially disfiguring skin disease can lead to interpersonal rejection and issues with social, vocational, and sexual competence, which in turn can have a negative impact on psychosocial and sexual maturity (Magin et al., 2006). Low self-esteem may be associated with anxiety and depression. In contrast, high self-esteem may serve as a protective factor when coping with new and chronic illness and challenges (Dalgard et al., 2008).
Our goal is to present the published data on self-esteem and acne to help us better understand the underlying psychological issues affect our patients. We will review the techniques to assess patients for low self-esteem that can help in providing more comprehensive care.
Methods
We conducted a literature search using PubMed and the terms “acne vulgaris” AND “self-esteem”. Only original research studies were included in the results. Additional articles were identified by reviewing the references. All age groups were included. Only papers that were written in or translated into the English language were included. A total of 13 studies met our criteria and were included.
Results
Acne vulgaris and self-esteem
AV affects quality of life and self-esteem across all age groups and cultures. Our research included data from 13 studies conducted in 11 countries. Different assessment styles were used to evaluate self-esteem, including validated questionnaires and loosely structured interviews. Demographic data, assessment technique, and outcome highlights from the studies are listed in Table 1. We will review the impact of age, sex, severity, and treatment of acne on self-esteem.
Table 1.
Studies that evaluate the effect of AV on self-esteem
| Author, Year | Population Size, n | Country | Average Age (years; male/female) | Population Studied | Relevant Assessment Tools | Relevant Outcomes |
|---|---|---|---|---|---|---|
| Hosthota et al., 2016 | 200 | India | 21; 42%/58% | Hospital-based study, 100 patients with AV and 100 age- and sex-matched controls. |
|
|
| Su et al., 2015 | 429 | Singapore | 29; 39%/61% | Students at three tertiary institutions who attended an acne “roadshow”. | U.S. FDA five-category global system assessment scale. Four questions related to the effect of acne on social life. |
|
| Vilar et al., 2015 | 355 | Brazil | 16; 47%/53% | High school students in Joao Pessoa, Brazil |
|
|
| Tasoula et al., 2012 | 1531 | Greece | 15; 48.7%/51.3% | Students from 23 high and senior high schools in Athens, Greece |
|
|
| Hassan et al., 2009 | 132 | United Kingdom | 22.31; 42.1%/57.9% | Patients with AV referred to specialized acne clinic | - DAS-59 (comprised of five scales: GSC, SSC, SBSC, NSC, FSC, PDD) |
|
| Abdel-Hafez et al., 2009 | 200 | Egypt | 20.1 subjects; 32%/68% 23.2- controls; 46%/54% |
Hospital-based study, 150 acne cases and 50 healthy volunteers as controls |
|
|
| Do et al., 2009 | 504 | South Korea | 50.2%/49.8% | Students from one middle school in Seoul |
|
|
| Magin et al., 2008 | 26 | Australia | Patients from dermatology clinic |
|
|
|
| Loney et al., 2008 | 50 | United Kingdom | 32.5; 40%/60% | Participants in national acne dermatology support group |
|
|
| Dalgard et al., 2008 | 3775 | Norway | N/A; 44%/56% | High school students from 32 secondary schools in Oslo, Norway |
|
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| Uslu et al., 2008 | 563 | Turkey | 15.24; 46.2%/53.8% | Students from four high schools in Aydin, Turkey |
|
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| Magin et al., 2006 | 26 | Australia | 31 | Patients from acne clinics |
|
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| Lasek and Chren, 1998 | 60 | United States | 31; 28%/72% | Patients with AV seen in dermatology offices compared with 44 patients with psoriasis, 75 patients with benign skin lesions, and 107 healthy volunteers |
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|
AV, acne vulgaris; BDI, Beck Depression Inventory; CADI, Cardiff Acne Disability Index; CDLQI, Children’s Dermatology Life Quality Index; CFSEI-AD, Culture Free Self-Esteem Inventory-Adult Version; DAS-59, Derriford Appearance Scale; DLQI, Dermatology Life Quality Index; DSA, Dermatological Social Anxiety; FDA, Food and Drug Administration; FSC, self-consciousness of facial appearance; GHQ, General Health Questionnaire; GSC, general self-consciousness of appearance; IPEx, intent to participate in sports/exercise; IPR, Index Of Peer Relations; NSC, negative self-concept; PDD, physical distress and dysfunction; QoL, quality of life; RSES, Rosenberg Self-Esteem Scale; SBSC, self-consciousness of sexual and bodily appearance; SCL-90-R, Symptom Check List-90-Revised; SIQ, Self-Image Questionnaire; SSC, social self-consciousness of appearance; WHOQOL-BREF, World Health Organization Quality of Life-BREF.
Assessment methods
Several assessment methods were used to evaluate self-esteem and AV. A full discussion of the assessment tools is beyond the scope of this paper; however, we will briefly review two frequently used questionnaires: the Rosenberg Self-Esteem Scale (RSES) and the Dermatology Life Quality Index (DLQI).
The RSES (Supplement 1) was developed in 1965 by Dr. Morris Rosenberg for use by adolescents. It consists of 10 questions and four answer choices. Each choice is given a point score. Higher scores correlate with higher self-esteem and lower scores correlate with lower self-esteem. Scores between 15 and 25 are considered average (Rosenberg, 1965).
The DLQI was created in 1994 by Drs. Andrew Finlay and Gul Khan and requires patients to answer 10 questions with up to five possible answer choices. Each choice has a different score. The higher the score, the greater the impairment. The questions assess symptoms and feelings, daily activities, leisure, work and school, personal relationships, and treatment (Finlay and Khan, 1994).
Age
Although AV disproportionately affects adolescents, we wanted to explore which age groups are most affected by the disease. Do et al. (2009) administered surveys to and performed clinical examinations on 504 students aged 13 to 16 years in one middle school in Seoul, South Korea. They found that the younger the student was when the acne began, the greater the stress that was experienced, along with greater impairments in interpersonal relationships and disturbances in daily life. In a series of loosely structured interviews with patients with acne, Magin et al. (2006) found that as soon as acne lesions appeared, psychological consequences immediately took root, including reduced self-esteem. These feelings were exacerbated by taunting, stigmatization, and perceptions of being judged.
In Athens, Greece, high school students ranging from 11 to 19 years of age completed surveys about self-esteem and quality of life. In students 14.1 to 16.4 years of age, acne had a significantly greater impact on quality of life compared with students aged 11 to 14 years and 16.5 to 17.5 years (Tasoula et al., 2012). In contrast, Uslu et al. (2008) employed school-based questionnaires to evaluate the effect of acne on teenagers in Aydin, Turkey, and found that there was no relationship between RSES scores and duration of acne.
Two studies examined the effect of acne in older patients. In 60 adults with acne, Lasek and Chren (1998) found that 70% of patients aged 30 to 39 years were most bothered by the appearance of acne. This was over twice the percentage of patients bothered by the appearance of acne in any other age group they studied. Even when controlling for the clinical severity of acne, older patients reported that acne had a greater effect on their quality of life when compared with younger patients. Similar results were found by Hassan et al. (2009), who administered the Derriford Appearance Scale-59 to 145 patients who attended a specialist acne clinic. Patients aged 20 years and older had greater general self-consciousness than patients aged 16 to 19 years. Older men were found to have greater self-consciousness of facial appearance and physical distress and dysfunction when compared with younger men (Hassan et al., 2009).
Sex
The majority of researchers found that women with acne were more likely to have greater self-consciousness (Hassan et al., 2009) and self-perceived stress, lower self-esteem (Do et al., 2009) and feelings of self-worth, poorer body satisfaction, lower self-attitude, and greater feelings of uselessness (Dalgard et al., 2008). Four studies found that men and women were equally affected by their disease (Lasek and Chren, 1998, Loney et al., 2008, Tasoula et al., 2012, Uslu et al., 2008). A single study in Egypt showed that male patients with acne had significantly lower self-esteem when compared with women (Abdel-Hafez et al., 2009).
Severity of acne
Across all studies, self-esteem became lower as severity of acne increased. Researchers used different techniques to assess acne severity, including objective and subjective reporting.
Several studies found that moderate-to-severe AV, as evaluated by a medical provider, correlated to reduced quality of life and self-esteem (Abdel-Hafez et al., 2009, Hosthota et al., 2016, Lasek and Chren, 1998). Vilar et al. (2015) found that patients with worse acne had a more impaired quality of life; however, there was no correlation between acne severity and self-esteem. Tasoula et al. (2012) noted embarrassment and decreased self-esteem in all patients with acne compared with their unaffected counterparts; however, it was more prevalent in those with more severe AV, occurring in up to 89.3% of these patients. Every question with regard to quality of life demonstrated significantly worse responses in patients with more severe AV (Tasoula et al., 2012).
Other studies demonstrated that patients with subjectively more severe AV had lower self-esteem. Su et al. (2015) surveyed 429 students in Singapore and administered objective and subjective AV grading. Overall, patients felt that their acne was worse than the objective examination demonstrated. Their subjective evaluation, not the objective evaluation, correlated to greater embarrassment (Su et al., 2015). Similarly, Do et al. (2009) compared both subjective and objective acne evaluations and found that subjective acne grading correlated more with self-image impairment and stress when compared with objective evaluations (Do et al., 2009). Fifty patients at an acne clinic graded their own acne severity. Their subjective scores demonstrated that those who ranked their acne as more severe had reduced self-esteem when compared with self-rated mild AV (Loney et al., 2008). In a survey of 3775 Norwegian students, boys’ attitudes toward themselves were diminished when they reported moderate-to-severe acne, and girls’ self-worth was significantly lower (Dalgard et al., 2008). A study of 550 students in Turkey found that there was a significant relationship between subjective acne severity and self-esteem but no relationship between objective acne severity and self-esteem (Uslu et al., 2008).
Taunting/bullying
In his early research, Magin et al. (2006) found that two exacerbating factors in self-consciousness and embarrassment in patients with AV were being taunted or teased or simply the perception of being judged by others. His later research explores the role of taunting and bullying in-depth (Magin et al., 2008). After conducting interviews with 26 patients with AV, he found that patients with AV are often bullied, which directly correlates with reduced self-esteem and self-image. For some patients, their social circle singled out acne as a defining feature on which to base power-relationships. Perceived transmissibility was a concern for many and led to taunting and teasing, even in medical settings where providers commented on the patients’ acne (Magin et al., 2008).
Treatment
One of the first steps in improving AV is seeing patients in a medical setting. Between 70% and 80% of patients used self-prescribed topical treatments, but only between 5% and 28.3% of participants had visited a dermatologist (Su et al., 2015, Tasoula et al., 2012, Vilar et al., 2015). In the study by Su et al. (2015), patients took an average of 22.2 months to seek medical treatment.
The more severe the acne, the more likely patients are to seek treatment. Tasoula et al. (2012) demonstrated that 61% of patients with moderate-to-severe AV saw a dermatologist. Vilar et al. (2015) showed that of those who visited a dermatologist, only half followed the treatment plan as a result of financial issues. Patients were overall more satisfied with results after medical treatment compared with nonmedical treatment (Su et al., 2015). Patients who feel that they have benefitted from treatment also have improved self-esteem, improved quality of life, and less anxiety than those who do not believe that they have benefitted from treatment. This was observed by Uslu et al. (2008) in adolescents and by Lasek and Chren (1998) in adults.
Discussion
Age
The majority of patients who suffer from AV are adolescents. The adolescent stage corresponds to a life stage during which the development of core ideology related to body image, sexuality, self-image, socialization, and vocational choices begins. The changes in hormone levels that are partially responsible for AV also lead to psychological vulnerability in this age group. Patients who develop acne earlier begin to experience lower self-esteem and impairment with relationships at an early age (Do et al., 2009, Magin et al., 2006). The actual age at which AV has the greatest impact may vary depending on the society. For example, Tasoula et al. (2012) found that students aged 14.1 years had the lowest self-esteem and quality of life compared with younger and older students. This age corresponds to middle school, when children may be especially vulnerable to taunting and bullying because their self-image may not be fully developed. Additionally, family relationships may not be able to buffer the social effects as well as they may have at younger ages.
Although the impact in younger populations is commonly recognized, the psychological burden that is placed on older patients should not be underestimated. In fact, in the United States, adults aged 18 years and older comprise 61.9% of acne visits to the dermatologist (Yentzer et al., 2010). Both Lasek and Chren (1998) and Hassan et al. (2009) demonstrated that general self-consciousness and concern regarding the appearance of acne was significant in older patients. Many societies value youth and beauty; therefore, having blemishes at an older age can have an even greater effect on self-esteem. Additionally, AV may influence employment and social functioning within this age group (Hassan et al., 2009, Lasek and Chren, 1998).
Sex
In Western culture, society and media portray the expectation that women should have clear skin to be beautiful and successful (Hassan et al., 2009). The appearance of acne tends to have a greater role in embarrassment and discomfort in women compared with men (Kellett and Gawkrodger, 1999). However, there is increasing pressure on men to adhere to the same standards as women, which is mirrored by an increasing number of procedures and dollars spent on male cosmetic procedures in the United States (Rieder et al., 2015). Our research showed that in certain age groups and cultures, women are more affected than men (Dalgard et al., 2008, Do et al., 2009, Hassan et al., 2009); in other studies, however, men and women are equally affected by the disease (Lasek and Chren, 1998, Loney et al., 2008, Tasoula et al., 2012, Uslu et al., 2008). The reason for the differing results may be the assessment techniques used, the population surveyed, or the age group studied.
Of note, a single study based in Egypt showed that male patients had significantly lower self-esteem when compared with women (Abdel-Hafez et al., 2009). Although this is the only Islamic study included in our research, these findings may result from the low social visibility of women in this society. More women stay at home and cover their faces as part of religious and cultural obligations.
Social expectations and the importance of appearance of men and women play a large role in creating a culture in which unblemished skin is highly valued, regardless of sex. As suggested by research, the greater the visibility a sex has, whether through employment or socially, the greater the effect of AV on self-esteem may be. Patients with acne are made to feel less worthy than their unblemished counterparts.
There is no research on the effect of AV on female-to-male transgender patients undergoing testosterone treatment. A handful of papers have been written on the severity of acne requiring isotretinoin use; however, no one has specifically addressed the effect of severe AV on self-esteem in this patient population (Mundluru et al., 2016, Turrion-Merino et al., 2015).
Severity of acne
Across multiple studies, the more severe the AV, the greater the impact on quality of life and self-esteem. Because both objective and subjective severity can influence a patient’s self-image, we recommend that patients evaluate their own AV. If they perceive their acne as being more severe than an objective examination suggests, a more aggressive approach in stepping up therapy to help them achieve their goals may be warranted. The importance of managing patient expectations during therapy cannot be overstated. Involving patients in these discussions will lead to a better physician–patient relationship, improved medical care, and better psychological functioning for the patient.
Taunting/bullying
Bullying encompasses verbal aggression, physical aggression, and social exclusion. Being teased (a form of bullying) has been associated with depression, impairment of self-esteem, anxiety, and social phobia (Magin et al., 2008, Magin et al., 2006). The role of taunting/bullying may not be visibly apparent to the medical provider. Although the social environment that a patient encounters on a daily basis cannot be directly controlled, dermatologists can assess for the impact of bullying on patients’ self-esteem. By asking patients if they have experienced teasing or bullying, we can help alleviate misinformation (e.g., if a patient thinks he or she is contagious) and modify treatment accordingly. Discussing camouflage techniques may help patients feel more comfortable in public during treatment. Patients may also need to be encouraged to adhere to treatment to see results.
Treatment
Our research shows that most patients who suffer from AV do not seek medical treatment (Su et al., 2015, Tasoula et al., 2012, Vilar et al., 2015). American Academy of Dermatology guidelines recommend that prescription medication be instituted for even mild acne, so there is an important role among patients who reach out to dermatologists early in the disease course before physical and psychological scarring occurs (Zaenglein et al., 2016). Patients who receive medical treatment are more likely to be satisfied with the results and experience a positive psychological result. This is supported by the literature, which demonstrates that patients who are treated with isotretinoin not only have an improvement in their severe acne but also an improvement in self-esteem (Cyrulnik et al., 2012), psychological functioning (Kellett and Gawkrodger, 1999), anxiety, and depression (Rubinow et al., 1987). Dermatologists need to work with local medical communities to encourage early referrals before the damage is done.
Because treatment for AV may take several weeks to months, physicians should counsel their patients on camouflage techniques, which can also improve negative psychological effects (Levy and Emer, 2012, Magin et al., 2006).
In the clinic
To evaluate patients’ self-esteem in the clinic, open-ended questions or a more formalized approach such as the RSES can be used. Patients can fill out this scale while waiting to be seen, and the results can improve the psychological relationship between patient and physician. Perhaps most importantly, a dermatologist who prescribes appropriate medical therapy, manages patient expectations, and educates patients on the results and timing will best help meet patients’ medical and psychological needs.
Depression and suicidality
The relationship between AV and depression and suicidality is a broad topic, and a comprehensive review is beyond the scope of this article. However, given the importance of the issue, we will briefly touch on the subject.
Patients with AV have been shown to have an increased risk of depression and suicide attempts, even when controlling for depression (Picardi et al., 2006, Purvis et al., 2006, Yang et al., 2014). Among those with severe acne, the risk of suicidal ideation may be two to three times that of their unaffected peers (Halvorsen et al., 2011). The Personal Health Questionnaire-9 (PHQ-9) or the PHQ-9 modified for adolescents are easy tools to administer during a visit to screen for depression. They are validated as effective screening tools and are used in many primary care settings (Kroenke et al., 2001). The questionnaires must be reviewed prior to discharge because questions that pertain to suicidality are included.
Behavioral signs such as poor eye contact, angry or negative verbalization, poor self-care and personal hygiene, compulsive behaviors, or self-mutilating behaviors may also be considered a high risk (Fried and Wechsler, 2006). Patients with AV should be assessed for suicidality and depression, and anyone with concerning findings should be appropriately referred.
Conclusion
Our review demonstrates that AV has a substantial negative impact on patients’ self-esteem. More severe AV and AV in women tend to have the greatest impact across cultures. Effective treatment improves patients’ self-esteem, and as dermatologists we have an armamentarium of treatment options to improve AV.
The following is the supplementary data related to this article.
Rosenberg Self-Esteem Scale.
Footnotes
Funding sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
References
- Abdel-Hafez K., Mahran A.M., Hofny E.R., Mohammed K.A., Darweesh A.M., Aal A.A. The impact of acne vulgaris on the quality of life and psychologic status in patients from upper Egypt. Int J Dermatol. 2009;48:280–285. doi: 10.1111/j.1365-4632.2009.03838.x. [DOI] [PubMed] [Google Scholar]
- Cunliffe W.J. Acne and unemployment. Br J Dermatol. 1986;115:386. doi: 10.1111/j.1365-2133.1986.tb05757.x. [DOI] [PubMed] [Google Scholar]
- Cyrulnik A.A., Viola K.V., Gewirtzman A.J., Cohen S.R. High-dose isotretinoin in acne vulgaris: Improved treatment outcomes and quality of life. Int J Dermatol. 2012;51:1123–1130. doi: 10.1111/j.1365-4632.2011.05409.x. [DOI] [PubMed] [Google Scholar]
- Dalgard F., Gieler U., Holm J.Ø., Bjertness E., Hauser S. Self-esteem and body satisfaction among late adolescents with acne: results from a population survey. J Am Acad Dermatol. 2008;59:746–751. doi: 10.1016/j.jaad.2008.07.013. [DOI] [PubMed] [Google Scholar]
- Do J.E., Cho S.M., In S.I., Lim K.Y., Lee S., Lee E.S. Psychosocial aspects of acne vulgaris: A community-based study with Korean adolescents. Ann Dermatol. 2009;21:125–129. doi: 10.5021/ad.2009.21.2.125. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Finlay A.Y., Khan G.K. Dermatology Life Quality Index (DLQI)--a simple practical measure for routine clinical use. Clin Exp Dermatol. 1994;19:210–216. doi: 10.1111/j.1365-2230.1994.tb01167.x. [DOI] [PubMed] [Google Scholar]
- Fried R.G., Wechsler A. Psychological problems in the acne patient. Dermatol Ther. 2006;19:237–240. doi: 10.1111/j.1529-8019.2006.00079.x. [DOI] [PubMed] [Google Scholar]
- Halvorsen J.A., Stern R.S., Dalgard F., Thoresen M., Bjertness E., Lien L. Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: A population-based study. J Invest Dermatol. 2011;131:363–370. doi: 10.1038/jid.2010.264. [DOI] [PubMed] [Google Scholar]
- Hassan J., Grogan S., Clark-Carter D., Richards H., Yates V.M. The individual health burden of acne: Appearance-related distress in male and female adolescents and adults with back, chest and facial acne. J Health Psychol. 2009;14:1105–1118. doi: 10.1177/1359105309342470. [DOI] [PubMed] [Google Scholar]
- Hosthota A., Bondade S., Basavaraja V. Impact of acne vulgaris on quality of life and self-esteem. Cutis. 2016;98:121–124. [PubMed] [Google Scholar]
- Kellett S.C., Gawkrodger D.J. The psychological and emotional impact of acne and the effect of treatment with isotretinoin. Br J Dermatol. 1999;140:273–282. doi: 10.1046/j.1365-2133.1999.02662.x. [DOI] [PubMed] [Google Scholar]
- Kroenke K., Spitzer R.L., Williams J.B. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–613. doi: 10.1046/j.1525-1497.2001.016009606.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lasek R.J., Chren M.M. Acne vulgaris and the quality of life of adult dermatology patients. Arch Dermatol. 1998;134:454–458. doi: 10.1001/archderm.134.4.454. [DOI] [PubMed] [Google Scholar]
- Levy L.L., Emer J.J. Emotional benefit of cosmetic camouflage in the treatment of facial skin conditions: Personal experience and review. Clin Cosmet Investig Dermatol. 2012;5:173–182. doi: 10.2147/CCID.S33860. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Little A.C., Roberts C.S. Evolution, appearance, and occupational success. Evol Psychol. 2012;10:782–801. [PubMed] [Google Scholar]
- Loney T., Standage M., Lewis S. Not just 'skin deep': Psychosocial effects of dermatological-related social anxiety in a sample of acne patients. J Health Psychol. 2008;13:47–54. doi: 10.1177/1359105307084311. [DOI] [PubMed] [Google Scholar]
- Magin P., Adams J., Heading G., Pond D., Smith W. Psychological sequelae of acne vulgaris: Results of a qualitative study. Can Fam Physician. 2006;52:978–979. [PMC free article] [PubMed] [Google Scholar]
- Magin P., Adams J., Heading G., Pond D., Smith W. Experiences of appearance-related teasing and bullying in skin diseases and their psychological sequelae: Results of a qualitative study. Scand J Caring Sci. 2008;22:430–436. doi: 10.1111/j.1471-6712.2007.00547.x. [DOI] [PubMed] [Google Scholar]
- Merriam-Webster Self-esteem [Internet] 2017. https://www.merriam-webster.com/dictionary/self-esteem [cited 2017 July 19]. Available from:
- Mundluru S.N., Safer J.D., Larson A.R. Unforeseen ethical challenges for isotretinoin treatment in transgender patients. Int J Womens Dermatol. 2016;2:46–48. doi: 10.1016/j.ijwd.2016.03.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Picardi A., Mazzotti E., Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol. 2006;54:420–426. doi: 10.1016/j.jaad.2005.11.1103. [DOI] [PubMed] [Google Scholar]
- Purvis D., Robinson E., Merry S., Watson P. Acne, anxiety, depression and suicide in teenagers: A cross-sectional survey of New Zealand secondary school students. J Paediatr Child Health. 2006;42:793–796. doi: 10.1111/j.1440-1754.2006.00979.x. [DOI] [PubMed] [Google Scholar]
- Rieder E.A., Mu E.W., Brauer J.A. Men and cosmetics: Social and psychological trends of an emerging demographic. J Drugs Dermatol. 2015;14:1023–1026. [PubMed] [Google Scholar]
- Rosenberg M. Princeton University Press; Princeton, NJ: 1965. Society and the adolescent self-image. [Google Scholar]
- Rubinow D.R., Peck G.L., Squillace K.M., Gantt G.G. Reduced anxiety and depression in cystic acne patients after successful treatment with oral isotretinoin. J Am Acad Dermatol. 1987;17:25–32. doi: 10.1016/s0190-9622(87)70166-2. [DOI] [PubMed] [Google Scholar]
- Su P., Chen Wee Aw D., Lee S.H., Han Sim Toh M.P. Beliefs, perceptions and psychosocial impact of acne amongst Singaporean students in tertiary institutions. J Dtsch Dermatol Ges. 2015;13:227–233. doi: 10.1111/ddg.12578. [DOI] [PubMed] [Google Scholar]
- Tasoula E., Gregoriou S., Chalikias J., Lazarou D., Danopoulou I., Katsambas A. The impact of acne vulgaris on quality of life and psychic health in young adolescents in Greece. Results of a population survey. An Bras Dermatol. 2012;87:862–869. doi: 10.1590/S0365-05962012000600007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Turrion-Merino L., Urech-Garcia-de-la-Vega M., Miguel-Gomez L., Harto-Castano A., Jaen-Olasolo P. Severe acne in female-to-male transgender patients. JAMA Dermatol. 2015;151:1260–1261. doi: 10.1001/jamadermatol.2015.0761. [DOI] [PubMed] [Google Scholar]
- Uslu G., Sendur N., Uslu M., Savk E., Karaman G., Eskin M. Acne: Prevalence, perceptions and effects on psychological health among adolescents in Aydin, Turkey. J Eur Acad Dermatol Venereol. 2008;22:462–469. doi: 10.1111/j.1468-3083.2007.02497.x. [DOI] [PubMed] [Google Scholar]
- Vilar G.N., Santos L.A., Sobral Filho J.F. Quality of life, self-esteem and psychosocial factors in adolescents with acne vulgaris. An Bras Dermatol. 2015;90:622–629. doi: 10.1590/abd1806-4841.201533726. [DOI] [PMC free article] [PubMed] [Google Scholar]
- White G.M. Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris. J Am Acad Dermatol. 1998;39:S34–7. doi: 10.1016/s0190-9622(98)70442-6. [DOI] [PubMed] [Google Scholar]
- Yang Y.C., Tu H.P., Hong C.H., Chang W.E., Fu H.C., Ho J.C. Female gender and acne disease are jointly and independently associated with the risk of major depression and suicide: A national population-based study. Biomed Res Int. 2014;2014:504279. doi: 10.1155/2014/504279. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Yentzer B.A., Hick J., Reese E.L., Uhas A., Feldman S.R., Balkrishnan R. Acne vulgaris in the United States: A descriptive epidemiology. Cutis. 2010;86:94–99. [PubMed] [Google Scholar]
- Zaenglein A.L., Thiboutot D.M. Acne vulgaris. In: Bolognia J.L.J., Joseph L., Schaffer J.V., editors. Dermatology. Elsevier; Amsterdam: 2012. pp. 545–559. [Google Scholar]
- Zaenglein A.L., Pathy A.L., Schlosser B.J., Alikhan A., Baldwin H.E., Berson D.S. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74:945–973. doi: 10.1016/j.jaad.2015.12.037. e33. [DOI] [PubMed] [Google Scholar]
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Supplementary Materials
Rosenberg Self-Esteem Scale.