Study shows “psychosocial stress can be a triggering factor for the worsening of acne”

Findings of a study* published in peer-reviewed journal Cosmetics​ ​in late October 2023 revealed the potential link between the worsening of skin condition acne vulgaris and high levels of anxiety and depressive symptoms, along with an elevated sense of stress and low-to-moderate levels of adaptability and resilience.

The observational, multicentre study aimed to measure the psychological impact of the COVID-19 pandemic lockdown on acne patients’ quality of life, stress levels, and anxiety and/or depression symptoms.

To examine this, the research team collected specific psychiatric data and examined the correlation between those specific scales and the development of the skin condition.

Research was carried out in five dermatology clinics in Italy and the data was obtained via remote telephone interview with 178 acne vulgaris patients (average age: 20 years; 63 males and 115 females), using questionnaires that were approved by a group of dermatologists and psychiatrists.

Evaluations included demographic information, treatment status, disease progression, dietary habits, and employment activities.

The researchers said that sufferers had developed a ‘maladaptive framework’ for coping with an unexpected social situation due to the effects of confinement, isolation, lifestyle and work activity changes and concerns about the future.

It found that chronic stress caused by the huge changes to everyday life worsened the condition.

Stress linked to worsening of condition​

The researchers said the relationships between psychological health and acne help to demonstrate how dermopathy is frequently linked to emotional issues or serious psychiatric disorders, which are often related to how the person perceives their body rather than to the actual severity of the disease.

Acne sufferers can experience psychological illnesses that include altered body image, diminished self-esteem and confidence, humiliation, social isolation, sadness, rage, frustration, shame, avoidance, and problems forming social connections.

Evaluations also included demographic information, treatment status, disease progression, dietary habits, and employment activities.

The study used the Hospital Anxiety and Depression Scale (HADS) to measure anxiety and depression; the Perceived Stress Scale (PSS) to measure perceived stress levels; and the Brief Resilience Scale (BRS) to measure resilience and adaptation. And the researchers also assessed the quality of life for patients with skin diseases using the Dermatology Life Quality Index (DLQI).

An equally significant association was found between worsening of the disease and feeling stressed about lower financial income, worries about future career, impaired family relationships during lockdown, and lack of sexual activity.

Increased alcohol and unhealthy food consumption was different among those who reported worsening of the disease compared to those who did.

In the multivariable study, there was a significant correlation between anxiety, depression and PSS and the severity of acne vulgaris.

Acne severity and stress levels were linked, especially when there are problems with family relationships and a lack of social and interpersonal connections.

The multivariable analysis also revealed that there was a 4.53-fold increased risk of developing pathological eating behaviours among patients whose condition worsened, with deterioration of family relationships and stress from missing social relationships, and who were found to have high levels of PSS, with changes in eating habits, dysregulation of daily main meals, increased consumption of food between meals, increased calorie intake and increased consumption of junk food.

Stopping treatment was not linked to significantly worse acne​

The study also noted that Dermatologists have had restricted in-person interactions during since the pandemic and operated by telemedicine and teledermatology due to the containment measures and pressure on healthcare systems.

Interestingly, there was no evidence that stopping treatment was significantly linked to a worsening of acne.

Among the study population, 29.2% reported worsening of the disease that was not related to either discontinuation of the medication or discontinuation of therapy.

Patients who continued treatment also experienced a worsening of the disease. The study found a correlation between changes in HADS, BRS, and PSS and worsening acne, which it said confirmed the well-known relationship between psychological distress and skin immune response.

Instead, acne worsening was strongly correlated with high levels of anxiety and depressive symptoms, with increased perception of stress and low-to-moderate adaptive and resilience skills.

The study noted that numerous mechanisms have been put forward as to how stress might exacerbate acne vulgaris. Some researchers think that times of emotional stress cause higher levels of glucocorticoids and adrenal androgens to be released, two hormones known to exacerbate acne and perhaps cause sebaceous hyperplasia. Additionally, it has been discovered that corticotropin-releasing hormone, the body’s stress response coordinator, promotes sebaceous lipogenesis and sebocyte conversion of androgen precursors to testosterone.

Several studies have demonstrated that stress-related releases of neuroactive chemicals from the epidermis might trigger inflammatory skin conditions. Recently, it was shown that substance P, a neuropeptide released by stressed peripheral neurons, stimulates the growth of sebaceous glands and increases lipid synthesis in sebaceous cells.

Researchers also noted that psychological stress can cause wound healing to be up to 40% slower, which could be a factor in slowing the repair of acne lesions.

Link to stress from poor social relationships​

Despite reports that work-related worries are another source of stress in our society, no link was discovered between work activities during the isolation time and increasing acne.

In fact, the multivariate analysis revealed that patients who were experiencing stress did so from a lack of social connections and worsening family relationships.

Stressful conditions are already known to cause an increase in hormones such as CRH, ACTH, MSH, cortisol, and catecholamines, which put the body in a state of alert. These hormones can promote adrenal DHEAS and cortisol production at the peripheral level, with hair follicles directly contributing to elevated cortisol production.

Although there is a lack of research on the direct effects of high serum cortisol on acne, both acute and long-term psychological stress have previously been linked to acne worsening.

While researchers said that there were some limitations to this study due to the small sample size and the use of self-reports of worsening acne, it has shown that this type of stress is not caused by the illness itself, but rather by adversity. In short, the researchers said that psychosocial stress can be a triggering factor for worse acne.

*MDPI ​
Grimaldi, M.; Micali, G.; Bettoli, V.; Odorici, G.; Potenza, C.; Musumeci, M.L.; Cacciapuoti, S.; Giovanardi, G.; Agrifoglio, B.; Guerriero, C. The Impact of COVID-19 Pandemic on Acne Patients and Their Management: An Observational Multicentre Study from Italy. Cosmetics 2023, 10, 146. https://doi.org/10.3390/cosmetics10060146​