The Role of Psychological Stress in Acne: Insights for Improved Outcomes

While previously only examined as a causal relationship, new research suggests that acne and stress have a bidirectional association.¹

“Even though emotional stress has long been put into the relationship with acne, its influence has been mostly underestimated. But in working with acne patients on a daily basis, we have seen that stress is a very important trigger and exacerbating factor in acne,” lead investigator Anamaria Balić, MD, from the dermatology and venereology department at the University of Zagreb School of Medicine in Croatia, told Dermatology Advisor.

“Almost every other patient states how his/her acne is worse lately due to a lot of stress at work, exam periods, not sleeping enough. Through our research, we have tried to fortify this bidirectional relationship between stress and acne and identify the underlying mechanisms that link emotional stress to acne according to the latest scientific findings.” 

While researchers have not pinpointed the exact mechanism of how stress affects the skin, one theory posits that it acts as a signal exchange with the endocrine, nervous, and immune systems. Stress activates the hypothalamus-pituitary-adrenal (HPA) axis, which in turn signals the cytokines, hormones, and neurotransmitters that have skin receptors.¹ Some of the targets implicated in acne include substance P, which is found in sebaceous glands.¹ Another target is the corticotropin-releasing hormone (CRH), a major component of the stress system that is found in human skin.¹

The Evidence Implicates Stress

Chlebus and Chlebus reported in a cohort study of 111 patients with adult acne that 56% implicated stress as an exacerbating factor and cited lifestyle changes (hostile work or school environment, moving, and traveling) among the most stressful events (P =.046).² Beyond stress, other factors that contributed to the severity of acne included having sensitive skin, discontinuing oral contraceptives, and using cosmetic foundation.² Most troubling was that 82% of patients reported 3 or more stressors that aggravated their acne (P <.0001).²

“It turned out that stress is a strong factor [in] triggering adult acne and stress associated with a change of lifestyle and place of residence is the most serious issue,” noted co-investigator Marcin Chlebus, PhD, from the University of Warsaw in Poland.

Even when hormonal factors may trigger acne in adulthood, stress is still implicated in its severity and exacerbations. Such was the case according to a study by Di Landro and colleagues that examined associations between acne and health and lifestyle choices in 518 women age ≥25.³ Women who had acne that had persisted since adolescence tended to have the following characteristics: first-degree relatives with acne; no previous pregnancies; little intake of fruit, vegetables, or fresh fish; psychological stress; and current office work. The team also reported that the higher the stress levels, the greater the likelihood of acne.³

“In principle, potential triggers or risk factors for acne should not be trivialized. Studies like ours could offer evidence to promote secondary prevention of acne, like modulating acne severity by nonpharmacological interventions such as stress reduction techniques,” said Professor Luigi Naldi, director of Centro Studi GISED and the department of dermatology at Ospedale San Bortolo in Vicenza, Italy.

Mitigating Factors to Curtail Stress in Acne

Because many chronic skin disorders can trigger psychological distress, it may be difficult to break the stress-acne cycle. Still, there are some strategies that may lessen the physical and emotional manifestations of acne.

Pärna and colleagues discovered that of 176 patients (mean age, 38.9) with chronic skin disease (acne, eczema, psoriasis, and seborrheic dermatitis) the patients with acne were the most likely to have anxiety and depression.⁴ Compared with other patients with chronic skin disease, patients with acne had the highest levels of depression (P =.098), general anxiety (P =.005), and social anxiety (P =.12) as measured by the Emotional State Questionnaire (EST-Q).⁴ These findings offer an explanation of why young people with severe acne have more difficulty than their healthy peers forming close relationships and endure more social ridicule.⁴

When compared with patients in the control group, patients with acne had significantly more general anxiety (P =.006).⁴ While patients with acne had the most severe depression and anxiety of patients with other chronic skin diseases, they did not have the physical limitations that other patients reported such as insomnia and fatigue.

Raising awareness of the skin-psychological connection will hopefully go a long way toward helping patients and improving overall outcomes. “In the university clinic we do pay more attention to the connection between skin diseases and psychology,” Ene Pärna, MD, MS, from Tartu University in Tartu, Estonia, told Dermatology Advisor.

“Knowing that there is a bidirectional intimate relationship between the skin and the mind, hopefully clinicians will approach their patients in a more holistic and interdisciplinary way[s] that involve[s] not only dermatologists but also psychologists and psychiatrists,” added Dr Balić. “Clinicians should encourage patients to try to minimize stress as much as possible, to rest more, participate in sports, meditate, and stay positive.”

References

1. Jović A, Marinović B, Kostović K, Čeović R, Basta-Juzbašić A, Bukvić Mokos Z. The impact of psychological stress on acne. Acta Dermatovenerol Croat. 2017;25(2):1133-1141.
2. Chlebus E, Chlebus M. Factors affecting the course and severity of adult acne. Observational cohort study. J Dermatolog Treat. 2017;28(8):737-744.
3. Di Landro A, Cazzaniga S, Cusano F, et al. Adult female acne and associated risk factors: results of a multicenter case-control study in Italy. J Am Acad Dermatol. 2016;75(6):1134-1141.e1.
4. Pärna E, Aluoja A, Kingo K. Quality of life and emotional state in chronic skin disease. Acta Derm Venereol. 2015;95(3):312-316.