Clinics in Dermatology (2014) 32, 767–771

Psychologic consequences of facial dermatoses

Edith Orion, MD a,b,⁎, Ronni Wolf, MD c
a
The Dermatology Department, Sourasky Medical Center, Tel Aviv, Israel
b
The Psychodermatology Clinic, Sourasky Medical Center, Tel Aviv, Israel
c
The Dermatology Unit, Kaplan Medical Center, Rehovot, Israel

Abstract The attractiveness of the human body has always been an important issue in the fields of
sociology, psychology, and psychiatry and also in the field of dermatology. In psychodermatology, one
often discovers how all these fields intermingle to produce elaborate situations and extreme human
difficulties. Perfect skin is widely adored in literature, poetry, and biblical texts, as well as in
advertisements, movies, and television. Because in most societies the face is the body part that is visible,
imperfections of the skin are also visible; therefore, its flawed appearance bears the potential to become
a source of misery to some.
© 2014 Elsevier Inc. All rights reserved.

Introduction The emotional impact of facial

Healthy, normal-looking skin is essential for an indivi-
dual's physical and mental well-being. Facial skin diseases
can affect the patient's life in various aspects; it can affect his
or her social status, romantic relationships, and emotional
health and self-esteem. It is the patient's “visible self." Facial
skin diseases have the potential to affect an individual's
quality of life to a great extent.
Psychodermatology is concerned with skin conditions that
are influenced by psychologic difficulties, as well as with
psychologic difficulties arising as a result of skin conditions. In
this paper, we discuss the effects of the soma on the psych—
the somatopsychic aspect of facial skin diseases.
We focus on the psychologic effects of skin conditions
that are typically facial (not dermatoses that affect other
body areas but can appear also on the face). Although we
shall discuss those facial dermatoses whose psychologic
impact is the most investigated, there are reasons to assume
that the emotional burden exists with most facial dermatoses.
⁎ Corresponding author. Fax: + 972 3 6436086.
E-mail address: eorion@013.net (E. Orion).
dermatoses: Stigmatization
In ancient times, skin diseases were often seen as an
expression of the wrath of a god visited on those who had
sinned. Skin disease sufferers were sometimes even
condemned to live separately and their approach announced
by a bell or a horn due to the belief that their disease was
contagious.1 Although occasionally patients are able to take
in stride disease that is disfiguring and visible, for many the
experience of being “different" is frightening, leading to
feelings of embarrassment and shame.1
The attractiveness of the human body has always been an
important issue in the fields of sociology, psychology, and
psychiatry and also in the field of dermatology. In
psychodermatology, one often discovers how all these fields
intermingle to produce elaborate situations and human
difficulties. One important problem deals with the feeling
of stigmatization resulting from a visible skin condition.
Stigma was defined by the sociologist Ervin Goffman as a
process by which the reaction of others spoils normal
identity. It is thus easily understood why many skin patients
feel stigmatized.2,3 In this context, skin conditions that alter
skin color, complexion, texture, or appearance can provoke

http://dx.doi.org/10.1016/j.clindermatol.2014.02.016
0738-081X/© 2014 Elsevier Inc. All rights reserved.
768
negative reactions and emotions in others. This can lead to
disapproval, rejection, exclusion, and discrimination.4
Most information we have about the nature and extent of the
situation concerns perceived stigmatization among psoriasis or
vitiligo patients2,3,5; less focused information exists about
stigmatization among patients with facial dermatoses.6 The
reason is probably less research rather than a lesser degree of
perceived stigmatization. It is expected that imperfections on
the face would cause more psychologic problems than
imperfections in other body areas, because it is more exposed
to others, and it is harder to hide or camouflage successfully.
Acne
Acne, a common skin disease, is prevalent mainly during
adolescence but also may be present in adulthood. The
disease's major complications include physical scarring and
psychologic effects that may persist long after the dermatitis
has disappeared.7,8
Acne's impact on psychosocial and emotional
problems is so significant that it is comparable to the
effects of those imposed by arthritis, back pain, diabetes,
epilepsy, and asthma.9
Panconesi finds acne a facial dermatosis with a high
incidence of psychoemotional factors.10 He also makes an
important distinction between adolescent acne, which causes
psychologic problems secondary to the skin disease
(somatopsychic), and adult acne, which can mainly be
evoked or exacerbated by psychologic problems or even by a
psychiatric disease (psychosomatic).10
From a psychoanalytical point of view, not able to
compete with the perfection of the idealized personalities or
peers, even minimal acne lesions may serve to confirm for
adolescents their worst fears of being ugly, dirty, and
flawed.1 The negative feelings lead to low self-esteem, and
self-conscious feelings that everyone is staring with
criticism.11 Due to the age-appropriate adolescent physical
changes and the early arousal of sexual feelings, guilt about
sexuality is often relevant and present, and the outbreak of
acne dermatitis may be experienced as a loss of control and
as a punishment. The stress of integrating into the body
image age-appropriate physical changes as well as acne may
lead to the fragility of that image, with the possible
development of body dysmorphic disorder.1
Data show that late adolescents feel stigmatized by their
visible facial skin condition.12 In adolescence, the individual
usually becomes more autonomous, relationships with
family members change, and peer or romantic relationships
become more important.13 The appearance of the skin is
important for successful social interactions and for high self-
image in this age group.14
It seems that adolescents are more influenced by the
psychosocial effects of acne than older patients.15 Although
acne can pose psychologic problems at any age, the condition
E. Orion, R. Wolf
itself is much more prevalent in adolescence (therefore most
acne sufferers come from this age group) and, more
importantly, adolescents are psychologically vulnerable and
tend to be more sensitive to modifications in their appear-
ance.16 This volatile combination can have a long-lasting
impact on their lives: It can affect self-esteem and assertive-
ness, factors that are crucial in forming relationships as well as
to the development of personality traits.15 Interviews with
patients revealed explicit links between appearance and
subjects' self-image, self-concept, and self-esteem, which
gave rise to much of the psychologic morbidity in those
patients.17 Embarrassment and self-consciousness were found
to be directly linked to self-image and self-esteem. Important
exacerbating factors in the relationship among acne, embar-
rassment, and self-consciousness were taunting or teasing and
a perception of being judged by others.17
Anxiety and depression are the two most prevalent
psychiatric morbidities linked to acne. In a small series of 34
patients with severe acne, significant levels of anxiety were
found in 44% of patients and depression in 18%.18
In a study of 72 adolescents and young adults with mild to
moderate noncystic acne, active suicidal ideation was elicited
in 5.6%.19 In a cross-sectional survey among 9567 teenagers
aged 12 to 18 years, “problem acne" was associated with
increased probability of depressive symptoms (24%), anxiety
(9%), suicide thoughts (34%), and suicide attempts (13%).20
The association of “problem acne" with suicide attempts was
found to be independent of anxiety and depressive symptoms.
In a recent large population-based study of 3775 adoles-
cents aged 18 to 19, the relationship of acne severity to suicidal
ideation, mental health problems, and social functioning was
explored. Among those with severe acne, suicidal ideation was
twice as frequently reported among girls and three times more
frequently reported among boys in comparison to the mild/no
acne patients.13 Suicidal ideation remained significantly
associated with substantial acne even after adjustments of
symptoms of depression, ethnicity, and family income were
done. The study also found a significant association of
substantial acne and mental health problems, low attachment to
friends, lack of thriving at school, lack of romantic
relationships, and sexual intercourse.13 These results are in
accordance to previous works showing impaired self-image
and self-esteem,21 impaired psychologic well-being,12 and
inhibition of social interactions.22 So the immediate impact of
acne on multiple aspects of patients' lives is immense;
moreover, it may have a huge influence on their well-being
in later life.
Regardless of the degree of severity, patients with acne are
at increased risk to develop anxiety and depression and even
suicidal ideation in comparison with the acne-free population.
Acne negatively affects quality of life, and the greater the
impairment secondary to the disease, the greater the level of
anxiety and depression.15 Unlike this correlation, other studies
show that in adult women acne can cause impairment in quality
of life regardless of its severity. Also, age and disease duration
do not necessarily correlate with quality of life as well.23
Psychologic consequences of facial dermatoses
The link between depression, suicide ideation, and the use
of isotretinoin is controversial. In a critical review of the
literature, it was concluded that although some drugs could
induce depressive symptoms, drug-induced depression seems
to differ symptomatically from classical major depression.
Interestingly, evidence was not presented linking isotretinoin
to depression.24 Several reviews have examined possible
linkage between isotretinoin and depression and suicide. Most
reviews found that at present there is no conclusive evidence to
either support such an association or reject it.25 In epidemi-
ologic studies, the results have been conflicting. No
association was found between isotretinoin treatment and
depression, psychotic symptoms, suicide, or suicide attempts
in a cohort of more than 7000 isotretinoin users26; however, in
a recent retrospective cohort study of 5756 patients aged 15 to
49 years prescribed isotretinoin for severe acne, observed
before, during, and after treatment, found an increased risk of
attempted suicide up to 6 months after the end of treatment. In
this study, however, the risk of attempted suicide was already
rising before treatment, so an additional risk as a result of
isotretinoin treatment cannot be established.27 Also, many case
reports and case series have reported serious adverse
psychiatric events associated with isotretinoin.27 To make
matters more confusing, depression, anxiety, and overall
psychiatric morbidity have been found to improve when acne
is treated, especially with isotretinoin.17
Rosacea
Rosacea is a common chronic inflammatory facial
dermatosis that is characterized by facial blushing, erythema,
telangiectasia, burning sensation, and a papulopustular acnei-
form eruption. It occurs most often in middle-aged people, 30
to 50 years old, with fair skin.28 Rosacea may be overlooked in
nonwhites due to a low index of suspicion or because skin
pigmentation results in an atypical presentation.29 Women are
affected two to three times more often than men 30 ;
nevertheless, the most obvious stigma of rosacea, rhinophyma,
occurs more often in men.31
Patients with rosacea suffer from a variety of emotional
and social stigmas. They may inaccurately be stigmatized as
alcohol abusers due to their red face or phymatous nose.28
Patients often have feelings of low self-esteem when facial
dermatitis progresses. 28 They may report feelings of
embarrassment, frustration, shame, or anxiety about their
facial flushing and erythema in social situations. This anxiety
may resemble panic disorder or may even worsen, causing
some patients to become reclusive because of social
phobia.32 Impaired contacts are a common finding.33
Psychologic studies among rosacea patients have revealed
a weak ego, autoaggression, tendency to self-accusation,
excessive feelings of responsibility for oneself and others,
low tolerance for frustration, and discrepancy between what
the person is and what he or she wishes to be. The measured
769
forms of anxiety—both situational fear and anxiety as a
personal trait—had the highest values in rosacea patients.34
Patients with rosacea are also prone to develop depression,
as was proven in a large survey of 608 million dermatology
visits.35 In this study, 1.04% of patients had a comorbid
psychiatric diagnosis; about 70% of them were depressive
disease. Depression was attributed to the cosmetic impact of
the disease.36 Of importance is the observation that use of
cosmetic products to conceal skin lesions can help improve
self-image and quality of life.37 A survey using a rosacea-
specific quality of life index revealed that flushing and skin
appearances are some of the most critical factors for patients.38
Both physicians and relatives of patients with rosacea
tend to underestimate the effect of the disease on patients'
quality of life. Apparently, it should be recognized and
addressed also in the dermatologist office.
Seborrheic dermatitis
Seborrheic dermatitis affects mainly the central aspect of
the face but can also involve the scalp and anterior aspect of
the chest. It can affect patients from infancy to old age but is
most common in infants within the first 3 months of life and
in adults 30 to 60 years of age.39 In adolescents and adults, it
manifests as dandruff and as erythema and greasy scaling of
the nasolabial folds. It can also affect the postauricular skin
and central portions of the face (auricles, bearded area,
eyebrows, and eyes), as well as other body areas.39
There are only limited data concerning the psychologic
consequences of seborrheic dermatitis, which is surprising
considering the high prevalence of this condition and its
visibility and potential disfiguring properties. Obviously, the
disfiguration problems must be emphasized, because socio-
phobic tendencies, communication impairments, and avoid-
ance and social withdrawal may result.34
Patients with mood depression have a high prevalence of
seborrheic dermatitis,40 as was shown in a group of patients
with psychiatric disorders. The reverse—an increased
predisposition to depression in seborrheic dermatitis pa-
tients—was also found.41 These investigators also found a
decrease in dermatology life quality index (DLQI) scores
among seborrheic dermatitis patients, as well as an increased
level of stress that patients encountered in their lives, perhaps
because of their disease-related stigmas. Another group of
researchers found that the impact of seborrheic dermatitis on
quality of life is significantly greater among women and
among the 16 to 25 years and 41 to 60 years age groups.42
Port-wine stains
Port-wine stain (PWS) is a benign, congenital disfiguring
vascular malformation that persists throughout life. It is a
770
common dermatosis, occurring in an estimated 3 to 5 in 1000
births. Approximately 80% of stains are found on the face or
neck.43,44 The lesions tend to darken with age and become
thicker, with possible nodule formation, causing substantial
disfigurement and potential psychological problems.44 In
medieval times, birthmarks such as PWS were taken as
evidence of the bearer's service to the devil,45 and nowadays
prejudice may also exist.
Some authors share their experience with PWS patients,
mentioning that, unexpectedly, most of their patients seem
well adjusted and psychologically normal.45 Several inves-
tigations concerning psychologic effects of laser therapy in
patients with PWS have revealed that these patients were no
different than normal controls, although they were found to
be perfectionistic and had unrealistic expectations of the
outcome of therapy. These patients felt they were at
considerable personal, professional, and social disadvantage
because of their nevus.46–48 Later investigations, using
different research questionnaires, indicated that PWS
patients suffer a significant degree of psychologic morbid-
ity.45 More than 50% of patients felt embarrassed and
depressed due to their birthmark. Forty-one percent felt that
people avoided looking at them. The authors suggest that
PWS patients suffer psychologic distress that is not apparent
in their social interactions or when applying indirect
psychologic testing. They found that these difficulties do
not improve with advancing age and thus may cause further
problems for patients adapting to their social environment.45
In another study, 47% of PWS patients rated their self-
esteem as lower compared with other people of the same age
group. After treatment, only 8% had this thought.49 An
interesting and unexpected observation in this study was that
nonfacial PWS disturbed the patients as much as facial ones,
but in other ways.
Conclusions
One’s body image is of fundamental importance in the
development of personality and interpersonal relationships.
The information given in this paper highlights the need to
screen for depression, anxiety, and suicidal ideation among
patients (especially teenagers) who come to be treated for
acne. Dermatologists who see young people with moderate
to severe acne have an important role because a significant
portion of them may have psychiatric difficulties and even a
record of a suicide attempt related to their skin disease.
Other facial dermatoses may be related to psychologic
difficulties as well. Although there is less research among
those patients, one would conclude that stigmatization and
flawed appearance may result in lower quality of life and the
consequent development of depression, anxiety, social
phobia, shame, and embarrassment, among other difficulties.
It is of utmost importance that the dermatologist acknowl-
edge those psychologic “side effects" of facial dermatoses,
E. Orion, R. Wolf
which patients rarely report, for the sake of prescribing the
right treatment (eg, isotretinoin) but also for offering
appropriate psychologic/psychiatric support.
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