Psychosocial judgements and perceptions of adolescents with acne vulgaris: A blinded, controlled comparison of adult and peer evaluations

Background The purpose of the current survey was to evaluate how teenagers and adults view teens with acne as compared to those with smooth, clear skin. We also surveyed teens and adults about their experiences with acne. Methods We hypothesized that teens with acne would be perceived in a more negative fashion as compared to teens with smooth, clear skin. We presented digitally altered photographs to our responders and asked how they perceived the two groups. No mention was made of acne. In the first survey (n = 1,002), both adults and teens provided their impressions on photo images of teenagers with either clear skin or acne. In the second survey (n = 1,006), the adults and teens also answered questions about their own experiences with acne. Results Survey 1. With respect to impressions of photo images, the first thing teens and adults noticed about a person with acne was their skin (65% and 75%, respectively). Teenagers with acne were perceived most often by other teens and adults (teen responder %, adult responder %) as being shy (39%, 43%), nerdy (31%, 21%), stressed (24%, 20%), lonely (23%, 22%), boring (15%, 6%), unkempt (13%, 7%), unhealthy (12%, 8%), introverted (9%, 23%), and rebellious (7%, 5%). Survey 2. Most teenagers with acne (64%) felt embarrassed by it and thought that getting acne was the most difficult aspect of puberty (55%). Teenagers with acne reported lower self-confidence or shyness (71%); difficulty finding dates (43%), problems making friends (24%), challenges with school (21%), and trouble getting a job (7%). Conclusions Teens with smooth, clear skin were rated higher on every favorable characteristic and lower on every unfavorable characteristic by both teens and adults. In most cases, the first thing that respondents noticed was the skin of teens with acne. Teenagers and adults alike perceived other teens with acne as generally being shy, less socially active, more likely to be bullied, and less successful in terms of finding a job. Overall, these results show that acne has a negative effect on the way people are perceived by others.


Background
We all know that how you look affects how you feel. In their recent book, The Beauty Prescription, Luftman and Ritvo describe a beauty-brain loop in which inner beauty/outer beauty health and environment interact with one another. This survey took a unique look at how outer beauty impacts the way others view you [1].
Our ancestors recognized that being attractive was important for survival [1]. Beautiful skin, nails, hair and teeth were indicators of youth, good health and even reproductive capability. Attractiveness equated to good health and perpetuation of the species. This is one reason why men still find women in their late teens and early twenties so alluring. At this age, young women are most loudly broadcasting signals of their vitality and fertility through their faces and bodies. Conversely, any change from the ideal appearance (ie unhealthy skin, asymmetric facial or body features, being underweight or overweight) is perceived negatively.
Etcoff, in Survival of the Prettiest, stated, "Our extreme sensitivity to beauty is hard-wired, that is, governed by circuits in the brain shaped by natural selection [2]. We love to look at smooth skin, thick shiny hair, curved waists, and symmetrical bodies because in the course of evolution the people who noticed these signals and desired their possessors had more reproductive success." The skin can be thought of as the most aesthetic organ of the body. One of the first things we notice about another person is their skin. On the average adult, skin weighs 8-10 lbs and covers about 22 square ft of surface area on the body [3]. Clear, healthy skin that is free of diseases such as acne is an important factor that contributes to our positive perceptions toward others.
Acne vulgaris (acne) is a common skin disease involving the pilosebaceous unit, including the follicular canal, hair follicle and sebaceous glands [4]. Microcomedones, caused by hyperproliferation and hyperkeratinization in the follicular canal, constitute the initial lesions in this disease [5]. The bacterial species Propionibacterium acnes colonizes the follicular channel. This stimulates cytokine production, which eventually leads to the formation of inflammatory lesions. Upon rupture of the follicular walls, granulomatous lesions and scarring often occurs [5]. The onset of acne is typically at adrenarche, which is one to two years before visible evidence of puberty (~age 10), however, acne vulgaris may start later, including in post-teenage years, especially in females [4,6].
The Global Alliance to Improve Outcomes in Acne Group recently published their update on the management of acne [6]. The group described acne as a chronic disease due to its prolonged course, pattern of recurrence, acute outbreaks, and slow onset. Due to the negative psychological and social effects of the disease, early and aggressive treatments were considered by the panel to be warranted.
The physical and emotional scars of acne can extend from adolescence and beyond. Many adolescents experience considerable psychological distress as a result of their acne [10]. Severe acne can cause extensive physical scarring, and can last well into the fourth and fifth decades [11]. This scarring can cause despair and other negative psychosocial effects. It is apparent that acne is a disease that causes many challenges to the psychological resources of a patient and these effects can last up to several decades.
Evidence abounds that teen acne leads to distress, higher rates of depression and in extreme cases treatment with isotretinoin has been associated with suicidal ideation and actions [12][13][14][15]. Antidepressants are used to combat the psychological symptoms of skin diseases such as acne [16]. Uhlenhake et al. reported that depression was two to three times more prevalent in acne patients than in the general population, with 8.8% of acne patients experiencing clinical depression [15]. Most cases of depression and antidepressant therapy utilization were observed in acne patients aged 18 and over.
Previously, it has been reported that people with acne suffer from a lack of confidence and self-esteem [17,18]. This survey attempted to assess whether acne changes how others perceive you.

Methods
The Ritvo/AARS Perception Survey was conducted by Kelton Research between April 10th and April 24th, 2009 using an email invitation. Two separate national online surveys, one with a sample of 1,002 nationally representative adults age ≥ 18 and one with a sample of n = 1,006 teenagers aged 13-17. Both groups of participants took the same survey. Quotas were set to ensure reliable and accurate representation of each audience.
Each respondent answered questions about several pictures of teens (males and females of Caucasian, African American, or Hispanic ethnicity) with or without acne (Figure 1 and 2). The total amount of visual stimuli used in the survey consisted of 12 picturesbased on a 2 × 3 × 2 exposure model (gender × race × acne/clear). Each respondent reacted to 3 randomly selected pictures, with the only condition being that it was a combination of either (a) 1 clear and 2 acne pictures or (b) 2 clear and 1 acne picture. This design allowed the respondents to focus in-depth on specific stimuli and kept the survey at a reasonable length. In an effort not to 'lead' the responses, acne was not specifically mentioned during the perception survey (Table 1). Respondents then answered questions about their own experiences with acne in the second survey ( Table 2).
Results of any sample are subject to sampling variation. The magnitude of the variation is measurable and is affected by the number of responses and the level of the percentages expressing the results. For this survey, the overall margin of error for each group (teenagers and adults) was ± 3.1 percentage points at the 95% confidence level.
Survey results regarding the respondents own experiences with acne ( Table 2) The majority of respondents in both age groups (92%) thought that the way they look is important. Fifty-five percent (55%) of teenagers 13-17 and 45% of        respondents aged ≥ 18 felt that getting acne was the most difficult aspect of puberty. Most teenagers with acne (64%) were embarrassed by it, while only 17% of parents found their teenager's acne a source of embarrassment. Teenagers with acne reported lower self-confidence or shyness (71%), difficulty finding dates (43%), problems making friends (24%), challenges with school (21%), and trouble getting a job (7%) (Figure 9). Most teenagers (68%) had not sought medical advice for their acne. Most of the teen respondents who had ever had acne indicated that they would stay off Facebook for a year (59%) or not go on a date for a year (30%) if they could get rid of their acne forever. Approximately 67% of teens ages 13-17 have tried 3 or more prescription acne treatments with 84% reporting that these treatments were effective. Most teens (66%) and adults (73%) were satisfied with the advice or treatment/medication they received from their doctors for their acne ( Figure 10).

Discussion
Survey results clearly show and confirmed the hypothesis that acne affected how people were perceived. Both    the adults and teenagers were more likely to first notice the skin of teens with acne. In contrast, when shown images of teens with clear skin, a variety of physical features were noticed first (ie shape of mouth, eye color, nose). Teenagers with clear skin were more commonly described as being happy, intelligent, self-confident, healthy, and fun. Interestingly, those with acne were most often perceived as being shy, stressed, unkempt, lonely, boring, nerdy, and introverted. Therefore, one might imply from these results that how you look affects how others view you. Greater acne severity has been shown to be associated with poorer social outcomes and quality of life [19]. Dermatological-related social anxiety appears to be negatively associated with intention to participate in sport/exercise, self-esteem and dermatological quality of life [18]. Among seven facial disfigurements, acne had the largest negative impact on finding a partner [20]. In the current survey people with acne were thought less likely to be currently dating someone. Murray and Rhodes found that 5 themes were revealed in interviews with acne patients: powerlessness and the variable    nature of acne; comparisons, self-image and identity; the experience of general social interaction; relationships with family and friends; and gender, sexuality, and romantic relationships [21].
Many of the negative psychological effects on those individuals who are afflicted by acne relate to a diminished perception of attractiveness [22]. Acne has been termed by some investigators to be a biopsycosocial skin condition [19]. Motley and Finlay reported that patients with facial acne felt that they were unattractive, reluctant to engage in dating activities, and were socially isolated [23]. There was a sense among adults and teenagers in the current survey that the lives of teens with acne are less fulfilling, with more weekend time spent alone. Adolescents with acne have reported lower scores for total body esteem, sexual attractiveness, and weight concerns than their clear-skinned colleagues [17].
Rubinow and colleagues conducted a survey of 55 acne patients to evaluate psychiatric morbidity and mood characteristics [14]. The most frequently reported adverse psychological effects of a severe form of acne called cystic acne included embarrassment, self-consciousness, social isolation, decreased physical activity, anxiety with the opposite sex, decreased self-confidence, preoccupation with acne, sleep disturbances, nuisance, feeling ill at ease, frustration, and decreased self-esteem. In our survey, a higher percentage of teens with clear skin were perceived as being self-confident. Nearly two in three (64%) teenagers acknowledged that acne has been a source of embarrassment. Magin and colleagues also found skin diseases like acne to be a cause for embarrassment and impaired self-esteem [24].
Not surprisingly, most (69%) teenagers with acne wished their physical appearance was better in some way, compared to 50% of those who have either never had it or don't have it currently. Acne caused so must frustration that nearly three in five teenagers would stay off Facebook for an entire year if they could get rid of their acne forever. Interestingly, 13% would actually pick one of their parents as a prom date if they could eliminate their acne for the rest of their lives. These responses underscore the value that teenagers place on their appearance and the lengths they would go to treat their acne.
Our survey suggests that acne can have a negative effect on relationships and social life. A smaller percentage of teenagers admitted that they would be friends with someone who had acne. More than 3-fold more teenagers than parents believe acne can cause difficulty for teens in regards to finding dates. Yet both adults and teenagers concur that in an average weekend, the teens with acne would be more likely than clear-skinned teens to stay at home with their parents than go out on a date. Overall, fewer teenagers with acne are described as likely to be in a romantic relationship by both adults and their teenage peers. A teen's social life can be negatively affected by acne-one in five have avoided social situations to keep blemishes a secret, and some have even cancelled a date.
Gender differences relating to the social pressures around acne and appearance have been reported in the literature. Girls were found to have higher levels of emotional and social impairments due to their acne [25]. Brook et al. studied the extent to which acne influences the emotional life of adolescent girls [26]. Neuroticism (anxiety level) was the first predictor of the sense of coherence measure for girls suffering from acne, followed by extraversion and psychoticism. One study showed that female students with acne were significantly more depressed than male students [27]. In our survey, more female teens with clear skin were perceived as being intelligent, happy, trustworthy, creative, and healthy compared with their colleagues. Conversely, a higher percentage of girls with acne were perceived as being shy, stressed, lonely, boring, and introverted. Teenaged boys with clear skin were thought by a higher proportion of respondents to be self-confident, fun, cool, athletic, popular, and outspoken than other teens. More male teens with acne were perceived as being more nerdy, unkempt, and unhealthy than their counterparts. However, regardless of gender, the first thing that both males and females noticed in photos of teens with acne was their skin.
Social bullying that occurs at school is a problem that has recently gained a great deal of media attention.
Most respondents from the current survey perceived that teens with acne are likely to be bullied, compared to a third who felt this about images of people with clear skin. Taunting, teasing, and bullying can be real problems for individuals with acne [24]. Teasing can be used as a means of social exclusion and establishing or maintaining dominance. Furthermore, this taunting behavior can perpetuate the lack of self-esteem and resultant depression in teenagers with acne.
Even with the extensive literature regarding acne's effects on behaviors, it is difficult to measure the shortand long-term psychosocial effect of this skin disorder [28]. Social interactions have changed with the times, in particular with the practically unlimited access to social networking sites on the Internet. Our modern preoccupation with blemish-free skin has increased the fear and emotional distress associated with acne. Adolescents, in particular, are an emotionally vulnerable population, and acne can place a significant burden on their psychological resources [29]. Over half of the teenagers in the current survey complained that acne is the most difficult aspect of puberty, even worse than their bodies changing, body odor, or changes in their voice. A higher percentage of adults and teenagers felt that acne causes more difficulty than other sources of embarrassment like braces or glasses.
The deleterious psychosocial effects of acne can be correlated with a reduction in employment opportunities. In studies by Mojon-Azzi et al., acne had the greatest negative impact on finding employment of all the facial anomalies tested [30,31]. Employment experience reports have shown limited opportunities resulting from acne and other skin diseases [28]. This may be due to the overall negative perceptions-being shy, nerdy, stressed and lonely-that tend to be linked to acne. In our survey, adults were less likely to consider hiring teenagers with blemished skin than the teens with clear skin. It has been shown that early employment and good work habits tend to translate into long term employment success [32].
Unfortunately, there may be a lack of understanding regarding the importance of seeking medical advice for the treatment of acne. Less than half of the parents in our survey have taken the initiative to take their teenagers to doctors for any kind of assessment, guidance or treatment for their acne. Many individuals do not go beyond basic efforts to deal with outbreaks of acne. Less than a third of teenagers and adults have taken the initiative to seek a doctor's advice about their own acne. Only about one third of respondents that ever had acne used a prescription medication to deal with their acne and the most popular reason for avoiding treatment was the simple belief that their skin condition wasn't bad enough to demand medical attention. However, 67% of teenagers 13-17 (who have sought medical advice for their acne) have tried 3 or more prescription acne treatments with about 84% reporting that these treatments were effective. Most teens and adults were satisfied with the advice or treatment/medication they received from their doctors for their acne.
The current survey had some limitations due to its survey nature. The participants were limited to people who were willing and able to respond to an online survey.
Future perception assessments may involve expanding the survey to other regions outside the US to see if cultural differences play a role in perception and whether they differ from the US responses. In addition, it would be interesting to evaluate perceptions of acne from different ethnic groups. Peoples' perceptions regarding visible acne scarring could be another area of future research.

Conclusions
In most cases, the first thing that respondents noticed was the skin of teens with acne. Teenagers and adults alike perceived other teens with acne as generally being shy, less socially active, more likely to be bullied, and less successful in terms of finding a job. The analysis by gender showed that a higher percentage of girls with acne were perceived as being shy, stressed, lonely, boring, and introverted while a higher proportion of their male counterparts with acne were perceived as being nerdy, unkempt, and unhealthy compared with their colleagues. In addition, most teens have been embarrassed by their acne and would be willing to make a substantial sacrifice if they could remain free of acne for the rest of their lives. Teenagers with acne reported lower self-confidence or shyness, difficulty finding dates, problems making friends, challenges with school, and trouble getting a job. Most teens who have sought medical advice for their acne have tried 3 or more prescription acne treatments and reported that these treatments were effective. Overall, these results show that acne has a negative effect on the way people are perceived by the others.