Introduction
Acne vulgaris (AV) is a chronic inflammatory disease of the pilosebaceous unit. The severity of skin involvement ranges from minimal lesions to highly inflammatory lesions that can lead to deformity [1]. Acne, one of the most common reasons for dermatology outpatient visits, affects more than 85% of adolescents and frequently persists into adulthood [2, 3].
Adolescence is a period when identity development and social and physical changes reach their peak. The modern adolescents have grown up with the illusion that they can rule over everything and everyone [4]. In an era where being “popular” is essential, appearance is a constant preoccupation. This century encourages people to always look their best. During adolescence, it can be challenging to meet the ideals of healthy skin, a muscular body, or an athletic appearance. Diseases that primarily affect the face can lead to significant psychosocial effects, especially in modern adolescents [3]. For these reasons, acne can lead to the development of emotional and behavioural reactions, such as a distorted body image, decreased self-esteem, shame, loneliness, anger, and withdrawal. It may contribute to the development of psychiatric disorders [3, 4].
In contemporary adolescents, severe acne is commonly associated with psychological distress, and the literature is rich in studies investigating psychiatric symptoms and quality of life (QoL) in individuals with acne [3, 5, 6]. However, the extent to which mild to moderate acne affects today’s adolescents, who are especially vulnerable to appearance-related concerns, has not been adequately explored.
Aim
This study seeks to answer that specific question, with a focus on body image, self-esteem, and depression.
Material and methods
Design
The survey conducted by Erzurum Regional Training and Research Hospital Dermatology and Bingöl Gynecology and Children's Hospital, Child and Adolescent Mental Health Clinic included 170 patients with mild/moderate acne whose parents agreed to participate in the study between January 2021 and March 2023.
Setting and participants
Patients between 12 and 17 years old who presented to the dermatology outpatient clinic with complaints of acne for the first time and did not have any chronic systemic medical condition were included in the study. The inclusion criteria for the study were as follows: obtaining informed consent from the participant’s legal guardian, presenting to a physician for the first time with complaints of acne, having sufficient cognitive function to complete the scales, and having a Global Acne Score (GAS) of 18 or lower.
The exclusion criteria included: cognitive impairment severe enough to prevent completion of the scales, previous consultation with a physician for acne, presence of acne caused by medication or cosmetic use, presence of an additional disease that may cause acne, having chronic systemic or dermatologic diseases other than acne, and a history of systemic isotretinoin treatment.
The control group consisted of 79 dermatologically and systemically healthy individuals selected from the relatives of patients presenting to a hospital. None of the individuals in the control group had a history or clinical signs of acne. These individuals were matched to the case group regarding age, educational level, and gender.
Variables and data sources
GAS and the Visual Analogue Scale (VAS) were used to determine the severity of acne in all adolescents with acne vulgaris. Sociodemographic information, including age, gender, and education level, was recorded for the patients. All patients answered the Children’s Depression Inventory (CDI), Body Image Questionnaire (BIQ), Rosenberg Self-Esteem Scale (RSES), and Turkish Acne Quality of Life Index (TAQoLI).
VAS is a measure of self‐assessment of the severity of acne, where the patient is asked to score their acne lesions on a scale of 0‐10.
GAS is a measurement system that determines the severity of acne, the distribution of acne lesions on the body, and the type of lesions. Acne lesions are scored on a scale of 0 to 44. With this scoring system, acne severity in the patient can be graded as no acne (0 points), mild severity/mildly severe (1–18 points), moderate severity/moderately severe (19–30 points), severe (31–38 points), and very severe (> 39 points) [7]. TAQoLI was developed to evaluate the effect of acne on patients’ quality of life [8]. The validity and reliability of the scale were determined for Turkish patients. A high score on this scale indicates a low quality of life [9].
The RSES consists of 10 questions developed by Rosenberg to assess self-esteem, particularly in adolescents [10]. Çuhadaroğlu conducted validity and reliability studies for Turkish patients [11]. In this unique scoring technique, 0–1 points refer to higher self-esteem, 2–4 points to moderate self-esteem, and 5 points or above are considered low self-esteem. As the self-esteem score increases, self-esteem decreases.
The Children’s Depression Inventory (CDI) is a 27-item scale developed by Kovacs (1981) based on the Beck Depression Inventory and can be applied to children and adolescents between the ages of 6 and 17. Each item receives 0, 1 or 2 points according to the severity of the symptom. The highest score is 54. The cut-off score is recommended as 19 [12]. The CDI validity and reliability study was conducted by Öy [13].
Secord and Jourard’s Body Image Questionnaire is a self-report scale developed by Secord and Jourard (1953) to measure dissatisfaction with various aspects of the body, including body parts and functions. The scale consists of 40 items on a 5-point Likert-type scale, with different body parts rated as follows: 1 = I don’t like it at all, 2 = I don’t like it, 3 = I’m neutral, 4 = I like it, and 5 = I like it a lot. As the score obtained from the scale increases, the dissatisfaction of individuals with their body parts and functions also increases. The validity and reliability study of the Turkish form was conducted by Hovardaoğlu on a university sample [14].
Statistical analysis
All procedures were performed using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA, v21.0) software. After checking the normality distribution of scale variables using the Kolmogorov-Smirnov test, continuous parameters were compared using the Kruskal-Wallis H and Mann-Whitney U tests, depending on the number of samples. The exact significance test for the Mann-Whitney U test was performed when the sample size was insufficient. Pearson’s χ2 or Fisher’s exact tests were used to compare independent categorical variables, given the sample sizes. Continuous variables were stated as mean ± standard deviation or median (interquartile range), and categorical variables as numbers (percentages). Bonferroni correction was applied post-hoc if significant results were obtained in more than two sample comparisons. The p-values achieved after post-hoc analysis were tabulated and adjusted. A two-sided p-value < 0.05 was considered statistically significant.
Results
A total of 249 volunteers participated in the study, with the patient group comprising 170 (68.3%) individuals and the control group composed of 79 (31.7%) individuals. The sociodemographic and clinical characteristics of the case and control groups are shown in Table 1. The mean age of the participants in the patient group was 15.1 ±1.4 years, while in the control group, it was 15.0 ±1.5 years. Women accounted for 68.3% of the patients and 57% of the control group. No significant differences were found between the groups regarding age or gender (p = 0.224 and p = 0.808, respectively). Among the patient group, 20% of the participants had a primary education level, while 80% had secondary education. In the control group, 15.2% had primary education, and 84.8% had secondary education. There was no statistically significant difference in education levels between the groups (p = 0.176).
Table 1
Sociodemographic and behavioural characteristics of patients and controls
In the patient group, 63.1% (157 individuals) reported having 1–3 siblings, 32.9% (82 individuals) reported having 4–6 siblings, and 4.0% (10 individuals) reported having seven or more siblings. The corresponding percentages in the control group were 59.5%, 34.2%, and 6.3%, respectively. No significant differences were observed in the number of siblings. Substance use and a family history of psychiatric disorders in the mother or father were also compared between the groups, with no significant differences observed (p = 0.325, p = 0.443, and p = 0.456, respectively). These findings indicate that the sociodemographic and demographic characteristics of participants in patient and control groups are generally similar. These characteristics suggest that the groups were comparable demographically, supporting the validity of the comparisons.
In the analysis of gender differences in the patient group (Table 2), male patients had a significantly higher GAS score than female patients (p = 0.017). In contrast, female patients had a significantly higher TAQoLI (p = 0.031) and CDI (p = 0.048). Additionally, BIQ score was lower in female patients than in males (p = 0.029).
Table 2
Comparison of variables by gender in the patient group
Health indicators
Regarding health indicators, the complaint duration in the patient group was significantly longer than in the control group (4.22 ± 0.93 months, p < 0.001). Similarly, the GAS score and VAS results were substantially higher in the patient group compared to the control group (GAS score: 4.50 ±0.93, p < 0.001; VAS: 2.68 ±0.97, p < 0.001). These findings indicate that the patient group reported a longer duration of symptoms and greater severity of acne compared to the control group. The results of the RSES showed no significant differences between the groups (p = 0.157). However, the TAQoLI (15.84 ±5.69, p < 0.001) and CDI (13.36 ±7.30, p < 0.001) were significantly higher in the patient group. BIQ scores were lower in the patient group (151.10 ±23.09, p = 0.014) (Table 3).
Table 3
Comparison of health indicators between patient and control groups
Correlation analysis
Pearson correlation analysis was used to compare the patient and control groups regarding various health indicators (Table 4). The study revealed significant relationships between the groups. Notably, negative correlations were observed between complaint duration and GAS score (r = –0.891 and r = –0.906, p < 0.05), indicating that the patient group exhibited significantly higher complaint durations and GAS scores. Similarly, a negative correlation was found between VAS and the group (r = –0.704, p < 0.05), supporting higher complaint levels in the patient group.
Table 4
Pearson correlation analysis of health indicators
| Variable | Group | Complaint duration | GAS Score | Visual Analogue Scale | Rosenberg Self-Esteem Scale | Acne Quality of Life | Body Image Questionnaire | Children’s Depression Inventory |
|---|---|---|---|---|---|---|---|---|
| Group | 1.000 | –0.891* | –0.906* | –0.704* | 0.087 | –0.372* | 0.155 | –0.225 |
| Complaint duration | –0.891* | 1.000 | 0.874* | 0.563* | –0.139 | 0.420* | –0.128 | 0.260* |
| GAS Score | –0.906* | 0.874* | 1.000 | 0.531* | –0.088 | 0.412* | –0.116 | 0.201* |
| Visual Analogue Scale | –0.704* | 0.563* | 0.531* | 1.000 | 0.112 | 0.091 | 0.026 | 0.123 |
| Rosenberg Self-Esteem Scale | 0.087 | –0.139 | –0.088 | 0.112 | 1.000 | –0.348* | 0.488* | –0.529* |
| Acne Quality of Life | –0.372* | 0.420* | 0.412* | 0.091 | –0.348* | 1.000 | –0.439* | 0.576* |
| Body Image Questionnaire | 0.155 | –0.128 | –0.116 | 0.026 | 0.488* | –0.439* | 1.000 | –0.586* |
| Children’s Depression Inventory | –0.225* | 0.260* | 0.201* | 0.123 | –0.529* | 0.576* | –0.586* | 1.000 |
A weak positive correlation (r = 0.087) was observed between RSES and the group, suggesting no significant differences in self-esteem levels between the two groups. In contrast, a negative correlation was noted between TAQoLI and the group (r = –0.372, p < 0.05), indicating lower acne-related quality of life in the patient group. A positive correlation (r = 0.155, p < 0.05) was found between the BIQ score and the group. In contrast, a negative correlation (r = –0.225, p < 0.05) was identified with CDI, suggesting higher depression levels in the patient group.
Regression analysis
Regression analysis results demonstrated that the model had high explanatory power, with an R 2 value of 0.916, indicating that the independent variables explained 91.6% of the variance in the dependent variable. ANOVA results confirmed the statistical significance of the regression model (F = 374.297, p < 0.001).
Relationships between variables
Table 5 shows the relationships between GAS score, VAS, RSES, TAQoLI, BIQ, and CDI in the patient group. A moderate positive correlation was observed between GAS score and VAS (r = 0.448), while a weak positive correlation was found with TAQoLI (r = 0.220).
Table 5
Relationship between GAS Score, Visual Perception, Rosenberg Self-Esteem Scale, Acne Quality of Life, Body Image Questionnaire, and Children's Depression Inventory in the patient group
[i] Data are presented as Pearson correlation coefficients (r), which measure the strength and direction of the relationship between variables. Significance is indicated by p-values, with p < 0.05 considered statistically significant. The strength of relationships is categorized as follows: none/very weak (r < 0.20), weak (0.20 ≤ r < 0.40), moderate (0.40 ≤ r < 0.60), strong (0.60 ≤ r < 0.80), and very strong (r ≥ 0.80). This table reflects correlations observed specifically in the patient group.
VAS showed weak negative correlations with RSES (r = –0.280) and the BIQ (r = –0.248). A weak positive correlation was also found between VAS and TAQoLI (r = 0.314).
The RSES showed weak negative correlations with TAQoLI (r = –0.370) and CDI (r = –0.573, p < 0.01); however, a moderate positive correlation was found with BIQ (r = 0.535), indicating that higher self-esteem is associated with more positive BIQ.
TAQoLI showed a weak negative correlation with BIQ (r = –0.435) and a moderate positive correlation with CDI (r = 0.560).
Finally, BIQ showed a moderate negative correlation with CDI (r = –0.554), suggesting that more negative BIQ is associated with higher levels of depression.
Discussion
Although acne vulgaris (AV) has long been considered a skin problem specific to adolescents, it is now recognised as a chronic disease that creates serious psychological and sociological effects on affected individuals. Given the high prevalence of the disease, its profound impact on individuals’ quality of life cannot be ignored [15]. In a study conducted in Turkey, acne was among the top five dermatological diseases that most significantly affect quality of life [16].
In the literature, most studies evaluating psychiatric disorders associated with acne have been conducted in the adult population, while studies focusing on adolescents with acne are pretty limited [17, 18].
Studies have emphasised the significant impact of acne on quality of life, body perception, depression, and social appearance anxiety in adolescents [19–21]. Recent research conducted on adolescents has demonstrated the adverse effect of acne on quality of life, with acne severity being associated with poorer quality of life and higher levels of depression [21–23]. Our findings are consistent with the literature, as TAQoLI was found to be significantly lower in the patient group (15.84 ±5.69, p < 0.001). Correlation analysis further showed that as acne severity increased, quality of life deteriorated (r = –0.372, p < 0.05). Additionally, our results revealed that CDI was significantly higher in the patient group (13.36 ±7.30, p < 0.001), with a positive correlation observed between acne and depression scores (r = 0.560). Moreover, a moderate positive correlation was found between TAQoLI and CDI (r = 0.560).
In our study, although male patients had higher acne severity than female patients, female patients had significantly higher TAQoLI (p = 0.031) and CDI (p = 0.048). Additionally, their body perception scores were substantially lower than those of males (p = 0.029). Our results indicate that females experience a more significant psychosocial burden due to acne and that their body image is more negatively affected. The literature on gender-related data is contradictory. At the same time, some studies have reported that acne does not significantly impact the quality of life [24–26]. However, many others have found results similar to ours, indicating a greater deterioration in the quality of life among females [27, 28].
In recent years, there has been growing evidence that adolescents with dermatological conditions are at risk of experiencing mental health issues such as low self-esteem and body dysmorphic disorder (BDD) [29]. Body image encompasses an individual’s perceptions, thoughts, and behaviours regarding their appearance. Perceived body image is affected when individuals have a skin disease [30]. Acne alters the appearance and leads to body image distortion [31]. Gupta et al. demonstrated that body image improved positively as acne cleared [32]. Similarly, a study by Tasoula et al. found that adolescents’ body image is influenced by the severity of their acne [25]. To evaluate body image in adolescents, we used Secord and Jourard’s BIQ, and our findings showed significantly lower scores in the patient group. Additionally, we identified a negative correlation between BIQ and CDI (r = –0.586). Our findings suggest that lower body image perception is associated with higher levels of depression.
According to Rosenberg, feelings of inadequacy and incompetence characterise low self-esteem and an inability to cope with difficulties. Average self-esteem is defined as a fluctuation between feelings of self-acceptance and self-rejection. In contrast, high self-esteem is characterised by an individual’s awareness of value, competence, and confidence [10]. A dermatological condition such as acne vulgaris (AV), which affects the aesthetics of the face and other exposed areas, is expected to negatively impact self-esteem, particularly in adolescents. However, Teixeira et al. emphasised the difficulty of predicting the actual impact of AV on self-esteem, as various factors, including age, baseline self-esteem, family support, and underlying psychiatric conditions, can influence this effect [33, 34]. Similarly, Vilar et al. suggested that financial concerns might be a significant factor preventing the detection of a relationship between self-esteem (measured by RSES) and acne vulgaris (AV) or its severity in low-income populations [35]. In our study, similar to this research, no correlation was found between self-esteem (measured by RSES) and AV, nor between self-esteem and acne severity. We believe that the increasing economic problems in our country in recent years may have contributed to this outcome by raising financial concerns.
Body dysmorphic disorder (BDD) typically begins during adolescence, with an average onset age of 16 years. However, the fact that concerns about appearance are often considered normal in this age group makes diagnosing BDD in adolescents more challenging [29]. Identifying abnormal or disproportionate preoccupations is crucial, as adolescents and young adults tend to experience BDD more severely than adults and exhibit lower levels of insight [36]. In adult patients seeking dermatological consultation for acne vulgaris, BDD has been identified in 8.6–14.1% of cases. These patients often demand invasive and unnecessary treatments, which are generally ineffective [37]. A meta-analysis conducted by Kuck et al. revealed that adults with BDD tend to have lower self-esteem levels [38]. Additionally, a study by Tros et al. on adolescents reported that self-esteem was significantly lower in adolescents with BDD compared to those without BDD [29]. In our research, since our population consisted of adolescents aged 12 to 17 years, considered a lower-risk group for BDD, we did not use a specific scale to measure BDD-related symptoms. However, we evaluated body perception, self-esteem, and psychological effects relevant to BDD risk assessment.
Our findings showed that while there was no significant difference between the groups in RSES, body image scores were lower in the patient group. It is well known that as acne severity increases, its negative impact on body image also intensifies. By excluding adolescents with severe acne, our study aimed to objectively assess the effects of acne on self-esteem and body satisfaction (BS)/body image. Our study highlights the need for healthcare providers and educational institutions to develop strategies aimed at reducing negative body image perceptions and improving the quality of life in adolescents with acne. We believe that awareness programs and support groups in middle and high schools in our region could help address the psychological effects of acne, creating a supportive environment for affected adolescents. Previous research has shown that effective acne treatment significantly improves self-esteem and quality of life, emphasising the importance of comprehensive care that includes psychological support [39].
Several limitations were identified in this study. The sample size was relatively small, and participants were selected from a specific geographic region, which may limit the generalizability of the findings to a broader population. A larger sample, including individuals from diverse socioeconomic and cultural backgrounds, could enhance the validity of the results. Additionally, the cross-sectional study design limits the ability to determine causality between variables. Longitudinal studies could provide a better understanding of the temporal relationships and causal connections between acne, self-esteem, social appearance anxiety, and quality of life. Moreover, a specific scale to measure BDD-related symptoms was not used. Instead, indirect assessments evaluating body perception, self-esteem, and psychological effects were utilised, which may limit the ability to detect BDD directly.
Conclusions
Our study emphasises that acne vulgaris is not merely a physical problem but also significantly impacts adolescents’ psychological and social lives, even when not severe. Therefore, effective treatment strategies should be developed for managing adolescents with acne, regardless of the severity of their acne. Treatment should not only target cutaneous lesions but also address the psychogenic effects of acne, such as body perception and depressive mood.
Healthcare providers and educational institutions must develop multidisciplinary approaches to improving the quality of life of adolescents. This study provides a strong foundation for future research, contributing to a better understanding of the psychosocial needs of individuals affected by acne.
