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 short- and 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
]. 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.