Art & science dermatology nursing
Preventing psychological distress in patients with acne Mooney T (2014) Preventing psychological distress in patients with acne. Nursing Standard. 28, 22, 42-48. Date of submission: July 30 2013; date of acceptance: October 28 2013.
Abstract Acne is a skin condition that affects people of all ages, although it is most common in adolescents. It is a condition that can be underestimated by healthcare professionals because it is generally not life threatening. However, acne can have profound psychological effects on an individual, and can result in reduced self-esteem, depression and suicide in extreme cases. It is important, therefore, that nurses are aware of the psychological effects of this condition to assist in providing support and optimising psychological recovery for patients.
Author Tracy Mooney Nurse practitioner, The Hollies GP Surgery, Essex. Correspondence to: [email protected]
Keywords Acne, Dermatology Quality Of Life Index, differential diagnoses, psychological distress, skin and skin disorders
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
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ACNE IS A COMMON skin condition that affects a significant proportion of the population. It tends to affect adolescents and in most cases, the condition improves significantly or disappears by early adulthood (Wlodek et al 2012). In view of this, the adverse effects of acne may be underestimated by healthcare professionals. However, the condition often has profound psychological effects on the patient, causing severe distress. Reduced self-esteem, and in extreme cases, depression and suicide, have been linked to the condition (Joseph 2010). Approximately 5% of 42 january 29 :: vol 28 no 22 :: 2014
women and 1% of men will continue to experience symptoms of acne in their thirties; therefore, these psychological effects can be long-standing in some individuals (NHS Choices 2013). While it is important to recognise the physical effects of acne, such as scarring, it is also essential to acknowledge the psychological effects, providing effective psychological assessment and support.
Pathophysiology Acne is a skin condition that is more common in adolescence (Layton et al 2004), with between 60% and 80% of adolescents expected to develop the condition to some degree (Wlodek et al 2012). The severity of acne varies, can be subjective and may be difficult to quantify. The condition results from a disruption of the pilosebaceous ducts in the skin, which are skin structures consisting of a hair follicle and its associated sebaceous duct (Wlodek et al 2012). The pilosebaceous ducts occur most densely on the face, upper chest and back, the areas of the body where acne is most likely to develop. An overproduction of sebum in the ducts can give the skin a red shiny appearance. Increased sebum production, along with keratin, can block the pores, leading to the development of comedones (whiteheads and blackheads). When increased sebum remains under the skin’s surface, it appears to have a whitehead appearance. However, when melanin rises to the surface or becomes oxidised, the sebum changes to black and results in the formation of blackheads. Papules are small pink raised areas that can be tender to touch, and pustules are usually red and inflamed at the base and have pus on the surface. Nodules are larger, more painful solid areas that occur deep in the skin. They can become cystic (filled with pus) and inflamed, and it is this presentation that is the most likely to result in scarring (Wlodek et al 2012). Although not all acne is inflammatory, there may also be an accumulation of the bacterium Propionibacterium acnes, which can colonise the comedones and result in inflammation (Layton et al 2004) (Figures 1 and 2).
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Severity of the condition A presentation of acne that might be considered mild can have a negative effect on the mental health and wellbeing of an individual, and little correlation exists between the severity of acne and the severity of psychological effects (Joseph 2010). Low self-esteem is common and can result in depression and suicidal ideation in extreme cases (Gupta and Gupta 1998). Therefore, acne can be significant irrespective of its appearance and severity. For this reason, it is important that when assessing a person with acne the nurse completes a holistic examination, including physiological and psychological assessment. Although recognising physical symptoms is essential, it is also important to consider that these visible signs might not indicate the severity of the effects of the disease on the individual. Acne that results in the formation of large nodules or cysts is often considered to reflect a severe acne presentation (Palmer 2013). The condition, generally termed nodulocystic acne, results in inflamed cysts that often appear on the buttocks, groin, armpits and deeper tissues. This type of presentation is associated with an increased risk of scarring and skin pigmentation changes (Palmer 2013). Scars vary in presentation, with the most common being ice pick scars (Fabbrocini et al 2010). Ice pick scars tend to look like small, deep indentations in the skin’s surface. Other types of acne scar are boxed scars, rolling scars and hypertrophic scars (Figure 3). In general, all depression scars rest on top of an area of fibrous, collagen-rich scar tissue. This fibrous tissue anchors the base of the scar to the subcutaneous tissue, maintaining the depression and preventing regrowth of healthy tissue (Fabbrocini et al 2010). Skin pigmentation changes may occur during a flare up of acne. This is usually a result of inflammation that occurs around the nodules
or cysts and is more likely to happen when the acne is aggravated. Any aggravation can increase the inflammatory response and, therefore, pigmentation changes may be avoided by ensuring that the cysts and nodules are not excessively scrubbed or touched. Grading scales have been developed to assist in diagnosing the severity of acne. These grading scales focus on the physical condition of the skin. The most commonly used scales are the Leeds
FIGURE 2 Development of acne lesions Healthy skin Skin surface
Sebaceous gland
Hair
Sebum Hair follicle
Open comedone Skin surface Blackhead Follicle opening enlarged Sebaceous gland
Hair follicle
FIGURE 1 Acne affects 60-80 per cent of adolescents Closed comedone
Sebaceous gland
Whitehead Follicle opening enlarged
Hair follicle PETER LAMB
SCIENCE PHOTO LIBRARY
Skin surface
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Art & science dermatology nursing acne scale (Burke and Cunliffe 1984), Cook’s acne grading system (Cook et al 1979) and Pillsbury scale (Pillsbury et al 1956). The scales mainly provide descriptions or images for the healthcare professional to compare with the patient’s signs and symptoms. Scores are then allocated, with a lower score indicating a less severe presentation of acne and a higher score indicating more severe acne (Table 1). It is important to explain to patients that acne is a chronic disease and that responses to treatment can be slow, to prevent these individuals from becoming discouraged and to ensure adherence to treatment regimens (Katsambas 1998).
Acne during adolescence Although the exact cause of acne is unknown, it is generally considered that there is a strong link between the development of acne and the increase in androgens during puberty, regardless
FIGURE 3 Types of acne scar
Icepick scar
Boxed scar
Rolling scar
Hypertrophic scar
(Jacob et al 2001)
TABLE 1 Acne severity grading and scoring Score
Grade
Description
0
Clear
Clear skin with no evidence of acne vulgaris.
1
Almost clear
Rare non-infl ammatory lesions are present, with rare non-infl amed papules (papules must be resolving and may be hyperpigmented, but not pink-red).
2
Mild
Some non-infl ammatory lesions are present, with few infl ammatory lesions (papules or pustules only; no nodulocystic lesions).
3
Moderate
Non-infl ammatory lesions predominate, with multiple infl ammatory lesions evident (several comedones and papules or postules present, and there may or may not be one small nodulocystic lesion).
4
Severe
Infl ammatory lesions are more apparent, with many comedones and papules or postules, and there may or may not be a few nodulocystic lesions.
5
Very severe
Highly infl ammatory lesions predominate, with a variable number of comedones, many papules or postules and many nodulocystic lesions.
(Adapted from Adityan et al 2009)
44 january 29 :: vol 28 no 22 :: 2014
of gender (Layton et al 2004). Production of several hormones, including the androgens testosterone, dihydrotestosterone and dehydroepiandrosterone sulphate, increases during adolescence and these hormones can cause the follicular glands to grow larger and produce more sebum (Layton et al 2004). Experience suggests that these hormonal changes are considered by some to be part of normal development. The individual with acne may consider that the condition will be trivialised and as a result he or she may become withdrawn and reluctant to discuss or seek help. The nurse is, however, ideally placed to encourage the patient to express any concerns. Nurses can provide support by ensuring that concerns are listened to in a non-judgemental way and that the effects of the condition are not underestimated (Joseph 2010). Adolescence is characterised by social, emotional and physical development (Joseph 2010). For many, it is a time when relationships are formed and peer status is important. Therefore, acne occurring at this time can be distressing. Historically, much emphasis has been placed on physical appearance, with judgements and behaviours often being based solely on this (Joseph 2010). Young people can be particularly self-conscious about their appearance and this can be influenced by media and celebrity culture. Some magazines, for example, portray celebrities without imperfection, often airbrushing photographs to erase anything that might be considered a flaw (New 2012). This may put pressure on adolescents who wish to compare themselves with these images, adding to the psychological burden of having acne. Patients may feel embarrassed, self-conscious, angry and frustrated about their skin condition, and the distress can be worsened by the reactions of others. If the effects of the condition are underestimated or misunderstood, the patient may develop poor coping mechanisms, which can lead to a loss of motivation and depression (Layton et al 2004). Poor lifestyle choices, such as risky sexual behaviour, may also become evident, which can affect the individual’s quality of life in the future.
Sexual health
Bhatti et al (2009) indicated that lifestyle choices can be influenced by skin conditions. A person who feels isolated and unattractive may enter into relationships to feel loved and desired. Because of the link between hormones and acne, female adolescents may also consider oral contraception as a treatment for the condition. Bhatti et al (2009) suggested that this, combined with low self-esteem, could increase the possibility of risky sexual
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behaviour, including an increased risk of pregnancy and sexually transmitted diseases. Although some oral contraceptive pills have been considered useful in the treatment of acne, they are not effective in all cases (Wlodek et al 2012). Co-cyprindiol is an anti-androgen-containing pill prescribed for women with severe acne who fail to respond to other treatments (British National Formulary (BNF) 2013). The drug is thought to work by decreasing sebum secretion that is otherwise under androgen control (BNF 2013). However, although it is effective as a contraceptive, it is not licensed for contraceptive use alone and should be discontinued a few cycles after the acne has resolved because of the increased risk of thromboembolism (BNF 2013). However, if this medication is effective, the patient may be reluctant to stop taking it despite the associated health risks.
Acne during adulthood In most cases of acne in adolescents, the acne will show signs of improvement and the assumption that the condition will disappear over time may be correct. However, in some cases, the condition can persist or develop in adulthood. When acne develops suddenly in adulthood, the person may not be diagnosed immediately with the condition and may undergo examinations that can cause concern and distress. Differential diagnoses
may include rosacea, folliculitis, endocrine abnormalities or drug-induced acneiform eruptions (Table 2). However, although a full medical history and physical examination are important, most cases tend to be a result of persistent adolescent acne (Layton et al 2004). The number of older adults experiencing acne is increasing, with as many as 12% of women aged between 41 and 50 displaying symptoms (Bowe 2013). Although the reason for this is unknown, there appears to be a close correlation between acne development and cigarette smoking (Capitanio et al 2009). Bowe (2013) suggested that smokers are at increased risk of developing acne and, therefore, its associated psychological complications. It has been suggested that adults with acne experience psychological difficulties equal to people with long-term conditions such as diabetes and asthma (Mallon et al 1999). Individuals who have acne are reported to have greater employment difficulties than those in the general population (Ayer and Burrows 2006). Ayer and Burrows (2006) revealed that as many as 22% of respondents felt that they had been turned down for employment because of their acne. As with other long-term conditions, a patient might need to take time off work to attend doctor’s appointments. This, and the often expensive cost of skin treatments, can affect the patient’s employment
TABLE 2 Differential diagnoses of adult acne Differential diagnosis
Prevalence
Characteristics
Additional considerations
Drug-induced acneiform eruptions
Uncommon, and mainly affects the chest and back.
Eruptions are predominantly caused by drugs such as corticosteroids, lithium, azathioprine and inhaled steroids.
Important to ascertain a full history from the patient.
Rosacea
Mainly in adults with fair skin, and light hair and eye colour.
Mainly characterised by facial flushing and erythema of the cheeks, nose, forehead and chin.
Comedones are notably absent.
Folliculitis
Sudden development of pustules (often in those already treated for acne with antibiotics)
Bacteria can be isolated in the pus.
Cultures of the pus should be obtained.
Perioral dermatitis
Most common in adult women during periods of stress.
Eruptions are characterised by erythema and scaling mainly around the mouth and chin.
Endocrine and hormonal causes, for example polycystic ovary syndrome, Cushing’s syndrome
Uncommon, and caused by an ovarian source that results in an increased androgen level.
Hormone levels via blood testing (mid cycle) should indicate the diagnosis. Checks should include testosterone levels, luteinising hormone/follicle stimulating hormone ratio and fasting glucose.
No oral contraception should be given within one month of blood tests. Patients with high androgen levels may also have some insulin resistance, and may be at increased risk of diabetes and heart disease.
(Adapted from Layton et al 2004)
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Art & science dermatology nursing and financial situation (Joseph 2010). Some specific occupations also have increased difficulties. For example, greater psychological effects may be experienced in individuals with acne who work in the health and beauty industry, because people with occupations that focus on appearance and hygiene might be at an increased risk of body dysmorphic disorder (Ayer and Burrows 2006). For an individual with acne also experiencing body dysmorphic disorder, his or her perception of the clinical skin problem will be significantly out of proportion to its presentation.
Other causes of distress Psychological distress can be increased through a common misconception that acne is caused by poor hygiene (NHS Choices 2013). For example, patients may perceive blackheads to be caused by dirt (Wlodek et al 2012) rather than an accumulation of sebum, which does not reflect poor hygiene. Over-the-counter products such as face scrubs and soaps are often overused in an attempt to clear the skin of blackheads. However, this can increase friction and inflammation in the affected area, worsening the condition (National Institute of Arthritis and Musculoskeletal and Skin Diseases 2010). Being perceived as dirty can lead to a loss of self-esteem, distress and depression (Joseph 2010). Patients with acne often blame themselves for the condition. For example, they may feel that it is their fault for eating the wrong food (NHS Choices 2013). Sweet foods, such as chocolate, tend to contain a varying amount of sugar that can lead to a high glycaemic load, and high glycaemic load diets may be associated with worsening acne (Ferdowsian and Levin 2010). In addition, Ferdowsian and Levin (2010) suggested that there is a positive association between the consumption of milk and increased prevalence and severity of acne. However, evidence of the relationship between diet and acne is generally not clear and no good quality evidence is available. In view of this, a well-balanced healthy diet is recommended (Ferdowsian and Levin 2010). Similarly, people with acne can feel that they have caused their acne because of their use of make-up. Although the evidence for this is limited, it is recommended that oil-free and non-comedogenic make-up should be used. Non-comedogenic products are usually natural products that claim not to clog the pores of the skin; however, many people develop acne even when using only these products (National Institute of Arthritis and Musculoskeletal and 46 january 29 :: vol 28 no 22 :: 2014
Skin Diseases 2010). Omitting make-up prevents camouflage and can result in increased visibility of the condition, leading the person to become more self-conscious and at a greater risk of depression (Joseph 2010).
Psychological assessment Because acne does not affect a person’s general medical health, the psychological effects of the condition may not be appreciated fully by a relative or healthcare professional, and the condition may be dismissed as a simple cosmetic problem (Halvorsen et al 2011). It is important to realise that the degree of psychological distress can vary. Psychological evaluation is not carried out routinely in primary care because assessment of psychological disability is generally undertaken in secondary care or when the assessment of psychological disability resulting from acne is deemed particularly severe (Papadopoulos and Bor 1999). This can be misleading because the perception of severe acne can differ considerably between patients and healthcare professionals (Joseph 2010). In addition, it has been suggested that the psychological effects of skin disease between patients in primary or secondary care are similar (Harlow et al 2000). Tools such as the Assessment of Psychological Effects of Acne (ASPEA) (Layton et al 2004) (Box 1) and the Dermatology Quality of Life Index (DQLI) (Basra et al 2007) have been validated and can help to identify the psychological effect of the condition (Basra et al 2007). Other assessment tools include the Cardiff Acne Disability Index (Mottley and Finlay 1992) and those that are prepared by individual specialists. However, there appears to be little consistency between the assessments undertaken, although they have the common goal of assessing quality of life. Quality of life questionnaires assess the effect of the condition over the preceding week of the patient’s life. Since this can change over time, it is important to repeat the questionnaire at regular intervals, and in doing this, quality of life can be quantified and any improvement or deterioration recognised (Joseph 2010). Psychological support may be required if there is evidence of low mood or depression. Early recognition of depression or psychological difficulties, alongside clinical findings, can promote holistic support for the patient, which is beneficial for recovery (Chinn et al 2002). The ASPEA assists the healthcare professional to recognise answers that could suggest psychological distress in a subjective way (Layton et al 2004). For example, a patient who indicates that he or
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she has worrying thoughts and is withdrawn should prompt the healthcare professional to provide further support (Basra et al 2007). This might include referral to specialist counselling or psychiatric support services. Other quality of life questionnaires result in the development of scores that should promote a more objective record for measuring distress (Joseph 2010). Despite the existence of several psychological scales, the assessments used vary considerably. Few are used in the primary care settling and many healthcare professionals are unaware of their existence (Layton et al 2004). The DQLI assessment tool is not specific to the diagnosis of acne and is designed to be used for all skin conditions that potentially affect psychological wellbeing (Basra et al 2007). It has been suggested that if the quality of life assessment is undertaken alongside the clinical assessment, greater quality of care is achieved. Completing a full clinical and psychological assessment can assist in guiding clinical decision making as well as highlighting when referral to secondary care is necessary (Joseph 2010). Joseph (2010) also suggested that measuring quality of life can result in increased patient satisfaction in the knowledge that a healthcare professional is concerned and interested in the way the condition is affecting the patient. Even if a formal assessment tool is not used, it is important that the healthcare professional is aware of the psychological effect of the condition so that the appropriate questions can be asked and areas of concern addressed (Layton et al 2004). These questions can then assist the nurse in identifying the effect of acne on the social and psychological wellbeing of the individual. Healthcare professionals working in primary care settings are in an ideal position to offer patients with acne the support and education they may need (Kernick et al 2000). Support can be given through written and verbal information, counselling services can be employed and referral to mental health support services in cases of severe acne can be arranged (Joseph 2010). In some areas, support groups have been set up and patients can be directed to these groups when appropriate. It is important that healthcare professionals are aware of what is available in their local area so that they can use these resources to maximum effect.
Conclusion Acne is generally considered a minor disorder, but it is important to appreciate that the condition can result in severe psychological and social disturbances. It is easy to dismiss these
BOX 1 Assessment of the social and psychological effects of acne In questions 1-6, tick the most appropriate answer: In the past week 1. Worrying thoughts have been going through my mind: a) Most of the time. b) A lot of the time. c) Now and again. d) Only occasionally. 2. I can still feel at ease and relaxed: a) Definitely. b) Usually. c) Not very much. d) Never. 3. I feel restless and have to be on the move: a) Definitely. b) Quite a lot. c) Not very much. d) Never. At this moment 4. I like how I look in photographs: a) Not at all. b) Sometimes. c) Very often. d) Most of the time. 5. I wish I looked better: a) Not at all. b) Sometimes. c) Often. d) Nearly always. 6. On the whole I am satisfied with myself: a) Strongly disagree. b) Disagree. c) Agree. d) Strongly agree. In questions 7-15 read and scale the answers from 1-10, with 0 being never and 10 being all the time. 7. I still enjoy the things I used to do. 0 1 2 3 4 5 6 7 8 9 10 8. I am more irritable than normal. 0 1 2 3 4 5 6 7 8 9 10 9. I feel that I am useful and needed. 0 1 2 3 4 5 6 7 8 9 10 10. My skin condition limits me going shopping. 0 1 2 3 4 5 6 7 8 9 10 11. My skin condition stops me socialising. 0 1 2 3 4 5 6 7 8 9 10 12. My skin prevents me going on holidays or outings. 0 1 2 3 4 5 6 7 8 9 10 13. My skin condition prevents me eating out. 0 1 2 3 4 5 6 7 8 9 10 14. My skin stops me using public changing areas. 0 1 2 3 4 5 6 7 8 9 10 15. I feel my skin condition might interfere with my chances of future employment. 0 1 2 3 4 5 6 7 8 9 10 (Adapted from Layton et al 2004)
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Art & science dermatology nursing disturbances when the clinical presentation appears mild because the psychological effect on quality of life might not directly correspond with the symptoms observed. This can make assessment complex. Because patients may have indirectly blamed themselves for the condition or accepted it as something that everyone experiences, they may have been experiencing physical and emotional symptoms for a period of time before seeking help. Therefore, it is important that a full prompt assessment of the condition is undertaken during which clinical and psychological needs are recognised (Joseph 2010). A discussion with the patient is required to dispel misconceptions about
the condition and to emphasise that acne is a chronic disease and that responses to treatments can be slow. Formal psychological assessment of skin conditions remains within the secondary care setting, even though the psychological effects of skin disease on patients in primary or secondary care are similar (Harlow et al 2000). Therefore, an increased awareness of the psychological effect of acne is important in improving quality of life for the patient. Early recognition of depression or psychological difficulties, alongside clinical findings, can promote holistic support for the patient, and is essential to ensure continual improvement in care NS
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Chinn DJ, Poyner T, Sibley G (2002) Randomized controlled trial of a single dermatology nurse consultation in primary care on the quality of life of children with atopic eczema. British Journal of Dermatology. 146, 3, 432-439. Cook CH, Centner RL, Michaels SE (1979) An acne grading method using photographic standards. Archives of Dermatology. 115, 5, 571-575. Fabbrocini G, Annunziata M, D’Arco V et al (2010) Acne scars: pathogenesis, classification and treatment. Dermatology Research and Practice. Doi: 10.1155/2010/893080. Ferdowsian HR, Levin S (2010) Does diet really affect acne? Skin Therapy Letter. 15, 3, 1-2, 5. Gupta MA, Gupta AK (1998) Depression and suicide ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. British Journal of Dermatology. 139, 5, 846-850.
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Preventing psychological distress in patients with acne Mooney T (2014) Preventing psychological distress in patients with acne. Nursing Standard. 28, 22, 42-48. Date of submission: July 30 2013; date of acceptance: October 28 2013.
Abstract Acne is a skin condition that affects people of all ages, although it is most common in adolescents. It is a condition that can be underestimated by healthcare professionals because it is generally not life threatening. However, acne can have profound psychological effects on an individual, and can result in reduced self-esteem, depression and suicide in extreme cases. It is important, therefore, that nurses are aware of the psychological effects of this condition to assist in providing support and optimising psychological recovery for patients.
Author Tracy Mooney Nurse practitioner, The Hollies GP Surgery, Essex. Correspondence to: [email protected]
Keywords Acne, Dermatology Quality Of Life Index, differential diagnoses, psychological distress, skin and skin disorders
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
ACNE IS A COMMON skin condition that affects a significant proportion of the population. It tends to affect adolescents and in most cases, the condition improves significantly or disappears by early adulthood (Wlodek et al 2012). In view of this, the adverse effects of acne may be underestimated by healthcare professionals. However, the condition often has profound psychological effects on the patient, causing severe distress. Reduced self-esteem, and in extreme cases, depression and suicide, have been linked to the condition (Joseph 2010). Approximately 5% of 42 january 29 :: vol 28 no 22 :: 2014
women and 1% of men will continue to experience symptoms of acne in their thirties; therefore, these psychological effects can be long-standing in some individuals (NHS Choices 2013). While it is important to recognise the physical effects of acne, such as scarring, it is also essential to acknowledge the psychological effects, providing effective psychological assessment and support.
Pathophysiology Acne is a skin condition that is more common in adolescence (Layton et al 2004), with between 60% and 80% of adolescents expected to develop the condition to some degree (Wlodek et al 2012). The severity of acne varies, can be subjective and may be difficult to quantify. The condition results from a disruption of the pilosebaceous ducts in the skin, which are skin structures consisting of a hair follicle and its associated sebaceous duct (Wlodek et al 2012). The pilosebaceous ducts occur most densely on the face, upper chest and back, the areas of the body where acne is most likely to develop. An overproduction of sebum in the ducts can give the skin a red shiny appearance. Increased sebum production, along with keratin, can block the pores, leading to the development of comedones (whiteheads and blackheads). When increased sebum remains under the skin’s surface, it appears to have a whitehead appearance. However, when melanin rises to the surface or becomes oxidised, the sebum changes to black and results in the formation of blackheads. Papules are small pink raised areas that can be tender to touch, and pustules are usually red and inflamed at the base and have pus on the surface. Nodules are larger, more painful solid areas that occur deep in the skin. They can become cystic (filled with pus) and inflamed, and it is this presentation that is the most likely to result in scarring (Wlodek et al 2012). Although not all acne is inflammatory, there may also be an accumulation of the bacterium Propionibacterium acnes, which can colonise the comedones and result in inflammation (Layton et al 2004) (Figures 1 and 2).
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Severity of the condition A presentation of acne that might be considered mild can have a negative effect on the mental health and wellbeing of an individual, and little correlation exists between the severity of acne and the severity of psychological effects (Joseph 2010). Low self-esteem is common and can result in depression and suicidal ideation in extreme cases (Gupta and Gupta 1998). Therefore, acne can be significant irrespective of its appearance and severity. For this reason, it is important that when assessing a person with acne the nurse completes a holistic examination, including physiological and psychological assessment. Although recognising physical symptoms is essential, it is also important to consider that these visible signs might not indicate the severity of the effects of the disease on the individual. Acne that results in the formation of large nodules or cysts is often considered to reflect a severe acne presentation (Palmer 2013). The condition, generally termed nodulocystic acne, results in inflamed cysts that often appear on the buttocks, groin, armpits and deeper tissues. This type of presentation is associated with an increased risk of scarring and skin pigmentation changes (Palmer 2013). Scars vary in presentation, with the most common being ice pick scars (Fabbrocini et al 2010). Ice pick scars tend to look like small, deep indentations in the skin’s surface. Other types of acne scar are boxed scars, rolling scars and hypertrophic scars (Figure 3). In general, all depression scars rest on top of an area of fibrous, collagen-rich scar tissue. This fibrous tissue anchors the base of the scar to the subcutaneous tissue, maintaining the depression and preventing regrowth of healthy tissue (Fabbrocini et al 2010). Skin pigmentation changes may occur during a flare up of acne. This is usually a result of inflammation that occurs around the nodules
or cysts and is more likely to happen when the acne is aggravated. Any aggravation can increase the inflammatory response and, therefore, pigmentation changes may be avoided by ensuring that the cysts and nodules are not excessively scrubbed or touched. Grading scales have been developed to assist in diagnosing the severity of acne. These grading scales focus on the physical condition of the skin. The most commonly used scales are the Leeds
FIGURE 2 Development of acne lesions Healthy skin Skin surface
Sebaceous gland
Hair
Sebum Hair follicle
Open comedone Skin surface Blackhead Follicle opening enlarged Sebaceous gland
Hair follicle
FIGURE 1 Acne affects 60-80 per cent of adolescents Closed comedone
Sebaceous gland
Whitehead Follicle opening enlarged
Hair follicle PETER LAMB
SCIENCE PHOTO LIBRARY
Skin surface
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Art & science dermatology nursing acne scale (Burke and Cunliffe 1984), Cook’s acne grading system (Cook et al 1979) and Pillsbury scale (Pillsbury et al 1956). The scales mainly provide descriptions or images for the healthcare professional to compare with the patient’s signs and symptoms. Scores are then allocated, with a lower score indicating a less severe presentation of acne and a higher score indicating more severe acne (Table 1). It is important to explain to patients that acne is a chronic disease and that responses to treatment can be slow, to prevent these individuals from becoming discouraged and to ensure adherence to treatment regimens (Katsambas 1998).
Acne during adolescence Although the exact cause of acne is unknown, it is generally considered that there is a strong link between the development of acne and the increase in androgens during puberty, regardless
FIGURE 3 Types of acne scar
Icepick scar
Boxed scar
Rolling scar
Hypertrophic scar
(Jacob et al 2001)
TABLE 1 Acne severity grading and scoring Score
Grade
Description
0
Clear
Clear skin with no evidence of acne vulgaris.
1
Almost clear
Rare non-infl ammatory lesions are present, with rare non-infl amed papules (papules must be resolving and may be hyperpigmented, but not pink-red).
2
Mild
Some non-infl ammatory lesions are present, with few infl ammatory lesions (papules or pustules only; no nodulocystic lesions).
3
Moderate
Non-infl ammatory lesions predominate, with multiple infl ammatory lesions evident (several comedones and papules or postules present, and there may or may not be one small nodulocystic lesion).
4
Severe
Infl ammatory lesions are more apparent, with many comedones and papules or postules, and there may or may not be a few nodulocystic lesions.
5
Very severe
Highly infl ammatory lesions predominate, with a variable number of comedones, many papules or postules and many nodulocystic lesions.
(Adapted from Adityan et al 2009)
44 january 29 :: vol 28 no 22 :: 2014
of gender (Layton et al 2004). Production of several hormones, including the androgens testosterone, dihydrotestosterone and dehydroepiandrosterone sulphate, increases during adolescence and these hormones can cause the follicular glands to grow larger and produce more sebum (Layton et al 2004). Experience suggests that these hormonal changes are considered by some to be part of normal development. The individual with acne may consider that the condition will be trivialised and as a result he or she may become withdrawn and reluctant to discuss or seek help. The nurse is, however, ideally placed to encourage the patient to express any concerns. Nurses can provide support by ensuring that concerns are listened to in a non-judgemental way and that the effects of the condition are not underestimated (Joseph 2010). Adolescence is characterised by social, emotional and physical development (Joseph 2010). For many, it is a time when relationships are formed and peer status is important. Therefore, acne occurring at this time can be distressing. Historically, much emphasis has been placed on physical appearance, with judgements and behaviours often being based solely on this (Joseph 2010). Young people can be particularly self-conscious about their appearance and this can be influenced by media and celebrity culture. Some magazines, for example, portray celebrities without imperfection, often airbrushing photographs to erase anything that might be considered a flaw (New 2012). This may put pressure on adolescents who wish to compare themselves with these images, adding to the psychological burden of having acne. Patients may feel embarrassed, self-conscious, angry and frustrated about their skin condition, and the distress can be worsened by the reactions of others. If the effects of the condition are underestimated or misunderstood, the patient may develop poor coping mechanisms, which can lead to a loss of motivation and depression (Layton et al 2004). Poor lifestyle choices, such as risky sexual behaviour, may also become evident, which can affect the individual’s quality of life in the future.
Sexual health
Bhatti et al (2009) indicated that lifestyle choices can be influenced by skin conditions. A person who feels isolated and unattractive may enter into relationships to feel loved and desired. Because of the link between hormones and acne, female adolescents may also consider oral contraception as a treatment for the condition. Bhatti et al (2009) suggested that this, combined with low self-esteem, could increase the possibility of risky sexual
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behaviour, including an increased risk of pregnancy and sexually transmitted diseases. Although some oral contraceptive pills have been considered useful in the treatment of acne, they are not effective in all cases (Wlodek et al 2012). Co-cyprindiol is an anti-androgen-containing pill prescribed for women with severe acne who fail to respond to other treatments (British National Formulary (BNF) 2013). The drug is thought to work by decreasing sebum secretion that is otherwise under androgen control (BNF 2013). However, although it is effective as a contraceptive, it is not licensed for contraceptive use alone and should be discontinued a few cycles after the acne has resolved because of the increased risk of thromboembolism (BNF 2013). However, if this medication is effective, the patient may be reluctant to stop taking it despite the associated health risks.
Acne during adulthood In most cases of acne in adolescents, the acne will show signs of improvement and the assumption that the condition will disappear over time may be correct. However, in some cases, the condition can persist or develop in adulthood. When acne develops suddenly in adulthood, the person may not be diagnosed immediately with the condition and may undergo examinations that can cause concern and distress. Differential diagnoses
may include rosacea, folliculitis, endocrine abnormalities or drug-induced acneiform eruptions (Table 2). However, although a full medical history and physical examination are important, most cases tend to be a result of persistent adolescent acne (Layton et al 2004). The number of older adults experiencing acne is increasing, with as many as 12% of women aged between 41 and 50 displaying symptoms (Bowe 2013). Although the reason for this is unknown, there appears to be a close correlation between acne development and cigarette smoking (Capitanio et al 2009). Bowe (2013) suggested that smokers are at increased risk of developing acne and, therefore, its associated psychological complications. It has been suggested that adults with acne experience psychological difficulties equal to people with long-term conditions such as diabetes and asthma (Mallon et al 1999). Individuals who have acne are reported to have greater employment difficulties than those in the general population (Ayer and Burrows 2006). Ayer and Burrows (2006) revealed that as many as 22% of respondents felt that they had been turned down for employment because of their acne. As with other long-term conditions, a patient might need to take time off work to attend doctor’s appointments. This, and the often expensive cost of skin treatments, can affect the patient’s employment
TABLE 2 Differential diagnoses of adult acne Differential diagnosis
Prevalence
Characteristics
Additional considerations
Drug-induced acneiform eruptions
Uncommon, and mainly affects the chest and back.
Eruptions are predominantly caused by drugs such as corticosteroids, lithium, azathioprine and inhaled steroids.
Important to ascertain a full history from the patient.
Rosacea
Mainly in adults with fair skin, and light hair and eye colour.
Mainly characterised by facial flushing and erythema of the cheeks, nose, forehead and chin.
Comedones are notably absent.
Folliculitis
Sudden development of pustules (often in those already treated for acne with antibiotics)
Bacteria can be isolated in the pus.
Cultures of the pus should be obtained.
Perioral dermatitis
Most common in adult women during periods of stress.
Eruptions are characterised by erythema and scaling mainly around the mouth and chin.
Endocrine and hormonal causes, for example polycystic ovary syndrome, Cushing’s syndrome
Uncommon, and caused by an ovarian source that results in an increased androgen level.
Hormone levels via blood testing (mid cycle) should indicate the diagnosis. Checks should include testosterone levels, luteinising hormone/follicle stimulating hormone ratio and fasting glucose.
No oral contraception should be given within one month of blood tests. Patients with high androgen levels may also have some insulin resistance, and may be at increased risk of diabetes and heart disease.
(Adapted from Layton et al 2004)
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Art & science dermatology nursing and financial situation (Joseph 2010). Some specific occupations also have increased difficulties. For example, greater psychological effects may be experienced in individuals with acne who work in the health and beauty industry, because people with occupations that focus on appearance and hygiene might be at an increased risk of body dysmorphic disorder (Ayer and Burrows 2006). For an individual with acne also experiencing body dysmorphic disorder, his or her perception of the clinical skin problem will be significantly out of proportion to its presentation.
Other causes of distress Psychological distress can be increased through a common misconception that acne is caused by poor hygiene (NHS Choices 2013). For example, patients may perceive blackheads to be caused by dirt (Wlodek et al 2012) rather than an accumulation of sebum, which does not reflect poor hygiene. Over-the-counter products such as face scrubs and soaps are often overused in an attempt to clear the skin of blackheads. However, this can increase friction and inflammation in the affected area, worsening the condition (National Institute of Arthritis and Musculoskeletal and Skin Diseases 2010). Being perceived as dirty can lead to a loss of self-esteem, distress and depression (Joseph 2010). Patients with acne often blame themselves for the condition. For example, they may feel that it is their fault for eating the wrong food (NHS Choices 2013). Sweet foods, such as chocolate, tend to contain a varying amount of sugar that can lead to a high glycaemic load, and high glycaemic load diets may be associated with worsening acne (Ferdowsian and Levin 2010). In addition, Ferdowsian and Levin (2010) suggested that there is a positive association between the consumption of milk and increased prevalence and severity of acne. However, evidence of the relationship between diet and acne is generally not clear and no good quality evidence is available. In view of this, a well-balanced healthy diet is recommended (Ferdowsian and Levin 2010). Similarly, people with acne can feel that they have caused their acne because of their use of make-up. Although the evidence for this is limited, it is recommended that oil-free and non-comedogenic make-up should be used. Non-comedogenic products are usually natural products that claim not to clog the pores of the skin; however, many people develop acne even when using only these products (National Institute of Arthritis and Musculoskeletal and 46 january 29 :: vol 28 no 22 :: 2014
Skin Diseases 2010). Omitting make-up prevents camouflage and can result in increased visibility of the condition, leading the person to become more self-conscious and at a greater risk of depression (Joseph 2010).
Psychological assessment Because acne does not affect a person’s general medical health, the psychological effects of the condition may not be appreciated fully by a relative or healthcare professional, and the condition may be dismissed as a simple cosmetic problem (Halvorsen et al 2011). It is important to realise that the degree of psychological distress can vary. Psychological evaluation is not carried out routinely in primary care because assessment of psychological disability is generally undertaken in secondary care or when the assessment of psychological disability resulting from acne is deemed particularly severe (Papadopoulos and Bor 1999). This can be misleading because the perception of severe acne can differ considerably between patients and healthcare professionals (Joseph 2010). In addition, it has been suggested that the psychological effects of skin disease between patients in primary or secondary care are similar (Harlow et al 2000). Tools such as the Assessment of Psychological Effects of Acne (ASPEA) (Layton et al 2004) (Box 1) and the Dermatology Quality of Life Index (DQLI) (Basra et al 2007) have been validated and can help to identify the psychological effect of the condition (Basra et al 2007). Other assessment tools include the Cardiff Acne Disability Index (Mottley and Finlay 1992) and those that are prepared by individual specialists. However, there appears to be little consistency between the assessments undertaken, although they have the common goal of assessing quality of life. Quality of life questionnaires assess the effect of the condition over the preceding week of the patient’s life. Since this can change over time, it is important to repeat the questionnaire at regular intervals, and in doing this, quality of life can be quantified and any improvement or deterioration recognised (Joseph 2010). Psychological support may be required if there is evidence of low mood or depression. Early recognition of depression or psychological difficulties, alongside clinical findings, can promote holistic support for the patient, which is beneficial for recovery (Chinn et al 2002). The ASPEA assists the healthcare professional to recognise answers that could suggest psychological distress in a subjective way (Layton et al 2004). For example, a patient who indicates that he or
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she has worrying thoughts and is withdrawn should prompt the healthcare professional to provide further support (Basra et al 2007). This might include referral to specialist counselling or psychiatric support services. Other quality of life questionnaires result in the development of scores that should promote a more objective record for measuring distress (Joseph 2010). Despite the existence of several psychological scales, the assessments used vary considerably. Few are used in the primary care settling and many healthcare professionals are unaware of their existence (Layton et al 2004). The DQLI assessment tool is not specific to the diagnosis of acne and is designed to be used for all skin conditions that potentially affect psychological wellbeing (Basra et al 2007). It has been suggested that if the quality of life assessment is undertaken alongside the clinical assessment, greater quality of care is achieved. Completing a full clinical and psychological assessment can assist in guiding clinical decision making as well as highlighting when referral to secondary care is necessary (Joseph 2010). Joseph (2010) also suggested that measuring quality of life can result in increased patient satisfaction in the knowledge that a healthcare professional is concerned and interested in the way the condition is affecting the patient. Even if a formal assessment tool is not used, it is important that the healthcare professional is aware of the psychological effect of the condition so that the appropriate questions can be asked and areas of concern addressed (Layton et al 2004). These questions can then assist the nurse in identifying the effect of acne on the social and psychological wellbeing of the individual. Healthcare professionals working in primary care settings are in an ideal position to offer patients with acne the support and education they may need (Kernick et al 2000). Support can be given through written and verbal information, counselling services can be employed and referral to mental health support services in cases of severe acne can be arranged (Joseph 2010). In some areas, support groups have been set up and patients can be directed to these groups when appropriate. It is important that healthcare professionals are aware of what is available in their local area so that they can use these resources to maximum effect.
Conclusion Acne is generally considered a minor disorder, but it is important to appreciate that the condition can result in severe psychological and social disturbances. It is easy to dismiss these
BOX 1 Assessment of the social and psychological effects of acne In questions 1-6, tick the most appropriate answer: In the past week 1. Worrying thoughts have been going through my mind: a) Most of the time. b) A lot of the time. c) Now and again. d) Only occasionally. 2. I can still feel at ease and relaxed: a) Definitely. b) Usually. c) Not very much. d) Never. 3. I feel restless and have to be on the move: a) Definitely. b) Quite a lot. c) Not very much. d) Never. At this moment 4. I like how I look in photographs: a) Not at all. b) Sometimes. c) Very often. d) Most of the time. 5. I wish I looked better: a) Not at all. b) Sometimes. c) Often. d) Nearly always. 6. On the whole I am satisfied with myself: a) Strongly disagree. b) Disagree. c) Agree. d) Strongly agree. In questions 7-15 read and scale the answers from 1-10, with 0 being never and 10 being all the time. 7. I still enjoy the things I used to do. 0 1 2 3 4 5 6 7 8 9 10 8. I am more irritable than normal. 0 1 2 3 4 5 6 7 8 9 10 9. I feel that I am useful and needed. 0 1 2 3 4 5 6 7 8 9 10 10. My skin condition limits me going shopping. 0 1 2 3 4 5 6 7 8 9 10 11. My skin condition stops me socialising. 0 1 2 3 4 5 6 7 8 9 10 12. My skin prevents me going on holidays or outings. 0 1 2 3 4 5 6 7 8 9 10 13. My skin condition prevents me eating out. 0 1 2 3 4 5 6 7 8 9 10 14. My skin stops me using public changing areas. 0 1 2 3 4 5 6 7 8 9 10 15. I feel my skin condition might interfere with my chances of future employment. 0 1 2 3 4 5 6 7 8 9 10 (Adapted from Layton et al 2004)
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Art & science dermatology nursing disturbances when the clinical presentation appears mild because the psychological effect on quality of life might not directly correspond with the symptoms observed. This can make assessment complex. Because patients may have indirectly blamed themselves for the condition or accepted it as something that everyone experiences, they may have been experiencing physical and emotional symptoms for a period of time before seeking help. Therefore, it is important that a full prompt assessment of the condition is undertaken during which clinical and psychological needs are recognised (Joseph 2010). A discussion with the patient is required to dispel misconceptions about
the condition and to emphasise that acne is a chronic disease and that responses to treatments can be slow. Formal psychological assessment of skin conditions remains within the secondary care setting, even though the psychological effects of skin disease on patients in primary or secondary care are similar (Harlow et al 2000). Therefore, an increased awareness of the psychological effect of acne is important in improving quality of life for the patient. Early recognition of depression or psychological difficulties, alongside clinical findings, can promote holistic support for the patient, and is essential to ensure continual improvement in care NS
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