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The Impact of Pyschological Stress on Acne

  • University Hospital Center Zagreb, University of Zagreb School of Medicine
  • University Hospital Centre Zagreb, Croatia, Zagreb


Acne is one of the most common skin disorders. it is a mul-tifactorial and complex disease, originating in the pilosebaceous follicle where a hereditary background, androgens, skin lipids, disorders of keratinization, inflammatory signaling, and regulatory neuropeptides seem to be mainly involved. even though emotional stress has long been suspected to trigger or exacerbate acne, its influence on acne severity has been mostly underestimated until recently when studies have brought new data about the different mechanisms and possible factors involved in this interaction. A point to note is that there have been relatively few studies examining stress as a possible cause of acne or acne exacerbation; more studies have focused on stress and mental health problems occurring as a result of acne. in this review, we have tried to identify the underlying mechanisms that link stress to acne according to the latest scientific findings, and we summarize this perplexing connection. the basis for the association between emotional stress and the onset or exacerbation of acne is in several cutaneous neuro-genic factors which interact with a pathogenic cascade in acne. this bi-directional intimate relationship of the skin and the mind emphasizes the importance of a holistic and interdisciplinary approach to caring for patients with acne that involves not only dermatologists but also psychologists and psychiatrists.
The Impact of Pyschological Stress on Acne
Anamaria Jović, Branka Marinović, Krešimir Kostović, Romana Čeović,
Aleksandra Basta-Juzbašić, Zrinka Bukvić Mokos
University Hospital Centre Zagreb, Department of Dermatology and Venereology,
University of Zagreb School of Medicine, Zagreb, Croatia
Corresponding author:
Anamaria Jović, MD
University Hospital Centre Zagreb
Department of Dermatology and Venereology
University of Zagreb School of Medicine
Šalata 4
10000 Zagreb
Acta Dermatovenerol Croat 2017;25(2):133-141 CLINICAL ARTICLE
ABSTRACT Acne is one of the most common skin disorders. It is a mul-
tifactorial and complex disease, originating in the pilosebaceous follicle
where a hereditary background, androgens, skin lipids, disorders of
keratinization, inammatory signaling, and regulatory neuropeptides
seem to be mainly involved. Even though emotional stress has long
been suspected to trigger or exacerbate acne, its inuence on acne
severity has been mostly underestimated until recently when studies
have brought new data about the dierent mechanisms and possible
factors involved in this interaction. A point to note is that there have
been relatively few studies examining stress as a possible cause of acne
or acne exacerbation; more studies have focused on stress and mental
health problems occurring as a result of acne. In this review, we have
tried to identify the underlying mechanisms that link stress to acne ac-
cording to the latest scientic ndings, and we summarize this perplex-
ing connection. The basis for the association between emotional stress
and the onset or exacerbation of acne is in several cutaneous neuro-
genic factors which interact with a pathogenic cascade in acne. This bi-
directional intimate relationship of the skin and the mind emphasizes
the importance of a holistic and interdisciplinary approach to caring
for patients with acne that involves not only dermatologists but also
psychologists and psychiatrists.
KEY WORDS: acne, psychological stress, sebaceous gland, neuroendo-
Acne vulgaris is, along with eczema and psoriasis,
one of the most commonly seen chronic inamma-
tory skin diseases aecting individuals of all ages.
Eighty-ve percent of people between the ages of 12
and 24 will have some form of acne (1). Direct costs
related to acne, including loss of productivity and
related depression, exceed $2.2 billion annually in
the United States (2). It is a multifactorial and com-
plex disease, originating in the pilosebaceous follicle.
Four primary inter-related pathogenic factors of acne
have been recognized for decades: overproduction
of sebum, abnormal shedding of follicular epithelial
cells, Propionibacterium acnes follicular colonization,
and inammation (3-6). However, other endogenous
and exogenous factors like psychological stress, diet,
smoking, hormone concentrations, oxidative stress,
and genetic predisposition have been considered as
factors that can trigger or worsen acne (7-15). In the
past, most of the studies have focused on stress and
psychological consequences occurring as a result
Received: July 25, 2016
Accepted: May 25, 2017
of acne with only a few studies examining stress as
a possible cause of acne or acne exacerbation. Even
though emotional stress has long been suspected
to exacerbate acne, previous reports on its inuence
on acne severity have mostly been scientically un-
founded until the recent decade when psychoemo-
tional stress was conrmed as a pathogenetic aspect
in acne vulgaris (16,17). Additionally, studies have
shown that psychological stress can alter the immune
functions of the skin (18,19) and cutaneous barrier
function (20,21). The association between the mind
or mental health and dermatology has been claried
by the mounting evidence that microbial residents
and the functional integrity of the intestinal tract may
play an interceding role in both skin inammation
and emotional behavior (the gut-brain-skin theory).
The physiological association between intestinal mi-
crobiota, psychological symptoms such as depres-
sion, and inammatory skin conditions such as acne
was examined long ago and was recently validated
further by modern scientic investigations (22-26). It
has become evident that gut microbes and oral pro-
biotics may be related to the skin, specically acne
severity, through their ability to inuence systemic
inammation, oxidative stress, glycemic control, tis-
sue lipid content, and even mood (27-29).
Acne is undoubtedly a cause of anxiety and stress
in those who suer from it, and these patients suer
mainly from social limitations and reduced quality of
life (30-33). Psychological factors associate with acne
in at least three ways, described below.
First, emotional stress can exacerbate acne, as re-
ported by a high number of acne patients. Second,
as a consequence of acne, it is common for patients
to develop psychiatric problems like social phobias,
low self-esteem, or depression. Last but not least,
some mental diseases like psychosis and obsessive-
compulsive disorder may be dependent on an acne-
related issue (34).
The main diculty in evaluating the signicance
of acne on quality of life is resolving the chicken or the
egg dilemma: does acne cause psychiatric distress, or
do the stress and daily life changes exacerbate acne?
Yes, it seems to. Many patients report that emo-
tional stress makes their acne worse, and these
statements were conrmed in several studies by a
signicant percentage of aected adolescents and
adults (varying between 50-80%) (35-38). Griesemer
found that patients with acne reported a lag time
of two days between a stressful episode and the ex-
acerbation of acne (39). Lorenz et al. found that in-
tense anger also may aggravate acne severity (40).
An Australian survey that included 215 graduating
medical students, reported that 67% of them identi-
ed stress as one of the factors leading to acne ex-
acerbations (37). Two Korean epidemiological studies
found psychological stress to be the main triggering
or aggravating factor inuencing acne as reported by
the majority (80-82%) of patients (38). A prospective
cohort study, published in 2003, which comprised 22
university students, showed increased acne severity
during stressful exam periods by using previously
validated scales measuring acne severity and per-
ceived stress. Acne severity was signicantly associ-
ated with increased stress levels in comparison with
the period without exams despite adjusting for con-
founding factors such as lack of sleep and changes
in diet (17). Similar ndings have also been reported
by other, mostly questionnaire-based studies (41-44).
One study conducted with high school students also
found that increased stress correlated with increased
acne severity; there also did not seem to be any in-
creased sebum production during times of stress
(45). On the other hand, conicting ndings were
presented in a recent study consisting of 40 patients
with acne vulgaris (46). The authors concluded that
the intensity of stress does not correlate with the se-
verity of acne and they hypothesized that course of
the disease may depend on the tolerance to stress
and methods of coping with stress.
Over the last few years, there has been more and
more discussion on adult acne, specically adult fe-
male acne that dierentiates itself from adolescent
acne by its specic clinical aspects, its evolution, and
dierent physiopathological mechanisms (47). Fre-
quently, stress is reported as a factor triggering fe-
male acne. For Dumont-Wallon, it is part of the four
most often described factors promoting acne (48).
Dreno et al. conducted a large-scale prospective ob-
servational international study evaluating clinical
characteristics of acne and lifestyle in adult women
(≥25 years). There was an association between job
stress and acne severity, which could bolster the re-
lationship between stress and acne. The signicant
majority of subjects (83.2%) reported at least moder-
ate stress, including 15.5% who reported high-stress
levels. A total of 23.0% examinees reported that their
jobs were psychologically stressful, and job stress
was correlated with more severe acne in women. It
has also been shown that compared to women with-
out localized acne, those with mandibular acne were
more likely to be employed, reported greater daily
stress levels (5.8% vs. 5.1%), and were more likely to
Jović et al. Acta Dermatovenerol Croat
Impact of psychological stress on acne 2017;25(2):133-141
dene their jobs psychologically stressful (71.4% vs.
57.5%) (49). Similar ndings were published by Poli
et al. who reported that stress was recorded as causal
factor for acne in 50% of women aged 25-40 years
who completed a self-administered questionnaire
Adult female acne has increased in prevalence in
recent years, reaching up to a reported percentage of
41-54% (47); this can be partly explained by the fact
that social pressure is high for adult women, speci-
cally the demands of work or a career in addition to
the duties of a mother and wife. Women also have a
greater risk of developing psychiatric disorders such
as depression and anxiety (50,51). Moreover, large
cities demand a lifestyle which requires sleep depri-
vation, an intrinsic stressor which is increased in the
modern lifestyle and has several negative conse-
quences on health, including hormonal secretion and
the immune system (21,52). Thus, the stress caused by
worsened sleep quality may exercise a relevant role in
adult female acne, as this disease has increased sig-
nicantly in the last decade (53).
Stress is a term we are faced with in everyday life,
being a stimulant for some but pressure for many
others. Psychological stress is an accepted fact of life,
usually triggered by a stimulus that induces a reac-
tion in the brain. As a consequence, additional physi-
ological systems are activated in the body, including
the immune, endocrine, and nervous systems (54,55).
The concept of the skin neuro-endocrine was formu-
lated twenty years ago, and recent advances in this
eld additionally strengthened evidence of its role.
We may say that skin is a bi-directional platform for
a signal exchange with other peripheral organs, such
as endocrine and immune system (56). Skin cells and
appendages not only respond to neuropeptides, ste-
roids, and other regulatory signals but also actively
synthesize a variety of hormones (57). The skin repre-
sents the rst line of defense against many noxious en-
vironmental inputs. Some researchers have indicated
that the skin is especially sensitive to psychological
stress. Experimental ndings demonstrate that stress-
ors aect cutaneous and adaptive immunity (18); fur-
thermore, psychological stress alters cutaneous bar-
rier homeostasis (20,21,58). For example, it has been
shown that the recovery time of the stratum corneum
barrier is reduced after elimination of psychological
stress (innate immunity) (59). Antigen presentation
by epidermal Langerhans cells (adaptive immunity)
was also altered (60). Moreover, psychological stress
may trigger or exacerbate immune-mediated der-
matological disorders. As an evolutionary adaptation
to the ght-or-ight response, psychological stress
generates some responses that can be detrimental in
some states. Stress signals initiate the hypothalamus-
pituitary-adrenal (HPA) axis and the sympathetic ner-
vous system, while also inducing secretion of dier-
ent neurotransmitters, cytokines, and hormones that
possess skin receptors and can aggravate several skin
diseases, including acne (24-27). The exact mecha-
nisms of stress-induced triggering or aggravation of
acne have not yet been completely understood; how-
ever, various mechanisms have been proposed. Some
believe that glucocorticosteroids and adrenal andro-
gens are released during emotionally stressful peri-
ods and lead to acne worsening. The skin expresses
specic genes involved in pathways associated with
inammation and extracellular matrix remodelling
at higher rates in acne-aected parts compared to
acne-unaected skin, including genes encoding for
matrix metalloproteinases 1 and 3, interleukin-8, hu-
man β-defensin 4, and granzyme B (61). Facial skin
from patients with acne is characterized by rich inner-
vation, by increased numbers of substance P-contain-
ing nerves and mast cells, and by high expression of
neutral endopeptidase in the sebaceous glands (SG)
compared with healthy skin (62).
New data regarding the physiology of SG indi-
cate that SG have receptors for numerous neuropep-
tides (β-endorphin, corticotropin-releasing hormone
(CRH), urocortin, proopiomelanocortin, vasoactive in-
testinal polypeptide, neuropeptide Y, and calcitonin
gene-related peptide), and these receptors modulate
inammation, proliferation, and sebum production
and composition, as well as androgen metabolism in
human sebocytes. These neuroendocrine factors with
their autocrine, paracrine, and endocrine actions ap-
pear to mediate centrally and topically induced stress
towards the SG resulting in the clinical course of acne
Corticotropin-releasing hormone (CRH)
As acne is apparently exacerbated by acute or
chronic psychological stress, the corticotropin-releas-
ing hormone (CRH) appears to be an important as-
pect in the development of acne lesions (63,64). CRH
is a 41-amino acid polypeptide; the innate eect of
CRH and related peptides involves interactions with
membrane-bound CRH receptor type 1 (CRHR-1) and
type 2 (CRHR-2), and it can be modied by its binding
protein (CRH-BP) at the central, local, or systemic lev-
els (65). Pro-CRH processing into CRH appears to be
similar at the central and peripheral levels, including
the skin (66). CRHR-1 is said to be the predominant
form of CRHR expressed in the human skin and pos-
sibly plays a signicant role in coordinating responses
Jović et al. Acta Dermatovenerol Croat
Impact of psychological stress on acne 2017;25(2):133-141
to external stress in analogy to the central response.
CRHR-2 expression was fully documented in cells of
adnexal structures, smooth muscle, blood vessels,
and selected cells of immune origin, and rather plays
a modulatory role. CRH is one of the main compo-
nents of the stress system, the HPA axis, acting to
stimulate attention, inhibit appetite, and promote
secretion of adrenocorticotrophic hormone (ACTH),
α-melanocyte-stimulating hormone, other proopi-
omelanocortin (POMC) derived peptides, and β-en-
dorphin in the pituitary gland via the activation of
CRHR-1 (67). ACTH, in turn, stimulates the production
and secretion of cortisol or corticosterone by the ad-
renal cortex through the activation of melanocortin
receptor type 2 (MC2R). CRH is synthesized among
others by keratinocytes, immune cells, and human
mast cells under the inuence of stress. Propioni-
bacterium acnes, a commensal bacteria of the skin
whose proliferation is linked to acne, can stimulate
the production of CRH by keratinocytes (68). CRH is
also reported to act as a growth factor in the skin by
activating CRHR-1. It plays a role in the regulation of
keratinocyte proliferation and dierentiation, repre-
senting an important step in the early stages of the
development of acne lesions (69). It is also an inhibi-
tor of the early and late apoptosis of many skin cell
types such as keratinocytes, dermal broblasts, and
melanocytes (70). Moreover, CRH is known to act on
inammation by inducing the degranulation of mast
cells (71), the release of inammatory cytokines, and
the modulation of immune cells; CRH enhances inter-
leukin-6 and inhibits IL-1β production in human kera-
tinocytes (72). On the other hand, a study examining
the concentrations of cortisol, 11-deoxycortisol, and
adrenal androgen in women aged 19-39 years with
idiopathic acne before and after inducing prolonged
adrenal stimulation via ACTH infusion reported there
were no signicant dierences in the levels of these
hormones among women with acne and controls
(73). However, this does not undermine the impor-
tance of these hormones in acne development but
rather leads us to the ndings that acne development
and its clinical course depend on the neuroendocrine
factors that mediate stress towards the SG (17,74).
It has become apparent that SG is an organ with
an independent peripheral endocrine function
which, together with the sweat glands, encompasses
the vast majority of androgen metabolism in the skin.
The presence of a complete CRH system in human
sebocytes has been conrmed in vitro and in vivo
(75,76). CRH is a major autocrine hormone in these
cell types with homeostatic dierentiation activity. It
directly induces lipid synthesis and steroidogenesis
and enhances mRNA expression of 5-3β-hydroxys-
teroid dehydrogenase, independently from the HPA
axis (16,76). CRH regulates the lipid synthesis in hu-
man sebocytes, promoting up-regulation at lower
concentrations of lipid content and inducing a de-
crease when the levels are higher (76). Testosterone
and growth hormone, which also enhance sebaceous
lipid synthesis, were found to antagonize CRH activ-
ity and CRHR expression; precisely, testosterone sup-
presses CRHR-1 and CRHR-2 mRNA expression in SZ95
sebocytes while growth hormone switches CRHR-1
mRNA expression to CRHR-2 (76). These ndings im-
plicate the involvement of CRH in the clinical devel-
opment of acne and seborrhea, as well as in further
skin diseases associated with alterations in the forma-
tion of sebaceous lipids. Ganceviciene et al. analyzed
CRHRs by immunohistochemistry in three groups of
biopsies; the facial skin biopsies of 33 acne patients,
non-involved thigh skin of these patients, and nor-
mal skin of eight age-matched healthy volunteers
(74). There was a denite positive reaction for CRH
in acne-involved skin in all types of SG cells, regard-
less of their dierentiation stage. The results diered
in noninvolved and healthy skin biopsies where SG
exhibited a weaker CRH staining depending upon the
dierentiation stage of sebocytes. The most positive
reaction for CRH-BP in acne-involved SG was in dier-
entiating sebocytes. CRHR-1 and CRHR-2 showed the
strongest expression in sweat glands and SG, respec-
tively. They concluded that expression of the com-
plete CRH system is abundant in acne-involved skin,
especially in SG, possibly activating pathways that af-
fect immune and inammatory processes leading to
the development and stress-induced exacerbation of
acne. Concerning the clinical perspectives of CRH and
its receptors in the pathogenesis and the course of
acne, CRHR antagonists could soon arise as possible
therapeutics. At this time, there have already been
some studies demonstrating this eect (77).
Melanocortin (MC) peptides can also directly af-
fect the function of human sebocytes via MC recep-
tors. Alpha-melanocyte-stimulating hormone -
MSH) has been demonstrated to act as a modulator
of the preputial rat gland, a specialized sebaceous
gland-like structure of rodents. The eect of α-MSH is
mediated through binding to G-protein-coupled MC
receptors (MC-R) on the cell surface of the target cell.
To this point, ve dierent MC-Rs have been cloned
(78). The presence of both MC-R, specically MC-1R
and MC-5R, which bind α-MSH, were detected in hu-
man sebocyte cultures established from the facial
skin as well as in immortal human sebocyte cell line
– SZ95 (79-81). In SZ95 sebocytes, α-MSH partially
Jović et al. Acta Dermatovenerol Croat
Impact of psychological stress on acne 2017;25(2):133-141
prohibited the inductive eect of IL-1β on the se-
cretion of IL-8, an important chemokine that directs
neutrophils to inammatory sites including SG (79).
In acne-involved skin, sebocytes and keratinocytes of
the ductus seboglandularis showed MC-1R expres-
sion to a high degree in contrast with less intense
dispersed immunoreactivity in normal skin samples,
suggesting that this receptor is involved in the initia-
tion of acne. It has been shown that proinammatory
signals up-regulate MC-1R (82). Since proinamma-
tory cytokines are upregulated in acne lesions (83),
based on the previously mentioned data, sebocytes
would respond to these cytokines with increased
MC-1R expression, thereby generating a negative
feedback mechanism for α-MSH which exerts direct
anti-inammatory actions as it inhibits IL-1β-medi-
ated IL-8 secretion.
The expression of MC-5R is weaker than that
of MC1-R, but it has been shown to be a marker of
human sebocyte dierentiation, since it is only ex-
pressed in dierentiated, lipid-containing sebocytes.
The targeted disruption of MC-5R in mice resulted in
reduced sebaceous lipid production and a severe de-
fect in water repulsion (81). These ndings of Zhang
et al. stimulated a search for MC-5R antagonists as
potential sebum-suppressive agents. As anticipated,
an antagonist-inhibited sebocyte dierentiation in
vitro and reduced sebum production in human skin
transplanted onto immunodecient mice. These data
suggest that antagonists of MC-1R and MC-5R could
be active sebum-suppressive agents, clinically useful
for the treatment of disorders with excessive sebum
production, such as acne (81,84). Clinical trials with
MC-5R antagonists, like topical gel MTC896, have
been initiated for the treatment of excessive sebum
production in subjects with acne and other skin con-
ditions. MTC896 has completed Phase II clinical trials
Substance P
There have been various reports that demon-
strate an association between human sebocytes and
neurogenic stress axes. Nerve bers release neuro-
genic neuromediators, neuropeptides (NEP), that
exert proinammatory responses on immune system
cells and/or cells of many peripheral tissues as well as
the skin (86,87). Substance P (SP), an important neu-
ropeptide related to stress response and pain, also
plays a fundamental role in acne (88). The sebaceous
gland of patients with acne expresses SP (6,62). In
2002, Toyoda et al. demonstrated for the rst time in
cultured sebocytes that SP stimulates NEP expression
by sebaceous cells in a dose-dependent manner, in
addition to the fact that more numerous SP-contain-
ing nerve bers were present around SG of the facial
skin in patients with acne compared with controls
(62). Later, Lee et al. demonstrated that the addition
of SP induced less proliferation and dierentiation.
Furthermore, the addition of SP increased immunore-
activity to interleukin-1 (IL-1), interleukin-6 (IL-6), and
tumor necrosis factor-α (TNF-α), demonstrating the
inuence of SP on the production of inammatory
mediators (89). Since these ndings, the active patho-
genic role of SP as a potential mediator of neurogenic
inammation in acne has been acknowledged. These
results indicate a connection of neurogenic factors
such as neuropeptides with the pathogenesis of acne
and represent a plausible mechanism for the exacer-
bation of acne from a neurological point of view (90).
There is increasing evidence that psychological
stress is an important factor in acne pathogenesis.
Emotional stress associated with the production of
hormones, neuropeptides, and inammatory cyto-
kines inuences the chronic course and exacerbation
of acne by altering the activity of the pilosebaceous
unit. These mechanisms involve the HPA axis and
the neuro-immuno-cutaneous system where neu-
ropeptides and hormones such as CRH, melanocor-
tins, and substance P play a substantial role. On the
other hand, great emotional distress and dysmorphic
tendencies may develop as the consequence of this
disease. Therefore, dermatologists should be capable
of recognizing the psychological factors which either
contribute to the exacerbation of acne or inuence
the self-perception of patients with acne. Addition-
ally, an interdisciplinary therapeutic approach should
be employed in qualifying patients, involving not
only dermatologists but also psychologists and psy-
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... Acne, particularly in the young population, can cause severe distress, resulting in poor self-image, depression, and anxiety, as well as uncertainty [18][19][20], and has a negative impact on quality of life (QOL) [21][22][23]. Acne's consequences worsen its severity and frequency. e central tenets of acne treatment include benzoyl peroxide, topical or oral retinoids such as isotretinoin, antibiotics, and oral spironolactone [24]. ...
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Stress plays an important role in the causation and aggravation of psychodermatological conditions such as acne vulgaris. Alpha casein hydrolysate (αs1-casein hydrolysate; Lactium) has been shown to decrease serum cortisol levels, reduce stress-related symptoms, and promote relaxation. “This study aimed to compare the efficacy and safety of Lactium™ plus standard care to those of standard of care alone in reducing stress levels and acne severity in patients with acne vulgaris.” The C.E.R.T.A.I.N trial (Name registered with Clinical Trials Registry-India-No. CTRI/2019/01/017172) is a randomized, controlled, multicenter, open-label, two-arm, investigator-initiated clinical trial. A total of 100 patients with moderate-to-severe acne vulgaris were enrolled and randomly assigned to one of the two groups: Lactium™ plus standard care or standard care alone. Stress levels were assessed using serum cortisol levels, Investigator’s Global Assessment (IGA) acne severity scale scores, Perceived Stress Scale (PSS) scores, and the Hamilton Anxiety Rating Scale (HAM-A) scores. The Dermatology Life Quality Index (DLQI) was also used to assess the impact of the skin disease on patients’ quality of life. At 12 weeks, stress levels were significantly lower in group A (Nixiyax plus standard of care) than that in group B(only standard care), as measured by the change in serum cortisol levels (4.75 ± 4.46 vs. −0.24 ± 5.22). Furthermore, the mean change in PSS scores (3.09 ± 2.04 vs. 0.90 ± 2.76) and HAM-A scores (5.11 ± 1.94 vs. 1.25 ± 3.13) was significant. Patients in both arms had a significant decrease in total, inflammatory, and noninflammatory acne lesions, as well as a significant improvement in DLQI and IGA scores. In patients with moderate-to-severe acne vulgaris, Lactium™ was found to be both safe and well-tolerated. Lactium™ plus standard care is more effective than standard care alone in reducing acne severity through stress reduction.
... B. Dreno et al. также относят значимый стресс (OR 1,15; р < 0,0001), нарушения сна (OR 1,15; р < 0,0001) к существенным факторам риска акне [19]. У взрослых женщин факторы стресса и нарушений сна предрасполагают к персистированию акне [42][43][44]. ...
The concept of the exposome, formulated more than fifteen years ago, is increasingly discussed in the modern scientific literature. The term “exposome” is understood as a cumulative measure of the impact of environmental factors on an individual throughout his or her life (from the prenatal period to death) and the biological response associated with it. The sum of these factors has a significant impact on the occurrence, course, and treatment efficacy of multifactorial diseases. The skin is a border organ and is constantly exposed to environmental influences, i.e., it is a target for the exposome. The influence of the latter components has been described in skin aging, atopic dermatitis, and malignant skin neoplasms. Acne is one of the most common chronic inflammatory dermatoses. Over the past decade, the worldwide increase in the incidence of acne, its early onset and a prolonged course, affecting adult men and women, has been noted. The review presents an analysis of the data on the effects of the components of the exposome – diet, medications, stress, and pollutants - on the course of acne. Particular attention is paid to the few data on the nature of interaction between the components of the exposome and the skin microbiome, which, on the one hand, is involved in the pathogenesis of dermatoses, including acne, and, on the other hand, is changed under the influence of exposome factors, acting as an intermediary between the environment and the human body. The search for environmental factors has at least two objectives: the discovery of potential pathogenetic links, the strength of their relationship with the clinical manifestations of the disease to develop new therapies aimed at new targets; and the creation and recommendation of a protective regime for factors with a proven effect on the course of the disease, for patients suffering from acne.
... anabolic steroids, hydantoin, benzodiazepines, ramipril, adalimumab, cyclosporin, isoniazid, lithium, iodides), congenital adrenal hyperplasia, adrenal tumours, polycystic ovarian syndrome and body dysmorphic disorders. [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] Pathogenesis Acne vulgaris is a chronic inflammatory process of the pilosebaceous unit. The condition usually occurs with the onset of puberty due to increased production of androgens by the adrenals and gonads and/or increased sensitivity of androgen receptors. ...
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Background: Acne vulgaris is the most common skin disease that can lead to disfigurement and psychological distress. This article aims to provide a narrative updated review on the management of acne vulgaris. Methods: A PubMed search was performed with Clinical Queries using the key term "acne". The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to articles published in English. Results: Treatments of acne include proper skin care, topical medications, oral medications and procedural therapies. Topical agents are the first-line treatment for mild-to-moderate acne and can be used as combination therapy for more severe acne. Systemic therapies are usually prescribed for the initial treatment of moderate-to-severe acne as well as for acne that is refractory to topical therapies. Conclusion: Topical retinoids are the drugs of choice for the treatment and maintenance therapy of patients with mild-to-moderate acne vulgaris. Depending on the severity of the acne, topical retinoids may be used alone or in combination with benzoyl peroxide and topical or oral antibiotics. Oral antibiotics are an important therapy for inflammatory acne unresponsive to topical therapy. Neither topical nor oral antibiotics should be used as monotherapy. Oral contraceptives and/or spironolactone are useful for many women with acne. Oral isotretinoin is the drug of choice for severe, extensive, nodular acne vulgaris but is also often used in moderate cases where scarring is evident, acne-related psychosocial distress is significant or other treatment modalities have failed.
... U patogenezi akne psihološki stres putem HPA osi sistemski povećava proizvodnju adrenalnih androgena, a u pilosebacealnoj jedinici potiče lučenje neuropeptida iz živčanih završetaka, kao što su CRH, MSH i tvar P. Sebociti posjeduju vlastite mehanizme za sintezu neuropeptida, a njihova lokalna produkcija stimulira lučenje citokina, utječe na produkciju i kompoziciju sebuma te potiče steroidogenezu u sebocitima, time pogoršavajući akne. Stres također može prolongirati proces cijeljenja rane važan u mehanizmu nastanka ožiljaka 47,48 . ...
Acne vulgaris kronična je upalna bolest multifaktorijalne etiologije koja zahvaća pilosebacealnu jedinicu. Karakteristično razdoblje obolijevanja je adolescencija, uz sve češće perzistiranje ili pojavu akne u odrasloj životnoj dobi. Klinička slika može varirati od blage do teške, a karakterizira je raznovrsnost lezija koje uključuju komedone, papule, pustule, nodule, ožiljke te hiperpigmentacije i postupalne eriteme. Etiopatogeneza akne složena je i uključuje interakciju brojnih endogenih i egzogenih čimbenika. Glavni patogenetski mehanizmi odvijaju se u pilosebacealnoj jedinici, a podrazumijevaju pojačanu produkciju i promijenjenu lipidnu kompoziciju sebuma, hiperkeratinizaciju, razmnožavanje Cutibacterium acnes bakterije i upalu. Osim navedenih danas se istražuju i drugi etiološki čimbenici koji mogu pridonijeti nastanku akne, a uključuju prehranu, stres, povezanost crijevne mikroflore, mozga i kože, utjecaj sunca, predmenstrualnu pojavu akne, komedogenu kozmetiku i pušenje. S obzirom na raznovrsnost etioloških čimbenika i složenost patogeneze pronalazak jednog lijeka zadovoljavajućeg učinka i dobre podnošljivosti nije lak. Akne zbog svoje lokalizacije na pogledu izloženim dijelovima tijela te karakteristične kliničke slike koja uključuje nastanak trajnih ožiljaka, mogu dovesti do nepoželjne stigmatizacije bolesnika i negativnih psihosocijalnih posljedica. Stoga je od iznimne važnosti dobro razumjeti i poznavati etiologiju i patogenezu akne kako bi se u budućnosti pronašle još bolje i učinkovitije metode liječenja.
... There is substantial evidence of the association between emotional stress and acne presentation [46]. The mechanisms of stress-induced triggering or aggravation of acne involve the hypothalamus-pituitary-adrenal axis and the neuro-immuno-cutaneous system where neuropeptides and hormones such as corticotropin-releasing hormone, melanocortins, and substance P-containing nerves and mast cells, play an important role [47][48][49][50]. However, these mechanisms have not yet been completely understood. ...
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Background Acne is a common chronic inflammatory skin disease with a high prevalence in adolescent and early adult years. The aim of this study was to assess the self-perceived beliefs of Montenegrin secondary school pupils regarding the acne aggravating and ameliorating factors. Methods This cross-sectional survey of the pupils was conducted during October and November 2020 in four randomly selected public secondary schools in Podgorica, Montenegro. All 500 pupils were asked to fill in a questionnaire that included questions on age, sex, presence of acne, perceived acne aggravating and ameliorating factors, and sources of their information about acne. Results A total of 500 pupils, 234 (46.8%) boys, and 266 (53.2%) girls, aged 14−17 years, participated in the study. Acne was self-reported in 249 (49.8%) pupils, whereas 251 (50.2%) did not report acne. Factors most often believed to aggravate acne were inadequate face washing (85.0%), hormones (84.0%), sweets (82.0%), greasy food (72.6%), makeup (71.2%), and stress (67.8%). Overall the most prevalent acne ameliorating factors were cosmetic treatment (80.4%), increased water consumption (77.6%), a diet change to a healthier food choice (77.4%), and being on school holidays (62.2%). Girls reported more frequently that genetics, stress, sweets consumption, inadequate face wash, and makeup are acne exacerbating factors, whilst cosmetic treatment, increased water consumption, smoking, and being on school holidays are acne ameliorating factors. Boys more frequently considered the benefit of losing weight. There was no statistically significant difference between pupils with and without acne in perceived factors, except for cosmetic treatment. Those with acne more frequently believed in the benefits of cosmetic treatment. Conclusions Many adolescents’ self-perceived beliefs about factors that aggravate and ameliorate acne are myths and misconceptions without evidence-based justification. More efforts are needed to educate pupils about the acne aggravating and ameliorating factors, its health-related consequences, and the treatment possibilities.
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Stress is one of the significant triggers of several physiological and psychological illnesses. Mobile health apps have been used to deliver various stress management interventions and coping strategies over the years. However, little work exists on persuasive strategies employed in stress management apps to promote behavior change. To address this gap, we review 150 stress management apps on both Google Play and Apple's App Store in three stages. First, we deconstruct and compare the persuasive/behavior change strategies operationalized in the apps using the Persuasive Systems Design (PSD) framework and Cialdini's Principles of Persuasion. Our results show that the most frequently employed strategies are personalization, followed by self-monitoring, and trustworthiness, while social support strategies such as competition, cooperation and social comparison are the least employed. Second, we compare our findings within the stress management domain with those from other mental health domains to uncover further insights. Finally, we reflect on our findings and offer eight design recommendations to improve the effectiveness of stress management apps and foster future research.
Background: Acne vulgaris (AV) is an inflammatory disease of the pilosebaceous unit, which often causes stress and disrupts quality of life. Correctly identifying precipitating factors and preventing disease development will holistically increase the effectiveness of acne therapy, enabling better therapeutic outcomes to be achieved. Purpose: The objective of this study is to identify the clinical profile and precipitating factors of AV patients who visited Dr. Saiful Anwar Hospital between 2015 until 2017. Methods: This was a descriptive study, using a retrospective case study approach. The sample data was collected from medical records of AV patients from the period of 2015–2017 who met the following inclusion criteria: new AV cases with a complete medical record including gender, age, and precipitating factors. The dependent variable of this study was new AV patients, while the independent variables were the patient clinical profile and precipitating factors. Results: This study included 930 samples, with the number of female patients significantly higher (75.48%) than the number of males. The highest AV prevalence was found in the 15–24 years age group. The most common precipitating factors in females were hormonal issues, stress, and cosmetics; in males, these were stress, genetics, and dietary factors. Conclusion: The incidence of AV at Dr. Saiful Anwar Hospital mostly occurs in the 15–24 years age group, with varying trigger factors. The most frequent AV trigger factor in female patients was hormonal issues; in males, this was stress.
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Introduction: Stress persists when a person is unable to cope with the situations of the past, present or future. Stress may be associated with physical and psychological abnormalities. Acne vulgaris is a chronic inflammatory disease of the pilo-sebaceous units with prevalence of more than 85% in adolescent age group. Materials and Methods: Three hundred one patients were recruited in the study. Inclusion criteria included new acne patients of age 16 years and above as well as those who were using but not improving with topical or oral acne therapies. Exclusion criteria included patients receiving sedatives, antidepressants, or glucocorticoids, patient suffering from chronic illnesses like diabetes, hypothyroidism, chronic kidney disease, migraine and other diseases. This questionnaire included biodata of the patients, clinical history and their perceived stress scale. Global Acne Grading System (GAGS) was used to assess acne severity in relation to stress using the Perceived Stress Scale (PSS). Results: The results indicated an increase in stress severity positively correlated with an increase in acne severity, which was statistically significant (p<0.01). Most of the patients were students. Subjects with higher stress scores, determined using the PSS, had higher acne severity when examined and graded using the GAGS. Conclusions: The results showed that there is a positive correlation between severity of stress and grade of acne. Stress management should be a part of acne management.
The relationship between stress and skin health has been documented since ancient times. This chapter provides an overview of the biological pathways believed to play a role in the relationship between psychosocial stress and the physical appearance of skin. It summarizes the clinically important relationships and emphasizes areas of significant academic, clinical, and commercial impact. The molecular factors that comprise the central (systemic) and cutaneous (peripheral) stress axes provide important background for the clinical effects of stress on skin health. Psychosocial stress affects skin health through complex interactions with neuroendocrine, immune, and microbial networks. The understanding of the classic hypothalamic‐pituitary‐adrenal stress axis has expanded to include its cutaneous analog, considering a likely bidirectional relationship between the systemic and local stress response. Emerging studies of the skin microbiome highlight the importance of commensal bacteria and demonstrate microbial activation of the stress axis.
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Background: Psychological stress is an important factor of acne pathogenesis. Stress related production of hormones, cytokines and neuropeptides may result in the chronic course and exacerbations of the disease. Objective: The aim of the study was to evaluate the relationship between acne severity, intensity of emotional stress and serum concentration of substance P (scSP), to compare the intensity of adversities, psychological stress and scSP in acne patients with healthy controls and to compare coping techniques for stress. Methods: The study consisted of 80 patients. Emotional stress was analyzed with the use of social readjustment rating scale, whereas the methods of coping with stress were assessed with the coping inventory for stressful situation questionnaire. The blood concentration of substance P was analyzed by enzyme-linked immunosorbent assay method in a group of 40 patients with acne vulgaris and in control subjects. Results: There was no statistically significant difference between the severity of acne and the intensity of stress. Acne patients presented a higher average scSP than the controls. No statistically significant correlation was observed between the severity of acne and scSP; however, the intensity of stress correlated with scSP in the control group. The evaluation of methods of coping with stress showed significantly higher rate for the avoidance-oriented coping among acne patients. Conclusion: The number of stressful events is not a factor that determines the severity of acne. The course of the disease may depend on tolerance to stress and methods of coping with stress. (Ann Dermatol 28(4) 464∼ 469, 2016)
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Sleep has a critical role in promoting health. Research over the past decade has documented that sleep disturbance has a powerful influence on the risk of infectious disease, the occurrence and progression of several major medical illnesses including cardiovascular disease and cancer, and the incidence of depression. Increasingly, the field has focused on identifying the biological mechanisms underlying these effects. This review highlights the impact of sleep on adaptive and innate immunity, with consideration of the dynamics of sleep disturbance, sleep restriction, and insomnia on (a) antiviral immune responses with consequences for vaccine responses and infectious disease risk and (b) proinflammatory immune responses with implications for cardiovascular disease, cancer, and depression. This review also discusses the neuroendocrine and autonomic neural underpinnings linking sleep disturbance and immunity and the reciprocal links between sleep and inflammatory biology. Finally, interventions are discussed as effective strategies to improve sleep, and potential opportunities are identified to promote sleep health for therapeutic control of chronic infectious, inflammatory, and neuropsychiatric diseases. Expected final online publication date for the Annual Review of Psychology Volume 66 is November 30, 2014. Please see for revised estimates.
Interest in the effect of emotional and nervous states on bodily function has been growing in this country during the past decade to a degree which makes it seem desirable that the literature on the subject as it affects the skin be collected and, when possible, critically summarized. We undertook this task with little realization of the labor and time required for even a partial fulfilment. When our bibliography approached three hundred titles on the general aspects of the matter alone, it became evident that such a résumé could not be offered before this association en masse, for the first paper itself approaches one hundred pages in length. We are therefore constrained instead to offer for this occasion one of the special summaries, of which eight were planned, dealing with that part of the field of somatopsychic correlations which is thus far most developed, in some of its possible dermatologic
Acne is a common skin disease with a high prevalence in adolescents and young adults. In addition to physical effects such as permanent scarring and disfigurement, acne has long-lasting psychosocial effects that affect the patient's quality of life. Depression, social isolation and suicidal ideation are frequent comorbidities of acne that should not be neglected in the therapy of acne patients. Research evidence suggests that the impairment of quality of life can be alleviated by appropriate topical acne treatment. © 2015 European Academy of Dermatology and Venereology.
Few clinical studies have examined the utility of bipolar fractional radiofrequency (FRF) therapy as a treatment for atrophic acne scars and active acne in people with darker skin. This study was designed to compare the safety and efficacy of bipolar FRF therapy as a treatment for atrophic acne scars and acne vulgaris. Twenty-three Japanese patients with atrophic acne scars and mild to severe acne on both cheeks were treated with a bipolar FRF system (eMatrix; Syneron, Yokneam Illit, Israel). Five treatment sessions were carried out at 1-month intervals, and the patients were followed up for 3 months after the final treatment. Assessments of scar severity and the number of acne lesions and 3-D in vivo imaging analysis were performed. Evaluations of the treatment outcomes and their effects on the patients' quality of life (QOL) were also carried out. We demonstrated that the improvement in scar volume was marked in the patients with mild scars and was at least moderate in 23 (57.5%) of the treated areas. With regard to the number of acne lesions, the treated areas exhibited significantly fewer lesions compared with the baseline at each time point (P < 0.05). The patients' assessments of the treatment outcomes and their QOL indicated that both had improved significantly by the end of the study. Furthermore, significant reductions in the patients' sebum levels, skin roughness and scar depth were observed. Bipolar FRF treatment significantly improved the atrophic acne scars and acne of Japanese patients and had minimal side-effects. © 2015 Japanese Dermatological Association.
There are four central factors that contribute to acne physiopathology: the inflammatory response, colonization with Propionibacterium acnes, increased sebum production and hypercornification of the pilosebaceous duct. In addition, research in the areas of diet and nutrition, genetics and oxidative stress is also yielding some interesting insights into the development of acne. In this paper we review some of the most recent research and novel concepts revealed in this work, which has been published by researchers from diverse academic disciplines including dermatology, immunology, microbiology and endocrinology. We discuss the implications of their findings (particularly in terms of opportunities to develop new therapies), highlight interrelationships between these novel factors that could contribute to the pathology of acne, and indicate where gaps in our understanding still exist.This article is protected by copyright. All rights reserved.
Acne pathogenesis is a multifactorial process that occurs at the level of the pilosebaceous unit. While acne was previously perceived as an infectious disease, recent data have clarified it as an inflammatory process in which Propionibacterium acnes and innate immunity play critical roles in propagating abnormal hyperkeratinization and inflammation. Alterations in sebum composition, and increased sensitivity to androgens, also play roles in the inflammatory process. A stepwise approach to acne management utilizes topical agents for mild to moderate acne (topical retinoid as mainstay ± topical antibiotics) and escalation to oral agents for more resistant cases (oral antibiotics or hormonal agents in conjunction with a topical retinoid or oral isotretinoin alone for severe acne). Concerns over antibiotic resistance and the safety issues associated with isotretinoin have prompted further research into alternative medications and devices for the treatment of acne. Radiofrequency, laser, and light treatments have demonstrated modest improvement for inflammatory acne (with blue-light photodynamic therapy being the only US FDA-approved treatment). However, limitations in study design and patient follow-up render these modalities as adjuncts rather than standalone options. This review will update readers on the latest advancements in our understanding of acne pathogenesis and treatment, with emphasis on emerging treatment options that can help improve patient outcomes.
Background Acne vulgaris is increasingly recognized in adult women; however, few studies have formally evaluated the clinical presentation and factors associated with acne in this population.Methods This prospective, observational international study evaluated the clinical characteristics and lifestyle correlates of acne in adults (≥25 years) at a dermatology visit for acne. Investigators conducted a detailed clinical examination and administered a validated questionnaire that covered medical history, disease evolution, lifestyle habits, previous treatments, skin care and quality of life.ResultsIn this study (n = 374), acne was mild or clear/almost clear in 47.3% of subjects; however, the study visit was not required to be an initial consultation for acne and as such, many patients were already on treatment. Most women (89.8%) had acne involving multiple facial zones (cheeks, forehead, mandibular area, temples) with a spectrum of facial acne severity similar to adolescents. Mixed facial acne (both inflammatory and non-inflammatory lesions present) was the most common presentation; 6.4% of women had inflammatory acne only (no non-inflammatory lesions reported) and 17.1% had comedonal acne with no inflammatory lesions. Truncal acne was present in 48.4% of patients. A small subset (11.2%) had acne localized only to the mandibular area. Compared to the women without localized acne, those with mandibular acne were more likely to be employed (90.5% vs. 78.6%), reported greater daily stress levels (5.8 vs. 5.1), and were more likely to say their jobs were psychologically stressful (71.4% vs. 57.5%). Women with mandibular acne alone were significantly less likely to have a global acne severity rating of moderate or higher (7.1% vs. 50.1%), truncal acne (19.0% vs. 51.9%), post-inflammatory hyperpigmentation (23.8% vs. 51.9%) and erythema (19.0% vs. 48.4%). At the completion of the study visit, this group was also more likely to receive a prescription for an anti-androgen (16.7% vs. 7.7%).Conclusions This study represents the first objective assessment of the facial distribution of acne lesions in adult women presenting to the dermatology office. The data surprisingly indicate that the acne distribution in almost 90% of cases is similar to that seen in adolescent acne. The stereotype of adult female acne being due to hormonal disturbances presenting as inflammatory acne localized only to the mandibular area was not found in the majority of this large group. The large majority (93.7%) of women had facial comedones. We recommend that the general treatment approach for adult acne should include agents that target each of the acne lesion subtypes. Subgroup analyses of recent large-scale controlled clinical trials have shown that many adult women respond well to standard first-line acne therapy.