When considering various plagues and epidemics in recorded history, adult acne does not exactly spring to mind. The Black Death was widespread and devastating; measles is airborne and highly contagious. (Conveniently, it is also easily avoided with vaccine.) Acne, by comparison, seems like a walk in the pus-filled park. And, fine, labeling it an epidemic or a plague borders on the hyperbolic (though it wouldn't be the first time it was said). Yet a whopping 85% of people between the ages of 12 and 24 experience some form of acne. That’s easy enough to write off as par for the course of adolescence, but the same can't be said for adult patients — particularly women, who are reporting breakouts in record numbers.
The American Academy of Dermatology states that the rates of acne in adults are increasing; information presented at AAD's annual meeting in 2012 found that acne affects more than 50% of women between the ages of 20 and 29, and more than 25% of women between the ages of 40 and 49. Women in all age groups were disproportionately impacted compared to their male peers.
While there is a lack of consensus on just how much those numbers have risen since 2012, both anecdotal accounts from dermatologists and a 2018 review show an overall increase in adult female acne patients in recent years. So, have we finally done it? Is our uniquely horrifying modern brand of stress, pollution, beauty-product abuse, hormonal shifts, and inserting our faces directly into our palms every time a Republican politician speaks bringing about the demise of clear skin?
It's hard to say. Fluctuating hormones are, and always have been, a major factor for women, and environmental variables are very real, says dermatologist Ainah U. Tan, MD, who estimates that over two thirds of her acne patients are women over the age of 18 and has published a review on the subject. "One reason for increased prevalence is due to living in a developed area," she says. "Studies have shown that industrialized nations have higher rates of acne." At the same time, adult acne cases — like all skin conditions — have historically gone underreported, says licensed psychotherapist Matt Traube, MFT, who specializes in psychodermatology, or the emotional aspects of skin conditions.
Couple that with the fact that we're more hyper-aware of our appearance than ever, and you've got a generation of women not only grappling with bumps and breakouts but severe psychological scarring that can linger even after it clears. "Social media and reality TV stars all contribute to the impossible standard for people to look 'perfect,'" says dermatologist Dendy Engelman, MD. According to Dr. Tan, these factors cause people to "agonize over every blemish," and therefore plant the seed for the symptoms of acne to transcend far beyond mere blemishes. Women are also increasingly reporting clinical depression, anxiety, and even social isolation as a result of their acne — and they're far more susceptible than adolescents.
"While teenagers are vulnerable to depression and anxiety stemming from the condition at this developmental stage, studies show that as a group, it’s the adult population that experiences it the most," says Keira Barr, MD, a board-certified dermatologist whose practice, the Resilient Health Institute, is dedicated to what she calls the "intimate and intricate brain-skin connection." Indeed, a German study from 2002 suggests that adult dermatological patients have a 40% prevalence of psychiatric overlap; acne, it goes on to say, "is the most common skin disorder of the second and third decades of life." And, Traube says, "Because the societal bar is often unrealistically high, it tends to create a lot more damage for women than it does for men."
Of adult female acne sufferers, Dr. Tan reiterates: "A common thing that I also see is that women try to blame themselves for why they are developing acne, whether they think it's due to bad diet or not exercising enough." When you're 13 and your forehead is covered in pimples, it seems "normal." But when you're 35 and your chin is a minefield, things are understandably a little different. Says Dr. Tan, "A lot of women feel that in addition to dealing with everything else that happens with womanhood, acne is the last thing that they want."
There is a culture of shame and stigma around acne, and though adolescents can and do face bullying and stigma of their own, there are different social factors at play when your skin erupts later in life. "It's hard enough to talk about your experience when you're a teenager, but it's intensified for adults because in many cases you're high-functioning, you're in control of your life, you're used to finding solutions for your problems, but acne is not always easy to solve," Traube says. "It doesn't always respond to treatments the way that it 'should,' so people feel a massive lack of control, and then they internalize that and beat themselves up over it and think something's wrong with them and they've caused it." In turn, he adds, those thought patterns make people less inclined to do things that could actually benefit and enrich their lives in the long run, like going on a first date or pursuing a job opportunity.
"People isolate with skin conditions more so as adults," Traube says. "It's a very tough thing to talk about with other adults. Kids have better resources — parents, school counselors. Adults don't have that, so they tend to isolate, and when people isolate it can distort their perception of reality and turn small concerns into much larger concerns because it's just them with their own thoughts. I might have an adult client say something like, 'My acne is terrible,' and that can turn into, 'Oh, my skin is terrible,' then, 'No one will love me, my life is hopeless, my future is hopeless.'"
Perhaps the strongest case establishing the link between acne and depression is a damning analysis published in The British Journal of Dermatology early last year. Investigators parsed through data from the UK's Health Improvement Network, one of the largest electronic medical records databases in the world, and found that, in the first year after acne diagnosis, sufferers showed a 63% higher risk of major depression than individuals without acne. The assessment deemed the importance of mental-health screening in acne patients "critical."
"The relationship between acne and depression has been known for some time — dermatologists and patients with acne are very familiar with this, but there had never been any specific study to document it," says the study's lead author, Isabelle Vallerand, MD, PhD, a dermatology resident and epidemiologist at the University of Calgary's Cumming School of Medicine University. "So while we weren't surprised that our data confirmed this relationship, we were surprised to uncover how large the risk of depression is among acne patients."
In another study published this past January, researchers surveyed a sample of roughly 20% of all US pediatric and adult hospitalizations, and found that patients with acne were much more likely to report mental-health conditions than those without an acne diagnosis — 43.7% vs. 20%, respectively. This, then, is why Traube and Dr. Barr have built successful careers around helping people of all ages see past their skin. The services they offer aren't superficial — they're needed. As a dermatologist, Dr. Barr focuses on creating treatment plans that incorporate coordinating care with a mental-health provider to manage the physical and emotional aspects of the condition. Traube deals directly with the psychological side, specializing in cognitive behavioral therapy and recovery from the inside out.
In some cases, both the cause and effect come down to self-confidence — which may well improve if your skin does. "Our self-confidence is intimately connected to our complexion," Dr. Barr says. "When your skin looks better, your sense of confidence improves exponentially. When it is riddled with red, inflamed, painful acne lesions, one’s sense of self and self-esteem can plummet." She points to a study that highlights the fact that the psychosocial effects of acne on quality of life are influenced more by the patients' self-perception of their acne vs. their objective appearance, and the effects are relevant more to adults than adolescents.
So there's an upside to this. Short of some earth-shattering innovation, people will always have acne — men, women, 34-year-olds, 14-year-olds. But the way we handle it is progressing, both in terms of treatment and, somewhat improbably, in the way society perceives adult acne as a whole, which has the potential to make it a little less depressing. "Acne acceptance" has entered the lexicon. The Bachelorette talks about being on Accutane. A-list celebrities, a class of people historically known for being unrealistically good-looking, show off their breakouts on Instagram. Even Dr. Vallerand's study found that the risk of depression goes back to baseline after five years. The clouds are clearing; there's light at the end of the tunnel. Nobody ever said that about the Spanish flu.