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Emotional stress like depression and anxiety have been proven to play a role in health conditions like coronary heart disease, cancer, infectious disease, and autoimmune conditions.1-2 Research investigating stress and skin conditions suggest that depression and anxiety are demonstrably linked with acne.3 Body image problems, social phobia, depression, and suicide have also been strongly associated with severe acne and related scarring.3
A 2003 dermatologic study at Stanford University School of Medicine demonstrated the correlation between acne severity and increased emotional stress. The study followed 22 university students with acne while they self-reported stress using the Perceived Stress Scale, a widely adopted indicator of emotional stress.4
The students were allowed to continue any existing topical acne therapies as long as they had been in place for at least eight weeks prior to the study and were continued throughout. The severity of acne outbreaks were graded on the Leeds scale (ranging from 0.0 to 10.0, based on photos and lesion counts) and each participant was judged to have at least a 0.5 level of severity at the beginning of the study. Those students who reported greater levels of stress during exams correspondingly had the greatest increase in acne severity. To ensure objectivity, researchers who graded the level of acne severity were unaware of the students' reported stress levels. Even after other factors (e.g., dietary or sleep changes) that may worsen acne were accounted for, stress still appeared a likely contributing factor to acne severity.4
This study highlighted interesting aspects about the relationship of acne with stress. On the one hand, acne itself represents a psychological stressor (especially if severe). On the other, mental stress from other life events seems to make acne worse. Could there be underlying biological mechanisms connecting stress and acne?
Oxidative Stress, Mental Stress, and Acne
A growing body of evidence from divergent fields of research suggests that the relationship between acne and emotional stress might go more than skin deep, and that oxidative stress may be the link:3,5
- Skin medications like steroids and retinol have been linked to psychological symptoms, and antidepressants have been shown to have antioxidant properties—especially in environments of lipid peroxidation (like acne).
- A number of associations have been revealed between high levels of markers for oxidative stress, low levels of antioxidants, and conditions like anxiety and depression.
- Acne and depression have been associated with consumption of high glycemic index and low-nutrient density foods, while the low glycemic load, nutrient and antioxidant dense diets have been associated with lower incidence of both.
- Experimental data indicates that consumption of high glycemic load, poor nutrient diets increases oxidative stress on the nervous system and fosters anxiety.
All of this has led some researchers to propose that the skin and the brain are affected by the same hormones and neurotransmitters. Results of experimental and clinical studies indicate they may be right—oxidative stress from lipid peroxidation in the body appears to affect both the central nervous system and the skin. The links between systemic oxidative stress, anxiety and/or depression, and acne are due to a number of different factors, but two of the most important appear to be insulin and antioxidant levels.5
The Insulin Connection
Research has shown that insulin can cause oxidative stress in the skin, and systemically, excess insulin can promote the development of acne. Higher insulin and insulin-like growth factor 1 levels stimulate the production of androgen, which plays a role in elevating the body's production of sebum. Although the role of sebum is to protect the skin and keep it from drying out, too much can create an environment that increases the incidence of acne.5
Acne Can Deplete Antioxidants and May Influence Brain Function
 Additional research shows that the acne condition itself contributes to systemic oxidative stress by generating free radicals and depleting antioxidants in the body. In a study of 100 patients with acne, levels of antioxidant vitamins A and E were lower in all of the patients, with the lowest corresponding to increased severity in acne. Antioxidants may be depleted because Propionibacterium acnes stimulates production of free radicals called reactive oxygen species, only further aggravated by nutritional deficiencies that emerging studies suggest acne patients are prone to.5,6
Evidence from a clinical trial involving adolescent girls and young female adults with acne corroborates the acne, depression, and oxidative stress link, and sheds some light on another possible causative factor. The 60 study participants were broken into groups of 15 based on obesity and acne status. Blood tests indicated that levels of oxidative stress markers were significantly higher in obese and non-obese participants with acne than in those participants without acne.6
Conversely, antioxidant and monoamine oxidase (MAO) enzyme activity levels in those with acne were much lower. MAOs regulate the levels of monoamines (i.e., serotonin, dopamine, and norepinephrine), which are neurotransmitters that influence mental health. Researchers suggest that depression, anxiety, and other mental stress disorders may be linked to free radical damage on brain lipids that causes imbalances of enzymes necessary to maintain stable mental health.5,6
This study also highlighted that the concurrent symptoms of acne and obesity appear to aggravate the effects of oxidative stress and decreased MAO activity. The group of study participants characterized as both obese and suffering from acne was found to have lower levels of both antioxidants and MAO activity than either the obese-only or acne-only groups.6 Interestingly, this compounding of negative effects is further corroborated by evidence that women suffering from polycystic ovary syndrome (PCOS)—symptoms of which include a tendency towards obesity and acne—also suffer from monoamine imbalances.7 Excess insulin production due to insulin resistance and the resulting increase in androgen are present in varying degrees in PCOS patients as well, underlining the biochemical links between acne patients, low antioxidant levels, and mental health.7,8
With ongoing research of the relationship between stress and skin conditions, more dermatologists are recognizing the role of mental well-being in their practice, in some cases referring patients for psychological consultations. As the research indicates, a holistic approach to acne treatment that takes emotional stress into account may require therapy beyond oral or topical dermatological medications. Acne sufferers may benefit from collaboration among dermatologists and mental health professionals.3
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