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 Table of Contents  
Year : 2021  |  Volume : 6  |  Issue : 2  |  Page : 189-193

Perceived stress and appearance anxiety among people with acne vulgaris

1 Department of Psychiatry, Yenepoya Medical College, Mangalore, Karnataka, India
2 Department of Dermatology, Yenepoya Medical College, Mangalore, Karnataka, India

Date of Submission16-Dec-2020
Date of Decision13-Apr-2021
Date of Acceptance19-Apr-2021
Date of Web Publication08-Jan-2022

Correspondence Address:
Dr. Anupama Priyamkari
Department of Psychiatry, Yenepoya Medical College, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjhs.bjhs_135_20

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BACKGROUND: Acne vulgaris is a chronic inflammatory, pilosebaceous condition. It is one of the world's most common skin diseases, affecting millions of patients. The frequency and length of the acne may not represent explicitly the psychological condition of a patient. This research was aimed at measuring perceived stress and anxiety of appearance among people with acne vulgaris.
MATERIALS AND METHODS: It is a cross-sectional, observational study, carried out at tertiary care teaching hospital following approval by the Institutional Ethics Committee. Seventy-five outpatients with acne vulgaris were included in the study and the perceived stress scale (PSS) and appearance anxiety inventory (AAI) administered to them.
RESULTS: There were 55 females and 20 males among the 75 acne patients. The mean age of the study patients was 23.55 ± 3.83. The mean duration of the acne was 3.35 years. The mean PSS was 19.48 ± 6.44 among the patients. The total AAI score among all the patients was 13.67 ± 5.67. The avoidance AAI score was 7.09 ± 4.5 and the threat AAI score was 5.82 ± 3.35. As the mean duration increased, the level of the stress was also increased.
CONCLUSION: The results show that the PSS and AAI have psychometric properties to decide whether improvements in cognitive processes and behaviors mediate outcomes in patients. The duration of acne vulgaris had a direct positive association with the higher PSS and AAI score.

Keywords: Acne vulgaris, appearance anxiety inventory, perceived stress scale, stress

How to cite this article:
Priyamkari A, Kakunje A, Shenoy MM. Perceived stress and appearance anxiety among people with acne vulgaris. BLDE Univ J Health Sci 2021;6:189-93

How to cite this URL:
Priyamkari A, Kakunje A, Shenoy MM. Perceived stress and appearance anxiety among people with acne vulgaris. BLDE Univ J Health Sci [serial online] 2021 [cited 2023 Jun 3];6:189-93. Available from: https://www.bldeujournalhs.in/text.asp?2021/6/2/189/335325

Acne vulgaris is a chronic inflammatory, pilosebaceous condition. It is one of the world's most common skin diseases, affecting millions of patients.[1] The clinical features of acne comprise of seborrhea, noninflammatory lesions (open and closed comedones), inflammatory lesions (papules and pustules), and various degrees of scarring.[2] It is the world's eighth most common disease, affecting 9.4% of the world's population.[3] The prevalence of anxiety in patients with acne is growing and the relationship between anxiety severity and acne severity is reported to be positive.[4] It is also widely believed that factors such as stress and anxiety which may be caused by acne, may also exacerbate acne.[5] The disease's major complications include physical scarring and psychosocial effects, which may persist long after active lesions have disappeared.[6] Clearly, there are some psychological components to etiology of acne, because treatments such as biofeedback relaxation and cognitive imagery have shown to be effective.[7]

Acne causes physical signs such as soreness, itching, and discomfort, but its primary impact is on one's quality of life. Psychological morbidity is not a minor issue, and it is exacerbated by a number of factors: Acne affects highly visible skin, a vital organ of social display; mainstream culture, and cultural pressures demand blemishless skin; acne is ignored by health-care practitioners as a superficial self-limiting condition; and acne peaks in adolescence, in whom building confidence and self-esteem are most important.[2]

Teenagers overly conscious regarding the self appearance and can be a very sensitive issue of social acceptance among the peer group. Acne has a negative impact on psychological well-being, causing depression, suicidal ideation, anxiety, psychosomatic symptoms, guilt, humiliation, and social inhibition among the adolescent individuals. Furthermore, they show the psychological signs which include the insomnia, hypersomnia, and anorexia or hyperphagia, may also be evident. Deterioration in acadetnic performance, social withdrawal, truancy, and delinquent behavior.[2],[6]

The perceived stress scale (PSS) is the most frequently used psychological tool for measuring the perception of stress. The scale also contains several direct questions about the existing stress levels encountered.[8] The appearance anxiety inventory (AAI) is a self-reporting scale of 10 questions measuring the cognitive and behavioral aspects of body image anxiety in general and body dysmorphic disorder (BDD) in particular. The scale is useful as part of a BDD screening protocol as well as during care symptom monitoring.[9]


The aim of this study is to measure perceived stress and appearance anxiety among persons with acne vulgaris.

  Materials and Methods Top

It is a cross-sectional, observational study, conducted at the department of psychiatry and dermatology of a tertiary care teaching hospital from February 2019 to January 2020. The sample size for the study was estimated using the applicable level of evidence from previous studies; a = 5%, p (anticipate proportion) = 22%, d (margin of error) = 0.1. The minimum sample size required for the study was 66. Ethical clearance was obtained from the Institutional Ethical Clearance Committee (Protocol number 2019/136). In this study, the PSS and AAI ratings included a total of 75 patients with acne vulgaris recruited from the department of dermatology. Written informed consent was obtained from all the participants. The patients included in the study were diagnosed with acne, with both male and female patients above the age of 18 years seeking primary acne treatment. Patients with no other physical deformity or impairments, with no sensory deficits, and subnormal intelligence clinically were excluded from the study.

Assessment tools

  1. PSS: Sheldon cohen et al. developed the scale in 1983. It is a questionnaire self-administered by 10 items that measure the degree to which situations are assessed as stressful in one's life. Administering the scale takes 15 min each per respondent. Individual scores on the PSS may vary between 0 and 40 with higher scores indicating higher perceived stress.[8] Interpretation: Scores ranging from 0 to 13 would be considered low stress; scores ranging from 14 to 26 would be considered moderate stress; and scores ranging from 27 to 40 would be considered high perceived stress
  2. AAI scale: Veale et al. created the scale in 2014. Scores consistent with a total raw score derived by summing each item as well as two subscales take 19 min to administer this scale. Veale et al. did not define a BDD diagnosis cutoff score, but Mastro et al.(2016) suggested a cutoff score of 20 to indicate a high risk of clinical problems.[9]

Statistical analysis

All the data were entered in Excel and analyzed using Microsoft Windows Statistical Package for the Social Sciences software version 23. The descriptive statistics were presented as the mean ± standard deviation, frequency, and percentages.

  Results Top

There were a total of 75 patients which comprised of 20 males and 55 females who had acne. In the sample, the mean age of the patients was 23.55 ± 3.83. The mean duration of the acne was 3.35 years [Table 1] and [Table 2].
Table 1: The demographic features of the patients included

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Table 2: The mean standard deviation of the age in years, duration of acne, perceived stress score, and appearance anxiety inventory scores

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The mean PSS was 19.48 ± 6.44 among the patients. The mean PSS scores among the males and females were 20.33 ± 6.4 and 19.16 ± 6.4, respectively. However, there was no significant difference in the mean values of PSSs between both the genders. The total AAI score among all the patients was 13.67 ± 5.67 (ranging from 2 to 30). The avoidance AAI score was 7.09 ± 4.5, and the threat AAI score was 5.82 ± 3.35. There was no statistically significant difference between the scores in males and females [Table 3].
Table 3: The mean difference of the perceived stress score and appearance anxiety inventory scores among male and female using student t-test

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In the PSS, 61.3% of patients had a moderate level of stress and 78.6% had low risk according to total AAI scores [Table 4].
Table 4: The impact of duration of acne vulgaris on the perceived stress score using analysis of variance

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The duration of the acne vulgaris had an impact on the stress experienced by the patients. As the mean of duration increased, the level of the stress was also increased; however, this finding was not statistically significant on the ANOVA analysis (P > 0.05) [Table 5].
Table 5: The impact of gender patient and duration of acne vulgaris on the perceived stress score and appearance anxiety inventory score in patients

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The mean duration in years of acne vulgaris was high in patients with high stress in the PSS and high risk of AAI total scores compared to the low mean duration of acne vulgaris. Patients with acne over the face had very much distress with higher scores in PSS and AAI total [Table 6].
Table 6: Distribution of all the patients in different level of stress assessed by perceived stress score and appearance anxiety inventory scores scale

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There is a weak nonsignificant negative relation of PSS with the education and socioeconomic status of the patient. However, the total AAI score had a significant negative relation with the level of education and socioeconomic status of patients. The higher the education and socioeconomic status, the lower were perceived stress and total AAI scores [Table 7].
Table 7: Relation between the education and socioeconomic status with perceived stress score and total appearance anxiety inventory score

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  Discussion Top

The result of the present study demonstrates a positive relation between stress and acne duration.[10] Skin appearance is important for the individual's self-image and social interaction.[11],[12] Although acne does not cause direct physical disability, the psychosocial burden can be severe.[13] It has been proposed that patients with moderate-to-severe acne suffer from poor body image, low self-esteem, and experience social isolation and activity restriction.

The patients who had acne vulgaris for the longer duration showed higher stress scores than those with a shorter duration.[14],[15] In the present study, the patients with acne suffered more in females than in males. However, the stress was not significantly different in both the genders.[5] Psychosocial problems such as low self-esteem, anxiety, and depression, and decreased social relationships in acne patients are considered to be caused by self-image disorder.[16],[17] Some parts of the body, including the face, play a significant role in the self-body image. In the present study, patients with acne over the face had moderate and high scores in PSS and high-risk score in AAI total.[18],[19]

Improvement in mental disorder and self-image has been reported in patients with acne following acne treatment, particularly oral isotretinoin. Based on the prevalence of certain mental disorders in patients with acne, regardless of age, sex, marital status, the extent of acne and its scar, diagnosis, and screening of these disorders were recommended in all patients with acne who have been referred for care.[20]

The association between stress and acne is potentially clinically relevant and worthy of investigation as potential behavioral interventions can become viable options for patients, as can therapeutic strategies that can be modified during periods of identified stressors.

Strengths of the study

Our study is among the few studies done in the Indian context with the semi-urban and rural population. This study was conducted using standardized scales. Both males and females were assessed during the study with sample size calculations. The mean stress levels did not show a statistically significant difference between the male and female, indicating that the males are equally conscious and concerned about their appearance.

Limitations of the study

It is a cross-sectional-based study conducted at ahospital outpatient department rather than a community-based study. Second, the stress scores were not assessed against the grade of the acne vulgaris, and also the treatment response was not considered in the present study. The study was conducted using a small sample size which also appears to be a limitation of the study. Patients were assessed when they visited the hospital for regular checkups which could be influenced by the anxiety of patients. Hence, a longitudinal study with first consultation participants and a larger sample size needs to be considered.

  Conclusion Top

The results suggest that the PSS and AAI have psychometric properties to decide whether patient outcome-mediated changes in cognitive processes and behaviors. The duration of acne vulgaris had a direct positive association with a higher score for PSS and AAI. This reflects its potential utility in clinical and research environments. Such questionnaires may be used, in addition to clinical signs, as a method for measuring the impact of treatment. Further research measuring the effect of different acne treatments is suggested using these questionnaires.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Williams HC, Dellavalle RP, Garner S. Acne vulgaris. Lancet 2012;379:361-72.  Back to cited text no. 2
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Golchai J, Khani SH, Heidarzadeh A, Eshkevari SS, Alizade N, Eftekhari H. Comparison of anxiety and depression in patients with acne vulgaris and healthy individuals. Indian J Dermatol 2010;55:352-4.  Back to cited text no. 4
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Chiu A, Chon SY, Kimball AB. The response of skin disease to stress: Changes in the severity of acne vulgaris as affected by examination stress. Arch Dermatol 2003;139:897-900.  Back to cited text no. 5
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Hughes H, Brown BW, Lawlis GF, Fulton JE Jr. Treatment of acne vulgaris by biofeedback relaxation and cognitive imagery. J Psychosom Res 1983;27:185-91.  Back to cited text no. 7
Cohen S, Kessler RC, Gordon LU. Measuring Stress: A Guide for Health and Social Scientists. New York: Oxford University Press on Demand; 1997.  Back to cited text no. 8
Veale D, Eshkevari E, Kanakam N, Ellison N, Costa A, Werner T. The appearance anxiety inventory: Validation of a process measure in the treatment of body dysmorphic disorder. Behav Cogn Psychother 2014;42:605-16.  Back to cited text no. 9
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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