Dermatological Issues and Mental Health: Examining the Connections

ACNE VULGARIS and rosacea are more than just skin conditions: They deeply affect mental health and daily life in patients who have them. Beyond physical symptoms, these conditions can lead to depression, anxiety and diminished self-esteem.

Acne vulgaris, commonly known as acne, has proven to lead to a 63 percent higher risk for depression within the first year of a diagnosis compared to individuals without the condition,¹ and around 31 percent of rosacea patients have been known to experience some level of depression.² Anxiety, low self-esteem and a decrease in personal quality of life are also common responses to both conditions. In fact, an alarming number of patients report suicidal thoughts (9.8 percent of those with facial dermatoses, including acne, compared to 3.2 percent in a control group; and 5.8 percent of rosacea patients, compared to 3.2 percent in a control group).

And it’s not just adolescents suffering. In fact, while 85 percent of adolescents are affected by acne,³ acne afflicts people well into adulthood, too. Acne affects 50.9 percent of women and 42.5 percent of men between the ages of 20 and 29; 35.2 percent of women and 20.1 percent of men between the ages of 30 and 39; 26.3 percent of women and 12 percent of men between the ages of 40 and 49; and 15.3 percent of women and 7.3 percent of men ages 50 and older.⁴

Rosacea affects approximately 5.46 percent of the adult population worldwide. Older populations (ages 60 to 70) report the highest prevalence at 5.7 percent. Ages 50 to 59 report a 3.5 percent prevalence; ages 40 to 49 report a two percent prevalence; and ages 16 to 39 report less than one percent prevalence.⁵ While less common than acne, rosacea is no less distressing to the people who have it.

Definitions

Acne vulgaris is a chronic inflammatory skin condition affecting the pilosebaceous unit (the hair follicle and its associated sebaceous gland), typically following a prolonged course. It is commonly triggered during adolescence by Cutibacterium acnes, a bacterial species, under the influence of normal circulating levels of dehydroepiandrosterone. The condition commonly manifests with papules, pustules or nodules (also known as pimples or zits) primarily on the face but can also affect the upper arms, trunk and back. The pathogenesis of acne vulgaris involves the interaction of multiple factors that ultimately lead to the formation of its primary lesion, which is known as a “comedo.”⁶

Rosacea is a chronic inflammatory disease that presents with recurrent flushing, erythema (skin redness), telangiectasia (small, widened blood vessels near the surface of the skin), and papules or pustules on the nose, chin, cheeks and forehead. There are four clinical subtypes of rosacea based on the predominant signs and symptoms: erythematotelangiectatic, papulopustular, phymatous and ocular; subtypes are not mutually exclusive. Rosacea is more common in people with fair skin. The exact cause of rosacea is unknown, but factors such as genetic predisposition, abnormal immune response and environmental triggers such as sun exposure, spicy foods, stress and alcohol can exacerbate symptoms.⁷

Case Studies

Managing these bothersome skin conditions involves a multifaceted approach that addresses both medical and psychological aspects. The following cases illustrate how these conditions can influence self-esteem, social interactions and overall mental well-being.

• After dealing with acne in high school, Natalie Elliott entered her early 20s acnefree, but then she developed cystic acne (the type of acne that causes pus-filled pimples that lodge deep in the skin). With cystic acne, scarring often occurs after the skin is cleared. The cysts started on her cheeks and progressed to her jawline, neck and even her back. She recalled going to a party and feeling hopeless — always thinking about her acne. As it got worse, she started canceling her plans and staying home. When her breakouts were especially bad, she felt like her personality changed. She became more self-conscious and timid. After moving and seeking treatment from a board-certified dermatologist, she found relief in time to pose for her wedding pictures without worrying about breaking out.⁸
• Lex Gillies, a 30-something-year-old blogger, has rosacea. Flare-ups cause her face to turn red, and it affects her mental health. “I feel like my face is a beacon, glowing bright red and attracting stares and judgments from others. I feel self-conscious and like my body is not my own. It’s often a very upsetting and disorientating experience,” she said. During flare ups, people asked her if she was sunburned, drunk, blushing or dealing with an allergic reaction. Some were even rude, asking, “What’s wrong with your face?” Such questions caused others to turn and stare at her face, making her feel exposed and vulnerable. Over time, she learned her triggers and how to manage them. Now she tries to educate people to raise awareness and, hopefully, discourage others from making unprompted comments.⁹

Treatment Options

While complete eradication of these conditions may not be possible, symptoms can be managed and quality of life can improve. For acne, timely and appropriate treatment can significantly reduce the severity, prevent scarring and improve overall well-being. Rosacea is not curable, but symptoms can be managed with lifestyle changes, topical treatments and medical therapies, improving both physical appearance and boosting confidence.

Patients may find a combination of medical and psychological treatment options best address their unique situation.

For acne. Medical treatments include:

Topical treatments

• Benzoyl peroxide is known for reducing bacteria and inflammation.
• Retinoids, such as tretinoin and adapalene, promote cell turnover to prevent clogged pores.
• Antibiotics, such as clindamycin and erythromycin, target acne-causing bacteria.
• Azelaic acid reduces inflammation and helps with post-inflammatory hyperpigmentation.
• Cabtreo is the first fixed-dose, triplecombination topical treatment for acne, combining antibiotic, retinoid and benzoyl peroxide medicines to address multiple acne-causing factors.

Oral treatments

• Antibiotics such as doxycycline and minocycline are effective for moderate to severe acne.
• Tazarotene lotion (0.045 percent) uses polymeric emulsion technology to provide an effective, well-tolerated topical retinoid for the treatment of acne.
• Hormonal therapies, such as oral contraceptives and spironolactone, are helpful for hormonally driven acne.
• Isotretinoin is a powerful option for severe or resistant acne, but it requires monitoring due to potential side effects.

For rosacea. Medical treatment options include:

Topical treatments

• Brimonidine gel reduces redness by constricting blood vessels.
• Metronidazole cream/gel acts as an antimicrobial and anti-inflammatory.
• Azelaic acid reduces inflammation and redness.
• Ivermectin cream targets Demodex mites and inflammation.

Oral treatments

• Doxycycline can be used in low doses for anti-inflammatory properties.
• Isotretinoin can be used for severe rosacea in cases that are unresponsive to other treatments.
• Emrosi is a 40 mg extended-release minocycline capsule for the treatment of inflammatory lesions. Both conditions. Patients with acne and/or rosacea may benefit from certain medical procedures including:
• Chemical peels, which can improve mild acne and reduce scars.
• Laser and light therapy, which target acne-causing bacteria and reduce oil production. Accure Laser System (which targets sebaceous glands to reduce acne lesions) was approved in 2024 by the U.S. Food and Drug Administration for the long-term treatment of mild to severe inflammatory acne vulgaris. Laser therapy such as pulsed dye laser and intense pulsed light are effective for persistent redness and visible blood vessels in rosacea patients.
• Intradermal botulinum toxin is an emerging treatment for refractory flushing for rosacea that needs further study.

Patients may also benefit from psychological treatment options:

• Cognitive-behavioral therapy (CBT) is a tool for managing the psychological impacts of both acne and rosacea by helping patients recognize problematic dysfunctions in thinking and develop strategies to change thinking and behavior patterns. One study suggests CBT helps patients reframe negative perceptions of their appearance and develop coping strategies, which reduces social anxiety and depressive symptoms.¹⁰ Another study found that patients with various dermatological conditions, including acne, who underwent CBT in addition to standard skin care demonstrated improvements in both quality of life and the severity of their skin condition.¹¹
• Support groups may help patients feel less alone. Adolescents and young adults with acne can find reassurance and coping strategies in peer-led support groups, which reduce feelings of isolation. Adult patients with rosacea can benefit from connecting with others who understand the specific challenges of managing triggers and flare-ups.
• Patient advocacy organizations, such as the American Academy of Dermatology and the National Rosacea Society, offer resources for emotional and physical management.

Looking to the Future

In addition to treatments that already exist for both conditions, many others are currently in development and at various stages of clinical trials.

Acne. Nitric oxide-based treatments are being explored for their antibacterial, anti-inflammatory and sebum-reducing properties. SB204, a leading candidate, is a topical nitric oxide-releasing gel that has shown promising results in Phase III clinical trials. Microbiome therapy, such as topical probiotics or engineered bacteria, aims to restore balance to skin’s microbial ecosystem.¹² B244 is undergoing Phase II trials and has demonstrated clinical efficacy. And in preclinical stages, mTOR inhibitors are showing they could restore NLA skin toward a healthier state.¹³

Rosacea. JAK inhibitors such as upadacitinib and abrocitinib have been explored in case reports for the treatment of rosacea. The reports show some promising results, but the long-term safety and efficacy of both upadacitinib and abrocitinib require prospective controlled studies to assess them more comprehensively.¹⁴ Microbiomebased rosacea topical treatments that target Demodex mites or rebalance the skin’s microbiome such as OM-85 are in development to address both inflammatory and vascular symptoms. Topical VEGF (vascular endothelial growth factor) inhibitors are being investigated to reduce persistent erythema.

A Holistic Approach Offers Hope

Whether dealing with acne or rosacea, dermatological patients need to know they are not alone in their journey. With the right combination of treatments and support, it is possible to achieve significant improvements in both the physical and emotional aspects of living with these skin conditions. Continued advancements in dermatological research and treatment options provide hope for even better outcomes in the future. By working closely with healthcare providers and utilizing available resources, patients can reclaim their confidence and feel more at ease in social situations.

Integrating medical treatments with psychological support, such as CBT or support groups, can address the emotional toll that acne and rosacea often bring. Empowering patients with education about their condition and fostering open communication with dermatologists ensures they can make informed decisions tailored to their unique needs. This combined, holistic effort not only offers the hope for improved treatment outcomes but also helps give patients agency in their journey.