Evidence
Alert

Misconceptions about acne lead to underuse of effective treatments; people need reliable information to manage the condition long-term

People with acne often blame themselves for their condition, wrongly thinking it is caused by their diet or skin care routine. Those who come forward for medical help often have unrealistic expectations and expect an immediate cure. New research demonstrates that such misunderstandings are a barrier to effective management of the condition. 

Previous research has shown that people often underuse effective treatments for acne. Researchers wanted to find out more about people's attitudes and experiences, to understand the impact the condition has on their lives and explore how best to help them manage it long-term.  

This study is believed to be the first to pool the findings of observations and interviews (qualitative research) on acne. It found four themes in participants' responses.

People with acne viewed it as a short-term condition that did not need long-term treatment. They felt their condition was seen as trivial, by healthcare professionals or others. They wanted a sense of control over their treatment, and they described the barriers that prevented or delayed them seeking and using treatments.

The research could help doctors to explain more clearly the long-term nature of acne, how best to use treatments, and to reassure people that their condition is not trivial, and that they are not to blame for it. 

What’s the issue?

Acne is a common skin condition, affecting people of all ages worldwide. It is especially common in teenage years as it is linked to hormones. Previous research has found that people do not always use their acne treatments as prescribed. They may forget to use them, or not use them for long enough. 

Researchers were not sure why this happens. This research was intended to find out whether the beliefs and attitudes of people to their acne could be behind their underuse of effective treatments. 

What’s new?

The researchers reviewed and summarised studies which asked people about their experience of and attitudes to acne and acne treatments. They put together findings of 20 papers from six countries (India, the UK, US, Australia, Italy and Germany). 

Four themes emerged from participants’ responses: 

1. Many people viewed acne as a short-term condition that would not need long-term treatment. They often expected to ‘grow out’ of the condition after puberty and were frustrated if this did not happen. People looked for possible causes, including hygiene and diet; some blamed ‘dirty’ jobs, pollution, sweat or make-up, or foods such as chocolate, fast food, soft drinks and alcohol. One said: “I avoid eating sweets but if I eat one piece of chocolate, my family tell me that’s the reason I break out. If I leave my face towel on the couch for one second, they tell me that’s the reason I break out.”

2. The impact on people’s wellbeing was not always recognised. They reported being embarrassed, self-conscious and angry about their acne, sometimes to the point of feeling suicidal. Low self-esteem and lack of confidence affected their relationships. Despite this, they felt that acne was often seen as trivial by healthcare professionals. One study found that many healthcare professionals did appreciate its psychological impact; but other research showed that professionals rated individual cases of acne as less severe than people with acne did. One participant said: “The fact is that I cannot be normal, when it hurts and is red. It pains and oozes out at times and hurts to smile, and then I cannot feel happy, even if I want to.

3. Feeling in control of the condition and its treatment appeared to lesson its psychological impact. People felt powerless when treatments were not working, and some preferred to use alternative treatments because they viewed them as more natural, with fewer side effects. One woman said: “When you get a severe bout of acne like that it does tend to reduce the sense of self control .… and if you can gain some of that control back then it makes you feel a little bit more empowered… it helps with the overall self-image.”

4. Barriers to using treatment: People’s decisions about whether to use treatments were complex and included beliefs about the cause of acne, and concerns about the side-effects and effectiveness of treatments. They received variable advice and support. Many thought treatments would cure rather than control acne. When treatment failed to work quickly, some looked for alternative treatments. One participant said: “A lot of the time I felt from the doctors a kind of attitude that there really wasn’t much they could do for me anyway, and this made me feel very frustrated. I felt sometimes just discounted, or like I am not really being listened to at times.”

All four themes influenced whether someone with acne would start or continue with treatment.

Why is this important?

This review is the first to bring together qualitative papers on acne. It suggests that misconceptions about causes and treatments are common. These misunderstandings could be behind people’s decisions not to start, or not to persist with, effective medical treatments. 

The findings suggest a gap in knowledge and understanding of acne. Healthcare professionals could use these findings to explain the long-term nature of the condition, and to ensure people know what to expect from acne treatments. For example, how long treatments take to start working, what to do about side effects and how to use them appropriately over the long-term. 

People could be signposted to reliable sources of information about acne. Healthcare professionals could be clear that they do not consider acne trivial, and reassure people that they are not to blame for the condition.  

What’s next?

Some changes could be implemented straight away. People with acne need  more and better information. Future research could investigate how best to support them to reduce the impact on their wellbeing. The research team has begun to develop materials to support people who are self-managing their condition. 

You may be interested to read

This paper: Ip A, and others. Views and experiences of people with acne vulgaris and healthcare professionals about treatments: systematic review and thematic synthesis of qualitative research. BMJ Open 2021;11:e041794 

A paper by the same researchers looking at young people in particular: Ip A, and others. Young people's perceptions of acne and acne treatments: secondary analysis of qualitative interview data. British Journal of Dermatology 2020;183:2 

Acne support website from the British Association of Dermatologists

 

Funding: This research was funded by the National Institute for Health Research (NIHR) School for Primary Care Research.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

I was surprised at how consistently across the studies participants thought their acne was their own fault. There is actually very little evidence that diet or hygiene make a difference. But they thought it was a result of something they were doing wrong, such as eating the wrong foods, or using the wrong face products. 

These findings show how important it is for health professionals to communicate key messages about acne, and to back this up with written or online information. People with acne need reliable sources of information/resources. We have started developing materials to support self-management of acne and to improve quality of life.

Athena Ip, Research Fellow, School of Health Sciences, University of Surrey 

British Skin Foundation 

Acne is one of the most common skin conditions worldwide, which often starts in puberty but can persist well into adulthood.  It is well-recognised that those who suffer with acne can experience profound mental health issues to include embarrassment, shame, stigma, low self-esteem, poor body image, anxiety and depression. The condition has a significant impact on psychological well-being and its effects can often be underestimated by healthcare professionals as well as close friends and family.

In the digital age where we are bombarded with a plethora of information online, myths and misinformation about acne treatments are rife. Not only do these hinder people from seeking and persisting with appropriate medical treatments, they can lead to feelings of self-blame within the sufferer that their acne is their own fault due to a lifestyle choice; there is however, very little data to support this.

It is clear that there needs to be better communication for those suffering with acne to guide them how to use topical treatments correctly, adequate explanation of side-effects as well as realistic timescales of improvement for their skin. We need to encourage those looking for advice on-line to use credible sources of information as well as create an environment where they can seek appropriate psychological support for their skin. This study reinforces that it is time for us to take quality of life issues for the acne sufferer seriously.

Anjali Mahto, Consultant Dermatologist & British Skin Foundation spokesperson 

Lived experience 

A family member has facial scarring from teenage acne which has undoubtedly damaged their self-esteem and self-confidence. As a teenager they would shut themselves away in their bedroom to paint or listen to music whenever they could. At times, the bullying at school because of their acne and related shyness was unbearable. Their acne went in their 20s but the low self-esteem continued into their adulthood, even though they are one of the most technically gifted people I’ve ever met.

Today’s social media pressures and the ever-increasing demands to look perfect are only going to make things worse for people of all ages who have acne or any kind of skin condition. 

It would be helpful to be clear about the long-term medication(s) and support (emotional and financial) people need to manage their acne long-term. Acne can have a life-long impact on an individual mentally, physically and financially. Research to evaluate the positive impacts of successful treatments needs to be carried out over the short, medium and long-term.

Abigail Dennington-Price, Public Contributor, Norfolk