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Many patients with acne personify their condition as "an intruder and unwanted companion" that burdens them throughout their lives, investigators in a qualitative study concluded.

As part of a personification exercise, patients with acne or acne scars completed a "Letter to My Disease," in which they expressed feelings of emotional and physical burden, as well as stigmatization. They held acne responsible for poor self-esteem and emotional impairment.

The findings highlight many acne patients' struggle for self-acceptance, concluded Jerry Tan, MD, of Western University Canada Schulich School of Medicine and Dentistry in Windsor, Ontario, and coauthors, in .

"The findings of this qualitative study suggest that FTA [facial and truncal acne] and AS [acne scars] inflict considerable psychological and physical burden on individuals with these conditions," the authors wrote, adding:

"These consequences should be considered in patient treatment through awareness, education, and appropriate symptom management to address insecurity and provide a greater sense of control. Accurate diagnosis, establishing a relationship of trust between the managing physician and the patient, and discussing potential consequences with patients may help reduce frustration and anger."

Using a novel qualitative technique, the authors added to an accumulating volume of evidence for a substantial psychological effect of acne and negative effects on patients' personal and professional lives, according to the authors of an .

"Despite these important effects, acne is often viewed as merely a cosmetic issue," wrote John S. Barbieri, MD, of Brigham and Women's Hospital in Boston, and Frances K. Barg, PhD, of the University of Pennsylvania Perelman School of Medicine in Philadelphia.

"There is also a common misperception that acne is only a disease of adolescence that will spontaneously resolve, which can lead to magnified feelings of depression and social isolation among those with acne persisting into adulthood," they wrote. "Going forward, it will be critical to expand on work describing the lived experience of persons with acne and to explore how these profound effects translate into broader contexts."

"Acne is a condition that goes more than skin deep," Barbieri and Barg added. "Dermatologists must continue to share our patients' stories about their experience with acne and involve them in identifying new treatments to care for their acne. Taking this approach will demonstrate value to payers to ensure access to care and to ensure that we are developing treatments attuned to our patients' needs."

Novel Approach

Most studies of acne's effects on psychosocial well-being have focused on facial acne and used dermatology-specific questionnaires, Tan and coauthors noted in their background information. Limited data exist on the association of facial and truncal acne and acne scars with psychosocial well-being.

For the personification exercise, investigators in six countries recruited 30 patients with facial and truncal acne and 30 with acne scars. Acne was defined by Investigator Global Assessment definitions. Patients with acne scars had atrophic scarring on the face and no active acne for at least the past 2 years.

Enrollment in the acne group was open to patients ages 13 to 40, with 70% age 25 or younger; the group with acne scars included patients ages 18 to 45, with 70% in the 25 to 45 range. Women accounted for 35 of the 60 participants and represented a majority of both groups.

All but four patients completed the Letter to My Disease exercise, which required participants to imagine their acne or scars with human qualities or characteristics and to engage with their conditions in their writing. Participants followed conversational writing style and used second-person pronouns to address their acne or scars.

"This technique proved to be a powerful, evocative tool for eliciting hidden meanings and emotions," the authors wrote. "The personification process of the condition dissociates the respondents to the answer they give, deactivating their conscious defenses. As such, this projective exercise gives permission to participants to challenge their condition, ask for accountability, and express their disagreement with the condition. Furthermore, it led them to formulate feelings in a way that could not have been assessed with standard guided questions."

Investigators used computerized thematic analysis to evaluate the letters and to compare datasets for patients with acne and those with scarring. An inductive analytic approach was applied to form the narrative of participants' emotional path.

Major Themes

Three major themes emerged from analysis of the letters: burden of the condition, attitudes and beliefs, and relationship to the personified condition.

Investigators found that burden of condition encompassed four subcategories, each associated with specific types of statements representing different emotions.

• Psychological effects -- "You hurt me so much emotionally."
• Feelings and emotions -- "I hate you."
• Physical effects -- "My image in the mirror is hard to bear."
• Treatment burden -- "I have [had] enough of taking pills and putting [on] cream."

Attitudes and beliefs encompassed two categories: attitudes and coping strategies ("I'm fighting against you," "I had to change a lot in my life because of the treatment") and socialization ("I was often afraid to relate to people because of my appearance").

Relationship to the personified condition revealed "deep psychological effects," the researchers noted. In their letters, patients often pleaded with or ordered the condition to leave. The concept of an intruder or unwanted companion emerged, reflected in statements such as "You are not welcome on my body" and "You always come back and even stronger." Some participants acknowledged a longstanding relationships "It's almost laudable how you attached to me. What can I say, thank you for such devotion even if I didn't consent?"

These imaginary conversations with their condition, "addressed the emotional/physical burden and social stigma associated with their skin condition," the authors said of their findings. "The major contribution of this projective, personification approach is that it documents the unprompted voice of individuals with acne as well as of those with AS using similar exercises at different time periods during their struggle with acne. Retracing such a path would have been difficult using other methodologies."

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