Dermatology in Contemporary Times: Building Awareness of Social Media’s Association With Adolescent Skin Disease and Mental Health

August 2023 | Volume 22 | Issue 8 | 817 | Copyright © August 2023


Published online July 31, 2023

doi:10.36849/JDD.7596

Evan A. Rieder MDa, Anneke Andriessen PhDb, Vanessa Cutler MDc, Mercedes E. Gonzalez MDd, Jennifer L. Greenberg PsyDe, Peter Lio MDf, Elyse M. Love MDh, Joyce H. Park MDi, Hinke Andriessen MsCj, Katharine A. Phillips MDk

aPrivate Practice, New York, NY  bRadboud UMC Nijmegen, Andriessen Consultants, Malden, The Netherlands cDepartment of Psychiatry, NYU Grossman School of Medicine, New York, NY  dPediatric Skin Research, LLC, Miami, FL eDepartment of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA  fNorthwestern University Feinberg School of Medicine, Chicago, IL gThe Kimberly and Eric J. Waldman Department of Dermatology at the Icahn School of Medicine at Mount Sinai, New York, NY hThe Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY  iSkin Refinery, PLLC, Spokane, WA jPsychonomics, Cognitive Psychology, Clinical Psychology specialist, CRO RBC Consultants, Amstelveen, The Netherlands kWeill Cornell College of Medicine, New York, NY

Abstract
Background: The contribution of psychological disorders to the burden of skin disease has been poorly explored in adolescent patients. The review aims to provide insights into the psychological, social, occupational, and social medias’ association with acne, atopic dermatitis (AD), and aesthetics in adolescent patients. Methods: The project used a modified Delphi process comprising face-to-face discussions followed up online.  The systematic literature search results informed the 14 draft statements. During an expert panel meeting, the draft statements underwent the panel’s evaluation at a workshop, followed by a plenary discussion adopting five statements using evidence from the literature coupled with the panel's opinions and experiences.  Results: Studies reported an association between poor sleep, social impairment, and mental health disorders, including body dysmorphic disorder (BDD) with acne or AD in adolescents with acne or AD. Education for patients and parents may improve self-management skills and self-responsibility, promoting better outcomes for acne and AD. The use of certain types of social media can contribute to unrealistic expectations regarding the outcomes of cosmetic procedures. Social media use may also be associated with, and potentially contribute to unrealistic appearance expectations and certain mental health conditions. However, social media use may have benefits, such as connection, diversity, social support, increased self-esteem, safe identity experimentation, and an increased opportunity for self-disclosure.  Conclusions: The association with negative life events, BDD, suicidal ideation, depression, and anxiety are thought to be high for adolescent patients with acne or AD. Using social media for information has both positive and negative aspects. Awareness of the risks and benefits of receiving health information about dermatological disease among adolescents needs to be improved through the education of patients and clinicians. Action-oriented items need to be developed to help dermatologists address these issues in clinical practice.Rieder EA, Andriessen A, Cutler V, et al. Dermatology in contemporary times: building awareness of social media’s association with adolescent skin disease and mental health. J Drugs Dermatol. 2023;22(8):817-825. doi:10.36849/JDD.7596

INTRODUCTION

Adolescence is a period during which individuals are subject to a high psychological burden and are often inclined toward depression and anxiety.1,2 During this vulnerable time, the visibility of acne, atopic dermatitis (AD), and other appearance concerns can negatively affect self-image and relationships.3-5 The magnitude of the mental health and psychosocial impact is proportional to acne or AD severity.6,7 Acne is a highly prevalent, chronic, inflammatory disease that affects approximately 80% of adolescents worldwide;5,8-10  and is moderate to severe In 20% of cases.11 Acne causes erythematous papulopustular lesions that often result in residual scarring and dyspigmentation12,13 of the face, a highly visible area critical to self-esteem as well as social communication, occupational, and psychological functioning.11,13,14 Unsurprisingly acne often
 
causes impairment of mental health, social functioning, and overall well-being.13,14 Because acne is common, it is often trivialized and dismissed as being a cosmetic problem.11,13 However, Its occurrence in adolescence adds significant psychological impact and comorbidity to the other emotional challenges commonly experienced in this age group.9,12 Atopic dermatitis is a common, relapsing,  chronic inflammatory skin disease that affects up to 20% of children and adolescents;7,15 approximately 20% of all cases are moderate to severe.15 It presents with pruritus, pain,  xerosis, and eczematous lesions.16,17 The unpredictable disease course and signs/symptoms of AD, including itch, pain, and sleep disturbance can significantly impact an adolescent’s mental health, potentially leading to depression, disrupted social functioning, and other impairments in quality of life (QoL).2,16,17 Several studies have shown that the itch-scratch cycle in AD is the main cause of decreased health-related quality of life (HRQoL), as it may cause sleep deprivation, confidence issues, and stigmatization due to the appearance of the skin.15,16,18
 
The complex psychological, social, and physiologic landscape that adolescents experience may also cause a desire for cosmetic surgery.3 Actual or perceived facial and body flaws can cause low self-esteem, psychological distress, and social isolation in adolescents.19 The introduction of social media, unrealistic appearance ideals, appearance-based bullying and cyberbullying, and body shaming by peers have all contributed to a dramatic worldwide increase in teenagers seeking cosmetic procedures.19,20 The American Society of Plastic Surgeons (ASPS) has reported  that cosmetic procedures performed on adolescent patients in the US rose from 14,000 in 199621 to 229,740 in 2020.22
Challenges that adolescents face regarding their skin and body image require further examination. Though the contribution of psychological disorders to the burden of skin disease has been explored in adults through the nascent field of psychodermatology, psychological comorbidities have been underexplored in adolescent patients living with dermatologic conditions.2,17 Many adolescent patients with acne or AD are undertreated, resulting in uncontrolled symptoms and a further strain on patients, caregivers, society, and the economy.15,23 Rates of youth mental health conditions, including body image dissatisfaction, among adolescents with acne or AD are high, and mental health treatment utilization is low and often inaccessible.23-26   Though many physicians recognize the need to address both the physical and psychological symptoms of their patients, they do not have clear guidelines on how to efficiently co-manage long-term psychosocial comorbidities in adolescent patients.4,5,17  This review aims to provide insights into the psychosocial, occupational, and social media association with acne, AD, and self-image in adolescent patients.

METHODS

The project used a modified Delphi process comprising face-to-face discussions followed up online.  A systematic literature search for the psychosocial, occupational, and social media association with acne, AD, and aesthetics in adolescent patients was performed by HA and AA from 14 to 16 January 2022. PubMed/Medline, Google Scholar, Cochrane Library, and PsycINFO were searched in the English language for publications from 01/01/2010 to 01/01/2022 on humans. The included article types comprised clinical studies (case-control, cohort, cross-sectional), consensus papers, meta-analyses, systematic reviews, and reviews.  Search terms used AND OR for three groups (acne, AD, and esthetic procedures) (Table 1). First, the titles of 432 articles and abstracts were reviewed and after removing duplicates (excluding 282) 150 full articles were reviewed. After filtering for the English language, publication date, and suitability (excluding 28) for the subject at hand the searches yielded 122 publications ( PubMed/Medline = 101, Google Scholar = 33, Cochrane Library = 2, and PsycINFO = 14 (Fig 1).
The systematic literature search results informed 14 draft statements. During the meeting, the draft statements underwent evaluation at the workshop by an expert panel of dermatologists, psychologists, and psychiatrists, followed by a plenary discussion. Five statements were adopted, using evidence from the literature coupled with the panel's opinions and experiences. The second step consisted of a post-meeting review of the manuscript by panel members.

RESULTS AND DISCUSSION

Statement 1: AD and acne are associated with an increased risk of poor sleep, social impairment, and mental health problems, including body image disturbance. Impaired sleep quality is one of the factors that is associated with the health of adolescents with acne or AD.6,18 In a study by Tasoula et al sleeping disorders were identified in 20.3% of students with acne compared with 16.5% in the entire study population (P>.05).6  The Children Dermatology Quality of Life Index scores for sleep disorders significantly correlated with acne severity (P<.0001). A study by Lim et al also found that a significantly higher percentage of students with acne had frequent insomnia compared with those without (11.6% vs 4.3%, P=.011).27
Sleep is reportedly disturbed in 60% of patients with AD.28  A longitudinal study of 13,988 participants by Ramirez et al found that subjects with active AD had nearly 50% higher odds of experiencing more sleep-quality disturbances than those without AD.29 In a study by Fishbein et al patients with AD had a higher frequency of daytime sleepiness (P<.01), difficulty falling back to sleep at night (P=.02),  restless sleep (P =.01), and teacher-
 
reported daytime sleepiness (NS)  than the control group.28 Persistent AD with sleep disturbances has also been associated with a wide range of behavioral problems,30 headaches,31 and neurocognitive deficits in adolescents.32
 
Acne and AD are also associated with a broad range of mental and psychosocial disorders in adolescents, such as anxiety, depression, embarrassment, negative life events, BDD, psychosomatic symptoms, social inhibition, suicide, and suicidal ideation.7,8,13,24,25,33 In a study by Kubota et al adolescent students with acne exhibited a significantly lower mean Mental Health Inventory (MHI) score (P<.01) and were significantly more depressed than those without acne (P<.01).24 In a study by Halvorsen et al adolescent subjects with “very much” acne, compared with those with “no/little” acne, reported suicidal ideation 2 times more frequently among girls (25.5% vs 11.9%, P<.01) and 3 times more frequently among boys (22.6% vs 6.3%, P<.01).34  Tasoula et al also identified a significant association (P <.0001) between impaired body image and severity of acne in children and adolescents.6
Numerous studies have identified psychological comorbidities in adolescent patients with AD. Kyung et al found that adolescent patients with AD experienced stress, depressive symptoms, and suicidal ideation at significantly (P<.001) greater rates (59.1%, 27.8%, and 13.9%, respectively), compared with those without AD.25  Lee and Shin similarly found that adolescents with AD were significantly more likely (P<.001) to experience depression (OR 1.27, 95% CI 1.19-1.36) and suicidal ideation (OR 1.34, 95% Cl 1.24-1.45), suicidal planning (OR 1.46, 95% Cl 1.32-1.65), and suicide attempts (OR 1.51, 95% Cl 1.33-1.72) compared with those without AD.35 Khandaker et al also found that AD is associated with psychotic episodes (PE) in younger adolescents.36 Compared with subjects without atopy, the risk of PEs at 13 y was increased for patients with AD (aOR, 1.33; 95% CI, 1.04–1.69) or both asthma and AD ( aOR, 1.44; 95% CI, 1.06–1.94).Acne and AD also affect psychosocial factors that contribute to self-esteem and identity development.37,38 The results of a systematic review by Nguyen et al indicated that acne has a more direct effect on self-esteem, self-confidence, and identity, especially in girls, whereas AD has a more prominent role in the formation of identity and gender roles in girls and a lack of opportunity for the development of proper coping skills.38 Moreover, the negative societal perception of skin diseases reinforces the psychological burden for adolescents with acne or AD.30 Feelings of stigmatization are common and often associated with QoL impairment in patients with chronic skin diseases, such as acne, AD, and psoriasis.1,4
 
Due to poor self-esteem and social phobia,8 adolescents with acne often have difficulty socializing, making friends, meeting new people, interacting with the opposite sex, and fully participating in society.6,39 The psychosocial and emotional impairment was found by Tasoula et al to be greater in adolescents with moderate/severe acne than in the general population (P<.0001).6
 
Hazarika et al identified a statistically significant correlation (P<.05) between acne grade and effect on work/studying; grade and site with embarrassment; site and post-acne pigmentation with interpersonal problems; grade with sexual difficulties; and grade and site with social activities.12  In a study by Halvorsen et al a multivariate model similarly identified a negative association between substantial acne and psychosocial factors such as failure to achieve at school, low attachment to friendships, and absence of romantic relationships or sexual intercourse.34
Adolescents with AD have reported experiencing similar psychosocial challenges. In a study by Slattery et al adolescents with AD were found to have elevated rates of anxiety disorders (26%, 95% CI, 11.23-40.19%) compared with community estimates (3%–6%), with social anxiety disorder being most common (14%; 95% CI, 7.35-25.88%).40  In a study by Muzzolon et al parents were more frequently concerned about socialization/bullying in children and adolescent subjects with AD compared with their siblings (33% vs 4%, P<.001).41  Ghio et al identified three psychosocial needs in adolescents and young adults with AD: 1) the need to feel understood; 2) the need to blend in and be perceived as “normal”; and 3) the need for emotional support.17  These needs reflect the emotions and behaviors of the subjects that were identified in this study, such as feeling low and anxious, socially isolating, hiding skin, and seeking support.
Statement 2: Severe body image concerns, including BDD, present with high levels of psychological distress and are significantly associated with inflammatory skin diseases such as AD and acne.
Adolescents with acne or AD, or those who desire cosmetic surgery, may present with BDD or body image concerns that resemble BDD.42,43 Body dysmorphic disorder is a mental health disorder that involves distressing or impairing preoccupation
 
 
with perceived defects in physical appearance that appear only slight or non-existent to others.42-44 A time-consuming obsessive focus on these perceived flaws can lead to many psychiatric comorbidities, social and occupational impairment, and a desire to have cosmetic surgery.43 The results of a systematic review by Veale et al indicated that BDD is common, but poorly identified, in dermatology and cosmetic procedure settings.45 This study found that the prevalence of BDD among adolescent and adult patients was 11.1% in acne dermatology clinics; 11.3% in medical dermatology outpatients;  9.2% in cosmetic dermatology outpatients; 13.2% in general cosmetic surgery patients; 20.1% in rhinoplasty surgery settings; and 11.2% in orthognathic surgery settings.  However, cosmetic treatment (eg, dermatologic, surgical) virtually never improves BDD appearance concerns.
Body dysmorphic disorder most often develops in early adolescence. Although the causes of BDD are complex and multifactorial, and include genetic risk factors, negative social experiences, such as bullying, trauma and abuse during childhood may also be contributing factors.21,43 An early age of onset increases the likelihood of developmental and psychological comorbidities and is associated with a higher rate of suicide attempts.43,44 A study by Möllmann et al found that significantly more adolescents and young adults with self-reported BDD (36.4%) compared with those without BDD (8.8%) reported appearance-related suicidal ideation (P=.002).44
Anxiety, depression, and BDD have been found to occur more frequently among patients with acne, AD,  and other inflammatory skin disorders compared with the general population.33,46 In a study by Elsadek et al 82.7% of adolescent subjects with acne
 
experienced anxiety, 76.9% reported depression, and 46.8% had BDD.46 Tasoula et al found that body image concerns have also been found to vary proportionately with self-reported acne severity (P<.0001).6  Studies by Tan et al and Desai et al found that the scores of subjects who self-rated their acne as “severe” indicated greater psychological impairment on validated HRQOL scales.1,23  A systematic review by Barlow et al found that in children and adolescents with chronic skin disorders, the prevalence of suicide attempts was 21.9% for subjects with acne and suicidal ideation occurred in 67% of subjects with BDD.33  The odds ratio for suicide attempts was significantly increased for subjects with acne or AD.
Statement 3: Education for patients with AD or acne and their parents leads to improved self-management skills and self-responsibility, better outcomes, improved quality of life for patients and caregivers, reduced treatment costs, and secondary prevention of comorbidities, including certain mental health disorders.  Beliefs, misconceptions, and economic factors regarding acne are major challenges among cultures worldwide.9,47,48 In addition many patients with acne don’t readily seek help, so the disease is often undertreated.9,23 Likewise many caregivers and patients with AD are also undereducated and undertreated, causing symptoms to often be uncontrolled, increasing stress on patients, caregivers, society, and the economy.15
 
Patients often have misconceptions regarding factors that exacerbate acne.9  A study by Kubota et al found that the three most common factors that adolescent subjects thought triggered or increased their acne were sweat (53%), stress (63.1%), and lack of sleep (55.5%).24 A study by Yousaf et al found that due to the high prevalence of acne treatment advice on social media, numerous adolescent and young adults (48%) adopted measures to treat acne (e.g. supplements or dietary changes) that aren’t supported by the American Academy of Dermatology.10  Instead of seeking treatment from a dermatologist, patients with acne also often seek other remedies.9  Tavecchio et al determined that while 65% of the study subjects were under treatment for acne, only 20% were consulting a dermatologist.49
Early evidence-based educational interventions are critical to extinguishing myths and misinformation that may lead to acne or AD mismanagement, delayed access to healthcare, and psychological and/or physical scarring. A systematic review by Claudel et al concluded that identifying and attending to the concerns of young individuals with acne may improve the patient’s sense of well-being as well as decrease emerging psychological comorbidities and related healthcare expenses.47 Many investigators have suggested that educational programs should be established in high schools and colleges to ensure that adolescent students with acne are knowledgeable about their condition and are aware of available treatments. Such programs could improve mental health outcomes and prevent associated psychological disorders.1,23,24,27
 
Adolescents with AD would also benefit from education regarding their medical, mental, and psychosocial needs.7 The German Atopic Dermatitis Intervention Study (GADIS) demonstrated that age-related educational programs for children and adolescents are effective in the long-term management of atopic dermatitis.50  The economic burden of AD is also higher when the patient’s condition is uncontrolled, highlighting the importance of education for patients and caregivers regarding disease control.15
 
Statement 4: Teens look to social media for medical information and support when seeking cosmetic and dermatologic treatment; however, social media can contribute to unrealistic expectations and mental health conditions, including body image dissatisfaction.
 
Social media has a powerful effect on frequent users of apps. The impact on adolescents may be more profound as they live in a period when physical and social comparisons, peer approval, and body self-consciousness influence self-worth.21,51,52 Readily available smartphones and the widespread use of social media sites such as Instagram, TikTok, Twitter, SnapChat, and Facebook, have become integral to adolescent communication, entertainment, and information sharing about skin conditions.21,53,54  Posting selfies that invite instant positive or negative feedback from one’s peers is one of the most frequent activities that adolescents participate in on social media sites.51,53
 
Consequently, social media can foster self-objectification and unrealistic expectations that are based on current trends and idealized or manipulated images.21,53 Participating in social media can cause adolescents to become obsessed with body image, depressed, isolated, and even suicidal.21  It can worsen psychological comorbidities that may already exist secondary to acne or AD, increase body dissatisfaction, and encourage a desire for cosmetic procedures. Aktepe et al found that adolescents with acne more frequently overused (P=.022) the internet, more often sought social benefit/comfort from the internet (P=.041), and more frequently participated in social media sites (P=0.044), but were more exposed to negative effects (P=.012) compared with the control group.55
Social media has also been found to exacerbate the desire for cosmetic procedures in adolescents who are suffering from anxiety, depression, and low self-esteem.21 In a study by Charmaraman et al, 19% of adolescent subjects reported dissatisfaction with their body image.51  The most common concerns among participants were not being sufficiently
 
attractive (60%) or thin (63%), and being dissatisfied with hair/face (54%) or body shape (61%). Subjects with social media-related body dissatisfaction were more likely to check their social media accounts frequently than those without social media-related anxiety (P=.024). These individuals were also more socially isolated (P=.017), had a greater rate of depression (P=.000), and online social anxiety (P=.000), and found it challenging to make new friends (P =.002). Selfie behavior and social media use has also been found to enhance cosmetic surgery acceptance in adolescents.52,53 Lyu et al investigated the relationship between selfie behavior, cosmetic surgery desire, social comparison, and concerns about facial appearance in a group of adolescents.53  The results of this study showed that selfie behavior was associated with a higher level of cosmetic surgery consideration (P<.001), which was mediated through an upward comparison of facial appearance (P<.01).
 
Devries et al, in a longitudinal study, also identified that more social media use increased appearance investment (P<.001), and prospectively predicted a greater desire for cosmetic surgery (P<.01).52
 
Statement 5: Social media use has potential benefits such as connection, support, increased self-esteem, safe identity experimentation, and an increased opportunity for self-disclosure. Body image acceptance and body positivity campaigns from social media platforms and social media-based micro-interventions may actively combat adverse outcomes in adolescent patients with AD or acne.
 
Social media can benefit adolescents by providing a platform to seek emotional support, share experiences, and acquire information.17,48 It also provides adolescents, including those with acne or AD, the opportunity to socialize while avoiding face-to-face interaction.39  Social media and the Internet allow adolescents to independently access information; however, doing so makes them less reliant on more credible sources such as parents, teachers, doctors, therapists, and pharmacists.48,56
Exposure to the internet and social media-driven misinformation highlights the importance of educational interventions to increase education about acne and AD in adolescents. Improved health literacy has been associated with better health outcomes in numerous conditions, and it can be employed as a method to reduce negative outcomes.48 The popularity of social media among adolescents makes it a powerful tool for advancing health literacy in this age group.54  Healthcare professionals can create engaging videos about conditions like acne and AD to educate, entertain, and counteract misinformation that they may have been exposed to. Such videos can improve access to true experts, particularly for those adolescents who may not have the proximity or resources to seek in-person consultation. In addition, the increased use of social media for consultation and interaction between patients and healthcare professionals or hospitals may facilitate educational efforts.10
 
Educating adolescents with acne or AD about their disease and effective treatments is vital. Broad-based, long-term interventions that target adolescents and their families, peers, school environment, and community can also increase awareness, prevention, and treatment of mental health disorders.57  Though most mental health services are still conducted in person, telehealth services are now widely available. Additional educational resources could soon be made available via low-cost digital interventions including websites and social media platforms established by healthcare providers, schools, and hospitals.23 These resources could be used to connect adolescent patients with peers who have the same diagnosis, providing community and support to cope with their challenges.4 Structured local and global informational campaigns could also be undertaken via the Internet and social networks.47
Physicians should be conscious to inquire about mental health and QoL impairment when treating adolescent patients with acne or AD and consider these issues when determining treatment.15,23 A multidisciplinary approach to care and support should be taken, including educational programs for patients and families.15  Patient needs, psychosocial factors, and education should be integrated into individual treatment and care plans to optimize patients’ self-management capabilities. Support programs addressing stigmatization and other psychosocial effects of acne or AD in adolescents should be included in these plans.

CONCLUSION

Adolescents living with acne or AD may experience substantial health comorbidities, including adverse life events, depression, anxiety, suicidal ideation, and body image concerns. In seeking information about skin disease or body image, adolescents often consult the internet and social media. Exploring these avenues may have positive or negative aspects, at times providing helpful information, enhancing community, and reinforcing body positivity, at other times, offering misinformation, increasing social isolation, and worsening body image concerns. Educational programs for patients, families, and clinicians could increase awareness of the positive and negative aspects of social media use among adolescents and also help educate them about comorbid skin and psychological conditions. Action-oriented items should be created to assist dermatologists in addressing these issues in clinical practice, increasing mindfulness during patient examination, and promoting multidisciplinary discussion and outreach.

DISCLOSURES

The authors disclosed receipt of an unrestricted educational grant from CeraVe US for support with the research of this work. The authors also received consultancy fees for their work on this project.
 
All authors participated in all steps of the project, reviewed the manuscript, and approved the final version of the publication.

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AUTHOR CORRESPONDENCE

Anneke E. Andriessen PhD [email protected]
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