Acne is a dermatological disorder with a high prevalence in teenager and young generation. It can affect human being in any age, a holistic approach in treatment of acne is necessary. Initial consultation should explore the type of acne as well as the behavioral changes of individuals. Acne has various psychological impacts like depression and Body dysmorphic syndrome. Dermatologists should treat the psychological co-morbidity of acne with the skin problem at the same time to achieve a satisfactory level of therapy in acne.

1. Dr. Faramarz Didar
Cosmetic Facial Uk Limited
www.cosmeticfacial.co.uk
info@cosmeticfacial.co.uk

2.  22 years old female
 History of acne from 11 years to 18 years of age.
 Active Acne settled after using tepal of lily in Russian Vodka. She had
been on topical treatments as well as systemic antibiotic and COC prior to
this traditional Russian herbal medicine.
 Patient version of acne as severe and aggressive. She often slept with a
towel on her pillow as my spots bled during the night.
 Admitted spending lots of time researching acne treatment as well as
makeup. She still does this as she has never been happy with her skin.
 The first foundation she ever used made her skin ten times worse than
better.
 Her family spent a lot of money on skincare products and treatments to
try to help her.
 Scrubbing and washing aggressively on daily basis. She still does.
 Doctors’ treatments did not help and instead made her skin dry,red and
uncomfortable.
 There was history of picking on acne lesions as well as squeezing them.
She never admitted this despite many confrontation from her mother.
 Admitted her relationship with others were affected and still is.
 This hindered her education (in a minor way) as she stayed quiet and
didn’t have as much participation with other pupils.
 Social isolation in past as well as present as often felt/feels that people
judged her or did not like her.
 Today, despite not having acne for years she has scars which she find
unattractive and cover up with makeup daily.

3.  Having aggressive acne throughout my teenage years (11-18) impacted me in many ways, both mentally
and socially, and has also impacted me in later life.
 it made her more aware of herself and her appearance. This resulted in lowered confidence.
 She thought acne comes from dirt and dirty hands. This belief mostly influenced her by her Grandmother.
She also felt embarrassed when having to look at people or them look at her as she felt she would be
judged by her acne (that she didn’t stay clean etc, even thought that was not the case).
 She became ashamed of the way she looked. This resulted in her staying at home and avoiding, having
to put lots of makeup on (which is a lot of effort- particularly when just popping to the shops). She still put
lots of make up on.
 She has not ever been fully happy with her skin. She did not/does not feel attractive or comfortable in her
own skin. She wished she was someone else.
 She is still scrubbing and washing her face to stay clean.
Assessment tools
 Dermatology Life quality index(DLQI) 15
 Hospital Anxiety and Depression Scale(HADS) depression: 8 anxiety: 14
 Skindex-29 psychosocial functioning 52
 The Cardiff Acne Disability Index 6/15
 The Acceptance and Action Questionnaire (AAQ-2) 43/70
 The Acceptance and Action Questionnaire – Revised (AAQ-R) 79/136
 Avoidance and Fusion Questionnaire for youth(AFQ-Y) 51/68
Summarise issues
 possible Acne excoriee in past
 Obsessive compulsive disorder in present
 Body Dysmorphic Disoredr : BDS
 Moderate anxiety

4.  BCT as first line of treatment/approach. This approach
failed as patient was unwilling to participate in
ERP(exposure and response prevention).
 ACT (Acceptance and Commitment Therapy) as
alternative therapy to CBT.
 Pharmacologic approach: SSRI(Paroxetine 20mg initially
each morning increased gradually in steps of 10mg up to
40mg daily)

5.  CBT resulted in higher quality of life, whereas ACT resulted in greater
psychological flexibility, and, among those who completed treatment((Arch & Craske,
2008)
 Jeanne Jung, MD, MS, and Eun Ju Hwang, MD, MS(2012), Do patients with acne
need cognitive behavioral therapy? Emphasised on CBT as main approach in
treatment of psychological aspect of acne.
 Volker Niemier(2006): acne vulgaris psychosomatic aspects: Doctor +patient
relationship is very important.
 ACT is part of a larger movement in the behavioral and cognitive therapies toward
the use of mindfulness and acceptance (Hayes, Follette, & Linehan, 2004),
 ACT is a highly viable treatment alternative to CBT, Joanna J. Arch et al 2012
 Volker Niemier(2006): Differential Diagnosis from psychosomatic point of view in
psychogenic excorietion: these patients have comorbid disorders like(OCD,BDD,
eating disorder, borderline personality disorders) , recommended treatment is
combination therapy like medical(SSRI) and CBT or alternative ACT.

6. study type CBT
or
ACT
Method Opinion
Jeanne Jung et
al 2012
questionn
aire
CBT 136 patients with acne at
Klaripa Clinic in Seoul ,
questions varied from
etiology to their habits
Cognitive and behavioral therapy can be
combined with the treatment of acne.
Arch & Craske,
2008
systemic
review of
RTC and
other
studies
Combine
treatment
They reviewed RCT and
systemic reviews studies in a
certain period of time.
This article presents a critical examination of
stereotypical differences between ACT and CBT
for anxiety disorders. The general conclusion
is that the treatments are more similar
than distinct.
Stefan G.
Hofmann 2008
Reviewin
g Arch&
craske
review
Combinati
on therapy
Acceptance and
Commitment Therapy: New
Wave or Morita Therapy?
Some proponents of ACT view it as part of a
third wave movement destined to replace cognitive
behavioral therapy (CBT) as the dominant form of
psychological therapy. This perception is
problematic,because the criticism offered by ACT
against CBT is based on a misrepresentation of the
empirical evidence.
Francisco J.
Ruiz
systemic
review of
RTC and
other
studies
ACT efficacy of ACT in a wide
range of psychological
problems and suggest that
it is working through its
hypothesized processes of
change
component studies are showing that
acceptance-based protocols are usually
more efficacious than other control-based
protocols
Hofmann &
Asmundson,
systemic
review of
Combinati
on therapy
ACT has a sound model of
psychopathology in EAD or psychological

7.  Significant improvement in patient psychological well being after 6month sessions of psychological intervention.
This was in combination with micro-needling of facial skin in order to reduce scars of acne.
◦ She was more social, less ashamed of her skin.
◦ She was not scrubbing the face any more but still using make up.
◦ She was more capable of handling anxiety situation by accepting them as part of her life.
◦ She was living more in present than in past or future.
◦ Her self-esteem improved.
◦ She was Allowing thoughts to come and go without struggling with them.
1. I put into practice the new theoretical knowledge of ACT in combination with CBT approach.
2. This one was a new task for me to approch a young patient who was initially reluctant to accept any
psychiatric intervention or assistant.
Psychological assessment
score before
Psychological assessment 6
months after
Dermatology Life quality index(DLQI) 15 Dermatology Life quality index(DLQI) 7
(HADS) depression: 8 anxiety: 14 (HADS) depression: 6anxiety: 7
Skindex-29 psychosocial functioning 52 Skindex-29 25
The Acceptance and Action Questionnaire 43/70 The Acceptance and Action Questionnaire
12/70
Avoidance and Fusion Questionnaire for
youth(AFQ-Y) 51/68
Avoidance and Fusion Questionnaire for
youth(AFQ-Y) 22/68

8.  skin-picking and Acne psychological impact may, in certain cases, amount
to a mental disorder. Effective communication skills are needed to explore
this area.
 Good assessment of patients’ history and personality traits are essential in
initial assessment of chronic skin disorder.
 selective serotonin reuptake inhibitors (SSRIs) may be useful in treating
pathological skin-picking but psychological interventions are proven to be
mandatory. Cognitive and behavioral therapy can be combined with the
treatment of acne.
 If CBT approach fails, ACT can be used as alternative treatment/approach
studies should be conducted that combine ACT and CBT techniques in
order to improve the efficacy of existing treatment protocols for specific
disorders.
 Health care professionals specially dermatologists and GPs should be
aware of psychological impacts of chronic skin condition and address them
 Perhaps the subspecialty of psycho-dermatology needs to be launch
quickly.