When I was 13, I was completely dedicated to a few hobbies outside of school. I did community theater, wrote Lord of the Rings fan fiction, and waited on AIM to talk to the boy I loved from afar. I also had a habit of locking myself in the bathroom I shared with my younger sister, where I’d put on a Good Charlotte CD, hoist myself onto the sink, and pick at my own face until I bled.
For a large part of my life, I felt compelled to pick at my zits. It seemed all-encompassing, as if I was dying from acne. I resented letters from readers in women’s magazines that made high drama of—gasp—a single pimple on prom night, and I’d fantasize about what I’d give up to have just one zit. I hated the mask of infection on my face so much that I started to hate my own face underneath.
Most people struggle with acne during their teen years, but mine was on another level. For years, my face produced these deep, painful, pus-filled cysts which I can still only describe as hateful. They sprouted like demonic mushrooms on the sides of my nose, along my jawline and my hairline, and in ripples across both my cheeks.
I was caught in a never-ending cycle; I’d sear off the surface of my face with products that smelled and burned like bleach, aggravate my skin further by prodding and picking at it, and then I’d try to cover up the wreckage with thick, pancake-consistency drugstore concealer. I had crayon sticks in two colors: green to counteract redness, and pale to mimic my skin.
When someone I went to school with started taking Accutane (isotretinoin), I was shocked by the results. I went to see a dermatologist too, but I was frightened by the drug’s many listed side effects. I remember the pamphlet they gave me was bright yellow and red like a toxic waste warning.
No way, I thought. I’m supposed to have acne because something is wrong with me.
What I didn’t realize at the time was that my deep feelings of self-loathing were also more pronounced than the average teenager’s.
I’d later learn through working with a cognitive behavioral therapist that my thoughts had been stuck in an anxious loop for a decade. She told me I had generalized anxiety. And I realized it was fueled by my acne. A bad thing out of my control would happen (acne), I’d internalize it as evidence that I was a bad person, I’d ruminate on the pain alone, and I’d punish myself by making every blemish worse.
I don’t think it’s a coincidence that my skin cleared up as I worked through my anxiety disorder. It’s also not a coincidence that my face looks more irritated when I’m coping with challenges in my personal or professional life.
As it turns out, it’s not unusual for cystic acne and anxiety to occur together. But managing them requires complementary strategies. Our skin and mental health are connected in ways we’re only beginning to understand.
This anxiety-acne relationship is the product of an “intricate brain-skin connection,” Keira Barr, M.D., dermatologist and founder of the Resilient Health Institute, tells SELF—an overlap that might fall under the umbrella of psychodermatology or psychoneuroimmunology. She says we’re still exploring how the mind, skin, and our immune system work in harmony, which explains why some people notice pimples or flare-ups of a skin condition when they’re under stress.
“Simply put,” Dr. Barr says, “what we think, feel, and see can play a significant role in what shows up on our skin.”
Though psychodermatology isn’t as widespread a science as it should be—no dermatologist ever explained things to me in this way—Dr. Barr says it has roots in old psychological concepts. She pointed me to a classic review article published in Medical Clinics of North America back in 1948. “There is no single disease which causes more psychic trauma and more maladjustment between parents and children, more general insecurity and feelings of inferiority and greater sums of psychic assessment than does acne vulgaris,” the authors conclude dramatically.
What happens, then, when people blame themselves for their skin conditions?
When I asked Dr. Barr about acne and self-blame, she sent me this study, published in 2001 in the Journal of the American Academy of Dermatology. For the study, researchers handed out questionnaires to 78 people visiting a dermatologist’s office to ask about their perceptions of their acne. Their results showed that 30 percent of the participants believed they caused their own symptoms through their hygiene habits or their diet, suggesting that some people with acne personally blame themselves for their skin issues.
For some people, both acne and anxiety disorders can start to feel like an integral part of a patient’s identity, especially when they’re persistent. A decade ago, both having acne and being “an anxious person” felt like permanent and deeply embarrassing things about me.
And sometimes, it gets worse.
When acne fuses with your identity, it can affect your romantic life, platonic relationships, and even your career, Erin Engle, Psy.D., psychologist and clinical director of Columbia University Psychiatry Specialty Services, tells SELF. “People who fear negative appearance-related judgments may choose to cope through isolation,” she explains. But that causes them to miss out on social, dating, and work experience that could actually foster self-worth and emotional resilience.
It’s also worth noting that some medical treatments prescribed to acne patients can come with adverse mental health side effects for some people. I was put on hormonal birth control at 13 in an effort to help treat my acne, which seemed to just exacerbate the mental health issues I was already starting to deal with. Medications like isotretinoin (formerly known as Accutane) “have been associated with significant improvement [in acne symptoms],” Engle says, but it’s also been linked to an increased risk for depression.
Overall, the experts I spoke to find it extremely common for patients with cystic acne to express feelings of self-doubt, anxiety, social paranoia, and even hopelessness, which are also common symptoms of anxiety and depression. That’s why they recommend treating acne and mental illness simultaneously, keeping the symptoms in conversation with each other. Treating one while ignoring how the other is connected is to ignore half the roadmap to recovery.
I wish I could travel back in time to my bathroom in seventh grade and talk it through. I’d show that teen girl the spots on my face that changed color and texture—not because of the acne, but because of my picking at it. (I’d also throw my Good Charlotte CD out the window and replace it with Sleater-Kinney.)
Though I can’t get those years back, I’m grateful to have found productive coping mechanisms and a healthier routine inside and out. My therapist and I never discussed my acne per se, but she did help me untangle my toxic thinking thread by thread. I think that emotional knot may have been contributing to my acne.
By virtue of crafting a healthier self-image, I began to make choices that made me feel mentally better—drinking water instead of soda, cutting down on alcohol, bringing micellar water to the gym to immediately cleanse after sweating—and that alleviated some acne symptoms. And slowly I stopped relying on my old ritual at the mirror.
The funny thing is, when you’re mentally healthier, you tend to attract people who love you—and you can’t hide in the bathroom picking at zits when people are counting on you to hang out.
Now, I’m not completely free of getting the occasional angry pimple, and I’ve been told by friends and family that I tend to be too pessimistic and hard on myself. But neither of those facts feel like a defining part of who I am. I might sometimes feel anxious, but that’s just one emotion in a complex array that I can feel fully now that my thought patterns are healthier. And a zit is a zit—it sucks, but like a negative emotion, it’s always temporary. Wallowing, blaming yourself, and prodding at a problem only exacerbates it. The key is to learn to let go and keep living.