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Anyone who has ever struggled with acne knows that the condition isn't just skin-deep.
Having a visible skin issue, particularly in adulthood, can have a serious impact on your confidence, emotional state and ultimately, your mental health.
Research published earlier this year found patients with acne had an increased risk of developing major depression.
Nikki Mattocks, 21, says she has struggled with acne since the age of 10.
"It really damaged my self-esteem and mental health and caused a lot of social anxiety especially when I was younger because at ten years old no one else really has spots yet," she says. "So I used to refuse to leave the house and be in pictures and I became very isolated and depressed.
"More recently I've learnt to accept it as part of me and due to medication and lifestyle changes, such as a better diet, it has got better. But more importantly I'm on a journey to love myself with acne included."
Dr Shirin Lakhani, from Elite Aesthetics, explains why acne can have such a detrimental impact on mental health.
"A very visible skin disorder such as adult acne has a multitude of psychological and social effects, causing depression and low self-esteem and even going as far as to impact on employment and relationships -patients come to see me tearful, frustrated and with very poor self-esteem," she says.
"The psychological impact of acne in adulthood can be overwhelming and, if not treated early and aggressively, adult acne can lead to scarring which can be devastating to a patient's confidence."
Dr Lakhani also advises skin specialists to not only help someone with the physical symptoms, but also offer emotional support too.
Psychodermatology is a field of research which studies the link between emotional issues and skin conditions and provides psychological support alongside dermatological treatments.
Lisa Mason-Poyner, director of medical standards at the skin clinic Sk:n, says having acne can lead to sufferers feeling isolated too.
"Acne can influence how you feel about yourself and can make an individual feel less attractive - social standards and pressures can contribute to this," she explains. "Many people with acne can feel judged and unattractive, and this can lead to lack of self-confidence and low self-esteem, which can lead to social isolation. Acne can, in some cases, touch every element of an individual's life."
"I genuinely felt like I was the only person in the world that struggled with it and that's a very isolating way to feel," says Bethany Rebecca, 24, who developed acne when she was 12.
"My acne heavily impacted my mental health even from being a teenager. It used to make me extremely low, I would pretend I was ill so i didn't have to go to school sometimes. I can specifically remember crying at myself in the mirror and wanting to physically rip my face off because I hated the way I looked so much."
There are many reasons why we get acne, from fluctuating hormones during periods or pregnancy, to stress.
"A common theory is that stress triggers the release of cortisol, a hormone that helps the body deal with stress," says Abbas Kanani, pharmacist at Chemist Click.
"Excess cortisol caused by increased stress levels stimulate the sebaceous glands in your skin to produce more sebum, a natural oil that lubricates your skin," he explains. "An overproduction of sebum can clog pores and create an environment for bacteria associated with acne to grow."
Genetics can also play a part in adult acne, Kanani. For example, you may have inherited an oily skin type making you prone to getting acne.
Certain medications or skincare products can also be the cause of acne. "Skincare products that make your skin too oily or too dry - dry skin encourages the sebaceous glands to produce more sebum - can contribute to adult acne," Kanani says.
So what can you do to treat acne? "The reality of the situation is that you have to find what works for you," Kanani says.
The first thing is to know your skin type. "Those who suffer from oily skin would benefit from a product that reduces excess oil produced by the skin. Be careful to ensure that you use such products in intervals to avoid drying your skin which can have a reverse effect and also cause acne. The same advice applies to people that suffer from dry skin (but the other way round)."
"Use an oil control cleanser each morning and evening to remove pollution and makeup from your skin," Lakhani says. "Exfoliation is the most important thing you can do on a regular basis to be fighting acne both in terms of preventing it and treating it."
Kanani advises seeing your GP. "Acne can be caused as a side-effect of medication you are taking, or could be a result of a hormone imbalance. Your GP or pharmacist can offer advice and support you in making clinical decisions that are better for your skin. You can also be prescribed medication that can help with acne."
Lifestyle changes may help too. "Tweaking your diet to include more water and vegetables, and less sugar could help to improve acne," Kanani says. "Clinical research has suggested that certain food which cause a spike in insulin levels, such as sugar, white rice, white bread can contribute to acne.
"Getting a good night's sleep and managing stress levels can keep your immune system healthy and also help in reducing acne."
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