How does stress influence acne?

The primary cause of dermatological consultation, acne is a very common skin disease, linked to the interaction of several biological mechanisms: hyperseborrhoea, blockage of hair follicles, proliferation of Cutibacterium acnes and local inflammation. Hormonal, genetic, environmental factors, as well as certain cosmetics, can favour its onset. Yet beyond these well-established causes, many people also report the appearance of a stress-induced spot or a stress-related acne flare-up during examination periods, intense fatigue or emotional tension.

This observation is not purely subjective. Several scientific studies have highlighted a correlation between stress levels and the severity of acne, suggesting that emotional fluctuations could influence the progression of lesions.

A first cross-sectional study investigated the relationship between perceived stress levels and acne severity in 144 female medical students in their sixth year, aged 22 to 24. The researchers assessed acne severity using the Global Acne Grading System (GAGS), while stress was measured with the Perceived Stress Scale (PSS), a tool widely used in psychology. The analysis also took into account several factors likely to influence the acne in order to limit interpretive biases (variations in hormones in the blood, medication intake, air humidity, perspiration, cosmetic habits...).

Our findings demonstrated a statistically significant positive correlation between stress intensity and acne severity. Specifically, participants with the highest stress scores also presented the most marked acne during clinical assessment. In the studied population, 72.2% of the students had mild acne, 22.9% moderate acne and 2.8% severe acne, whereas only 2.1% had no lesions. These data therefore suggest that an increase in stress may be accompanied by a worsening of acne, supporting the idea that it is possible to have an acne flare-up due to stress.

These findings are not isolated. A second cross-sectional study explored the association between acne severity, stress level and the dietary habits among 585 medical students. Clinical assessment of acne also relied on the GAGS, while stress was measured using the PSS. Researchers simultaneously analysed eating behaviours to determine whether these could influence the lesions. In this population, the overall prevalence of acne was 88.2%, predominantly mild (59%) or moderate (23.9%). Regarding stress, 78.5% of students exhibited a moderate level and 11.8% a high level. Statistical analyses revealed a significant positive correlation between stress scores (PSS) and acne severity (GAGS) : students subjected to the most intense stress had, on average, more pronounced lesions. These results bolster the notion of a link between cortisol and acne flare-ups.

A third study, this time carried out among 288 adolescents aged 10 to 21 in Indonesia, also explored the effect of stress on acne severity. In this cohort, 76.7% of participants reported being under stress, and among these, the majority exhibited moderate acne (51.6%), while the non-stressed adolescents mostly had mild acne (52%). The association between stress and acne severity was statistically significant, suggesting that as stress levels increase, acne tends to become more pronounced.

Taken together, these studies converge on the existence of a link between psychological stress and acne exacerbation, consistent with the involvement of neuro-hormonal mediators such as cortisol in cutaneous inflammatory processes and acne flare-ups. However, these findings should be interpreted with caution.

Indeed, most available studies are cross-sectional, which allows for identifying a correlation but not for establishing a direct causal relationship. Furthermore, the populations studied are often specific (medical students, adolescents from a given region), which limits the generalisation of the conclusions. Above all, acne remains a multifactorial disease: hormonal factors, genetic predisposition, cutaneous microbiota, diet, cosmetics, sleep or even the environment can all influence its progression. Stress thus appears more as a modulating factor liable to exacerbate existing lesions rather than as a sole cause. This complexity explains why management strategies aimed at eliminating stress-induced acne or considering treatment for stress-related acne generally rely on a holistic approach that integrates both dermatological and psychological dimensions.

The stress corresponds to the body's response to stimuli internal or external. Biologically, this response involves activation of the hypothalamic-pituitary-adrenal axis: the hypothalamus secretes corticotropin-releasing hormone (CRH), which stimulates the pituitary to release ACTH, in turn prompting the adrenal glands to produce cortisol. However, prolonged elevation of cortisol is associated with a rise in cutaneous inflammatory phenomena. This link between cortisol and acne flare-ups can be explained by various effects on the skin: stimulation of the sebocytes, the cells of the sebaceous glands, thus increasing sebum production, altering keratinocyte differentiation favouring follicular obstruction, and modulating the immune response via cytokine secretion.

Beyond cortisol, stress also triggers an increased release of neuropeptides, particularly substance P, released by cutaneous nerve endings. This molecule stimulates both the lipid production by sebocytes and the activation of local immune cells, thereby intensifying follicular inflammation. Simultaneously, elevated levels of pro-inflammatory cytokines such as IL-1, IL-6 and TNF-α enhance the influx of inflammatory cells into hair follicles and contribute to the development of acne lesions. In the long term, chronic stress can thus impair immune mechanisms, leading to a dysbiosis that favours the persistence of acne.

These mechanisms are consistent with clinical observations reported by numerous patients, of whom a substantial proportion—ranging from 50 to 80 percent according to studies—report a worsening of acne during periods of emotional stress.

If stress can influence the progression of acne, the reverse is equally true: acne itself is a significant source of psychological stress.

Visible facial lesions, which can sometimes persist, may undermine self-esteem and social interactions, particularly during adolescence and young adulthood, when individuals are still developing. This emotional dimension transforms acne into a genuine psychosomatic condition, in which cutaneous and psychological factors sustain each other, creating a vicious cycle: stress promotes flare-ups, which in turn heighten stress.

A cross-sectional study conducted in 150 patients with acne precisely assessed the psychological impact of the condition, alongside clinical severity measured by the Global Acne Grading System (GAGS). The results show that participants presented significantly higher levels of depression and anxiety. Correlation analysis revealed a strong association between acne presence and depression, anxiety and stress, all statistically significant. Furthermore, regression analyses indicated that acne and the associated psychological distress had a significant negative impact on self-esteem and quality of life.

Acne transcends the dermatological sphere and can affect quality of life, heightening stress which itself may exacerbate the condition.

When dealing with persistent acne, the first step remains to consult a dermatologist, regardless of the presumed origin of the lesions.

Moreover, in practice, it is often difficult to assert that a pimple is solely due to stress, given the numerous factors contributing to acne. Medical management can achieve a treatment tailored to the severity and type of acne, with improvements that may become visible after a few weeks to a few months. Above all, it is essential not to face the psychological distress caused by acne lesions alone: a well-managed therapeutic strategy can, in many cases, markedly reduce lesions and improve quality of life.

In addition to dermatological follow-up, certain techniques can help to reduce the stress and thus limit its potential impact on the skin:

These measures do not replace a dermatological treatment when it is necessary, but they can provide valuable support for better managing stress and help break the vicious cycle between stress and acne flare-ups.

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