Research has proposed that psychological stress may be a factor in acne. There is little direct scientific evidence indicating what effect stress has on acne. However, based on what we know about how stress affects the skin, it is reasonable to suspect that stress may contribute to increased skin oil production and more inflammation in the skin, both of which are known to lead to more acne. Stress may also slow wound healing, and since acne lesions are wounds, ongoing stress has the potential to reduce the body's capacity to heal acne as it should.
The Body’s Response to Stress
The body’s stress response is a normal and healthy phenomenon that evolved to help us survive. When stress occurs, the body responds by releasing chemicals called neurotransmitters as well as hormones that prepare the body to fight the perceived stress.
Neurotransmitters are molecules that enable communication between neurons (nervous system cells) and other neurons, between neurons and skin-cells, and between neurons and the immune system.
The body also releases hormones, such as adrenaline, the classic “fight or flight” hormone, in times of stress.
However, the stress response is meant to be activated only periodically, in response to real dangerous situations. In today's world, however, the stress response can go into overdrive, leading to chronic stress. Chronic stress results in continuous activation of the stress response and this can negatively affect health, including skin health.
The skin is the body’s largest organ and has the ability to react to neurotransmitters and hormones. Since stress response involves neurotransmitters and hormones, the skin readily reacts to stress.1-3
Acute Stress vs. Chronic Stress
Psychological stress can be:
- Acute - temporary
- Chronic - ongoing
Acute stress: Acute stress means once the stressor goes away, the body’s response calms down. Taking an exam is an example of acute stress: you are anxious before the exam, so your body mounts a stress response. Once the exam is over and you are no longer anxious about it, your body calms down. With acute stress, the body responds by releasing neurotransmitters and hormones that stimulate the body’s protective mechanisms.
Chronic stress: With chronic stress, the stressor does not go away. An ongoing difficult job or school situation, or ongoing relationship issues are all examples of chronic stress. In these situations, the stressor remains for a long period of time and so does the body’s response to the stressor. The body continues to release stress-fighting chemicals, and the resulting continuous stimulation eventually overwhelms the body's immune system and causes it to stop responding correctly, which can cause problems, such as an increase in skin oil production and inflammation. Acne is an inflammatory disease that is associated with increased skin oil levels, so anything which causes inflammation and/or increased skin oil production can theoretically aggravate acne.
It is still unclear exactly how stress affects acne, but based on what we know about the impact of stress on the skin’s immune system, we can infer that chronic stress may cause an adverse effect on acne. One study published in 2006 found that using techniques to reduce stress may also help reduce acne.2
A 2006 study in Dermatologic Therapy looked at the relationship between stress and acne by testing if stress-management could improve acne. In this study, the researchers used the techniques of biofeedback, relaxation, and cognitive imagery to reduce stress in patients. The authors stated, “Patients who underwent treatment experienced significant improvement in acne as compared with controls. Interestingly, patients experienced recurrence of [blackheads and whiteheads] when relaxation techniques were discontinued. Longer-term utilization of stress management techniques may lead to improved acne control.”2 This study suggests not only that stress affects acne but also that reducing stress may improve it.
Stress-related Neurotransmitters and Hormones Linked to Increased Skin Oil Production and Inflammation
Exactly which chemicals the body releases in response to stress may end up increasing sebum (skin oil) production, and thus worsening acne, remains a subject of study. For example, some neurotransmitters, such as substance P, may increase sebum production. Hormones released in response to stress, such as androgens (male hormones that are present in both males and females), corticotropin-releasing hormone, and α-melanocyte-stimulating hormone may also increase sebum production, and in turn aggravate acne.4
Neurotransmitters: Two studies have looked at the neutrotransmitter called substance P in acne sufferers. Both studies found evidence that people with acne tend to have more substance P near skin oil glands, which may lead to increased skin oil production, and potentially more acne. But the second study suggests that this could be either a cause or effect of acne, as having acne can itself trigger stress.4,5
A 2002 study in Experimental Dermatology tried to determine how the chemicals released by the nervous system might affect acne by looking at nerve fibers in the skin of acne patients. This study found that acne patients had more nerves that release substance P in close proximity to sebaceous glands (skin oil glands), than people who didn’t have acne. Substance P increases the expression of a molecule called neutral endopeptidase, which leads to an increase in sebum production.5
Similarly, a 2003 clinical study in Archives of Dermatology found that acne patients had an increased concentration of neurotransmitters, especially substance P, in sebaceous glands. However, the authors of this study cautioned that the relationship between substance P and sebaceous glands was only a correlation and that it did not indicate cause and effect. The authors noted that, since having acne can be stressful, an increased concentration of stress-related molecules in the sebaceous glands could also be a consequence of acne rather than a cause.4
Hormones: Androgens, corticotropin-releasing hormones, and α-melanocyte-stimulating hormones are important hormones that the body releases as part of the stress response. Research has found that people who have acne have higher levels of these hormones than people who do not have acne. Androgens and corticotropin-releasing hormones can result in increased sebum production, and α-melanocyte-stimulating hormone can result in skin inflammation.6,7
Conflicting Studies on Stress and Sebum Production
Some researchers propose that sebum might provide the link between stress and acne, since most studies so far have shown that neurotransmitters released in response to stress affect sebaceous glands. Sebaceous glands have receptors for neurotransmitters, and activation of these receptors leads to increased sebum production as well as inflammation. In other words, as suggested in one 2004 study, stress may trigger neurotransmitter release, which in turn may lead to more sebum and more acne.8
According to a 2004 study in Experimental Dermatology, “[t]here is increasing evidence to suggest that the nervous system (such as emotional stress) can influence the course of acne. Cutaneous neurogenic factors may contribute to the onset and⁄or exacerbation of acne inflammation. The current findings […] indicate that [stress] may, indeed, influence the feedback regulation in the sebaceous gland, thus inducing the development of clinical inflammation in early acne lesions.”8
In contrast, another study found no relationship between stress and sebum levels, despite agreeing that stress seems to be correlated with more severe acne.9
A small 2007 study in Acta Dermato-Venereologica that looked at the relationship between stress, sebum production, and acne in adolescents found no relationship between stress and sebum levels. However, this study did find a positive correlation between stress and acne severity. The authors concluded, “In adolescents, psychological stress does not appear to affect the quantity of sebum production. The study suggests a significant association between stress and severity of [inflammatory acne] especially in males. Increased acne severity associated with stress may result from factors other than sebum quantity.”9
Does Stress Cause Acne or Does Acne Cause Stress?
While we do not know for sure whether stress causes acne or not, we do know that the reverse can be true: acne can cause psychological stress.
According to a 2011 article in Gut Pathogens, “[a]cne vulgaris is a common dermatological disorder frequently associated with depression, anxiety and other psychological [issues]. The mental health impairment scores among acne patients are higher vs. a number of other chronic, non-psychiatric medical conditions, including epilepsy and diabetes.”3
From what we can tell, stress most likely does make acne worse. But, worrying about stress is of course counterproductive and will just cause more stress. The best bet is to exercise, get outside, and try meditation or deep breathing to handle your stress a bit better.