Pulling in: Scars caused by loss of tissue

Some acne scars appear as holes, pits, or craters in the skin. Called
atrophic scars or crateriform scars, these depressed, cavity-like,
inward-directed scars are associated with a lack of tissue that
occurs when the inflammation from healed acne causes destruction
to the skin (similar to scars that often result from chickenpox). The
scar tissue contracts and binds the skin down.
Terms and descriptions related to this type of scarring will be help-
ful when talking with your dermatologist and reviewing treatment
options, because some treatments work better than others for dif-
ferent scars. Here are some more descriptive names:
Ice-pick scars: These scars are the most common acne scars
that occur on the cheeks. They’re most often small, with a
somewhat jagged edge and steep sides — like wounds from an
ice pick. They can be shallow or deep. Ice-pick scars may
evolve into depressed fibrotic scars over time.
Depressed fibrotic scars: These scars are usually quite large,
with sharp edges and steep sides.
Boxcar scars: These scars are angular and usually occur on
the temple and cheeks, and can be either superficial or deep.
They are similar to chickenpox scars.
Rolling “hill and valley” scars: These scars give the skin a
wavelike appearance. They have gently sloping rolled edges
that merge with normal skin.

acne scars and a look at the treatment

Thinking about Therapy

Your dermatologist, internist, pediatrician, school nurse, school
counselor, or other healthcare provider may be able to steer you in
the right direction and find someone who can help you or your
child contend with some of these emotional issues while they work
on the physical ones.
The good news is that the vast majority of people suffering from
depression can be treated successfully. Speak to your doctor about
the way you feel and ask her to treat you or your child or to make a
referral to a psychologist or psychiatrist.
Ideally, you or your child’s primary care provider or psychothera-
pist should maintain a close relationship with your dermatologist
so that they can discuss treatment and any changes in medica-
tions, and so on.
There are many types of psychotherapy and psychotherapists. You
can choose from:
 Psychiatrists: They are medical doctors and are able to pre-
scribe prescription medications, if required.
 Clinical psychologists: They usually have a master’s or doc-
toral degree in psychology.
 Psychiatric social workers: To become qualified as a social
worker that provides psychotherapy, a person must have
earned a minimum of a master’s degree in clinical social work.
 Counselors: Generally, they may have only a bachelor’s
degree in education, psychology, or theology.
Some dermatologists, albeit few and far between, are capable of
handling both the physical and emotional consequences of acne.
Several of my colleagues have been trained as dermatologists as
well as psychologists and psychiatrists. If you’re fortunate to have
access to any of these specialists, go for it!
Avoid quick fixes promised by audio and videotapes or books. You
can’t find true “quickie cures” for acne or for its emotional compo-
nents. Both sets of symptoms require time and patience.

Recognizing acne as a feature of emotional disorders

When self-esteem and self-image become an overwhelming preoccupation in some
people, they may show signs and symptoms of types of acne that have severe
underlying emotional and psychiatric underpinnings.
 Acne excorieé. This is a self-inflicted skin condition in which the sufferer has a
compulsive, irresistible urge to manipulate their skin and to pick real, as well as
imagined, acne lesions. This results in a worsening of acne and sometimes scar-
ring of the face. Also known as acne excorieé des jeunes filles, this type of acne
is almost invariably seen in young females. Jeunes filles means “young girls” in
French, but this condition is also seen in adult women (and males aren’t immune).
Many of these females deny that they manipulate their skin, but it’s rather obvi-
ous when you can see scabs that are almost always present on their faces. It’s
assumed that they have an underlying obsessive-compulsive disorder, a type
of emotional problem characterized by persistent thoughts and ideas and repet-
itive behavior.
 Body Dysmorphic Disorder (BDD). This psychiatric condition is characterized
by a fixation and chronic complaining about a nonexistent or minimal cosmetic
defect or minor flaw in one’s physical appearance. The “flaw” can be wrinkles,
large pores, or just a few pimples. The person with BDD exhibits an unreason-
able amount of anguish about them. BDD occurs equally in males and females.
BDD often results in significant suffering and social difficulties. Individuals with
BDD have variable degrees of awareness concerning the psychiatric nature of
the illness. Many people continue to agonize about an imagined defect although
they’re aware that their concerns are excessive, while other folks have no insight
into their unusual preoccupation with their appearance. Some people with BDD
frequently develop major depressive episodes and are at risk for suicide.
Treating acne excoriée and BDD is a major challenge. Certain medications and
cognitive-behavior therapies can complement each other and be helpful for some
people. Cognitive-behavior therapy involves discovering, challenging, and changing
the underlying negative thoughts and beliefs that the people with these conditions
repetitively dwell upon.
In addition to these treatments, family education and counseling, to help family
members understand what’s going on and how to help the sufferer, and group ther-
apy may be of benefit. Unfortunately, individuals with acne excoriée and BDD often
refuse psychiatric referral because of their poor insight into the underlying psychi-
atric illness.

Accutane and depression: Is there a link?

For several years, there has been debate over whether Accutane
(isotretinoin), a drug prescribed for serious cases of acne, could be
causing depression that results in suicide in teenagers taking this
powerful medication. Turn to Chapter 13, where I take on this con-
troversial debate about this drug and its generic formulations.
Lots of kids with acne who have never taken Accutane are
depressed. Moreover, since Accutane was introduced in 1982, it’s
likely that depression during this time has decreased in those who
sorely needed the drug and were successfully treated with it.

Helping Your Child Deal with Acne

Acne affects adolescents at a time when they’re developing their
personalities and evolving into adulthood. During this time, peer
acceptance is very important to them and physical appearance
and attractiveness is highly associated with peer status. Besides
the physical scars that severe acne can produce, your teen may
also be suffering emotionally.
Acne can be a real drag on a kid’s daily life. Acne on the face can
bring out cruel taunts, teasing, and name calling from other kids.
Some kids become so preoccupied with how their skin looks, that
they may not want to go to school, lose self-confidence, pull away
from their friends, show a dramatic change in their thinking and
behavior, become withdrawn, and even may begin to feel depressed.
The following list goes over some of the various teenage behaviors
and coping mechanisms that they may develop to deal with acne:
 Grow their hair long to cover their face.
 Become so embarrassed that they avoid eye contact.
 “Cake on” heavy makeup to hide the pimples.
 Lose interest in sports such as swimming or basketball
because of the need to undress in locker rooms and expose
their back and chests.
 Become shy and even isolated and prefer to stay in their
bedrooms.
 Start to develop any of the symptoms of depression from the
list in the “Detecting depression in teens” section.Offering your help
Here are a few seemingly simple, yet effective, ways to communi-
cate your willingness to help:
 Let your children know how much you care: Give your child
adequate time to bring up the subjects of their acne and allow
them to address or respond to your questions about the
behavioral changes you’ve noticed.
 Listen patiently: They may want to communicate their feel-
ings but have difficulty doing so. Think back to your own teen
years. You may not have always felt like it was easy to be open
about your thoughts and feelings.
 Don’t be overly judgmental about your child’s appearance:
Approach the subject of acne in a gentle, caring manner and
try to give a little space when it comes to some of the rela-
tively harmless decisions they make about their clothing and
grooming habits.
 Keep the lines of communication open: Take the time to pay
undivided attention to your kid’s concerns. It’s important to
keep the lines of communication open, even if your child
seems to want to withdraw.
 Don’t lecture on the subject: Try to avoid telling your child
what to do. Instead, pay careful attention and you may dis-
cover more about the issues causing his problems.
Detecting depression in teens
It is common for adolescents — or anybody for that matter — to
occasionally feel unhappy. However, when the unhappiness lasts for
more than two weeks, and the teen experiences other symptoms,
then he may be suffering from depression. Determining if a teenager
is depressed can be a very tricky undertaking. Dramatic physical
and mental changes seem to take place almost overnight and it
sometimes seems hard to tell the “normal” from the “abnormal.”
Depression is a more commonly recognized condition in adoles-
cents than it had been in the past. Parents should look for common
signs of depression in adolescents and they should be dealt with in
a serious manner and not just passed off as “growing pains” or the
normal consequence of adolescence. If you observe some of the
signs or behaviors listed in the following bulleted list, they may be
indicators of depression. They’re not always diagnostic of teen
depression; however, they may indicate other psychological,
social, family, or school problems. Among these are:
 Sadness, anxiety, or a feeling of hopelessness
 A sudden drop in grades
 Loss of interest in food or compulsive overeating that results
in rapid weight loss or gain
 Staying awake at night and sleeping during the day
 Withdrawal from friends
 Unusual irritability, rebellious behavior, or cutting school
 Physical complaints, such as headaches, stomachaches, low
back pain, or excessive fatigue
 Use of alcohol or drugs
 Promiscuous sexual activity
 A preoccupation with death and dying
Don’t be afraid to talk to your child about feelings. If you sense a
change or that something is seriously troubling your child, you
may be right. You can even ask about suicidal thoughts. You won’t
increase the possibility of suicidal behavior by asking if someone
has thought about it. Asking such a question does not “put
thoughts into their heads” but rather is more likely to identify if
they may be at risk.
If you or your loved one is finding it extremely difficult or impossi-
ble to handle the emotional aspects of acne, get help. And, if you
don’t feel that you can communicate effectively with your adoles-
cent, get help. Talk to your pediatrician or primary care practi-
tioner or ask for a referral for counseling. Strong suicidal thoughts
are an emergency and call for immediate action. Don’t go it alone.

Detecting Depression in Yourself and Your Family

It’s very normal for people with severe acne to feel down and
despondent; even mild acne can give you the blues. However, if
you or someone in your family is feeling unhappy more often and
doesn’t seem to enjoy anything anymore, you need to consider the
possibility that you or that person may be suffering from depres-
sion. Here are some of the signs of depression:
 Increased fatigue, low energy
 Feelings of pessimism
 Loss of enjoyment in things that previously gave pleasure
 Crying spells
 Sleep disturbances
 Hating to get out of bed
 Social isolation
 Loss of appetite or the opposite
 Lots of new physical complaints
 Decrease in sexual drive
 Irritability, anger, or aggressiveness
 Feelings of worthlessness and guilt
 Withdraw from family and friends
 Suicidal thoughts
If one or more of these descriptions rings a bell, talk to your doctor
about it. If you or your loved one is having suicidal thoughts, seek
immediate evaluation and treatment.