How does stress influence acne?

As the primary reason for dermatology consultations, acne is a very common skin disease linked to the interaction of multiple biological mechanisms: excess sebum production, obstruction of hair follicles, proliferation of Cutibacterium acnesand local inflammation. Hormonal, genetic, environmental factors, or even certain cosmetics can promote its onset. Yet, beyond these well-established causes, many people also report the appearance of a stress-related pimple or a stress-induced acne flare-up during exam periods, intense fatigue, or emotional tension.

This observation is not purely subjective. Several scientific studies have demonstrated a correlation between stress levels and acne severity, suggesting that emotional fluctuations may influence lesion progression.

A first cross-sectional study examined the relationship between perceived stress level and acne severity in 144 sixth-year medical students, aged 22 to 24. The researchers assessed acne severity using the Global Acne Grading System (GAGS), while stress was measured by the Perceived Stress Scale (PSS), a tool commonly used in psychology. The analysis also accounted for several factors likely to influence acne in order to limit interpretation bias (variations in hormone levels in the blood, medication use, air humidity, perspiration, cosmetic habits...).

The results demonstrated a statistically significant positive correlation between stress intensity and acne severity. Specifically, participants with the highest stress scores also exhibited the most pronounced acne lesions during the clinical evaluation. In the studied population, 72.2% of the students presented with mild acne, 22.9% with moderate acne, and 2.8% with severe acne, while only 2.1% showed no lesions. These data therefore suggest that a rise in stress may be accompanied by a worsening of acne, supporting the idea that an acne flare-up can be due to stress.

These findings are not isolated. A second cross-sectional study explored the association between acne severity, stress level, and dietary habits among 585 medical students. Clinical assessment of acne also relied on the GAGS, while stress was measured by the PSS. The investigators concurrently analyzed eating behaviors to see if they might influence lesions. In this population, the overall acne prevalence was 88.2%, primarily mild (59%) or moderate (23.9%). Regarding stress, 78.5% of students exhibited a moderate level and 11.8% a high level. Statistical analyses highlighted a significant positive correlation between stress scores (PSS) and acne severity (GAGS): students under the most intense stress exhibited, on average, more pronounced lesions. These results strengthen the idea of a link between cortisol and acne flare-ups.

A third study, conducted this time among 288 adolescents aged 10 to 21 in Indonesia, also examined the influence of stress on acne severity. In this population, 76.7% of the participants reported experiencing stress, and among them the majority presented with moderate acne severity (51.6%), whereas the non-stressed adolescents tended to have mild acne (52%). The association between stress and acne severity was found to be statistically significant, suggesting that the higher the stress level, the more pronounced the acne tends to be.

Taken together, these studies converge on 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 of the available studies are cross-sectional, which allows for identifying a correlation but not establishing a direct causal relationship. Moreover, the populations studied are often specific (medical students, adolescents in a given region), which limits the generalizability of the conclusions. Above all, acne remains a multifactorial disease: hormonal factors, genetic predisposition, skin microbiota, diet, cosmetics, sleep, or environmental factors can all influence its progression. Stress thus appears more as a modulating factor likely 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, integrating both dermatological and psychological dimensions.

The stress response corresponds to the body’s reaction to stimuli that are internal or external. Biologically, this response involves the activation of the hypothalamic-pituitary-adrenal axis: the hypothalamus secretes corticotropin-releasing hormone (CRH), which stimulates ACTH release from the pituitary, thereby triggering cortisol production by the adrenal glands. Prolonged cortisol elevation is associated with a heightened cutaneous inflammatory processes. This link between cortisol and acne flare-ups is explained by various effects on the skin: stimulation of sebocytes, the cells of the sebaceous glands, leading to increased sebum production, altered keratinocyte differentiation that favors follicular blockage, and modulation of 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 simultaneously stimulates lipid production in sebocytes and activates local immune cells, thereby intensifying follicular inflammation. At the same time, the rise in pro-inflammatory cytokines such as IL-1, IL-6, and TNF-α promotes the influx of inflammatory cells into hair follicles and contributes to the development of acne lesions. In the long term, chronic stress can thus disrupt immune mechanisms, leading to a dysbiosis that favors the persistence of acne.

These mechanisms are consistent with clinical observations reported by numerous patients, a significant proportion—ranging from 50 to 80% according to studies—report an exacerbation of acne during periods of emotional stress.

If stress can influence the development of acne, the converse is also true: acne itself is a significant source of psychological stress.

Visible lesions on the face, sometimes persistent, can undermine self-esteem and social interactions, especially during adolescence and young adulthood when identity is still developing. This emotional dimension turns acne into a true psychosomatic condition in which skin-related and psychological factors feed off one another, creating a vicious cycle: stress promotes breakouts, which in turn heighten stress.

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

Acne extends beyond the dermatological domain and can impair quality of life, heightening stress that itself can worsen the condition.

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

Moreover, in practice, it is often challenging to establish that a pimple is solely caused by stress, given the numerous factors contributing to acne. Medical intervention can provide 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 alone the psychological distress that acne pimples can cause: a well-conducted therapeutic strategy can, in many cases, significantly reduce pimples and improve quality of life.

In addition to dermatological monitoring, certain techniques can help reduce stress and thereby limit its potential impact on the skin:

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

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