Examining Common Mental Health Disorders and Their Impact on Skin
Diseases (Case Study: Acne)
ABSTRACT
Most common mental disorders include anxiety and depression. This review examines these
disorders and some factors that cause or influence them, both positively and negatively, such as
the effects of nature, urbanization, and social media. Many of these disorders have a direct
connection with our hormones and can lead to an increase or decrease in them. We explore
how these illnesses affect specific hormones, as well as how the medications prescribed for
these disorders alter our hormonal system. Finally, we examine the relationship between
hormones and the effects of hormonal changes on the skin, offering solutions for the skin issues
that may arise due to these disorders and their treatments.
Keywords:
Anxiety , Depression , Hormonal changes , The skin , Acne , Treatment , Bioptron , chemical
peels , Lasers , Microneedling , facial
1. Introduction
Sometimes, the initiatives for the sake of mental health are aimed just at reducing mental
illness, thus implicitly identifying mental health with the absence of diagnosable psychiatric
disease (7). A definition of good health encompassing the mental and social domains varies
across systems, cultures or clinical practices that differ in values (9). One of the most
extensively used definitions for mental health is the one by the World Health Organization
(WHO), which defines it as “a state of well-being in which the individual realizes his or her own
abilities, can cope with the normal stresses of life (9). This definition indicates that the absence
of mental disorder is not sufficient to experience good mental health (9). Some individuals are
at increased risk of developing a certain disorder as a consequence of an attribute,
characteristic or exposure that increases their likelihood of developing a certain disease or
injury(9). Approaches to addressing mental health issues in society have overwhelmingly
focused on the provision of clinical services to individuals, not on fostering conditions that promote positive mental health, mental health promotion, or the primary prevention of mental
illness (3).The purpose of this review is to explore aspects such as the mental health benefits of
nature, the drawbacks of urbanization on mental well-being, and the harmful effects of social
media. Additionally, it provides a detailed examination of common conditions like stress,
anxiety, and depression, and their impact on skin diseases such as acne.
2. Nature and mental health
A growing body of empirical evidence is revealing the value of nature experience for mental
health (10). A wealth of studies has demonstrated that nature experience is associated with
psychological well-being (10). Human well-being is linked to the natural environment in myriad
ways, and actionable understanding of these links is deepening in diverse disciplines (10).
Many of the contributions of living nature (diversity of organisms, ecosystems, and their
processes) to people’s quality of life can be referred to as ecosystem services (10). They include
water purification, provision of food, stabilization of climate, protection from flooding, and
many others (10).
2.1)Nature experience as a determinant of mental health
Several aspects of contemporary lifestyles are associated with reduced routine nature contact
(10). One is urban living (10). Cities are centers of prosperity, employment opportunities, access
to education, health and human services, and cultural advancement, all aspects of life that may
promote mental health (10). However, they can also be associated with decreased access to
nature, especially for individuals living within economically deprived urban areas (10). other
factors contributing to a decrease in nature contact include perceived barriers such as fear ,
increased time spent indoors and on screens, and decreased outdoor recreation activities (10).
Excluded from our considerations here are the clear ways in which nature contact may be
harmful to health, such as wildfires, wildlife attacks, and allergies (10).
Research has shown that various types of nature experience are as-sociated with mental health
benefits in many ways (10). Mental health benefits may vary by socioeconomic status,
preferences, residential location, occupation, personality traits, culture, gender, and age (10).
Effects may also differ according to the type of interaction with nature , and the form of
sensory input e.g., visual, olfactory, auditory, or tactile (10) .Nature experience has been
associated with improved sleep and reductions in stress (10). These impacts on sleep and stress
may entail decreased risk for mental illness, as sleep problems and stress are major risk factors
for mental illness, especially depression (10). In addition, there is growing evidence that nature
experience is associated with a decreased incidence of other disorders (10).
3.Urban mental health .
3.1)Urbanization and Mental Health
Large-scale epidemiological studies show that a higher degree of urbanization leads to a greater burden of disease from common psychiatric disorders such as depression, anxiety and addiction
(2). Urban factors that have a negative impact on common conditions can be divided into
surrounding environmental factors e.g. air or noise pollution, physical environmental factors
e.g. green space or urban development and social environmental factors e.g. social cohesion,
crime or socio-economic inequality (2). Dozens of meta-analyses show associations between
these urban factors and an increased risk of (sub-)syndromic depressive disorders, anxiety
disorders and substance use disorders in diverse populations in cities around the world (2). In
addition, the influence can take place at different times with an effect within a few hours to a
few decades (2). For example, noise pollution can have an immediate negative effect on sleep,
while lack of social cohesion and socio-economic deprivation After a few weeks to months can
lead to depressed mood, and insomnia and air pollution earlier after prolonged exposure can
lead to cognitive symptoms, whether or not as part of depression (2). In addition, the different
factors interact with each other, which can lead to feedback loops (2).
Some examples
Meanwhile, there are numerous large-scale studies that show a direct link between specific
urban factors and certain psychiatric conditions (2). For example, a recent meta-analysis shows
an increased risk of depression of 7 and 4% with (long-term) exposure to particulate matter and
nitrogen (2). In particular, small airborne particles in particular are thought to end up in the
brain, leading to cognitive and depressive symptoms via neuroinflammatory pathways (2).
The degree of urbanicity in itself increases the risk, but indirect factors such as social exclusion,
perceived discrimination, cannabis use and early childhood trauma also increase the risk (2). Of
course, these indirect factors also play a role in rural areas, but are more common in urban
environments with relative risks of 2-3,9.4 Our Dutch and Flemish cities are also more likely to
experience illegal drug use (2). With rapid urbanization and declines in human contact with
nature globally, crucial decisions must be made about how to preserve and enhance
opportunities for nature experience (10).
4. impacts of social media on mental health
The use of social media significantly impacts mental health (1). It can enhance connection,
increase self-esteem, and improve a sense of belonging (1). But it can also lead to tremendous
stress, pressure to compare oneself to others, and increased sadness and isolation (1).
Social media has become integral to our daily routines: we interact with family members and
friends, accept invitations to public events, and join online communities to meet people who
share similar preferences using these platforms (1). According to recent research, people spend
2.3 h daily on social media (1).
YouTube, TikTok, Instagram, and Snapchat have become increasingly popular among youth in
2022, and one-third think they spend too much time on these platforms (1).
The considerable time people spend on social media worldwide has directed researchers’
attention toward the potential benefits and risks (1). several studies have pointed out the
potentially detrimental effects of social media use on mental health (1). Concerns have been
raised that social media may lead to body image (1). dissatisfaction , increase the risk of
addiction and cyberbullying involvement , contribute to phubbing behaviors , and negatively
affects mood (1). Excessive use has increased loneliness, fear of missing out, and decreased
subjective well-being and life satisfaction (1). Users at risk of social media addiction often
report depressive symptoms and lower self-esteem (1).
However, by teaching people social media literacy, we can maximize their chances of having
balanced, safe, and meaningful experiences on these platforms (1).The factors that have been
examined so far are just a portion of the major factors that generally affect our mental health
(1). The most common mental disorders that can arise from the aforementioned factors are
depression and anxiety (1). In recent years, the connection between the mind and body has
been validated, showing mutual effects on each other. We will explore its impact on human
skin, which serves as a vital organ.
5.Anxiety and Depression .
Anxiety and depression form a large group of interrelated, overlapping psychiatric disorders
whose precise taxonomy and terminology can at first be confusing (6).Depression represents
the number one cause of disability worldwide and is often fatal. Major depressive episodes are
defined in DSM-5 by a constellation of signs and symptoms (DSM-5, 2013). Patients with major
depression exhibit alterations in a variety of critical functions including sleep, appetite,
psychomotor activity, cognition, and, of course, mood (5).In particular, the overlap between
depression and anxiety has been well established; more than 50% of patients with depression
report clinically significant anxiety and have greater refractoriness to standard treatments than
patients who have depression without anxiety (11).
6.The pharmacotherapy
Currently, such disorders are treated with medication, and less emphasis is placed on
treatments like increasing testosterone levels because it can have different effects on each
individual and is not used as the primary treatment for these disorders. Various antidepressants
are commonly used to treat depression and anxiety disorders. it is evident that most
antidepressants can influence testosterone and estrogen levels.
7. cortisol
Cortisol is the stress hormone, and uncontrolled stress leads to anxiety and depression. When a
person experiences stress along with anxiety and depression, cortisol levels increase.
7.1 Increased cortisol
Increased cortisol levels have very negative effects on the skin and menstrual cycle, leading to
excessive acne and inflammation. In the mentioned studies, we found that when a person
experiences stress, cortisol levels rise.
7.2 Cortisol & hormonal changes
Importantly, the increase in prevalence of these disorders is observed during periods of drastic
hormonal changes, such as puberty, the pre-menstrual period, pregnancy, postpartum and
menopause (8). These observations suggest that interactions between sex hormones, regulated
by the hypothalamic-pituitary-gonadal axis, and cortisol, a stress hormone under the control of
the hypothalamic-pituitary-adrenal (HPA) axis, may be critical determinants of stress-related
disorder development and progression (8). In men, unlike in women, when cortisol levels rise,
testosterone increases. In women, however, when cortisol levels rise, progesterone drops to its
lowest level (8). Increased cortisol is associated with a decrease in progesterone and an
increase in estrogen (8). Ultimately, if estrogen decreases, progesterone is regulated, leading to
healthier skin (8)
.
8.Drugs and Hormones
many studies suggest a significant interaction between sex hormones and antidepressants (4).
Similarly, several clinical studies have expressed the importance of ample circulating hormonal
levels in patients receiving certain antidepressant treatment, while omitting to measure
hormonal fluctuations prior- and post-treatment or investigate whether hormonal changes are
involved in the mechanism of action of the antidepressants (4).
9.Effects of changes in hormones by anti-anxiety and anti-depressant drugs on
the skin
Individuals affected by such disorders often experience changes in their skin due to the onset of
these conditions in their bodies. One of the most common side effects is acne, which frequently
occurs as a result of these medications. Additionally, once individuals are diagnosed with these
disorders, they begin taking medications for treatment, which can further influence hormonal
changes. According to data reviewed and studies conducted from 2020 to the present, these
medications primarily affect testosterone levels. In some cases, they also impact estrogen
levels, particularly in women, leading to a reduction in estrogen.
10.Acne
Acne is a common skin condition that happens when hair follicles under the skin become
clogged. Sebum—oil that helps keep skin from drying out—and dead skin cells plug the pores,
which leads to outbreaks of lesions, commonly called pimples. Most often, the outbreaks occur
on the face but can also appear on the back, chest, and shoulders.
10.1 main reasons for the appearance of acne:
10.Hormones
We have three types of hormones in our body: androgen, estrogen, and progesterone
Androgen : A group of hormones usually associated with male sexual characteristics, including
two main subgroups: testosterone and dihydrotestosterone. Androgens play an incredibly
important role in the growth and development of male sexual traits. These hormones are
produced not only in men but also in women, where they have multiple functions. In men,
androgens contribute to the growth of facial hair, deepening of the voice, muscle mass
increase, sebum production, sperm production, and the maintenance of muscles and bones, as
well as the regulation of sexual drive and ability. Androgens, especially testosterone, also play a
role in sebum secretion from sebaceous glands in the skin. When testosterone production
increases in the androgen glands, excess sebum is produced. The level of androgens,
particularly testosterone, is influenced by various factors, with puberty being one of the most
important. When puberty begins, the hypothalamus in the brain is activated, leading to the
release of a hormone that moves to another part of the brain and causes the release of two
other hormones, LH and FSH. These hormones send signals to the testes in men, increasing the
secretion and release of testosterone. In women, LH signals the ovaries, stimulating the
increase in the secretion and release of testosterone.
10.1.2.1 Review of Testosterone Production Increase:
An enzyme called 5-alpha reductase exists in the sebaceous glands, which converts
testosterone into dihydrotestosterone.
1-Polycystic Ovary Syndrome : One of the factors that increases testosterone levels in women is
polycystic ovary syndrome, and insulin resistance is a contributing factor to it. When the body
does not respond properly to insulin, the pancreas compensates by producing more insulin.
High insulin levels stimulate the ovaries to secrete more testosterone. 2-Hormonal Production
Disorders: Various abnormalities in hormone production can disrupt the balance between
hormones, leading to conditions like polycystic ovary syndrome. In particular, increased
secretion of LH (Luteinizing Hormone) stimulates the ovaries, resulting in increased
testosterone production. 3- Factors such as the use of sports supplements and testosterone
injections, which athletes and bodybuilders use, and the use of steroids aimed at increasing
muscle growth and athletic performance, because they have a structure similar to testosterone,
can elevate testosterone levels in the body. Additionally, anti-estrogen drugs like Clomiphene,
which are used for treating infertility, raise testosterone levels, as do medications prescribed by
doctors for mood disorders like anxiety and depression, which also increase testosterone levels
in the body. 4- Effects of Obesity on Hormonal Disorders: Insulin is a vital hormone produced by
the pancreas. When a person becomes obese, their body becomes less sensitive to insulin, a
condition known as insulin resistance. As insulin sensitivity decreases, the pancreas produces more insulin to regulate blood sugar levels. When insulin secretion increases, two things
happen. In women, insulin stimulates the ovaries to produce testosterone. In the second case,
it prevents the liver from producing enough sex hormone-binding globulin . This protein, when
produced, binds to testosterone and deactivates it. When insulin levels rise, the liver does not
produce this protein, and testosterone remains active. Weight gain and obesity in women can
increase testosterone activity through these two mechanisms, making overweight women more
likely to develop polycystic ovary syndrome. 5- Liver and Kidney Issues: The liver and kidneys
play a very important role in hormone metabolism, especially testosterone. When the liver is
impaired due to various reasons, such as inflammation, hepatitis, or alcohol poisoning, it cannot
properly break down and eliminate waste materials. As a result, testosterone accumulates in
the body. The kidneys eliminate waste materials through urine, and when the kidneys are
compromised, waste materials, including metabolic substances like testosterone, cannot be
excreted effectively, leading to the accumulation of testosterone.
10.1.3 Clogged pores
are another factor that causes acne. Pores are located on the surface of the skin and are
responsible for tasks such as transferring oil to the surface and perspiration. When the pores
become clogged, a bacterium known as Propionibacterium or Cutibacterium which is an
anaerobic bacterium starts to become active. This bacterium mainly resides in the pores of the
skin especially near the sebaceous glands. When skin pores are blocked this bacterium feeds
on sebum and begins to grow and multiply. The substances produced by the metabolism of this
bacterium lead to inflammation. Although this bacterium can grow in environments with
oxygen it becomes stronger in oxygen-deprived conditions. As P-acnes grows and excretes
waste products Langerhans cells become activated and move to the area where the bacterium
is present causing pain swelling or redness.
Inflammatory responses 10.1.4
occur when bacteria grow and produce waste products. Langerhans cells react to these
changes with inflammatory responses, activating immune cells, which in turn result in redness,
swelling, and pain.
11.Factors That Exacerbate Acne
11.1Hypertrophy and Hyperplasia
Hypertrophy refers to an increase in the size of fat cells, while hyperplasia refers to an increase
in the number of cells within a tissue or organ. The follicular duct of hair is composed of keratin.
When hyperplasia occurs in the follicular duct, a condition called follicular hyperkeratinization
develops, which means an increased number of keratinocytes in the follicular duct. This leads to
blocked pores, providing a suitable environment for P. acnes bacteria to thrive and proliferate.
11.2 Impairment of Desquamation
Lack of sufficient moisture in the stratum corneum layer disrupts the process of desquamation
(shedding of dead skin cells). Enzymes such as desmosomes and phospholipases are essential
for the desquamation process and regulate it in the epidermis.
11.2 Increased Skin Sebum
Excessive skin sebum leads to increased adhesion of skin cells, alters the skin’s environment,
and impacts the composition and activity of lipids on the skin.
11.3 Stress
While stress alone does not cause acne, it can worsen the condition of existing acne.
11.4 Diet
Consuming certain foods like milk, protein, cheese, refined carbohydrates, alcohol, sugar, and
fats can exacerbate acne.
11.5 Specific Medications
Certain medications, such as corticosteroids, testosterone, and lithium, can trigger or worsen
acne.
12.Case report
A 23-year-old man suffering from a mood disorder, specifically depression, visited our clinic. He
has combination skin and, based on his history and reports, he was not prone to acne before
developing this disorder. However, since experiencing depression and starting medication to
manage it, he has developed significant acne on his forehead and under his cheekbones, along
with oilier skin. Initially, we prescribed a daily skincare routine that included a cleanser
specifically for oily skin, a toner containing salicylic acid and benzoyl peroxide to control acne
and inflammation, as well as an oil-free moisturizer and sunscreen. To prepare the skin, we
performed two facial sessions, focusing on oil control and acne treatment. As expected, some
signs of improvement should have been visible after these two sessions. However, due to the
ongoing use of mood-stabilizing medications and their hormonal effects, particularly on
testosterone, no signs of improvement were observed. For this reason, we referred the
individual to the health psychologist at the center. Over the sessions he attended (4 sessions
over 2 weeks), the dosage of his medications was gradually reduced. After these two weeks, we
restarted his treatment. The treatment began on a weekly basis, while his sessions with the
health psychologist continued simultaneously. In the first week, we focused on oil control and
acne management through facials.
In the second week, we started chemical peeling treatments, performing three weekly sessions.
By the third week, during the second session of chemical peeling, the health psychologist
decided to discontinue his medications. By the fourth week, during the third chemical peeling
session, we observed significant improvement in his acne based on his reports and our
observations. In the fifth week, we advanced the treatment to address acne scars through
mesoneedling. In the sixth week, we reviewed his progress, took a detailed history, and made
adjustments to his skincare routine. The toner in his routine, which contained salicylic acid, was
replaced, as the successive treatments for oil control and acne management necessitated a
change. Additionally, niacinamide was introduced into his skincare routine in place of benzoyl
peroxide. In the sixth week, we also started a treatment to further improve the remaining scars.
Using the Bioptron laser, which is highly effective in various areas, we successfully achieved
significant improvement in his scars.
13.Types of treatments I recommend
Acne treatment varies depending on its severity (mild, moderate, or severe) and skin type.
Modern methods for treating acne include:
13.1 Medical Treatments
13.1.1 Topical Medications
– Retinoids (e.g., Tretinoin, Adapalene): Prevent clogging of pores.
– Topical Antibiotics (e.g., Clindamycin): Reduce bacteria and inflammation.
– Salicylic Acid : Decrease oil and remove dead skin cells.
– Niacinamide: An anti-inflammatory and skin brightener.
– Benzoyl Peroxide: This substance eliminates acne-causing bacteria and reduces inflammation.
13.1.2 Oral Medications
– Oral Antibiotics (e.g., Doxycycline, Minocycline): For severe acne.
– Isotretinoin (Accutane): Effective for treatment-resistant acne.
– Hormonal Contraceptive Pills: For acne related to hormonal changes.
– Spironolactone: Reduces androgen effects in women.
13.2 Non-Medical Treatments
13.1.2 Laser and Light Therapy
– Fractional Laser: Reduces acne scars and active acne.
– Blue Light Therapy: Reduces acne-causing bacteria.
– PDL or IPL Laser: Decreases redness caused by acne.
– bioptron: Improving the appearance of scars, acne, skin spots, and reducing inflammation.
13.2.2 Chemical Peels
– Using chemical acids such as glycolic, lactic, or salicylic acid to cleanse the skin and reduce
pore clogging.
13.2.3 Microdermabrasion and Hydradermabrasion
– Methods for superficial skin exfoliation and collagen stimulation.
13.2.4 Microneedling
– Improves acne scars and enhances drug absorption into the skin.
13.3 Diet and Supplements
– Intake of Vitamin A, Zinc, and Omega-3 for skin health improvement.
– Avoid high-sugar and fatty foods that may worsen acne.
13.4 Advanced Technologies
13.4.1 Plasma-Rich Platelet (PRP) Therapy
– Improves acne scars and regenerates skin.
13.4.2 Cryotherapy
– Uses cold to reduce inflammation and bacteria.
13.4.3 Acne Patches
– Patches containing antibacterial and anti-inflammatory substances directly applied to acne.
13.5 Lifestyle and Dietary Changes
13.5.1Reducing sugar and fatty food intake
A healthy diet helps control oil production in the skin, contributing to reduced acne.
13.5.2 Stress management
Stress can worsen acne; utilizing relaxation techniques can be effective.
Conclusions
At the beginning of this review, the factors that lead to the development of these disorders are
discussed. Although we only examined a few of these factors, based on the information
provided and the conclusions drawn, it is better to focus on preventing these disorders before
they occur. For example, one of the factors we reviewed is urbanization and the disconnection
from nature. Since 2000, more than 50% of the world’s population has lived in an urban
environment and it is expected that by 2050 70% will live in cities(2). With rapid urbanization
and declines in human contact with nature globally, crucial decisions must be made about how
to preserve and enhance opportunities for nature experience(10). So that we may follow the
path of prevention. Another review we conducted was related to social media, which affects
people’s lives, such as body image dissatisfaction , increase the risk of addiction and
cyberbullying involvement , contribute to phubbing behaviors , and negatively affects mood(1).
Excessive use has increased loneliness, fear of missing out, and decreased subjective well-being
and life satisfaction (1). Users at risk of social media addiction often report depressive
symptoms and lower self esteem. However, by teaching people social media literacy, we can
maximize their chances of having balanced, safe, and meaningful experiences on these
platforms. In any case, since more attention is given to treatment rather than prevention, a
large percentage of people may struggle with depression and anxiety disorders, which can
range from mild to severe. The most common method of treatment is medication, and most of
the drugs used come with side effects. Hormonal changes are one of the side effects that have
a direct impact on our skin. Patients with depression may show varied alterations of hormones.
It is important to note that for treating any type of skin condition caused by mood disorders
and the medications used to manage them, improvement can only be achieved when the
underlying cause is controlled. Therefore, our recommendation for this particular case was to
first begin treatment with the health psychologist to regulate and reduce the medication
dosage, enabling us to effectively address the skin issues that had developed.
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