Increased stress is strongly correlated with greater acne severity a study of medical students. The study was published in Clinical, Cosmetic and Investigational DermatologyAlthough it is widely accepted that there is a relationship between stress and acne, few studies have assessed this relationship.

Factors In Acne

Students were asked to complete the Perceived Stress Scale (PSS). This 14-item self-questionnaire is widely used in stress research and includes some confounding factors in acne severity, such as, menstruation, heat and humidity, sweating, use of makeup and cosmetic products, oily hair products, use of topical steroids, and squeezing pimples.

Once the students had completed the questionnaire, they were examined by an intern, who had been trained by a consultant dermatologist, for the presence of acne lesions. Acne severity was graded according to the global acne grading system (GAGS), and the type of acne lesions present (comedones, papules, pustules, and nodules) and their location were noted.

Three students (2.1%) had no acne, 104 students (72.2%) had mild acne, 33 students (22.9%) had moderate acne, and four students (2.8%) had severe acne. Increased stress severity was found to strongly correlated with increased acne severity, and this relationship was statistically significant (r=0.23; p<0.01).

Of the eight acne aggravators included in the Perceived Stress Scale questionnaire, only excessive heat and humidity were found to have a statistically significant impact (p<0.05%). The researchers said that heat and humidity might make it more favorable for Propionibacterium acnes to colonize the ductal hyperplasia.

Acne Severity

Acne is known to affect the quality of life and mood negatively, so it is possible acne can lead to stress and not vice versa, he said. One way to establish a stronger causal relationship would be by evaluating whether stress-reduction techniques can significantly reduce acne severity.

Chronic Stress

In adult women with acne, chronic stress increases the secretion of adrenal androgens and results in sebaceous hyperplasia. Activation of the hypothalamic–pituitary–adrenal (HPA) axis is the main adaptive response to systemic stress. In response to emotional stress, the HPA axis activates increased levels of cortisol release.

Corticotropin-releasing hormone (CRH) is the most proximal element of the HPA axis. CRH acts as a central coordinator for neuroendocrine and behavioral responses to stress. CRH stimulates sebaceous gland lipid production and steroidogenesis, which contributes to acne.

Studies have also shown an increase of CRH expression in the sebaceous glands of the acne-involved skin, compared to low expression in normal skin. This upregulation of CRH expression in the acne-involved skin may influence the inflammatory processes that lead to stress-induced acne lesions.


CRH also induces cytokines IL-6 and IL-11 production in keratinocytes, contributing to inflammation, which is regarded as a key component in the pathogenesis of acne. For people with acne, psychological stress could delay wound healing, which could affect the repair of acne lesions.

Furthermore, peripheral nerves release the neuropeptide substance P or gastrointestinal peptide in response to stress. Substance P stimulates the proliferation and differentiation of sebaceous glands and upregulates lipid synthesis in sebaceous cells.