Acne Might Increase Eating Disorder Risk: What to Know

The many detrimental psychosocial effects of acne have been well-studied in existing research, including stigmatizing attitudes toward individuals with acne and the increased risks for psychiatric disorders such as anxiety and depression.^1,2 In our recently published study in the Journal of the European Academy of Dermatology and Venerology, we spotlight another, likely underrecognized, psychiatric comorbidity of acne: eating disorders.³ Eating disorders encompass a range of unhealthy eating behaviors, with among the most common forms being anorexia nervosa (ie, severely reducing food intake to avoid weight gain), binge eating disorder (ie, recurrent episodes of excessive eating with loss of control over consumption), and bulimia nervosa (ie, experiencing episodes of binge eating followed by purging behaviors such as forcing oneself to vomit).^4,5 Each of these disorders is defined by specific features and diagnostic criteria, which can be found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR).⁵ What is critical to know about these conditions is just how serious they can be—anorexia nervosa has the highest mortality rate of any mental health condition.⁶ 

What We Found

In our study, we leveraged electronic health record data from the large and diverse cohort of US adults enrolled in the National Institutes of Health’s All of Us research program to better understand the link between acne and eating disorders.⁷ Our retrospective analysis included more than 7000 individuals with acne and over 200,000 individuals without acne. Using multivariable logistic regression, we identified a greater than 2-fold increased odds of eating disorders among patients with acne compared with controls, after adjusting for demographic factors such as age and sex. We further controlled for the presence of comorbid anxiety, depression, and/or body dysmorphic disorder, and we found that the independent association of acne with eating disorders persisted (adjusted odds ratio, 1.65; 95% confidence interval, 1.41-1.92; P <0.001). Our findings build on a smaller cohort study conducted in Turkey, which also demonstrated higher levels of eating disorder risk among patients with acne compared to controls, as well as several case reports linking the conditions.^8-10

Clinical Implications for Psychiatrists

For psychiatrists and other mental health professionals encountering patients with concerns about acne, referral to a dermatologist is ideal, regardless of the severity of the acne. One important observation that has been made in smaller cohort studies on acne and eating disorders is that eating disorder risk appears to be most associated with quality-of-life impairments rather than clinician-assessed acne severity.^8,18 Thus, while a patient might have mild-to-moderate clinician-assessed acne, that acne could have severe effects on the patient’s emotional and psychological well-being. These effects might warrant the expertise of a dermatologist to escalate acne treatment to achieve skin clearance and help improve the patient’s overall mental health.¹⁶

Clinical Implications for Dermatologists

Our findings substantiate that acne can be a risk factor for eating disorders. But, what can dermatologists do about this potential risk of eating disorders among their patients with acne? There remains a need for further research on optimal strategies for detecting eating disorders among those with acne and among adolescents and adults more generally. In 2022, the US Preventative Services Task Force determined there is insufficient evidence to evaluate the benefits and risks of screening for eating disorders among asymptomatic adolescents and adults.¹¹ However, dermatologists—who are often the only doctors that patients with acne see—can be aware of and attuned to the signs and symptoms of eating disorders.¹² These include, but are not limited to, patients who mention having an intense fear of gaining weight, substantial changes in their eating habits (eg, restricting the amount or type of food they eat, or feel like there are times when they cannot control how much they are eating), or those patients who display physical signs of self-induced vomiting (worn enamel and tooth decay, swelling of the salivary glands, calluses of the knuckles [ie, Russell’s sign], etc.).^5,13-14 In addition to the DSM-5-TR for clinicians, the National Institute of Mental Health offers a freely-accessible, brief overview of many of the common signs and symptoms of eating disorders for patients and families to reference. Dermatologists who are concerned that a patient might have or is developing an eating disorder should refer the patient to a mental health professional for further evaluation and treatment. There are also hotlines that provide support and resources for individuals with eating disorders.

Relatedly, it is estimated that up to approximately 90% of patients with acne try a dietary change to help manage their acne.¹⁵ So, what should dermatologists do when asked about what dietary interventions for acne? The most recent version of the American Academy of Dermatology’s Acne Guidelines in 2024 did not provide dietary recommendations for acne management as existing evidence is limited and/or conflicting (eg, role of dairy and chocolate).¹⁶ Until there are more data to support specific dietary recommendations in acne, dermatologists should consider simply recommending that patients pursue well-balanced, healthy diets.^16,17

Limitations and Future Directions

The results of our study should be interpreted in the context of its design limitations. Notably, since our study was a retrospective analysis assessing an association, we cannot speak to the pathophysiologic, psychological, and cognitive mechanisms underlying the observed association. Based on existing cognitive behavioral theories of eating disorders, we hypothesize that acne might be a trigger that heightens concerns about body appearance among individuals with psychological risk factors, which ultimately drives the development of cognitive biases (eg, overestimating body size) and maladaptive behaviors (eg, restricting eating) that are theorized to cause eating disorders.¹⁹ However, prospective studies are needed to better evaluate this hypothesis.

Another important future direction is the evaluation of the link between acne and eating disorders among adolescents under 18 years- old, a common time of life for the development of both acne and eating disorders.^20,21 Larger studies are also needed to evaluate the association of acne and eating disorders specifically among males, as the majority of individuals in our study primarily were females with acne. Furthermore, continued work is needed to elucidate the best ways for dermatologists and other providers caring for patients with acne to detect eating disorders and refer those patients with eating disorders to mental health care.

Concluding Thoughts

Building on several case reports and a smaller cohort study, our study’s findings provide additional evidence that acne can be a risk factor for eating disorders.^8-10 Our research adds to the growing body of literature identifying the many potential psychosocial consequences of acne.^1-2 Although further research is needed to evaluate the optimal strategies for detection of eating disorders among patients with acne, dermatologists can be attuned to signs and symptoms of eating disorders and refer patients to mental health professionals for further evaluation and treatment when appropriate. Psychiatrists and other mental health professionals caring for patients with concerns about acne should consider referring those patients to a dermatologist to ensure that patients are receiving expert acne treatment. Ultimately, for patients with acne and eating disorders, effective dermatological and mental health care interventions will likely lead to the best overall health and quality of life outcomes.

Acknowledgements

We gratefully acknowledge All of Us participants for their contributions, without whom this research would not have been possible. We also thank the National Institutes of Health’s All of Us Research Program (https://allofus.nih.gov/) for making available the participant data examined in this study.

Mr Nock is a 4^th-year medical student at the Yale School of Medicine.

Dr White is a clinical psychologist specializing in eating and weight disorders. White is a professor of social and behavioral sciences in the Yale School of Public Health, and she holds a secondary appointment in the Department of Psychiatry at the Yale School of Medicine.

Dr Cohen is a board-certified dermatologist, specializing in inflammatory skin diseases. Cohen is an associate professor in the Department of Dermatology at the Yale School of Medicine, and he holds a secondary appointment in the Department of Biomedical Informatics and Data Science.

References

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