In 1996, Baz Luhrmann’s Romeo + Juliet came out and, as a 12-year-old blond boy with pale blue eyes and clear skin, I got plenty of attention as a wannabe Leonardo DiCaprio. I still remember my London Underground travelcard photo, styled to resemble the 90s heartthrob. I thought I’d look like this for ever.
It wasn’t to last. The spots arrived, gradually at first, then all at once. Blackheads sprouted across the “T-zone” (chin, nose, forehead); pimples appeared; and my skin took on a raw, reddish hue.
When I realised this was something that might not be done with in a few months, I panicked. It felt as if, at 14, I’d been plucked from the Garden of Eden – a place in which girls fancied me and I got admiring glances on the bus – and cast out into the wilderness. None of the people I looked up to at school seemed to have the same problem. I saw myself as part of an untouchable group of outsiders, heads bowed, unable to share in each other’s pain.
My acne came to reflect my inner turmoil: I grew unhappy, and was bullied; I felt unlovable, and my skin represented that to the world. The problems I was having with friends, and growing up, seemed to be inextricably tied to the state of my skin.
I funnelled my distress into dealing with my acne. I wanted to do something – anything – about what was happening to me, and my skin became the focus. My mornings now were defined by a torturous skincare routine: face wash, cleanser, an over-the-counter cream or liquid designed to treat acne – there was one that had the consistency of wood glue, and made my skin peel, something I persisted in seeing as a “good sign” – and finally a topical solution I’d got from my GP.
The whole process took almost half an hour. I felt duty bound to perform every part of it, no matter where I was. Staying at my French exchange partner’s Paris flat, with one bathroom shared between five, I agonised my way through the routine every morning, knowing I was holding everyone up, but also that it was a deathly superstition, a ceremony that had to be observed. It made no difference: my skin remained angry.
My parents could see how much this bothered me, and did their best to listen. But I didn’t go to a dermatologist, and certainly not a therapist. Acne was seen as a normal condition you just had to accept. At 17, I stopped talking to anyone.
The British Association of Dermatologists defines acne – which affects 650 million people worldwide – as a “very common skin condition identified by the presence of comedones (blackheads and whiteheads) and pus-filled spots (pustules)”. It usually starts during puberty and, untreated, lasts about five years. In contrast to my teenage experience, it is now considered a serious condition: in June, the National Institute for Health and Care Excellence (Nice) published guidance that, for the first time, recommended mental health support for people severely affected by their spots.
Julie Long is a psychotherapist who treats young people with acne and other skin conditions. For teenagers with a less secure sense of themselves, she says, acne can be “confirmation that they are worth less. Growing up also involves learning to tolerate our imperfections; to navigate the gap between who we think we ought to be and who we are.” In my case, acne’s appearance undermined the image I had of myself as Leo-Romeo, with clear skin. I realise now that I felt a great sense of betrayal. The real world had arrived, in all its trauma and confusion, and I didn’t like it.
As with most forms of talking therapy, the thing that leads the patient to seek help is often just the starting point and masks deeper sources of pain. Getting to that pain can be an arduous task. Long recalls one teenage patient who for a couple of years would only talk about his bad skin. It was the reason he couldn’t have a sexual relationship, form meaningful friendships or feel any confidence in himself. Eventually, he was able to move beyond talking about his skin, and after three years of therapy he was in a lasting romantic relationship.
He reminds me of some of the users on the Acne subreddit, which has 289,000 members. While most of the group is taken up with pictures of acne and recommendations for treatment, it is also a place to share the enduring pain caused by skin problems. I can imagine that, as a teenager, I might have found some useful community there.
“I have no one in my life who wants to talk about this with me,” one Welsh Redditor tells me. At 18, his spots have largely cleared up, but he still fixates on them. He was convinced his acne had led to scarring, but says when he posted pictures of his face on the subreddit, he was told this wasn’t the case and given a lot of support. “It’s crazy to me that people don’t understand why your spots make you feel this way,” one user replied. Another shared a story about her aunt, who had told her she should just wash her face properly.
Despite the new Nice guidelines, Long says someone would have to be severely affected by acne to receive mental health support on the NHS. Child and Adolescent Mental Health Services is “on its knees due to severe underfunding and cuts to longer-term psychotherapy”, she says, and adult services have no provision for 17-23-year-olds who remain particularly affected by acne. This means being shunted in the direction of online therapy or short courses of cognitive behavioural therapy – which, Long says, often lead to poor treatment – or seeking out therapy privately, which is unaffordable for many.
The kind of miracle treatment I dreamed of has yet to appear. Dr Anjali Mahto, a consultant dermatologist who, like me, had acne as a teenager in the 90s, says patients are still treated with topical retinoids that remove dead skin cells; benzoyl peroxide, which works as an antiseptic to reduce bacteria on your skin; and oral antibiotics. Cutibacterium acnes, the acne bacteria, lives on everyone’s skin, usually causing no problems. But in those with acne, the buildup of oil produced by the sebaceous glands, which are affected by our hormones, creates an ideal environment for the bacteria to multiply. All these treatments have the potential to be effective after a few months of use but, as Mahto points out: “The psychology of acne is such that if you think your skin is bad, you dollop more on in an effort to dry it out and clean it up, and if anything, all that does is disrupt things further.”
This is exactly what I did: mixing creams with solutions, piling cleansers on top of washes. I took the napalm approach to my acne: desecrate the terrain to defeat the enemy. What happened was that my skin became angry and inflamed, a reaction I treated with… more solutions and ointments.
These are big business. The global anti-acne cosmetics market was valued at $2.8bn in 2020 and is expected to be worth close to $6bn by 2030. A slew of products are marketed for “acne-prone skin”, but Mahto says these do not penetrate deep enough to have any effect. Instead, big companies are preying on the anxiety of teenagers, who will look anywhere for something to make their spots go away. “I’m fed up with people being sold absolute rubbish,” Mahto says. “It’s unethical.”
What has changed is how we view acne. A new generation of influencers are seeking to take the stigma out of the condition, by sharing pictures of their skin as it really is. As Cosmopolitan put it in an article about “acne positivity”: “Influencer trend we are here for: Real. Effing. Skin.”
Sofia Grahn, 26, is a Swedish influencer who has almost 100,000 followers on Instagram and mainly shares beauty tips and selfies that show her skin, spots and all. She says acne positivity “challenges the belief that people with acne need to hide; everyone deserves to feel represented and confident, no matter the state of their skin”. She gets messages “every day” from people saying her content helps them feel better about themselves.
“When my acne peaked, I was depressed, anxious and my self-worth was at an all-time low,” Grahn says. “It made me feel terribly lonely. Despite acne being one of the most common skin conditions, I still felt as if I was the only one dealing with it, because I never saw anyone with acne in my social media feeds, on TV or in magazines.”
Grahn started her Instagram page in 2018, initially as a way of documenting her treatment with acne medication. To begin with, she was very nervous. “The first picture I posted of myself without editing, makeup or flattering angles, I really had to count down from five and just press publish,” she says. “I had never posted a picture of myself where the aim was to capture my skin the way it actually looked, so it was really scary.”
The Swede says she wasn’t trying to gain a huge following – “I was terrified of even my close circle of friends finding my page” – but her account soon connected her to people who had similar experiences with acne. She felt as though she was part of a community. She began to feel less lonely.
Mahto is also a social media influencer, much of whose Instagram account is dedicated to sharing no-nonsense advice and debunking acne myths. Diet, for example, doesn’t make much difference, and having spots does not mean you are “dirty”.
But social media is a double-edged sword. While for Grahn it offers community, it is also a source of endless images of seemingly perfect skin. When I was a teenager, with no phone, I was at least able to close my bedroom door and not find a curated simulation of the world waiting there for me.
“Social media has made it increasingly difficult for adolescents to find any respite from their pain and embarrassment,” Long says. Consumer capitalism, with its focus on images of beauty and the marketing of products to solve our human imperfections, can keep us trapped in a desperate cycle: the images remind us of our own acne, we fixate on that, and any hope of thinking about what might be behind the pain it’s causing us is lost.
When I tell Long about my teenage routine, the phrase she picks up on is “if only”. If only all those chemicals had stripped away my spots. If only I had a stronger sense of myself. If only I felt loved. I was hoping the products I bought and used would solve these deep issues for me.
In the end, something else happened. I finished school and left London. I made new friends and did new things. I gradually realised I didn’t need to follow my routine any more. No more anguished mornings staring into the mirror, applying too many creams and solutions. I could still trace the outline of my acne, but for the most part, it wasn’t there any more. My skin ceased to be a problem.
Looking back at the few photos of me from my teenage years, I can see what appear to be some blackheads, some inflamed skin, a few spots. I asked family and friends about my acne, and they didn’t recall anything severe. What my father did say was that the medication I used badly dried up my skin.
What I realise now, of course, is that it was never really the spots that were the problem. I channelled the turmoil of adolescence – much of it perfectly routine – into a fixation on what was happening to my face. I took the feelings I had about having no control over my life and created a morning routine that actually made my skin worse. Thinking about my skin became a magical act of displacement. It’s only now, looking back at that confused, not particularly spotty boy, that I can see it.