Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(2):5053 1 Assessment of Eating Attitude and Psychiatric Parameters in Patients with Acne Vulgaris Hazel Ezgi Kaya1, İlknur Kıvanç Altunay1, Aslı Aksu1 1 University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, Dermatology Department, Seyrantepe, İstanbul, Turkey Key words: Acne vulgaris, Eating attitude, Disordered eating, Depression, Obsessive-Compulsive Disorder Citation: Kaya HE, Altunay IK, Asli A. Assessment of Eating Attitude and Psychiatric Parameters in Patients with Acne Vulgaris. Dermatol Pract Concept. 2025;15(2):5053. DOI: https://doi.org/10.5826/dpc.1502a5053 Accepted: February 21, 2025; Published: April 2025 Copyright: ©2025 Kaya et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: HK: Data curation, Conceptualization, Methodology, Writing-Original draft preparation. İKA: Supervision. AA: Supervision. All authors have read and approved the final manuscript. Ethical Approval: Reviewed and approved by the University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital local ethics committee. Approval number: 2837 on date 16.06.2020. The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Consent to Participate: Informed consent was obtained from all individual participants included in the study. Consent to Publish: The participants in this manuscript have given written informed consent to the publication of their case details. Data Availability Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request. Corresponding Author: Hazel Ezgi Kaya, MD. University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, Dermatology Department, Seyrantepe, Huzur Mah., Cumhuriyet ve Demokrasi Cad., No: 1, Sarıyer, İstanbul, Turkey. ORCID ID: 0000- 0002-5146-138X. E-mail: hazelezgikaya@gmail.com Introduction: Redundancy of psychological comorbidities in acne vulgaris may contribute to disturbed eating attitude. Objective: The aim of this study was to investigate a possible relationship between acne vulgaris and disturbed eating attitude. Methods: One hundred acne patients and 86 healthy volunteers evaluated by the Symptom Checklist-90 Revised (SCL-90) and possible indication of disordered eating using the Eating Attitudes Test-40 (EAT-40) and Eating Disorders Examination-Questionnaire (EDE-Q). Results: Mean EAT-40 score was significantly higher in acne group (24.1±17.4) compared to control group (14.2±9.0) (P=0.001). Global score of EDE-Q and all subscores were statistically higher in acne group (for each, P=0.001). The proportion of participants whose meaningful scores for Restraint Eat- ing and Weight Concern subscores of EDE-Q was significantly higher in the patient group compared to the control group (P=0.003 and P=0.034, respectively). Obsessive-compulsive and Depression ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(2):5053 Introduction Acne vulgaris is a chronic inflammatory disease of piloseba- ceous unit that affects 85% of adolescents [1]. Considering the involvement of visible areas such as the face and neck, which cannot be concealed easily and the age group affected, acne and its sequelae can affect many domains of life, leading to social dysfunction as well as to substantial psychological burden [2]. It has long been known that acne is associated with problems of self-esteem/self-confidence, disturbed body image, embarrassment/social withdrawal, anger, preoccupa- tion with acne, frustration/confusion, limitations in lifestyle, and problems with family relationships [3]. A meta-analysis revealed that anxiety and depression were more prevalent among acne patients [4]. Furthermore, among facial derma- toses, the most severe symptoms of anxiety and depression, as well as a higher frequency of suicidal ideation were found in acne patients [5]. All of these may lead to inappropriate selection of coping strategies to regulate emotional stress. Eating disorders are psychological disorders characterized by abnormal and disturbed eating attitudes with or without compensatory behaviors, as diagnosed by Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) [6]. Behaviors include food restriction, binge-eating, purging, laxative use, diet pills, and excessive exercise. Disordered eat- ing is a condition characterized by the same features of lesser frequency or lower level of severity as that of an eating disor- der [6]. Eating disorders are relatively common, with a point prevalence of 7.8%, as demonstrated in a recent meta-analysis, while disordered eating was predicted to be twice as com- mon [7]. Psychological outcomes common in acne vulgaris may contribute to disordered eating, since aforementioned comorbidities are core risk factors for disordered eating. Case reports regarding the association between acne vulgaris and eating disorders have been published as early as 1991. Lee et al. [8] report two patients that had body image concerns caused by acne vulgaris, leading to exacerbated eating disor- der while searching for pseudosolutions. In a study conducted by Gupta and Gupta [9], it is emphasized that body image pa- thologies such as eating disorders may coexist with acne vul- garis, since body image disturbance in eating disorders is not necessarily confined to a distorted perception of body shape but also may generalize to concerns about different aspects of body image, including dissatisfaction with skin appearance. Objectives The aim of the present study was to determine whether there is a relationship between acne vulgaris and disordered eating attitudes. A secondary aim was to evaluate the psychologi- cal dimensions associated with disordered eating attitude in acne vulgaris patients. Methods Study Design We designed a prospective study consisting of 100 acne vul- garis patients and 86 healthy volunteers. Patients were re- cruited from among those of the dermatology outpatient clinic between June 2020 and October 2020 and a control group of healthy volunteers. To meet the inclusion criteria, patients had to be 16–40 years old and diagnosed with acne vulgaris by a dermatologist. Patients who had psychological disorders, known psychiatric drug usage or medications that can affect mood or appetite, endocrinological problems that may affect eating cycle (such as diabetes mellitus, hypothyroidism, adre- nal gland disease), who had a body mass index (BMI) ≤16 kg/m2, polycystic ovary syndrome, hirsutism, or who had de- clared menstrual irregularities were excluded. All participants were asked to answer a questionnaire designed by authors which included sociodemographic information and that, for acne vulgaris patients, included duration of acne disease and age at disease onset recorded. Patients with acne vulgaris were subdivided into the following three categories according to the Classification of the American Academy of Dermatology: 1) mild acne, characterized by the presence of a few papules and pustules mixed with comedons, but no nodules; 2) moderate acne, characterized by the presence of many papules and pus- tules, together with a few nodules; or 3) severe acne, charac- terized by the presence of numerous or extensive papules and pustules as well as many nodules [10]. Body mass index (BMI) was calculated using formula weight (kg)/height2 (m). Screening Tools All participants were requested to complete the EAT-40 (Eating Attitudes Test-40) and SCL90-R (Symptom Check List-90 Revised) and EDE-Q (Eating Disorder Examina- tion Questionnaire) to crosscheck and identify the charac- teristics of a possible eating disorder. In a review assessing subscores of SCL-90-R among acne patients had meaningful EAT-40 scores that were statistically higher compared to those had EAT-40 scores <30 (P=0.030 and P=0.006, respectively). Conclusion: Because of higher mortality and morbidity rates, clinicians should screen acne patients for possible disordered eating, with particular attention to those with obsessive-compulsive disorder and depression. Original Article | Dermatol Pract Concept. 2025;15(2):5053 3 the tools used to estimate eating disorders, EAT-40 is the most commonly used screening tool, highlighting the need for further psychological assessment [11]. EAT-40 is a 40- item self-report Likert-type scale. The rating range is from “always” to “never,” and the resulting score ranges from 0 to 120. Individuals scoring ≥30 points are considered to be at high risk for eating disorders. The questionnaire was developed by Garner et al. [12] in 1979, and the Turkish validity and reliability study was conducted by Savaşır et al. [13]; internal consistency calculated by Cronbach alpha was 0.70. The SCL-90-R, developed by Derogatis et al. [14], is a 90-item self-report symptom inventory. Each item is rated on a five-point scale of distress (0–4), ranging from “not at all’’ to “extremely.’’ This scale is a psychiatric screening tool that measures the severity of psychiatric symptoms and neg- ative stress reactions that person experiences. It is used in patient populations over age 17 years. Due to assessment difference, we were unable to include patients with acne vul- garis aged <16 years. The questionnaire evaluates the nine dimensions of psychological symptoms, including somatiza- tion, obsessive-compulsive, interpersonal sensitivity, depres- sion, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism; the Turkish validity and reliability study was conducted by Kılıç [15]. The EDE-Q was developed by Fairburn et al. [16] and adapted into Turkish by Yücel et al. [17] in 2011, with an internal consistency coefficient of 0.93 and reliability of 0.91. EDE-Q is composed of 28 self-report questions that score between 0–6 on Likert-type response categories, and higher sores indicate the extent of eating disorder. By taking the average of relevant questions, five subscales are calculated: restraint eating (RE), eating con- cern (EC), shape concern (SC), binge eating (BE), and weight concern (WC). The global score is calculated by taking the average of RE, SC, WC, and EC subscale scores as cogni- tive features, since the BE evaluates open-ended questions that exhibit behavioral dimensions of eating disorder. Global score and subscores ≥4 are considered clinically indicative of disordered eating behaviors requiring further psychological assessment through clinical interview, and disordered eating is classified as a global EDE-Q score ≥1.52 [18]. EDE-Q as- sesses only the previous 28 days. Reported frequencies were considered representative of the previous three months for the purpose of fulfilling diagnostic criteria. Statistical Analysis All statistical analyses were carried out using SPSS for Win- dows Version 15.0 (SPSS Inc., Chicago, IL). Descriptive statis- tics are presented as numbers and percentages for categorical variables and as average, standard deviation, minimum, maximum, median and interquartile range for numerical variables. Comparisons of categorical variables in indepen- dent groups were performed with Pearson’s chi-squared test. To compare numerical variables between two independent groups, the Student’s t-test was used when the normal dis- tribution condition was met; the Mann-Whitney U test was used when the normal distribution condition was not met. The relationships between numerical variables were evalu- ated with Pearson Correlation if variables provided normal distribution and with Spearman Correlation if not. Statisti- cal significant was defined as P<0.05. Results A total of 100 patients and 86 healthy volunteers were in- cluded in the study. The mean age was 23.0±5.2 among acne patients and 23.0±4.3 for the control group, with no sta- tistically significant difference (P=0.472). Mean BMI was 21.6±3.1 for acne patients and 21.4±2.3 for control group, again, with no statistically significant difference (P=0.821). There was also no statistically significant difference in terms of marital status, education level, or smoking habits between groups (P=0.401, P=0.342, and P=0.280, respectively). The baseline sociodemographic characteristics are summarized in Table 1. The questionnaire and scale scores were analyzed in study groups (Table 2). The mean EAT-40 score was signifi- cantly higher in acne group (24.1±17.4) compared to control group (14.2±9.0) (P=0.001) (Figure 1). Likewise, a signifi- cantly higher proportion of acne patients (27%) had EAT-40 score ≥30 compared to the control group (6.97%) (P=0.001) (Table 3). The global score of EDE-Q and each subscore were statistically higher in the acne group (P=0.001) (Figure 2). The proportion of participants who received 4 or above for the Restraint Eating and Weight Concern subscores of EDE-Q was significantly higher in the patient group compared to the control group (P=0.003 and P=0.034, respectively) (Table 3). EAT-40 scores were positively correlated with EDE-Q scores for each group (P=0.001) (Figure 3). The Anxiety, Hostility, and Psychoticism subscales of SCL-90R were statistically higher among acne patients compared to the control group (P=0.001, P=0.002, and P=0.021 respectively). When we evaluated the SCL-90-R subscores among acne patients, we found that Obsessive-Compulsive (P=0.026; r=0.222), De- pression (P=0.003; r=0.295), and Phobic Anxiety subscores (P=0.044; r=0.202) were positively correlated with EAT-40 scores (Table 4). Also, we found that Obsessive-Compulsive and Depression subscores of acne patients who had mean- ingful EAT-40 scores were statistically higher compared to those that had EAT-40 scores <30 (P=0.030 and P=0.006, respectively). Different from the patient group, Somatiza- tion, Interpersonal Sensitivity, and Paranoid Ideation sub- scores of the controls who had meaningful EAT-40 scores were statistically higher compared to those that had EAT- 40 scores <30 (P=0.022, P=0.014, and P=0.044, respec- tively) (Table 5). The correlation between SCL-90 subscores 4 Original Article | Dermatol Pract Concept. 2025;15(2):5053 Table 2. Scores and Subscores of EDE-Q, SCL-90, and EAT-40 for Acne Patients and Control Group. Acne patients (N=100) Control group (N=86) PMean ±SD (Min-Max) Mean ±SD (Min-Max) EDE-Q Dietary Restraint 2.10±1.71 (0-6) 1.09±1.13 (0-4.20) 0.001 Eating Concern 0.92±0.98 (0-3.60) 0.20 (0-0.60)# 0.001+ Shape Concern 2.14±1.49 (0-7.20) 1.00±0.94 (0-4.38) 0.001 Binge Eating 0.50 (0-0.95) # 0 (0-0.60) # 0.001+ Weight Concern 1.65±1.28 (0-5.20) 0.64±0.68 (0-2.60) 0.001 Global score 1.50±1.07 (0-4.10) 0.68±0.64 (0-2.97) 0.001 SCL90* GSI 0.41 (0.22-0.74) # 0.42±0.36 (0-1.48) 0.074+ SOM 0.71±0.71 (0-3.17) 0.52±0.58 (0-2.50) 0.053 OC 0.20 (0-0.40) # 0.27±0.30 (0-1.10) 0.498+ INS 0.33 (0.22-0.88) # 0.82±0.82 (0-3.11) 0.387+ DEP 0.89±0.75 (0-2.92) 0.61 (0.30-1.01) # 0.296+ ANX 0.40 (0.20-1.00) # 0.25±0.31 (0-1.20) 0.001+ HOS 0.35±0.46 (0-1.83) 0.18±0.22 (0-0.80) 0.002 PHO 0.14 (0-0.28) # 0.13±0.18 (0-1.14) 0.090+ PAR 0.33 (0-0.66) # 0 (0-0.28) # 0.955+ PSY 0.25±0.31 (0-1.40) 0.14±0.16 (0-0.60) 0.021 EAT-40 24.10±17.40 (3-76) 14.20±9.00 (0-41) 0.001 #Median (Interquartile range) +Mann-Whitney U test. Abbreviations: ANX = anxiety; DEP = depression; EAT-40 = Eating Attitudes Test- 40; EDE-Q = Eating Disorders Examination Questionnaire; HOS = hostility; GSI – General Severity Index; INS = interpersonal sensitivity; OC = obsessive-compulsive; PAR = paranoid ideation; PHO = phobic anxiety; PSY = psychoticism; SCL-90 = symptom checklist-90; SD = standard deviation; SOM = somatization. Table 1. Sociodemographic Characteristics of Study Groups.     Acne Patients N=100 Control Group N=86 pN % N % Sex Male 30 30.0% 32 37.2% 0.298 Female 70 70.0% 54 62.8% Age Mean±SD (Min-Max) 23.0±5.2 (16-39) 23.0±4.3 (16-37) 0.472 BMI Mean±SD (Min-Max) 21.6±3.1 (16.9-34.4) 21.4±2.3 (18.1-28.4) 0.821 Marital Status Single 93 93.0% 77 89.5% 0.401 Married 7 7.% 9 10.5% Educational Status High School 24 24.0% 18 20.9% 0.342 Degree 64 64.0% 51 59.3% Postgraduate 12 12.0% 17 19.8% Smoking habits 39 39.0% 27 31.4% 0.280 Abbreviations: BMI = body mass index; SD standard deviation and EAT-40 scores among the study groups are shown in Figures 4, 5 and 6. Twenty-nine percent of patients had mild, 28% had moderate, and 43% of patients had severe acne. The severity of disease was not correlated with the EAT- 40 scores (P=0.747). Also, disease duration, age at disease onset, presence of family history of acne, and acne subtype (vulgaris, conglobata, cosmetica, and others) were not cor- related with EAT-40 scores among acne patients (P=0.092, P=0.966, P=0.148, and P=0.572, respectively). Likewise, sociodemographic characteristics such as age, BMI, and sex were not correlated with EAT-40 scores among acne patients (P=0.361, P= 0.551, and P=0.432, respectively). Original Article | Dermatol Pract Concept. 2025;15(2):5053 5 Figure 1. EAT-40 score distribution among study groups Figure 2. EDE-Q global score and subscore distribution among study groups 6 Original Article | Dermatol Pract Concept. 2025;15(2):5053 Figure 3. Correlation between EDE-Q and EAT-40 scores among study groups Table 3. Comparison of EDE-Q and EAT-40 Scores Between Study Groups. Acne Group (N=100) Control Group (N=86) pn % n % EDE-Q Dietary Restraint ≥4 19 19.0% 4 4.65% 0.003 EDE-Q Eating Concern ≥4 3 3.0% 1 1.16% 0.625 EDE-Q Shape Concern ≥4 12 12.0% 4 4.65% 0.075 EDE-Q Binge Eating ≥4 11 11.0% 5 5.81% 0.209 EDE-Q Weight Concern ≥4 10 10.0% 2 2.32% 0.034 EDE-Q-Global score ≥4 2 2.0% 0 0.0% 0.500 EAT-40 ≥30 27 27.0% 6 6.97% 0.001 Abbreviations: EAT-40 = Eating Attitudes Test-40; EDE-Q = Eating Disorders Examination Questionnaire. Conclusions Although the skin findings and increased prevalence of acne among patients with eating disorders are well known, there are few studies in the literature investigating the disturbed eat- ing attitude among acne patients. In a pilot study designed by Öner et al. [19], the mean EAT-40 score of acne patients was significantly higher compared to the control group; this result Original Article | Dermatol Pract Concept. 2025;15(2):5053 7 Table 4. Correlation Between EAT-40 and SCL-90 Subscores. EAT-40 Total Acne Patients Control Group r p r p r p SCL90 GSI 0.282 0.001 0.192 0.056 0.435 0.001 SOM 0.212 0.004 0.096 0.342 0.411 0.001 OC 0.277 0.001* 0.222 0.026* 0.292 0.001 INS 0.195 0.008* 0.079 0.435* 0.416 0.001 DEP 0.331 0.001 0.295 0.003 0.438 0.001* ANX 0.291 0.001* 0.168 0.095* 0.264 0.015 HOS 0.224 0.002* 0.168 0.095 0.250 0.012 PHO 0.246 0.001* 0.202 0.044* 0.244 0.024* PAR 0.220 0.003* 0.146 0.148* 0.356 0.002 PSY 0.267 0.001* 0.167 0.098 0.300 0.008 *GSI: General Severity Index; SOM: Somatization; OC: Obsessive-Compulsive; INS: Interpersonal sensitivity; DEP: Depression; ANX: Anxiety; HOS: Hostility; PHO: Phobic anxiety; PAR: Paranoid ideation; PSY: Psychoticism *Spearman Correlation Analysis. Abbreviations: ANX = anxiety; DEP = depression; EAT-40 = Eating Attitudes Test-40; HOS = hostility; GSI – General Severity Index; INS = interper- sonal sensitivity; OC = obsessive-compulsive; PAR = paranoid ideation; PHO = phobic anxiety; PSY = psychoticism; SCL-90 = symptom checklist-90; SD = standard deviation; SOM = somatization. Table 5. SCL-90 Subscore Correlations Among Participants According to the EAT-40 Scores. EAT-40 P <30 ≥30 Mean±SD (Min-Max) Mean±SD (Min-Max) Acne Patients SOM OC INS DEP ANX HOS PHO PAR PSY 0.65±0.70 (0-3.17) 0.30±0.47 (0-2.50) 0.72±0.88 (0-4.11) 0.76±0.66 (0-2.92) 0.61±0.81 (0-4.70) 0.31±0.42 (0-1.67) 0.19±0.27 (0-1.14) 0.42±0.47 (0-2.17) 0.21±0.27 (0-1.20) 0.86±0.71 (0-2.33) 0.45±0.46 (0-1.70) 0.70±0.71 (0-2.67) 1.23±0.86 (0-2.92) 0.93±0.91 (0-3.70) 0.46±0.56 (0-1.83) 0.30±0.42 (0-1.83) 0.57±0.60 (0-2.50) 0.37±0.37 (0-1.40) 0.133 0.030 0.879 0.006 0.051 0.343 0.245 0.302 0.050 Control Group SOM OC INS DEP ANX HOS PHO PAR PSY 0.48±0.56 (0-2.50) 0.26±0.31 (0-1.10) 0.76±0.78 (0-3.11) 0.72±0.64 (0-3.50) 0.24±0.30 (0-1.20) 0.18±0.22 (0-0.80) 0.12±0.19 (0-1.14) 0.41±0.40 (0-1.33) 0.13±0.16 (0-0.60) 1.07±0.71 (0.42-2.08) 0.33±0.25 (0.10-0.80) 1.67±0.95 (0.56-2.78) 1.26±0.84 (0.46-2.77) 0.35±0.42 (0-1.10) 0.31±0.19 (0-0.50) 0.19±0.15 (0-0.43) 0.78±0.44 (0.33-1.33) 0.23±0.19 (0-0.50) 0.022 0.191 0.014 0.054 0.510 0.116 0.141 0.044 0.118 Abbreviations: ANX = anxiety; DEP = depression; HOS = hostility; INS = interpersonal sensitivity; OC = obsessive-compulsive; PAR = par- anoid ideation; PHO = phobic anxiety; PSY = psychoticism; SD = standard deviation; SOM = somatization. was attributed to psychopathological mechanisms common in acne and in eating disorders. The relation between disordered eating and acne vulgaris is multidimensional and likely to be a result of the interplay between psychological, hormonal, and metabolic influences. Regarding the psychological dimension, the research consistently shows that among psychosocial vari- ables, body image distortion is the strongest predictor of dis- ordered eating behaviors [20]. It is also known that body image disturbances are central to eating disorders both at the onset and maintenance [20]. As one of the psychological 8 Original Article | Dermatol Pract Concept. 2025;15(2):5053 Figure 4. Correlation between General Severity Index of SCL-90 and EAT-40 scores among study groups Figure 5. Correlations of Depression subscores of Scl-90 and EAT-40 scores among study groups Original Article | Dermatol Pract Concept. 2025;15(2):5053 9 factor, the psychologically delicate nature of acne disease, body dissatisfaction bought on by social norms, negative self-image due to appearance-related criticism from peers, poorer social adjustment than their counterparts, and their impaired quality of life determined by perceived stigma among acne patients can contribute to disordered eating. Further- more, Sneddon et al. [25] suggested that conditions such as acne excoriee des jeunes filles present with psychological dy- namics that are very similar to the dynamics encountered in adolescents with eating disorders in terms of difficulties cop- ing with the emerging developmental tasks of young adult- hood. Disturbed eating behaviors have been found to be related to the disturbed experience of one’s own body and anxiety towards particular food groups, which is a common trend among acne patients. It is evident that patients fre- quently implement erroneous dietary regimens as a conse- quence of their increased awareness of acne and the mounting evidence supporting the role of high-glycemic index diets as a contributing factor to the pathogenesis of acne. This is primar- ily due to their reliance on inaccurate informational sources. In a study evaluating beliefs of acne patients, 62.3% reported diet as a casual or exacerbating factor of acne [22]. In another study conducted on 852 adolescents, approximately 30% comorbidities, body dissatisfaction was reported to be preva- lent among acne patients [21]. Thus, high levels of body dis- satisfaction may predispose patients to overeat or engage in restrictive eating in an attempt to cope with the psychosocial stressors associated with acne symptoms. In a study conducted among acne patients, 64.4% believed that acne was compro- mising their self-image [22]. Similarly, in a study investigating the rate of body dysmorphic disorders in patients with acne, the risk increased by two times in severe acne patients, and mirror checking occurred for at least two hours a day [23]. Likewise, perceived self-presentation failures can affect eating behavior, and people may regulate their weight as a self- presentation strategy, since physical attractiveness involves not only facial appearance but also appropriate physical shape. Considering body image disturbances, adolescence, the period in which acne vulgaris is commonly observed, is the most vulnerable life stage because it is a period characterized by physiological, emotional, cognitive, and above all, social changes [24]. During adolescence, the body is experienced as a source of identity, self-concept, and self-esteem. As a result, there is a greater concern for physical appearance. Moreover, the research has shown that eating disorders typically occur during adolescence [20]. Besides sharing the same age as a risk Figure 6. Correlations between Obsessive-Compulsive subscores of Scl-90 and EAT-40 scores among study groups 10 Original Article | Dermatol Pract Concept. 2025;15(2):5053 Öner et al. [19] reported no significant relationship between patients’ acne severity and EAT-40 scores. In another study on acne patients, there was no statistically significant correlation between acne severity and three-factor nutrition questionnaire scores [27]. Our study has methodological limitations due to the use of self-reported questionnaires; we are unable to con- duct interviews, which is the gold standard in diagnosing par- ticular eating disorders. Also, the cross-sectional nature of this study makes it difficult to assess the causality. To avoid bidi- rectional association between acne and eating disorders, we excluded subjects with BMI≤16 kg/m2, since this is considered a critical value at which skin changes are more frequent in eating disorders [34]. Psychometric parameters which are dif- ficult to calculate, such as personal characteristics, stressful life event effects, psychological developmental period, person- ality coping styles, family support system, and family history of eating disorders were not included in the analysis. Finally, the small number of participants included in the study is a limitation. Because of shared comorbidities clinicians should screen acne patients for possible disordered eating psychopathology, with particular attention to those with obsessive- compulsive and depression, hence early referral and intervention can reduce the morbidity associated with eating attitudes and preventing the long-term consequences of acne in terms of physical as well as psychological health. Acknowledgement: This study was shared as an oral pre- sentation at the 19th Congress of the European Society for Dermatology and Psychiatry (ESDaP) and the 2nd Brain Skin Colloquium Conference (BSC), 11–13 June 2021, London. References 1. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May;74(5):945-73.e33. DOI: 10.1016/j.jaad.2015.12.037 PMID: 26897386. 2. Sood S, Jafferany M, Vinaya Kumar S. Depression, psychiatric comorbidities, and psychosocial implications associated with acne vulgaris. J Cosmet Dermatol. 2020 Dec;19(12):3177-3182. DOI: 10.1111/jocd.13753 PMID: 33006820. 3. Wu SF, Kinder BN, Trunnell TN, Fulton JE. Role of anxiety and anger in acne patients: a relationship with the severity of the dis- order. J Am Acad Dermatol. 1988 Feb;18(2 Pt 1):325-33. DOI: 10.1016/s0190-9622(88)70047-x PMID: 2964458. 4. Samuels DV, Rosenthal R, Lin R, Chaudhari S, Natsuaki MN. Acne vulgaris and risk of depression and anxiety: A meta- analytic review. J Am Acad Dermatol. 2020 Aug;83(2):532-541. DOI: 10.1016/j.jaad.2020.02.040 PMID: 32088269. 5. Lukaviciute L, Ganceviciene R, Navickas P, Navickas A, Grigaitiene J, Zouboulis CC. Anxiety, Depression, and Sui- cidal Ideation amongst Patients with Facial Dermatoses (Acne, Rosacea, Perioral Dermatitis, and Folliculitis) in Lithuania. thought that being overweight worsened their acne [26]. This may explain the considerably higher Restrained Eating (RE) and Weight Concern (WC) subscores of EDE-Q among the patient group in our study. It is imperative to exercise caution when advising patients on the potential implications of high glycemic index diets on acne. An overemphasised warning may be counterproductive, as it could mislead patients to- wards calorie restriction. Dermatologists, therefore, must as- sume a pivotal role in providing clear explanations to address these concerns. The fact that participants who had meaningful EAT-40 scores had different SCL90-R subscore distributions in the patient and control groups suggests that acne may affect different psychopathologies while causing disordered eating. We found that the Depression and Obsessive-Compulsive sub- scores of SCL-90-R were correlated with EAT-40 scores among acne patients. Correspondingly, a study conducted by Karaağaç et al. [27] demonstrated the relationship between depression and emotional and uncontrolled eating behaviors among acne patients. Consistent with the prior literature, in this study the EAT-40 scores correlated with depression. It has been known that depression is considered a risk factor for body dysmorphic disorder and concerns related to eating, and it is the most common comorbid diagnosis, with lifetime rates in eating disorders ranging between 50% and 75% [28]. Fur- thermore, in a study conducted by Sarkar et al. [29] to investi- gate personality disorders among acne patients, 13% of participants with severe acne had obsessive-compulsive per- sonality disorder, which is considered a common risk factor for anorexia nervosa [30]. Regarding the hormonal aspect, androgens implicated in binge eating behavior and disordered eating among women with polycystic ovary syndrome (PCOS) have been known to increase, but this relationship seems to be independent from serum androgen levels [31]. In this study, we excluded those acne patients who had a medical history of menstrual irregularity or hirsutism to ensure that our results were not affected by this population, but there may be a simi- lar mechanism between acne and eating disorders in PCOS. When examining the metabolic influence, acne patients were more predisposed to dietary restriction, which is predicted to improve acne lesions by reducing androgenic hormone levels [32]. This subsequently led to overeating via disinhibition mechanisms. Even a single day of high-fat overeating is enough to impair glycemic control and reduce insulin sensitiv- ity in healthy adults; thus, severe binge eating behaviors may have instantaneous metabolic health consequences for indi- viduals [33]. Altered insulin levels may contribute to IGF-1 (insulin-like growth factor-1) level changes and subsequent acne exacerbations. This may lead patients to dietary restric- tion, thus triggering a vicious cycle. In our study, EAT-40 scores were not related to clinical characteristics of acne pa- tients such as severity of disease, duration, age at disease on- set, type of acne, and family history. Similar to our results, Original Article | Dermatol Pract Concept. 2025;15(2):5053 11 Dermatol. 2011 Jul;4(7):35-41 PMID: 21779418; PMCID: PMC3140907. 22. Rigopoulos D, Gregoriou S, Ifandi A, et al. Coping with acne: beliefs and perceptions in a sample of secondary school Greek pupils. J Eur Acad Dermatol Venereol. 2007 Jul;21(6):806-10. DOI: 10.1111/j.1468-3083.2006.02091.x PMID: 17567312. 23. Marron SE, Miranda-Sivelo A, Tomas-Aragones L, et al. Body dysmorphic disorder in patients with acne: a multicentre study. J Eur Acad Dermatol Venereol. 2020 Feb;34(2):370-376. DOI: 10.1111/jdv.15954 PMID: 31515838. 24. Lawler M, Nixon E. Body dissatisfaction among adolescent boys and girls: the effects of body mass, peer appearance culture and internalization of appearance ideals. J Youth Adolesc. 2011 Jan;40(1):59-71. DOI: 10.1007/s10964-009-9500-2 PMID: 20058058. 25. Sneddon J, Sneddon I. Acne excoriée: a protective device. Clin Exp Dermatol. 1983 Jan;8(1):65-8. DOI: 10.1111/j.1365-2230.1983. tb01746.x PMID: 6220845. 26. Poli F, Auffret N, Beylot C, et al. Acne as seen by adolescents: re- sults of questionnaire study in 852 French individuals. Acta Derm Venereol. 2011 Sep;91(5):531-6. DOI: 10.2340/00015555-1125 PMID: 21611685. 27. Karaağaç M, Akça HM, Acat Ö. Lack of Association of Acne Severity with Depression, Anxiety, Stress, and Eating Attitudes: A Cross- Sectional Study. J Pers Med. 2024 Jan 23;14(2):133. DOI: 10.3390/jpm14020133 PMID: 38392567; PMCID: PMC10890547. 28. Ferreiro F, Seoane G, Senra C. Toward understanding the role of body dissatisfaction in the gender differences in depressive symptoms and disordered eating: a longitudinal study during adolescence. J Adolesc. 2014 Jan;37(1):73-84. DOI: 10.1016 /j.adolescence.2013.10.013 PMID: 24331307. 29. Sarkar S, Patra P, Mridha K, Ghosh SK, Mukhopadhyay A, Thakurta RG. Personality disorders and its association with anxi- ety and depression among patients of severe acne: A cross- sectional study from Eastern India. Indian J Psychiatry. 2016 Oct-Dec; 58(4):378-382. DOI: 10.4103/0019-5545.196720 PMID: 28196993; PMCID: PMC5270261. 30. Altman SE, Shankman SA. What is the association between obsessive-compulsive disorder and eating disorders? Clin Psychol Rev. 2009 Nov;29(7):638-46. DOI: 10.1016/j.cpr.2009.08.001 PMID: 19744759. 31. Greenwood EA, Pasch LA, Cedars MI, Huddleston HG. Obesity and depression are risk factors for future eating disorder-related attitudes and behaviors in women with polycys- tic ovary syndrome. Fertil Steril. 2020 May;113(5):1039-1049. DOI: 10.1016/j.fertnstert.2020.01.016 PMID: 32386615. 32. Gupta MA, Gupta AK, Ellis CN, Voorhees JJ. Bulimia nervosa and acne may be related: a case report. Can J Psychiatry. 1992 Feb;37(1):58-61. DOI: 10.1177/070674379203700113 PMID: 1532340. 33. Parry SA, Woods RM, Hodson L, Hulston CJ. A Single Day of Excessive Dietary Fat Intake Reduces Whole-Body Insulin Sen- sitivity: The Metabolic Consequence of Binge Eating. Nutri- ents. 2017 Jul 29;9(8):818. DOI: 10.3390/nu9080818 PMID: 28758920; PMCID: PMC5579612. 34. Hediger C, Rost B, Itin P. Cutaneous manifestations in anorexia nervosa. Schweiz Med Wochenschr. 2000 Apr 22;130(16): 565-75 PMID: 10842772. Dermatology. 2020;236(4):314-322. DOI: 10.1159/000506627 PMID: 32252051. 6. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric As- sociation: Arlington, VA, USA, 2013. 7. Galmiche M, Déchelotte P, Lambert G, Tavolacci MP. Prevalence of eating disorders over the 2000-2018 period: a systematic lit- erature review. Am J Clin Nutr. 2019 May 1;109(5):1402-1413. DOI: 10.1093/ajcn/nqy342 PMID: 31051507. 8. Lee S, Leung CM, Wing YK, Chiu HF, Chen CN. Acne as a risk factor for anorexia nervosa in Chinese. Aust N Z J Psychiatry. 1991 Mar;25(1):134-7. DOI: 10.3109/00048679109077729 PMID: 1828663. 9. Gupta MA, Gupta AK. Dissatisfaction with skin appearance among patients with eating disorders and non-clinical controls. Br J Dermatol. 2001 Jul;145(1):110-3. DOI: 10.1046/j.1365 -2133.2001.04292.x PMID: 11453917. 10. Pochi PE, Shalita AR, Strauss JS, et al. Report of the Consensus Conference on Acne Classification. Washington, D.C., March 24 and 25, 1990. J Am Acad Dermatol. 1991 Mar;24(3):495-500. DOI: 10.1016/s0190-9622(08)80076-x PMID: 1829466. 11. Lindvall Dahlgren C, Wisting L. Transitioning from DSM-IV to DSM-5: A systematic review of eating disorder prevalence assessment. Int J Eat Disord. 2016 Nov;49(11):975-997. DOI: 10.1002/eat.22596 PMID: 27528542. 12. Garner DM, Garfinkel PE. The Eating Attitudes Test: an in- dex of the symptoms of anorexia nervosa. Psychol Med. 1979 May;9(2):273-9. DOI: 10.1017/s0033291700030762 PMID: 472072. 13. Savaşır I, Erol N. Yeme Tutumu Testi. Anoreksiya nevroza belirtileri indeksi. Psikoloji Dergisi 1989; 7: 19-25. 14. Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psy- chiatric rating scale--preliminary report. Psychopharmacol Bull. 1973 Jan;9(1):13-28 PMID: 4682398. 15. Kılıç M. ‘’Belirti Tarama Listesi (SCL-90-R)’nin Geçerlilik ve Güvenilirliği’’. Türk Psikolojik Danışma ve Rehberlik Dergisi 1991; 1: 45-52. 16. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord. 1994 Dec;16(4): 363-70 PMID: 7866415. 17. Yucel B, Polat A, Ikiz T, Dusgor BP, Elif Yavuz A, Sertel Berk O. The Turkish version of the eating disorder examination question- naire: reliability and validity in adolescents. Eur Eat Disord Rev. 2011 Nov-Dec;19(6):509-11. DOI: 10.1002/erv.1104 PMID: 21400637. 18. Mond JM, Hay PJ, Rodgers B, Owen C. Eating Disorder Exam- ination Questionnaire (EDEQ): norms for young adult women. Behav Res Ther. 2006 Jan;44(1):53-62. DOI: 10.1016/j.brat .2004.12.003 PMID: 16301014. 19. Öner Ü, Hacınecipoğlu F. Could acne be a risk factor for de- veloping eating disorders? Acne vulgaris and eating disorders. J Cosmet Dermatol. 2022 May;21(5):2176-2182. DOI: 10.1111 /jocd.14330 PMID: 34214235 20. Stice E, Shaw HE. Role of body dissatisfaction in the onset and maintenance of eating pathology: a synthesis of research find- ings. J Psychosom Res. 2002 Nov;53(5):985-93. DOI: 10.1016 /s0022-3999(02)00488-9 PMID: 12445588. 21. Bowe WP, Doyle AK, Crerand CE, Margolis DJ, Shalita AR. Body image disturbance in patients with acne vulgaris. J Clin Aesthet