Exploring Social Avoidance and Psychosocial Factors in Young Adults with Acne in East China

Introduction

Acne vulgaris ranks among the most prevalent dermatologic conditions, affecting approximately 9.4% of the population,¹ with peak incidence occurring during adolescents and young adults.² Visible facial lesions are frequently linked to avoidance of social situations and to anxiety/depressed mood, impairing daily functioning.^3,4 Defined as the deliberate withdrawal from social interactions due to appearance-related distress, social avoidance affects 30–50% of acne patients— a rate 3–5 times higher than healthy controls.⁵ From a stigma perspective, acne represents a concealable stigma—lesions can sometimes be hidden, yet the anticipation of “being seen” heightens vigilance and self-consciousness in interactions.^6,7

Beyond individual symptoms, contemporary media and culture likely shape these responses. Social media encourages idealized appearance norms and upward comparisons among young people.⁸ In Chinese collectivist contexts, sensitivity to social evaluation and the salience of mianzi (“face”) may intensify the perceived social costs of visible acne, potentially amplifying avoidance behavior.⁹

Although prior work connects acne with body image disturbance and other psychosocial outcomes,¹⁰ several gaps remain. First, despite established associations between lower income and poorer dermatologic/mental health outcomes,¹¹ most studies emphasize psychological mediators while neglecting to specify the role of socioeconomic moderators. Second, lesion distribution is underexplored; given the social salience of the face, combined facial/neck plus truncal involvement may carry greater stigma than single-site disease. Third, young adulthood (18–29 years)—a life stage marked by pivotal transitions in education, employment, and relationships—remains understudied, despite its heightened vulnerability to psychosocial strain.¹² Empirical data from China remain limited, particularly on how these factors jointly relate to social avoidance.

Despite nursing’s critical role in acne management, existing protocols often emphasize physical symptom alleviation (eg, topical therapies, antimicrobial agents) over structured psychosocial interventions.¹³ This oversight contradicts the biopsychosocial model¹⁴ and the holistic care framework.¹⁵ This study addresses these gaps by examining how socioeconomic factors, clinical characteristics (eg, lesion distribution), and psychological variables collectively influence social avoidance among Chinese young adults, a population navigating both acne stigma and intense social competition during critical developmental years.

Materials and Methods

Study Design and Participants

A multicenter, cross-sectional survey using consecutive sampling method to recruit young adult acne patients from the dermatology clinics of two tertiary hospitals in Hangzhou City, Zhejiang Province, China, from December 2024 to February 2025.

The study was conducted following ethical approval and permission from the participating hospitals. All methods were carried out in accordance with relevant guidelines and regulations including the Declaration of Helsinki. The participants of this study are young adults aged 18–29, who have reached the legal age of majority (≥18 years old) and have full civil capacity and independent informed consent. The research protocol has been approved by all participants providing electronic informed consent after a detailed verbal and written explanation of study procedures. During the study, participants have the right to withdraw from the study at any time, and personal information is processed anonymously to ensure data privacy and security.

The inclusion criteria for acne patients included: meeting the diagnostic criteria of the “Guidelines for the Diagnosis and Treatment of Acne Vulgaris in Primary Care”;¹⁶ aged between 18 and 29 years; disease duration for more than 3 months; clear mind and no comprehension difficulties; and willing to sign an informed consent to participate in this study.

Exclusion criteria for patients with acne included: having received structured psychological intervention from a psychiatrist or psychologist; having cognitive impairment or psychiatric disorder (according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria)¹⁷ that precluded them from completing the study; and other serious dermatologic diseases likely to confound acne severity or psychosocial outcomes (eg, psoriasis, bullous pemphigoid, extensive vitiligo, atopic dermatitis/eczema, rosacea, seborrheic dermatitis, hidradenitis suppurativa), or serious chronic systemic illnesses (eg, uncontrolled endocrine disease, active malignancy, end-stage renal/hepatic failure, autoimmune connective-tissue diseases), as determined by the attending clinician.

Data Collection

The study team members received standardized training to ensure a clear understanding of the study’s purpose, methods, content, and significance. Permission was obtained from the original authors to use the validated instruments in this study. Data were collected using the following tools:

1. Demographic Information Questionnaire: Captured age, gender, education level, residence, marital status, medical insurance type, employment status, and household income.
2. Clinical Variables: Included Body Mass Index (BMI), acne location, disease duration, family history, physician-rated acne severity, and treatment details.
3. Social Avoidance Subscale of Social Avoidance and Distress Scale (SADS-SA): A 14-item self-report tool assessing the tendency to avoid social interactions. Scores range from 0 to 14. SADS-SA is a subscale of the Social Avoidance and Distress Scale (SADS).¹⁸ It consists of 28 dichotomous items with a total score range of 0 to 28, where higher scores indicate greater social avoidance and distress. In a Chinese adaptation, SADS reported a Cronbach’s alpha of 0.85 for the entire scale, with subscale alphas of 0.77 and 0.73 for avoidance and distress, respectively.¹⁹
4. Body Image Disturbance Questionnaire (BIDQ): A 7-item self-report tool assessing appearance-related concerns, distress, social/occupational impact, and avoidance behaviors.²⁰ Scores range from 7 to 35, with higher scores indicating greater disturbance. The BIDQ has demonstrated excellent reliability (Cronbach’s alpha = 0.89–0.90 for females, 0.87–0.89 for males).²¹ The Chinese version, validated by Chen et al²² showed good reliability (Cronbach’s alpha = 0.82) and validity in Chinese populations.
5. Generalized Anxiety Disorder Scale (GAD-7): A 7-item tool for screening generalized anxiety disorder and assessing symptom severity.²³ Scores range from 0 to 21, with higher scores indicating more severe anxiety. The scale has excellent internal consistency (Cronbach’s alpha = 0.92) and test–retest reliability (r = 0.83). The Chinese version, validated by He et al,²⁴ demonstrated a Cronbach’s alpha of 0.90, confirming its reliability for use in Chinese populations.

Sample Size Calculation

When designing this study, the researcher carefully considered how many participants we would need to reliably detect the complex relationships between acne and its psychosocial impacts. Using Kendall’s well-established method for multivariate studies, we calculated that our analysis required at least 5 participants for each of the 21 independent variables we planned to examine—including demographic factors, social avoidance measures, body image disturbance, and anxiety symptoms. This initial calculation suggested a minimum of 105 participants. However, recognizing the practical challenges of clinical research, such as potential participant dropouts or incomplete questionnaires, we prudently increased this target by 20%. This adjustment brought our minimum sample size to 126 participants, ensuring we would maintain sufficient statistical power even if some data could not be used.

In practice, we went beyond this minimum threshold to enhance the robustness of our findings. Our team distributed 220 questionnaires across two tertiary hospitals, reflecting our commitment to obtaining comprehensive data. After careful quality checks to eliminate incomplete or inconsistent responses, we retained 201 valid questionnaires for analysis – a strong final sample that both met and exceeded our initial power calculations.

Statistical Analysis

Data were analyzed using the Statistical Package for Social Sciences (SPSS Version 25.0). Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize sociodemographic data and scores from the SADS-SA, BIDQ, and GAD-7, Pearson’s correlation coefficient was employed to examine relationships among SADS-SA, BIDQ, and GAD-7 scores. Univariate analysis was conducted to identify potential factors associated with social avoidance, using appropriate statistical tests based on variable types and distributions. Multivariate regression analysis was performed to determine independent predictors of social avoidance, adjusting for confounding variables. Results were reported as beta coefficients with 95% confidence intervals (CI), and statistical significance was set at P < 0.05.

Results

Comparison of Body Image Disturbance Status Among Different Clinical Demographic Characteristics

A total of 201 patients were included in this study, with a mean score for social avoidance of 5.71±3.79 and a mean disease duration of 6.11±5.41 years. Among them, 28.9% (n=58) had a family history of acne. The distribution of acne lesions was mainly on the face and neck (74.1%, n=149), followed by simultaneous involvement of the face, neck, and torso (22.9%, n=46). Most patients had moderate acne severity (42.8%, n=86), followed by mild (26.4%, n=53) and moderate-to-severe (22.9%, n=46) cases. Topical treatments, including external applications, dressings, and phototherapy, were the most common therapeutic approach (69.6%, n=140), followed by combined Chinese and Western medicine (53.7%, n=108) (Table 1).

Table 1 Clinical Characteristics and Comparison of Social Avoidance Scores of Participants (N=201)

First, monthly income showed a graded association (overall F = 3.300, P = 0.039): participants with ≥5000 CNY reported lower avoidance than those <3000 CNY (eg, group means 5.52 ± 3.78 vs 9.00 ± 4.47). Second, lesion location mattered (overall F = 5.560, P = 0.004): the face/neck + torso group had higher scores (6.83 ± 3.89) than face/neck only (5.52 ± 3.70), whereas torso-only involvement was lowest (1.83 ± 1.72). Other variables were not significant (all P > 0.05) (Table 1).

The Reliability of the SADS-SA, BIDQ, and GAD-7

The reliability of the scales was evaluated using Cronbach’s α coefficient. The reliability coefficients for the SADS-SA, BIDQ, and GAD-7, were all greater than 0.8, indicating high Internal consistency (Table 2).

Table 2 Reliability of the SADS-SA, BIDQ, and GAD-7

Correlation Between Social Avoidance and Psychological Factors with Pearson’s Correlation Coefficient

The average scores of social avoidance (SADS-SA), body image disturbance (BIDQ), and anxiety (GAD-7) for the participants were 5.71±3.79, 30.91±12.49, and 6.43±5.26, respectively. Pearson correlation analysis revealed that social avoidance correlated with body image disturbance (P < 0.01) and anxiety (P < 0.01). BIDQ also correlated with GAD-7 (P < 0.01). See Table 3 for coefficients.

Table 3 Correlation Between Social Avoidance and Other Factors with Pearson’s Correlation Coefficient

Univariate Linear Regression Analysis of Factors Affecting Social Avoidance

In univariate regressions (Table 4), higher anxiety and body image disturbance were associated with greater social avoidance (both P < 0.001). Compared with <3000 CNY, 3000–4999 CNY (P = 0.030) and ≥5000 CNY (P = 0.011) were associated with lower avoidance. Relative to face/neck only, face/neck + torso was higher (P = 0.038), and torso-only was lower (P = 0.018).

Table 4 Univariate Linear Regression Analysis of Factors Affecting Social Avoidance

Multivariate Regression Analysis of Factors Affecting Social Avoidance

In multivariable analysis (Table 5), anxiety showed the strongest independent association with higher social avoidance (P < 0.001). Higher income (≥5000 CNY) was associated with lower avoidance (P = 0.022). Relative to face/neck only, face/neck + torso was higher (P = 0.040), and torso-only was lower (P = 0.003). Body-image disturbance showed no significant direct association (P = 0.053).

Table 5 Multivariate Regression Analysis of Indicators Influencing Social Avoidance

After the multivariable model (Table 5), two visuals aid interpretation. Figure 1 visualizes the standardized coefficients (β) with P values, highlighting the same pattern as the model; Figure 2 presents an association schematic summarizing the observed cross-sectional associations.

Figure 1 Visualizes the standardized coefficients (β) with P values. Notes: β: Standardized regression coefficient; P < 0.05 is used as the criterion for statistical significance.

Figure 2 Association schematic. Note: Undirected lines denote associations observed in the multivariable model; solid lines indicate P < 0.05 and dashed lines indicate P ≥ 0.05. Symbols mark the association’s direction: “+” (positive), “−” (negative), “+/−” (mixed by levels), and “ns” (non-significant).

Discussion

This study found that Chinese young adults with acne exhibit moderate social avoidance (mean score: 5.71 ± 3.79)—a level higher than that reported in young adults with type 1 diabetes (5.55 ± 3.46)²⁵ and breast cancer patients (5.43 ± 3.37),²⁶ but lower than in patients with permanent enterostomies (8.47 ± 3.91).²⁷ This discrepancy may stem from the fact that acne, unlike enterostomies (which involve concerns about involuntary defecation, fecal leakage, and odor), allows for temporary relief of appearance anxiety via makeup or short-term treatment. By contrast, acne’s visibility likely explains why its associated social avoidance is more pronounced than in diabetes or breast cancer, where symptoms are often less externally apparent. Li et al²⁸ reported that social avoidance in patients with facial vitiligo correlates with coping mechanisms and social support—findings consistent with our emphasis on psychosocial factors. Our data extend this by identifying anxiety as having the strongest direct association with avoidance in acne, highlighting a specific, modifiable target for care.

Analysis of Sociodemographic Characteristics

Our results reveal a clear socioeconomic divide: patients with monthly household income ≥5000 CNY show significantly lower social avoidance compared to those earning <3000 CNY (β= −0.288, P < 0.05). This aligns with Faro et al’s³ observation that socioeconomic hardship correlates with greater psychological distress in acne, likely because higher income improves access to quality dermatologic care, psychological counseling, and resources to manage appearance-related concerns.²⁹

Notably, marital status and education level had no significant impact on social avoidance (both P > 0.05). While unmarried patients exhibited slightly higher scores (6.02 ± 3.85 vs married: 4.90 ± 3.51), the difference was not statistically significant (P = 0.089)—a finding potentially linked to cultural norms around “face” (mianzi) and social interaction needs among young unmarried adults,³⁰ though the small effect size suggests this is not a priority for intervention.

Analysis of Clinical Characteristics

Acne distribution emerged as a key risk marker: patients with combined facial/neck and torso involvement had higher social avoidance scores (6.83 ± 3.89) than those with facial/neck only (5.52 ± 3.70) or torso only (1.83 ± 1.72). This underscores the critical role of lesion visibility in driving avoidance, as facial and trunk areas are harder to conceal than isolated torso lesions (which can be covered by clothing).³¹ These findings align with Dréno et al,³² who demonstrated a direct link between skin lesion visibility and social avoidance in psoriasis—supporting the need to prioritize patients with highly visible acne in dermatologic care.

In contrast, acne severity (mild/moderate/moderate-severe/severe) did not independently predict social avoidance (P = 0.349), reinforcing that clinical focus should center on visibility rather than severity grades alone.

The Predictive Role of Anxiety in Social Avoidance

Anxiety’s dominant role likely reflects the influence of collectivist cultural norms in China, where sensitivity to social evaluation amplifies the impact of anxiety on avoidance behaviors.^33,34 This distinguishes our findings from Western studies that prioritize body image concerns as the primary driver of avoidance,³⁵ highlighting the need for culturally adapted interventions—such as cognitive-behavioral therapy (CBT) modules emphasizing self-compassion in collectivist contexts.³⁶

While body image disturbance did not directly predict social avoidance (β = 0.129, P = 0.053), it correlated significantly with both social avoidance (r = 0.343, P < 0.01) and anxiety (r = 0.486, P < 0.001). This suggests an indirect pathway: negative body image may exacerbate anxiety,³⁷ which in turn increases avoidance^20,38—supporting dual targeting of anxiety and body image in psychosocial support.

Clinical Implications

These findings advocate for integrating brief anxiety screening (eg, GAD-7) into routine dermatologic care, with targeted interventions for high-risk groups—particularly patients with combined facial/neck and torso acne. Drawing on evidence from other dermatologic conditions: Incorporating “situational exposure training” into health education programs can help patients gradually confront and adapt to social settings, thereby reducing avoidance behaviors.³⁹ Third-wave therapies like Acceptance and Commitment Therapy (ACT) or schema therapy—shown effective for improving psychological well-being in vitiligo patients⁴⁰—may also benefit acne patients by fostering acceptance of appearance-related distress; Similar to the UK-based work by Ahmed et al⁴¹ which identified “tailored support” as a core component of dermatologic psychological care, interventions for acne should prioritize patient-centered strategies (eg, one-on-one counseling for high-anxiety cases).

Complementary approaches, such as education on temporary concealment techniques (eg, appropriate makeup) and referrals to psychologists for elevated anxiety, will further ensure holistic care.

Limitations

This study has several limitations. First, we used the SADS-SA subscale (score range 0–14) to assess social avoidance; the full SADS (0–28) might offer greater sensitivity to subtle differences. Second, the cross-sectional design precludes definitive causal inference—longitudinal studies tracking acne, anxiety, and social avoidance over treatment or remission are needed to confirm temporal relationships. Third, we did not measure social media exposure, which emerging evidence links to heightened appearance anxiety via social comparison.⁴² Finally, our sample consists of East China dermatology clinic patients, limiting generalizability to other regions or community-dwelling individuals with acne.

Conclusion

In Chinese young adults with acne, anxiety is strongly associated with social avoidance—not acne severity itself. Higher income acts protectively, and combined facial/neck and torso distribution indicates greater risk. These findings support integrating anxiety screening and culturally tailored psychosocial support (including evidence-based interventions like situational exposure training) into dermatologic practice, prioritizing patients with highly visible lesions. Future research should explore longitudinal outcomes of anxiety interventions and the role of social media in exacerbating appearance concerns.