Sexual dysfunction in female patients with acne vulgaris – A questionnaire-based survey

Introduction

Acne vulgaris is one of the most common chronic skin conditions, affecting 9% of the global population, with nearly 90% of teenagers and 20% of young adults, especially women, experiencing it.^1,2 The condition results from obstruction of sebaceous glands and Cutibacterium acnes colonization, leading to comedonal, inflammatory, and nodulocystic lesions, often causing visible scars on the face and torso.^1,2 Treatment includes topical retinoids, antibiotics, benzoyl peroxide, and, for severe cases, isotretinoin or hormonal medications.¹

Acne can also have a significant psychological impact, especially due to its visible nature. Common issues include depression, anxiety, body dysmorphic disorder, and even suicidal thoughts, with women being more mentally affected due to societal pressures for a flawless appearance.³ These emotional consequences often worsen the quality of life and can negatively affect relationships and sexual health.⁴

Sexual health, as defined by the World Health Organisation, encompasses physical, emotional, mental, and social well-being.⁵ Female sexuality is complex, involving both physiological and psychological factors.⁶ Common sexual dysfunctions in women, such as low desire, arousal issues, orgasmic difficulties, and dyspareunia, affect 40-56% of women.^7-9 However, assessing female sexuality is more challenging than male sexuality, which can lead to underdiagnosis.⁶ Given the stigma surrounding acne, we aimed to explore the presence of sexual dysfunction in women with acne.

Methods

The study included 82 adult women diagnosed with acne vulgaris and 133 female controls without skin diseases. The exclusion criteria were: age below 18, pregnancy, breastfeeding, gynecological/urological interventions in the past [Supplementary File 1], administration of drugs influencing sexual functions [Supplementary File 2], history of depression, alcohol addiction, smoking (> 20 cigarettes/day).

The research was performed via an anonymous internet questionnaire which was administered to patients with acne vulgaris diagnosed by a dermatologist (study group) and dermatosis-free volunteers (control group). Since the study concerned an intimate area, the survey was online and constructed to be completed by as many subjects as possible.

The questionnaire included questions about demographics, past medical history, acne course, Dermatology Life Quality Index [DLQI; only study group; Supplementary File 3], as well as Female Sexual Function Index [FSFI; Supplementary File 4].

FSFI consists of 19 questions grouped into six different domains: desire, arousal, lubrication, orgasm, sexual satisfaction, and pain. The total possible score is between 2-36. A score of </=26 indicates sexual dysfunction.¹⁰

Smoking over 20 cigarettes daily and alcoholism are established risk factors for sexual dysfunction.^11,12 Hence, interviewees were asked questions regarding smoking habits and administered the Alcohol Use Disorder Identification Test (AUDIT) to exclude participants with these two risk factors.

Results

The study had 82 female patients. Table 1 presents the basic data of the participants. There was a slight age difference between the patients and controls, which was possible since acne is common in young women.

As for the place of origin, the majority of patients (42.7%) came from cities with 150,000-500,000 inhabitants, 22% of patients lived in cities with more than 500,000 inhabitants, and the rest in smaller cities. There were no significant differences compared to controls. A significant difference was observed in partnership status. Around 73.2% of patients and 57.1% of controls were in a relationship.

The median duration of acne was 8 years (0.5-40). Women mostly used topical agents (32.93% – emollients, 8.54% – topical retinoids, 4.88% – antibiotics, 2.44% – benzoyl peroxide). Oral retinoids were taken by 23 patients (28.05%). The median DLQI was 5.5 points (0-27) of the total 30, which meant the impact of acne on the life quality was between small and moderate [Figure 1].

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Figure 1:

Acne impact on quality of life (QoL) of female patients (QoL: Quality of life).

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We noticed an upward trend between question 9 in DLQI and acne duration (r = 0.25).

Interestingly, when patients were divided into two groups: one group having only facial acne and the other group also having other areas involved, there was no significant difference in DLQI between the groups (p > 0.05). However, we found two upward trends, in questions 3 as well as 6 (p = 0.074 and p = 0.086, respectively) [Table 2].

We asked patients directly if they felt that their skin condition was affecting sexual desire. Of all surveyed, 54 (65.85%) participants gave an affirmative answer [Figure 2]. We also asked about the intensity of that effect: minimal, mild, moderate, severe, or extreme. Moderate, severe, and extreme effects were stated in total by 34 (41.46%) of patients [Figure 3].

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Figure 2:

Answers to the direct question ‘Do you feel that your skin condition is affecting sexual desire?’

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Figure 3:

The intensity of acne influence on sexual desire.

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The mean FSFI score was 21.91 ± 1.28 in patients and 18.9 ± 1.06 in controls. There was no statistically significant difference in total FSFI score in both groups (p > 0.05), but both groups had a score below 26, which implied impaired sexual health. In our study, sexual dysfunctions occurred in 48% of the patients and 58% of the control group. It was noteworthy that patients had significantly higher scores than controls in the satisfaction domain (3.77 ± 0.25 vs 2.96 ± 0.21, respectively, p > 0.05). Moreover, a similar difference (2.99 ± 0.22 in patients vs 2.42 ± 0.16 in controls, p > 0.05) was observed in question 6 of FSFI.

A positive correlation was found between the direct question about patients’ desire mentioned before and DLQI (r = 0.29), as well as with the probability of sexual dysfunctions in FSFI (r = 0.33).

After the division of patients into two groups regarding the involved area [only face vs. face and extrafacial areas, Table 3], we found no statistically significant difference in the mean FSFI scores between patients and controls (p > 0.05).

Additionally, patients were divided into two subgroups depending on the use of oral retinoids. There was no statistically significant difference in the total FSFI and DLQI scores between patients using or not using them (p > 0.05). Patients using retinoids had slightly decreased FSFI (p = 0.44), which negatively correlated with retinoid use (r = -0.4257). Women receiving oral retinoids had downward trends in the satisfaction and pain domains (p = 0.41 and p = 0.198, respectively). Retinoid treatment was negatively correlated with question 6 of FSFI (r = -0.4557), question 8 (r =-0.4345), and an overall score in the lubrication domain of FSFI (r = -0.4268). Furthermore, a negative correlation was also found between the retinoid therapy and question 12 (r = -0.6287), question 13 (r = -0.639), and an overall score in the orgasmic domain of FSFI (r = -0.6014) [Table 4].

Discussion

Acne vulgaris is known to negatively impact patients’ quality of life, including sexual function, but research on this topic is limited. Acne, affecting the face, can lower self-esteem, and female patients may feel a stronger burden due to societal pressures for the perfect appearance.¹³ This study is one of the few to address sexual dysfunction in acne patients through an anonymous online survey. We found a slight reduction in quality of life in acne patients, as indicated by the DLQI. Although the FSFI showed greater impairment of sexual function in acne patients compared to controls, this difference was not significant, possibly due to the younger age of the acne patients or the effects of treatment on self-esteem.

Previous studies have found a decrease in sexual quality of life for women with acne, though illness severity and duration did not appear to significantly impact sexual health.¹⁴ Our study noted an upward trend suggesting that longer illness duration could lead to increased sexual difficulties, potentially due to frustration with ongoing skin issues. Notably, we have not found similar conclusions in other studies, so we seem to be the first to report on it. Interestingly, the severity of acne lesions did not correlate with sexual dysfunction or distress, which contrasts with other dermatological conditions where lesion severity is a key factor in sexual health impacts.¹⁵ We could not objectively assess lesion severity in this survey, which may limit our findings.

Beisert et al. highlighted the negative impact of self-esteem on sexual functioning, particularly in women, while Magin et al. noted acne’s impact on sexual attractiveness, especially for women.^4,16 However, in our study, most patients were in relationships, suggesting a more complex association between acne and sexual confidence. In contrast, other studies have found lower sexual activity among young women with acne.¹⁷

The effect of isotretinoin on sexual function remains unclear, as most studies lack detailed information on dosage and patient characteristics.^2,18 Isotretinoin reduces acne severity and improves life quality, but its side effects, such as skin and mucosal dryness, may contribute to sexual dysfunction.¹⁹ Research on isotretinoin’s impact on female sexual health is less extensive than in men, but studies have reported issues like low sexual desire, vaginal dryness, and orgasmic disorder in women.^17,20,21 Our study found similar results, with lower scores in lubrication and orgasmic domains for patients on oral retinoids.

Additionally, patients with acne are at higher risk for depression and anxiety, which may also contribute to sexual dysfunction. However, many studies exclude these patients to avoid bias.²²

Lastly, oral contraceptives, often used alongside isotretinoin, can further negatively impact sexual function, reducing lubrication and libido.²³

Limitations

A key limitation of this study is the inability to assess acne severity online. While the sample size is the largest in similar Polish studies, it remains relatively small. We also could not match cases and controls by age or include physician-confirmed treatment data.

Conclusion

Most female acne patients reported reduced libido and lower quality of life, consistent with previous research, but more frequently stayed in relationships. No increased risk of sexual dysfunction was found compared to controls, though dysfunction was noted, suggesting the need for more specific questionnaires. As in previous studies, women using oral retinoids experienced worse lubrication and lower orgasm scores. Retinoids may have a dual impact on sexual health—improving skin but potentially worsening sexual dysfunction. Women with acne may face higher sexual health risks due to lower self-esteem and psychological stress, highlighting the need for support.