You've been anticipating — and possibly dreading — the "big day" for weeks. The nature of the event isn't important; it may be a first date, an important job interview, or your own birthday party. You try to hide behind hair or heavy make-up. But you can't ignore the face in the mirror. Sound familiar? For acne sufferers all over the world, these scenarios are all too common. Even routine social interactions — a day at the office, a trip to the market — can be a nightmare of stress and self-loathing. Yet, due to the "merely cosmetic" nature of acne vulgaris, these very real emotions are widely dismissed as oversensitivity. Clear-faced friends and co-workers say, "Really, it looks worse to you." And they're probably right. But they're missing an important point: Acne is as much about how you feel as how you look. Over the years, the research methods and medical treatments may have changed, but the answers to the question "how does your acne make you feel?" have remained alarmingly constant: Ugly. Angry. Dirty. Depressed. These answers are consistent across gender lines, age barriers and national borders. What is being done? Every year, millions of dollars are devoted to the medical study and treatment of acne; millions more are spent on the development and marketing of over-the-counter remedies. Comparatively little energy, however, has been spent determining the psychological and social effects of the condition. Consider the following statement: There is no single condition which causes more psychic trauma, more maladjustment between parent and children, more general insecurity and feelings of inferiority and greater sums of psychic suffering than does acne vulgaris.1 Made by Sulzberger and Zaidems in a 1948 article, this statement rings true today. Despite acne's limited impact on overall patient health, several studies have concluded that it produces a similar degree of emotional stress to skin conditions causing significant physical disability. The implications are fairly obvious: Acne hurts more on the inside. So why is it so easy for people to dismiss these feelings as vanity? The problem of measuring emotion. The difficulty lies not in validating acne's negative affects, but in quantifying them. For years, researchers have been struggling to find an accurate means of measurement for this particular kind of study. Scientists use psychometrics to measure conditions of the mind, but have yet to develop a scale for evaluating the psychological effects of physical conditions such as acne. And the use of psychometric scales for evaluating acne patients has been largely inconclusive. Why? Emotional symptoms — depression, anger, low self-esteem — are influenced by an incredible number of variables. So it's difficult to know for sure whether one's depression is caused by acne alone or a combination of factors, ranging from trouble in school to on-the-job stress. At the moment, the best way to understand the psychosocial effects of acne seems surprisingly simple: Listen. The power of patient testimony. Until science develops an accurate scale, the best way for us to learn about acne's emotional effects is from the patients themselves. The following passages are excerpted from verbatim quotes taken during a 1995 study in San Francisco.2 In dramatic contrast with the psychometric questionnaires used in the past, patients were asked open-ended questions and encouraged to answer at length. It has been many years since I have looked in a mirror. I comb my hair using a silhouette on the wall to show the outline of my head. I have not looked myself in the eyes in years, and that is painful to not be able to do that, and that is a direct result of acne. When my acne got more severe, I began to really examine more things, become more aware of social norms, what is acceptable, what is attractive. That is when I began to have lower self-esteem; it made me become more of an introvert. It made me want to avoid certain occasions. 'Ask her out? Well, maybe not. She won't be interested because of how I look. It's associated with being dirty, and I hate that, because it's not at all like that. I inherited it from my mother, and she is always telling me that she had the exact same thing, and that it will go away. I am mad that I inherited it from her. My dad makes me feel bad because he never had bad skin when he was younger, so he doesn't understand. My mother doesn’t know what she has done to hurt me. If I ate fatty foods, she would criticize. If I ate spicy food — which Thai food is, they are all spicy — she would say that because I ate spicy food, that was why I had pimples. She kept telling me how ugly my face was, and no one was going to marry me if I had bad-looking skin. And that really hurts me. I know I am so insecure in this way — but if I go into a store, I won't buy candy, even if I really want it. I think in my mind that people are looking at what I am buying, and thinking, 'Oh, she eats junk. No wonder she has so many zits on her face. From just this small sample, it's easy to see the wide-ranging emotional impact of acne on those who suffer from it. These accounts of family conflict, social withdrawal and deep private suffering are, according to the patients, the direct result of their acne. While it's hard to measure the impact of this condition, the message within these testimonies is clear: Acne can cause profound emotional suffering. Of course, if you live with acne, this isn’t news — but it may be helpful to know you’re not alone.