Individuals living with visible skin conditions, including acne vulgaris (acne), can experience stigmatization from others (enacted stigma) and internalize feelings of stigmatization (felt stigma) [1-9]. Individual accounts of stigma [2,4,5] are corroborated by experimental research that indicates an implicit preference for clear skin and negative assumptions about individuals with acne [6-8]. Stigma has important implications for psychosocial well-being; surveys of individuals with acne report that felt stigma explains the largest variance (25%-36%), beyond other predictors (eg, perceived severity and gender), across quality-of-life domains: self-perception, social, and emotional [1,9]. Similar findings have been reported in populations with other skin conditions [10,11].

The psychological burden of acne has been well documented [12]. Of the various domains of impact, the impact of acne on self-perception has been the most widely reported. So, acne leads to appearance-related distress [13], body image disturbance [14], and feeling unattractive or ugly [15]. In order to reduce the psychological burden associated with acne, it is essential to understand the psychological mechanisms involved in acne stigmatization. Understanding these mechanisms using psychological theory has the potential to provide theoretical “proof of concept” for suitable targets for psychological therapy. Although dermatological (severity and duration) [1,16,17] and demographic (employment status, age, relationship status, and gender) [1,16-20] variables have limited predictive power, wider sociocultural factors are likely to play a more significant role. Sociocultural factors, including contemporary media, are theorized to influence societal norms and appearance ideals, contributing to the stigmatization of individuals who are unable to meet these ideals [21-23]. Correspondingly, within a qualitative study, participants with acne, eczema, and psoriasis described a pervasive media ideal of perfect skin [24]. Failure to meet this ideal was related to greater depression and stigmatization in female, but not male participants [24]. However, there was no distinction between media platforms or investigation of the specific psychological mechanisms that might be involved.

Web-based activity now plays a major role in our lives. As of 2021, a total of 88% of all UK adults possessed a social media account [25]. Facebook remains the most popular site (66% of adult social media users report using Facebook) [25]. Instagram, an image-based platform allowing users to digitally manipulate and share images, is growing in popularity (48% of adult social media users) [25]. Acne frequently affects adolescents [26], a group who are particularly engaged with social media [27].

A number of studies have established a relationship between Facebook use and psychosocial outcomes [28], with the role of individual difference variables in social media use and behavior showing greater promise in explaining the impact of such media, over and above simple usage [29-31]. For example, higher photo-function use, over and above total Facebook usage, has been reported to predict greater weight dissatisfaction, thin-ideal internalization, appearance comparison, and self-objectification [30]. Similar findings are emerging for Instagram use, with undergraduate students experimentally exposed to idealized Instagram images of celebrities and peers, as opposed to Instagram travel pictures, reporting increased body dissatisfaction and negative mood, mediated by appearance comparisons [32].

Early theories of social comparison posited that humans have an innate drive to compare themselves with others as part of maintaining group relationships [33]. As such, a perceived sense of difference may act as a threat, which may drive unhelpful comparisons. Social comparison theory has been expanded to include appearance-based comparisons, and downward and upward comparisons, where individuals compare themselves with others they perceive as superior (upward) or inferior (downward) [34]. Social and upward appearance comparisons have been established as predictors of body dissatisfaction [35], body-shaming [36], and mediators between media exposure to idealized images and body dissatisfaction [30,31,37-39]. Social comparisons are reported to be an important mechanism in the way individuals with a stigmatized identity evaluate themselves [40] and have been theorized as a core process implicated in skin-shaming [41]. Further, Kellett and Gibert [41] have anecdotally found that patients they treat who are distressed in relation to the appearance of their skin condition are often engaging in making such comparisons. However, the relationship between skin-specific appearance comparisons, social media use, and felt stigmatization has thus far not been investigated, nor has the related role of protective factors like self-compassion.

Self-compassion is theorized to involve 3 main components that influence how we treat ourselves and react to difficulties: self-kindness, mindfulness, and common humanity [42]. Self-compassion may act as a protective factor against psychosocial distress in stigmatized populations [43,44], and intervention-based studies using compassion-based training have shown promise in reducing feelings of shame in participants with acne [45].

As a consequence of the lack of research on social media and acne stigmatization, we conducted a web-based survey to investigate the relationship between photo-related social media use and felt stigma in people with acne. We hypothesized that relative photo-based social media use (Facebook photo activity and total time on Instagram), not total time on Facebook, would be related to felt stigmatization: (1) individuals who spend proportionally more of their time using photo- or appearance-orientated social media will have higher levels of felt stigmatization, (2) this relationship will be mediated by upward skin appearance comparisons, and (3) these relationships will be moderated by self-compassion.

This study sought to investigate the relationship between photo-related social media use and feelings of stigmatization in adults with acne. Consistent with the hypothesis, a higher proportion of time engaged in Facebook photo activity, not overall time on Facebook, was correlated with greater feelings of stigmatization in participants with acne, and this relationship was mediated by upward appearance comparison. However, this was the case for Facebook users only, as no such relationship was identified for participants using Instagram; yet among these users, upward appearance comparisons predicted felt stigmatization. Interestingly, although greater self-compassion was related to lower stigmatization, it did not moderate the relationship between social media photo use and acne-related stigma in either Facebook or Instagram users.

It is unclear why there was an indirect relationship between relative Facebook photo activity and stigma but not between Instagram use and stigma. This may reflect the choice of measures, as the measure of Instagram usage did not differentiate between types of usage [32]. Future research should therefore distinguish between types of Instagram use.

Existing research on stigmatization in individuals with skin conditions has primarily focused on stigmatization as a predictor of depression and impaired quality of life, and demographic and condition variables as predictions of stigma. Such research has consistently identified perceived stigmatization as a predictor of reduced quality of life and psychological morbidity. In line with previous research, this study identified associations with stigmatization and gender, perceived severity, and possessing a diagnosis of acne [10,17,20]. However, skin-related comparisons and self-compassion were more consistently associated with felt stigmatization. These findings suggest that the way individuals interact with social media is more important than how long they use it for understanding the associations between social media and well-being. This is important as such meta-cognitive processes are amenable to modification within psychological therapy.

This study has a number of limitations. Clearly, the cross-sectional design prevents comment on causation, and experimental research could usefully investigate the relationship between social comparisons and social media use. Participants for this study were recruited via a web-based platform from a community sample; therefore, information on objective diagnoses and severity was not obtainable, and this prevented the investigation of treatment factors and clinical severity. It is possible that some participants did not have acne and may have had other undiagnosed skin conditions. Also, there were a greater proportion of females in the Instagram group and a higher proportion of people 25 years or older (considered to have adult acne [49]) in the Facebook group, which may have affected the results. However, the majority of individuals with acne tend to self-manage [51], and consequently, the use of a community sample has a number of merits in reaching a wider range of people living with the condition. A final important limitation is that social media use was self-reported, which may have affected the reliability of the data obtained. This could be addressed in future experimental studies.

Nevertheless, the finding that appearance comparisons were associated with stigmatization in both Facebook and Instagram users and mediated the relationship between relative Facebook photo activity and stigmatization provides further support for the important role of skin-specific appearance comparisons in the psychosocial well-being of individuals living with acne, as reported in qualitative research [5,52]. Therefore, the role of upward appearance comparisons on feelings of stigmatization should be considered when working with individuals with acne-related distress. Future research could explore whether this relationship is present in populations with other skin conditions and further explore the relationship with other measures of psychological distress, such as shame, depression, and social anxiety. Given that self-compassion was consistently related to lower levels of stigmatization, interventions based on increasing self-compassion provide an additional avenue for exploring ways of reducing feelings of stigmatization in individuals with acne.