Impact of Acne Vulgaris on Quality of Life and Self-esteem

Results

The study consisted of 100 cases and 100 controls. The mean age was 21 years. The majority of cases reported an age of onset of acne of 11 to 20 years (66%), were predominantly female (58%) from rural backgrounds, and had a family history of acne (68%). The majority of lesions ceased within 24 months (60%). The face was the most commonly involved area (80%) and papules were the most prevalent lesion type (62%).

Cases predominantly had grade 2 acne (46%), and there was medium to high impairment in QOL according to CADI scores.

The scores for all the domains of the WHOQOL-BREF as well as the total score were lower in cases compared to controls (Table). There was a statistically significant difference between the 2 groups in the psychological (P=.0402) and environment (P=.006) domains.

The RSES mean (SD) score was higher in controls (19.74 [4.23]) than in cases (15.72 [5.06]) and was statistically significant (P<.0001). Low self-esteem was noted in 38% of cases and 16% of controls, and high self-esteem was noted in 62% and 84%, respectively.

In reviewing the correlation between acne severity, CADI, WHOQOL-BREF, and RSES scores, we found a positive correlation between acne severity and CADI scores (R=0.51), which implies that as the severity of acne worsens, the QOL impairment increases. There was a negative correlation between acne severity, WHOQOL-BREF score (R=–0.13), and RSES score (R=–0.18), which showed that as the severity of acne increases, QOL and self-esteem decrease. We observed that as the grade of acne increases, there is a statistically significant impairment in the QOL according to CADI (P<.001), while there is a reduction in QOL and self-esteem according to WHOQOL-BREF and RSES, respectively (P>.05).

Comment

Patients are more likely to develop acne than any other skin disease in their lifetime. Only in recent years has the psychodermatologic literature begun to address the possibility of acne having a psychological and emotional impact.⁴ Although the cause-and-effect relationship between acne and psychological trauma has been debated for decades, only recently has the measurement focus shifted from psychological correlates (eg, personality) and emotional triggers (eg, stress) to the effect of acne on patients’ QOL and self-esteem. This shift occurred as validated instruments for measuring disability, QOL, and self-esteem, specifically in patients with skin diseases, became available.⁹

In our study, the age of onset of acne was 11 to 20 years and it affected predominantly females (58%), which is in concordance with other studies, as acne develops in adolescence and subsides in adulthood.^1,10 Acne is more common in females due to hormonal factors and use of cosmetics. We observed that the face (80%) was most frequently affected, followed by the back (14%) and chest (6%), which is similar to prior studies.^1,10 Because the face plays an important role in body image, the presence of facial lesions may be unacceptable for patients and therefore they may present more frequently to dermatologists.

In our study, 68% of cases and 22% of controls had a family history of acne. A similar correlation also was noted in other studies, which suggests acne has an inherited predisposition due to involvement of the cytochrome P450-1A1 gene, CYP1A1, and steroid 21-hydroxylase, P-450-c21.^1,11 We found 46% of cases had grade 2 acne and 36% had grade 1 acne, which was congruent with prior studies.^12,13 Patients with severe acne are more likely to seek medical intervention in hospitals.

In our study, 58% of the cases had medium to high impairment in QOL according to CADI scores. We noticed as the severity of acne increased there was severe impairment in QOL. Similar findings have been found in studies that used other scales to assess QOL.^1,6,9

In our study, 38% of cases and 16% of controls had low self-esteem, which was statistically significant (P<.0001). There was a negative correlation between the severity of acne and self-esteem. In a prior study of 240 professional college students, 53% had feelings of low self-esteem and 40% revealed they avoided social gatherings and interactions with the opposite sex because of their acne.¹⁴ In a questionnaire-based survey of 3775 students, it was observed that the presence of acne correlated with poor self-attitude in boys and poor self-worth in girls.³ We found patients with grade 1 acne had higher self-esteem as compared to other grades of acne. Similarly, a cross-sectional study by Uslu et al¹⁵ found a direct correlation between acne severity and lower self-esteem using the RSES questionnaire. Although acne may be viewed as a minor cosmetic issue, it can have a negative impact on self-esteem and interpersonal relationships. Many of the studies had not used a validated structured questionnaire to assess self-esteem and there is a paucity of literature in relation to acne and self-esteem.^3,16,17

According to the WHOQOL-BREF, the psychological domain was affected more in cases than in controls, which was a statistically significant difference. One study observed that patients experience immediate psychological consequences of acne such as reduced self-esteem, poor self-image, self-consciousness, and embarrassment.³ These effects are exacerbated by taunting, stigmatization, and perceptions of scrutiny and being judged, causing patients to avoid interaction and social situations. Similarly, Pruthi and Babu¹⁸ observed that acne had an impact on the psychosocial aspects of adult females using the Dermatology Life Quality Index and CADI.

Financial resources, health and social care accessibility, and opportunities for acquiring new information and skills were the factors that were considered in the environment domain of the WHOQOL-BREF.⁸ We noted that the environment domain scores were significantly lower in cases than in controls. The cases could have had a detrimental effect on the latest opportunities in occupational functioning due to acne, and as most of the population was from a rural area, they were having less favorable circumstances in acquiring new information about the management of acne.

There was no statistically significant difference between cases and controls in the social and physical domains of the WHOQOL-BREF, which suggests that these fields do not influence QOL. Similarly, patients in Sarawak, Malaysia, were least affected in the domain of social functioning, which was likely attributed to the upbringing of this population encouraging stoicism.¹⁹