The psychosocial impact of acne: patients' perceptions

Quality of life measures for acne patients

Acne vulgaris affects most adolescents and two-thirds of adults and is associated with substantial psychosocial burden. Health-related quality of life (HRQOL) for patients with acne is an important factor of patient care, and several dermatologic and acne-specific measures have been created to assist in acne research, management, and care. This review describes several skin disease and acne-specific HRQOL measures and their applications in clinical care or research. The ideal HRQOL measure for the management of patients with acne is a concise questionnaire that places minimal burden on respondents and allows physicians to track improvement in HRQOL with successful treatment.

Acne

Acne is a disease that primarily affects adolescents but it may also be seen in neonates, children and adults. The main areas of involvement are the face, chest and back. Many individuals with acne are embarrassed by their condition, and even refuse to go to school and become socially withdrawn. Early treatment can prevent the devastating physical and emotional sequelae of acne. There are numerous effective therapies, and it is not necessary for patients to go through the trauma that plagued previous generations.

Retinoid plus antimicrobial combination treatments for acne

BACKGROUND

Acne vulgaris is a chronic disease with several pathogenic factors. Multiple medications are typically used that can lead to nonadherence and treatment failure. Combination medications target multiple pathways of acne formation and may offer therapeutic benefit.

PURPOSE

To explore the efficacy and tolerability of combination retinoid plus antimicrobial treatments in acne vulgaris.

METHODS

A PubMed and Google search was conducted for combination therapies of clindamycin and tretinoin, with secondary analysis of related citations and references. Similar searches were completed for the combination medications of benzoyl peroxide plus clindamycin or erythromycin, and for the combination therapy of adapalene and benzoyl peroxide.

RESULTS

Combination clindamycin phosphate and tretinoin gel was found to be more efficacious than monotherapy of either drug or its vehicle for acne, including inflammatory acne, and has a greater onset of action than either drug alone. Clindamycin phosphate and tretinoin gel was well-tolerated, and adherence to its use exceeded that of using both medications in separate formulations. Benzoyl peroxide-containing combination medications with clindamycin or erythromycin were both more effective in the treatment of acne than either drug alone. Both medications were well-tolerated, with dry skin being the most common adverse effect.

CONCLUSIONS

Combination medications have superior efficacy and adherence, and have a similar tolerability profile compared with monotherapy of its components. Several studies have found antibiotic-containing combination products with a retinoid effective for acne. The use of antibiotic-containing combination medications for acne can lead to bacterial resistance. Due to this potential for bacterial resistance, benzoyl peroxide treatments are also recommended in combination with a retinoid.

Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-based study

We performed a cross-sectional, questionnaire-based study to explore the relationship of suicidal ideation, mental health problems, and social functioning to acne severity among adolescents aged 18-19 years. A total of 4,744 youth were invited and 3,775 (80%) participated. In all, 14% reported having substantial acne (a lot and very much). Among those with very much acne, as compared those with no/little acne, suicidal ideation was twice as frequently reported among girls (25.5 vs. 11.9%) and three times more frequently reported among boys (22.6 vs. 6.3%). Suicidal ideation remained significantly associated with substantial acne (odds ratio 1.80, 95% confidence interval 1.30-2.50) in a multivariate model including adjustments of symptoms of depression, ethnicity, and family income. Mental health problems, as assessed by the Strengths and Difficulties Questionnaire (2.25, 1.69-3.00), low attachment to friends (1.52, 1.21-1.91), not thriving at school (1.41, 1.12-1.78), never having had a romantic relationship (1.35, 1.05-1.70), and never having had sexual intercourse (1.51, 1.21-1.89) were all associated with substantial acne in a multivariate model. Acne is frequently found in late adolescence and is associated with social and psychological problems. Adverse events including suicidal ideation and depression that have been associated with therapies for acne may reflect the burden of substantial acne rather than the effects of medication.

Evaluation of acne quality of life and clinical severity in acne female adults

Acne is a common disease especially among teenagers. It has a considerable psychological impact on affected individuals. The aim of this paper was to assess if the effect of acne on acne-related quality of life is correlated to acne clinical severity. 112 university female students attending the university medical clinics with acne complaints were examined. Cardiff Acne Disability Index (CADI) was used to assess acne-related quality of life, and global acne grading system (GAGS) was used to assess clinical severity of acne. There was no correlation between acne severity (GAGS scoring system) and quality of life impairment as assessed by CADI score (r = 0.145, P = .127). Additionally, CADI score did not correlate with disease duration or age of patients. We therefore conclude that acne clinical severity alone does not affect acne-related quality of life changes. Many other factors might play a role.

Is the association between acne and mental distress influenced by diet? Results from a cross-sectional population study among 3775 late adolescents in Oslo, Norway

BACKGROUND

Several studies with conflicting findings have investigated the association between acne and mental health problems. Acne usually starts in adolescents, as does an increase in the prevalence of depression and anxiety. Recently, there has been more focus on the link between diet and acne and diet and mental health problems. The objective of this study is to investigate the association between acne and mental distress and to explore a possible influence of dietary factors on the relation.

METHODS

A population-based cross-sectional study in Oslo of 18 or 19 year old adolescents. The participation rate was 80%. Acne was self-reported. To measure mental distress, the Hopkins Symptom Checklist 10 was used. Diet and lifestyle variables were also collected by questionnaire and socio-demographic variables were obtained from Statistics Norway.

RESULTS

The prevalence of acne was 14.4% among the males and 12.8% among the females. The mean score of mental distress increased when the severity of acne increased. In the crude analyses, the significant associations with acne among the males were: mental distress OR = 1.63, frequent consumption of chocolate/sweets OR = 1.40, frequent consumption of potato chips OR = 1.54. The significant crude associations with acne among the females were: mental distress OR = 2.16, infrequent consumption of raw vegetables OR = 1.41, non-Western background OR = 1.77 and low family income OR = 2.14. No crude associations with acne were identified in either gender for the consumption of sugary soft drinks, fatty fish, cigarette smoking or alcohol. In adjusted models which included diet and socio-demographic variables, the association between acne and mental distress was unchanged for both males (OR = 1.68) and females (OR = 2.04), and between acne and infrequent consumption of raw vegetables among the females (OR = 1.38).

CONCLUSION

Among late adolescents in Oslo, self-reported acne is significantly associated with mental distress and, among girls, with infrequent consumption of raw vegetables. Our finding does not support the hypothesis that dietary factors alter the relationship between acne and mental distress.

Changes of psychiatric parameters and their relationships by oral isotretinoin in acne patients

Oral isotretinoin is a highly effective agent for the treatment of moderate to severe acne, but ever since oral isotretinoin was introduced as a modality for acne, the relationship between oral isotretinoin therapy and psychiatric problems, especially depression, has been controversial. The purposes of this study were to know the acute effects of oral isotretinoin therapy on psychiatric symptoms and to investigate the relationships among them, which have not been reported in the published work. This cohort study included 38 acne patients who started oral isotretinoin therapy. Individual patients were examined before administering oral isotretinoin and 2 and 8 weeks after commencement. Acne severity was graded using the Leeds revised acne grading system. Acute psychiatric effects of oral isotretinoin were assessed using a questionnaire authorized by two psychiatrists. This questionnaire included assessments of acne-related quality of life (Assessment of the Psychological and Social Effects of Acne [APSEA]), depression (Beck's depression inventory [BDI]), anxiety (Beck's anxiety inventory [BAI]) and psychopathology (Symptomchecklist-90-revised [SCL-90-R]). Acne grading and APSEA showed similar change patterns. Both improved after 8 weeks of oral isotretinoin treatment. On the other hand, the severity of depression decreased after 2 weeks of treatment. A significant correlation was found between BDI and APSEA, but no correlation was found between BDI and acne grade. These results indicate that oral isotretinoin therapy alleviates depressive symptoms. Improvements in depression are directly related to acne-related life quality improvements rather than to improvement in acne grade.

Psychosocial Aspects of Acne Vulgaris: A Community-based Study with Korean Adolescents

BACKGROUND

Acne vulgaris is a distressing condition that affects the majority of adolescents, but the impact of acne vulgaris on the psychological aspects in this age group is poorly understood.

OBJECTIVE

The purpose of this study was to determine the prevalence of acne, and the level of emotional, social, and functional impairments among Korean adolescents with acne.

METHODS

Five hundred four middle school students (13~16 years) participated. The severity of acne was graded by visual examination using the Korean Acne Grading System. Self-reported questionnaires, including subjective acne severity rating, the Self Image Questionnaire, the Rosenberg Self-Esteem Questionnaire, the Index of Peer Relations, and the Beck Depression Inventory were used to assess psychologic status.

RESULTS

There was a prevalence of acne in 78.9% of the study samples, with 10.2% of students having moderate-to-severe acne. Acne was more prevalent and severe in boys than girls. Participants with severe acne and girls had higher levels of emotional and social impairments. The longer the acne persisted, the more stress the students felt. The degree of stress and extent of self-image impairment were related to subjective severity more than objective grading.

CONCLUSION

Acne is a common disorder among Korean adolescents and appears to have a considerable impact on mental health. Dermatologists should be aware of the importance of basic psychosomatic treatment in conjunction with early medical, educational intervention in the management of acne.

Isotretinoin and psychopathology: a review

Isotretinoin, a synthetic oral retinoid that is used against severe nodulocystic acne, has been associated with various psychiatric side effects such as depression, suicidality and psychotic symptoms. A great number of reports on its effects have been published since its introduction into the market. However, a causal relationship has not been established and the link between isotretinoin use and psychiatric events remains controversial. The present paper reviews the available evidence regarding the association of isotretinoin and psychiatric side effects. All published material reporting psychiatric side effects following isotretinoin treatment, including case reports, case series, reports from adverse drug event reporting systems, prospective surveys and retrospective case-control studies, are presented. In addition, the neurobiology of the retinoids and possible biological mechanisms that may lead to psychopathology are described.

Prevalence and predictors of mental disorders among women in Sanliurfa, Southeastern Turkey

BACKGROUND

Mental health is one of the most important public health issues because of major contributor to the global burden of disease. In this study, we examined the prevalence and predictors of mental disorders among married women from 15 to 49 years of age and the need for mental health services in the primary health care settings.

METHODS

In this cross-sectional study, 270 women were selected using probability cluster sampling method at 95% confidence interval (91.5% response rate). The Structured Clinical Interview for DSM-IV (SCID-I) and women socio-demographic information form were used to collect data.

RESULTS

Although the prevalence of mental disorder was 25.9% (8.5% with one diagnosis; 17.4% were two or more diagnoses), 4.7% of these women had contacted a carer in the last year for psychological reasons. According to the SCID-I assessment, the most prevalent diagnoses were major depressive disorder (7.3%), phobic disorder (4.8%) and posttraumatic stress disorder (3.6%). In this study, comorbid diagnoses were present in 67.2% of patients. Logistic regression analyses revealed that domestic violence, history of previous trauma, anemia and cutaneous leishmaniasis were significant predictors of any mental disorders (P < 0.05).

CONCLUSIONS

These findings highlight the need for systematic development of community-based mental health services in conjunction with primary health care services for the screening, early identification and treatment of women suffering from mental disorders, and the improvement of anemia and cutaneous leishmaniasis control programme.

A pilot study of the safety and efficacy of picolinic acid gel in the treatment of acne vulgaris

BACKGROUND

Cost limitations, adverse effects or lack of efficacy limit the use of current topical therapies in mild to moderate acne vulgaris.

OBJECTIVES

To determine the safety and efficacy of picolinic acid, a novel zinc finger therapy, in the treatment of mild to moderate acne vulgaris.

METHODS

Twenty subjects with mild to moderate acne vulgaris were treated at our centre during an open-label study with 10% picolinic acid gel (PCL-016) twice daily to the face over 12 weeks.

RESULTS

Fifteen patients completed the 12-week open-label study. A reduction of 58.2% (P < 0.001) in mean total lesion count, 55.5% (P < 0.001) in mean inflammatory lesion count and 59.7% (P < 0.005) in noninflammatory lesion count was seen in this population. No serious adverse events or clinically significant changes in laboratory values were noted.

CONCLUSIONS

Results from this study suggest that 10% picolinic acid gel applied twice daily may be safe and effective in the treatment of mild to moderate acne vulgaris.

The 1,450-nm diode laser reduces sebum production in facial skin: a possible mode of action of its effectiveness for the treatment of acne vulgaris

BACKGROUND AND OBJECTIVES

Over the last several years, several light-based systems have been employed for the treatment of acne vulgaris. The 1,450-nm diode laser has been shown to improve acne, and this has been suggested to be due to effects on sebaceous glands. However, an effect on sebum production has not been demonstrated. The objective of this study was to evaluate if the 1,450-nm diode laser indeed reduces sebum production.

STUDY DESIGN/MATERIALS AND METHODS

Eight patients with a history of acne were recruited and treated with the 1,450-nm diode laser on the right side of the nose over a 6-week period, for a total of three treatments. Sebum production was quantified using the Sebutape method.

RESULTS

The number of sebum-producing follicles was reduced by 8.5 and 16.7% at weeks 4 and 6, respectively (P<0.05). A significant reduction in total collected sebum (-18%) was observed at week 6.

CONCLUSION

This data suggests that the clinical effectiveness of the 1,450-nm diode laser may be based, at least in part, on its effects on sebaceous glands, with subsequent reduction in sebum production.

Tretinoin gel microspheres 0.04% versus 0.1% in adolescents and adults with mild to moderate acne vulgaris: A 12-week, multicenter, randomized, double-blind, parallel-group, phase IV trial

BACKGROUND

Topical retinoids are considered first-line therapy in the treatment of acne vulgaris, yet can be associated with cutaneous irritation, including erythema, peeling, dryness, burning, and itching. Tretinoin gel microsphere (TGM) formulations were developed to minimize these effects. A lower-strength TGM formulation may be desirable to further reduce exposure to tretinoin.

OBJECTIVE

This study was conducted to assess the efficacy and safety profile of a lower-dose TGM (0.04%) formulation compared with TGM 0.1% for the treatment of mild to moderate acne vulgaris.

METHODS

In this multicenter, double-blind, parallel-group, Phase IV dose-ranging study, patients with facial acne were randomized to apply either TGM 0.04% or TGM 0.1% to the face each night for 12 weeks. Patients must have discontinued systemic retinoid treatment for at least 1 year before the study and were not to have used any topical retinoids, systemic antibiotics, nicotinamide, or systemic steroids for at least 1 month. All other topical medications applied to the face (including corticosteroids, antimicrobials, salicylic acid, and benzoyl peroxide) were to be discontinued at least 2 weeks before the study. End points were the acne lesion count (total, inflammatory, and noninflammatory lesions) and the investigators' and patients' assessments of improvement. Adverse events (including severity and relationship to treatment) and signs and symptoms of cutaneous irritation at the treatment site were monitored at each study visit.

RESULTS

One hundred fifty-six patients (78 TGM 0.04%, 78 TGM 0.1%) were randomized and received treatment. Patients ranged in age from 12 to 41 years (mean, 18.4 years) and were predominantly white (n = 89 [57.1%]) and male (n = 80 [51.3%]). Both TGM 0.04% and TGM 0.1% were associated with a reduction from baseline in total, inflammatory, and noninflammatory lesions. The differences between groups in the change in lesion counts from baseline to weeks 2, 4, 8, and 12 were not statistically significant. However, there was a greater reduction in inflammatory lesions at week 2 for TGM 0.1% compared with TGM 0.04% (14.8% vs 6.0%, respectively; P < 0.047). Both treatment groups had similar improvements in the investigators' global evaluation and the patients' assessment of the response to treatment. Both TGM 0.04% and TGM 0.1% were well tolerated. The most common adverse events were skin-associated burning sensation (2.6% in the TGM 0.04% group and 7.7% in the TGM 0.1% group) and irritation (6.4% and 3.8%, respectively). In the TGM 0.04% group, significantly fewer patients experienced dryness of the treatment area during the early phase of treatment (P < 0.027). However, for other measures of cutaneous irritation (peeling, burning/stinging, and itching), either there were no statistically significant differences between treatment groups or, in the case of erythema, there was a significant difference in favor of TGM 0.1% (P = 0.035).

CONCLUSIONS

Both TGM 0.04% and TGM 0.1% were associated with reductions in lesion counts in these patients with mild to moderate facial acne. Both concentrations were generally well tolerated. The results suggested an early (week 2) incremental benefit for the use of TGM 0.1% in the treatment of inflammatory lesions.

"Ur skin is the thing that everyone sees and you cant change it!": exploring the appearance-related concerns of young people with psoriasis

PURPOSE

The failure of research to capture the qualitative experiences of young people who have chronic skin conditions means that their psychosocial needs are poorly understood. Using a grounded theory approach, this study facilitated group discussions between adolescents with psoriasis in order to rapidly identify themes about their support needs.

METHODS

Three online focus groups were hosted in a real time forum. In total, 8 young people aged 11-18 years were recruited through the websites of psoriasis support organizations. Focus groups lasted an average of 1 hour and data was analysed using grounded theory techniques.

RESULTS

Appearance-related concerns are central to the experiences of young people with psoriasis. Participants constructed their individual struggle (It and Me) in physical, emotional, motivational and intellectual terms. A strong sense of Us developed as participants recognized the value of meeting peers with psoriasis. This enabled groups to blame Them for their negative social experiences.

DISCUSSION

The findings are discussed in the context of literature around adolescence and appearance. It is suggested that the experience of negative social encounters in adolescence may have long-term implications for appearance anxiety specifically and self-esteem generally. The potential of peer support to improve these outcomes is considered.

Two randomized studies demonstrate the efficacy and safety of dapsone gel, 5% for the treatment of acne vulgaris

BACKGROUND

A new aqueous gel formulation of dapsone has been developed that allows clinically-effective doses of dapsone to be administered topically with minimal systemic absorption.

OBJECTIVES

The goal of these studies was to evaluate the efficacy and safety of dapsone gel, 5% in the treatment of acne.

METHODS

Patients 12 years of age and older with acne vulgaris (N = 3010) participated in two identically-designed 12-week, randomized, double-blind studies of twice-daily monotherapy with dapsone gel, 5%, versus a vehicle gel.

RESULTS

Dapsone gel-treated patients achieved superior results in terms of the investigator's global acne assessment (P < .001) and the mean percentage reduction in inflammatory, noninflammatory, and total lesion counts (all, P < .001) at week 12. Reductions in inflammatory lesion counts favoring dapsone gel over vehicle were apparent as early as 2 weeks and reached statistical significance by 4 weeks. No clinically significant changes in laboratory parameters, including hemoglobin, even among glucose-6-phosphate dehydrogenase-deficient patients, were observed. Adverse events were comparable between the treatment groups and rarely led to discontinuation.

LIMITATIONS

Adjunctive topical treatments and their impact on acne were not studied in this trial.

CONCLUSIONS

Dapsone gel, 5% appears to be an effective, safe, and well-tolerated treatment for acne vulgaris, with a rapid onset of action.

Mulheres adultas com acne: aspectos comportamentais, perfis hormonal e ultra-sonográfico ovariano

OBJETIVOS: abordar os aspectos comportamentais, o perfil androgênico e as alterações ultra-sonográficas ovarianas de uma amostra de mulheres adultas com acne. MÉTODOS: estudo de série de casos envolvendo uma amostra de 60 mulheres, escolhidas por conveniência. As pacientes foram submetidas a exame clínico, dosagens hormonais e ultra-sonografia para avaliação da morfologia ovariana. Na análise estatística, foi aplicado o Teste de Fischer para análise de correlação entre as variáveis. RESULTADOS: a média de idade foi de 26,5 anos. Todas as pacientes referiram atitudes e sentimentos negativos em relação à acne, sendo os mais freqüentes ansiedade (88,3%) e manipulação constante das lesões (88,3%). O grau de acne mais observado foi o grau II (48,3%). Foram identificados níveis de androgênios fora da faixa de normalidade em 63,3%, com elevação mais freqüente do, dehidroepiandrosterona (57,6%). O padrão ultra-sonográfico mais observado foi o microcístico (74,6%). CONCLUSÕES: as formas clínicas leves de acne predominaram nas mulheres estudadas. Ainda assim, essas apresentaram, com grande freqüência, atitudes e sentimentos negativos em relação à doença. Foram identificados, ainda, modificação dos níveis séricos dos androgênios, bem como do padrão de normalidade do exame ultra-sonográfico.

Acne vulgaris--psychosomatic aspects

More than a cosmetic nuisance, acne can produce anxiety, depression, and other psychological problems that affect patients' lives in ways comparable to life-threatening or disabling diseases. Emotional problems due to the disease should be taken seriously and included in the treatment plan. A purely dermatological therapy by itself may not achieve its purpose. Even mild to moderate disease can be associated with significant depression and suicidal ideation, and psychologic change does not necessarily correlate with disease severity. Acne patients suffer particularly under social limitations and reduced quality of life. Psychological comorbidities in acne are probably greater than generally assumed. Attention should be paid to psychosomatic aspects especially if depressive-anxious disorders are suspected, particularly with evidence of suicidal tendencies, body dysmorphic disorders, or also in disrupted compliance.Therefore, patients who report particularly high emotional distress or dysmorphic tendencies due to the disease should be treated, if possible, by interdisciplinary therapy. The dermatologist should have some knowledge of the basics of psychotherapy and psychopharmacology, which sometimes must be combined with systemic and topical treatment of acne in conjunction with basic psychosomatic treatment.

Acne, anxiety, depression and suicide in teenagers: a cross-sectional survey of New Zealand secondary school students

AIM

To examine the associations between acne and depressive symptoms, anxiety and suicidal behaviours.

METHODS

This was a secondary analysis of a cross-sectional survey -'Youth2000' (New Zealand national survey of youth health). A total of 9567 secondary school students aged 12-18 years participated in the survey. The main outcome measures were self-reported acne, depressive symptoms (Reynolds Adolescent Depression Scale > 77), anxiety (Anxiety Disorder Index from Multidimensional Anxiety Scale for Children) and self-reported suicide attempts.

RESULTS

'Problem acne' was associated with an increased probability of depressive symptoms, odds ratio 2.04 (95% confidence interval 1.70-2.45); anxiety, odds ratio 2.3 (1.74-3.00); and suicide attempts, odds ratio 1.83 (1.51-2.22) in a logistic model that included age, gender, ethnicity, school decile and socio-economic status. The association of acne with suicide attempts remained after controlling for depressive symptoms and anxiety, odds ratio 1.50 (1.21-1.86).

CONCLUSION

Young people presenting with acne are at increased risk of depression, anxiety and suicide attempts. Attention should be paid to their mental health, and the importance of asking directly regarding suicide is emphasised.

Cross validation of the Turkish version of dermatology life quality index

BACKGROUND

The aim of this study was to test the linguistic validation of the Turkish version of the Dermatology Life Quality Index (DLQI) for Turkish speaking dermatology patients.

METHODS

The DLQI is a 10-item dermatology specific index developed originally in English. The methodology of this study consists of four consecutive sections: Translation, cognitive debriefing, field testing and statistical analysis. Translation steps: (a) Two forward independent translations into Turkish, (b) reconciliation of these translations by a dermatologist, (c) backward translation of the consensus Turkish version by a bilingual person into its original language (English), (d) and comparing the original questionnaire with the backward translated one. Cognitive debriefing: Sessions were performed on five patients from each of the seven different dermatological diagnosis groups. Field testing: The final Turkish version on which the face validity was approved by specialists on a total of 79 inpatients/outpatients with various dermatological diagnoses treated at Celal Bayar University Hospital.

STATISTICAL ANALYSIS

Internal consistency (using Cronbach a) and item-total score correlations (Pearson correlation) were used for reliability analysis. Validity analysis was carried out by construct testing (principal components factor analysis), convergent (Pearson correlation) and (discriminate Student's t-test and Mann-Whitney U-test) validity, and SF-36 was used in parallel with DLQI in order to test convergent validity. The data were analyzed by the SPSS version 10.0 (SPSS Inc., Chicago, IL, USA) statistical package.

RESULTS

The mean age of the patients in the study was 30.77+/-15.91 years; the mean score of DLQI was 7.61+/-6.12. The median of item-total correlation coefficient was found to be 0.66, within a range of 0.48-0.81. The internal consistency of the index was found to be highly sufficient (alpha=0.85). The DLQI was found to be highly related to the physical domain of SF-36. Life quality score was found to be significantly low for the inpatients compared with outpatients (differential validity).

CONCLUSION

It was found that the Turkish version of the DLQI was an acceptable index for dermatologists and dermatology patients and, moreover, to be valid and reliable in a cross-sectional level. The responsiveness of the Turkish version of the DLQI needs to be tested further on a variety of dermatological conditions with different severities.

Chronic administration of 13-cis-retinoic acid increases depression-related behavior in mice

Retinoid signaling plays a well-established role in neuronal differentiation, neurite outgrowth, and the patterning of the anteroposterior axis of the developing neural tube. However, there is increasing evidence that nutritional vitamin A status and retinoid signaling play an important role in the function of the adult brain. 13-Cis-retinoic acid (13-cis-RA) (isotretinoin or Accutane), a synthetic retinoid that is an effective oral treatment for severe nodular acne, has been linked with depression and suicide in patients. The purpose of this study was to test the hypothesis that chronic administration of 13-cis-RA would lead to depression-related behaviors in mice. Young, adult male mice received 13-cis-RA (1 mg/kg) by daily intraperitoneal injection for 6 weeks. This treatment paradigm produced plasma levels of 13-cis-RA that are comparable to those reported in human patients taking Accutane. In both the forced swim test and the tail suspension test, we found that 13-cis-RA-treated mice spent significantly more time immobile compared to vehicle-treated controls. In the open field test, there was no change in anxiety-related behavior in 13-cis-RA-treated mice. Furthermore, chronic administration of 13-cis-RA did not impair locomotion in either the open field or the rotarod test. Taken together, these results suggest that administration of 13-cis-RA increases depression-related behaviors in mice.

Psychological problems in the acne patient

Acne is a ubiquitous affliction that can leave physical and emotional scars that can persist throughout the life of the affected individual. Recent studies have substantiated the psychological impact and support a causal, and at times reciprocal, link between acne and the emotional and functional status of the patient. The present article will examine the recent data substantiating the emotional and functional impact of acne on the affected individual. Criteria to identify high-risk patients are provided. High-risk patients are those at increased risk for psychological and functional impairment or self-injurious behavior.

Acne: improving skin and self-esteem

Many safe and effective treatments are available to the acne sufferer. The clinician is encouraged to offer treatment to the adolescent with a face full of pimples, even if not asked for by the patient, as psychosocial underpinnings may be present but not obvious on examination. Obvious physical benefits will result, but psychosocial improvements also may occur.

Prevalence and correlates of suicidal ideation among patients with skin disease

BACKGROUND

Concerns have been raised about the potential of deliberate self-harm and suicide among patients with dermatologic conditions.

OBJECTIVE

We sought to estimate the prevalence of suicidal ideation among patients with dermatologic conditions, and to identify demographic, clinical, and psychosocial correlates.

METHODS

Two samples of outpatients with dermatologic conditions (N = 294) and inpatients (N = 172) completed the 12-item General Health Questionnaire, the Skindex-29, and the Patient Health Questionnaire.

RESULTS

Forty patients (8.6%) reported suicidal ideation during the previous 2 weeks. In univariate analysis, the presence of suicidal ideation was associated with female sex, inpatient status, presence of a depressive or anxiety disorder, and higher 12-item General Health Questionnaire and Skindex-29 scores. The size of the diagnostic groups allowed reasonable prevalence estimates only for psoriasis (10%) and acne (7.1%). In multivariate analysis, only emotional distress (12-item General Health Questionnaire) and impaired social functioning (Skindex-29) were independently associated with suicidal ideation.

LIMITATIONS

We lacked an observer-rated evaluation of skin condition and could rely only on the Skindex-29 symptoms subscale as a measure of disease severity. In addition, the measurement of suicidal ideation was limited as a result of the use of only one question to assess it. Furthermore, the cross-sectional design prevented causal inferences.

CONCLUSION

Suicidal ideation is not rare among patients with dermatologic conditions. Assessing suicidality would be warranted in dermatologic practice among patients at particular risk such as women with high psychologic distress and impaired social functioning. The development of psychiatric consultation-liaison services is mandatory to provide effective treatment and careful follow-up of patients who are suicidal.

Acne, depression, and suicide

Acne is a common disorder that may have a considerable psychologic impact including anxiety and depression. Depression and suicide occur frequently in adolescents and young adults. Although case reports suggest an association between isotretinoin and depression and suicide, more rigorous observational studies and epidemiologic studies, using different designs, have not shown any effect of isotretinoin use in increasing the occurrence of depression and suicide. It is prudent for the practitioner to continue to use isotretinoin to treat severe acne, while at the same time informing patients and their relatives that depressive symptoms should be actively assessed at each visit and, if necessary, referral to a psychiatrist and a discontinuation of isotretinoin should be considered.

Objective assessment of compliance with treatments in acne

BACKGROUND

Acne occurs in prepubertal individuals, teenagers and adults, and can have a devastating effect on self-esteem and social relationships. Whether an acne sufferer will seek treatment often depends, apart from the severity, on cultural and social aspects, which play a significant role in the attitude of the individuals and how they cope with the condition. Compliance with treatment regimen is an essential element in overall effectiveness of therapy.

OBJECTIVES

To assess patient compliance in acne vulgaris.

METHODS

In an open prospective study at a dermatology outpatient clinic, patients with acne, and on isotretinoin or conventional therapies, were examined and completed a questionnaire consisting of: (i) a brief medical and social history, (ii) a compliance assessment sheet, and (iii) the Dermatology Life Quality Index (DLQI). Patients were re-examined after 3 months and their actual treatment usage was directly assessed and compared with expected use. The objective medication adherence (Med Ad) was calculated as (actual treatment use/expected treatment use) x 100. The interview (self-report) Med Ad was obtained by direct questioning. To avoid influencing the behaviour of the subjects, they were not informed of the specific aim of the study: the Local Research Ethics Committee gave approval for this approach. Patient attendance was recorded by referring to the outpatient clinic appointment charts.

RESULTS

Of 687 patients seen who fulfilled the inclusion criteria, 403 completed the study. The mean +/- SD overall objective Med Ad was 64.7 +/- 24% (range 0-111%). The mean +/- SD DLQI was 17.7 +/- 8.1 (range 2-30). There was a highly significant negative correlation (r = -0.87) between DLQI scores and Med Ad. The correlation between age and Med Ad was significantly negative (P < 0.01). Being female, married, employed and not paying for prescriptions were characteristics associated with increased Med Ad and a lower DLQI. Med Ad was greater for isotretinoin therapy and for first time usage of isotretinoin. The major reasons for missing treatment given by the patients were being fed up, forgetful or too busy. Smoking cigarettes and drinking alcohol resulted in reduced Med Ad. The mean +/- SD interview Med Ad was 93.9 +/- 5% (range 85-100%).

CONCLUSIONS

The study demonstrates that a range of disease-related and social factors may influence compliance with treatment in acne. The inverse relationship between DLQI and Med Ad probably reflects the profound interaction of physical and psychological factors as well as perceived treatment failure.

Anger and acne: implications for quality of life, patient satisfaction and clinical care

BACKGROUND

Acne is a common skin disorder with a significant psychological and social impact for some people. Little is known about how personality and emotional traits affect acne and its impact on quality of life and treatment. Trait anger (TA), which is related to heart disease and other morbidities, may also affect acne and patients' adjustment to it.

OBJECTIVES

To evaluate the relationship between TA and acne severity, skin-related quality of life, satisfaction with treatment, and adherence to treatment.

PARTICIPANTS AND METHODS

A sample of 479 individuals with acne completed a survey instrument to assess acne severity, skin care practices, skin-related quality of life, satisfaction with treatment, adherence, TA and demographic variables. Respondents who reported high TA were compared with individuals with low TA on outcome variables. Regression analyses adjusted for covariates and identified the significant predictors of quality of life, satisfaction and adherence.

RESULTS

High TA was unrelated to acne severity (P = 0.2) or frequency of face washing (P = 0.9). Anger was significantly related to both global quality of life (P < 0.001) and skin-related quality of life (P = 0.002) as well as to satisfaction with treatment (P = 0.001) and adherence to treatment advice (P = 0.05) in bivariate analyses. Regression analyses revealed that high TA remained a significant predictor of global (P < 0.001) and skin-related quality of life (P = 0.003) and satisfaction with treatment (P = 0.04), but not adherence to treatment advice (P = 0.8) after controlling for covariates.

CONCLUSIONS

Anger is associated with the quality of patients' lives and with their satisfaction with treatment. Care of acne patients should include attention to anger and other chronic emotional states, quality of life, as well as to clinical severity. Simple guidelines are suggested for how clinicians might approach this important aspect of care.

The psychological impact of cutaneous leishmaniasis

A psychiatric disorder would be associated with extensive, unsightly lesions on exposed body parts. Cutaneous leishmaniasis (CL) has long been endemic in Sanliurfa and is called 'beauty scar'. The aim of this study was to determine psychological impact of CL. Patients with active CL, with CL that had healed with scaring, and healthy controls were included in this case-control study. The Hospital Anxiety Depression Scale (HAD), Body Image Satisfaction Scale (BIS), and Dermatology Quality of Life Scale (DQL) assessments were performed to determine the psychological effect of CL. The patients with CL had significantly higher HAD anxiety and depression subscale scores than the control groups. Patients with CL have decreased body satisfaction and lower quality of life than those in the control group. It was found that CL patients with active lesions have the lowest quality of life score than other groups. CL lesions on exposed body parts such as the face and hands, active CL for more than 1 year, permanent scar formation, and social stigmatization cause anxiety, depressive symptoms, decreased body satisfaction and quality of life in CL patients.

Acne: Systemic treatment

Acne vulgaris is a disease affecting mostly adolescents and young adults that, when severe, has the potential to result in scarring and permanent disfigurement. Systemic treatment is necessary to prevent significant psychological and social impairment in these patients.(1) Significant inflammatory and nodulocystic acne is usually recalcitrant to topical treatment, whereas uncommon acne variants, such as acne fulminans, pyoderma faciale, and acne conglobata, need to be promptly and effectively controlled. In all of these circumstances, systemic agents are indispensable. The choices include oral antibiotics, isotretinoin, and hormonal treatment (Table 1).

Disease-specific quality of life is associated with anxiety and depression in patients with acne

OBJECTIVE

We aimed to evaluate the relationships between acne severity, anxiety, depression and disease-specific quality of life in patients with acne.

METHOD

A total of 61 patients with acne vulgaris and 38 healthy volunteers were included in the study. Acne severity was assessed by the Global Acne Grading System. All patients were asked to complete the Acne Quality of Life Scale (AQOL), Dermatology Life Quality Index (DLQI) and Hospital Anxiety and Depression Scale (HAD), and healthy controls to fill only the HAD.

RESULTS

The mean HAD anxiety subscale (HAD-A) and HAD depression subscale (HAD-D) scores of the patients were significantly higher than those of the controls. The rates of subjects at risk for anxiety (26.2%) and for depression (29.5%) were significantly higher in the patient group than in the control group (0% and 7.9%, respectively). We found no correlations between acne severity and scores of AQOL, DLQI, HAD-A and HAD-D. AQOL and DLQI scores were positively correlated with HAD-A and HAD-D scores in the patient group. The patients at risk for anxiety had significantly higher scores on AQOL and DLQI compared to those who were not at risk. There were no statistically significant differences between the female and male patients with respect to AQOL, DLQI, HAD-A and HAD-D scores.

CONCLUSION

(1) Irrespective of the degree of severity, patients with acne are at increased risk for anxiety and depression compared to the normal population. (2) Acne negatively affects quality of life, and the greater the impairment of quality of life due to acne, the greater the level of anxiety and depression. (3) A greater impairment of dermatologic quality of life seems to put the patient at an increased risk for anxiety disorder.

How do you foster medication adherence for better acne vulgaris management?

Suboptimal medication adherence is one of the major reasons for treatment failure among patients with acne vulgaris. Motivating patients to adhere to treatment, especially during the maintenance phase, remains a challenge. Although the literature on medication adherence in the acne vulgaris patient population is sparse, the available literature on patients with dermatologic and nondermatologic disorders suggests that a multifactorial approach, combining nonpharmacologic interventions and effective, well tolerated, and simplified drug regimens, appears to be associated with the greatest success. Furthermore, it is important to evaluate the patient for underlying affective disorders (e.g., depression) that can undermine adherence. The dermatologist can play a major role in enhancing patient adherence by prescribing adherence-enhancing therapeutic regimens and by forming a therapeutic alliance with patients.

Isotretinoin use and subsequent depression and suicide: presenting the evidence

The growing number of reported cases of depression and suicide associated with isotretinoin (a retinoid receptor agonist) use in patients with acne has prompted concern among dermatologists, patients, and their relatives and has triggered new warnings from regulators including depression-related, patient-informed consent forms. In establishing a cause-effect relationship, it is useful to judiciously consider whether there is an association, what is the nature of that association, if there is a plausible biological mechanism of action, the validity and reliability of measures used and the strength of study designs. Hoffmann-La Roche estimates that by April 2001 approximately 12 million patients worldwide have used isotretinoin, with 5 million patients in the US.A MEDLINE search between January 1966 and May 14 2003 of the published medical literature found 24 documented cases of isotretinoin-associated depression, with 3 suicides. One additional patient committed suicide during the fourth month of isotretinoin treatment and 3 further patients attempted suicide by taking an overdose of isotretinoin. The US FDA's Adverse Event Reporting System (AERS) contains almost 23,000 reports for isotretinoin from its approval in 1982 to December 2002. As of November 30, 2002, AERS contained 3,104 reports (US and foreign) with at least one reported psychiatric event. The FDA is aware of 173 reports of suicide (both US and foreign) in association with isotretinoin. Reports of positive dechallenge and rechallenge present a strong signal pointing to an association between isotretinoin and depression. A Hoffmann-La Roche sponsored epidemiological study failed to find any evidence of an association between isotretinoin and depression or suicide. However, the design of the study was flawed and the evidence was deemed inconclusive. Further studies using strong study designs, reliable and valid measures, and adequate sample sizes may bring us closer to the answer. The evidence suggesting a relationship between isotretinoin and depression needs to be weighed against the increasing prevalence of depression among adolescents and young adults and the psychological impact of acne. The literature contains credible evidence that isotretinoin treatment may reduce the psychosocial impact of acne in some patients. At the present time, there is no known pharmacological mechanism that would account for psychiatric symptomatology as a result of isotretinoin treatment; however, retinoid receptors are widely distributed in the brain and more research is needed to ascertain whether they have a role in depression. In the meantime, for the practitioner, the obvious benefit of isotretinoin in treating acne should encourage continued use. However, patients and their relatives must be informed and depressive symptoms should be actively assessed at each visit and, if necessary, referral to a psychiatrist, antidepressant therapy or discontinuation of isotretinoin should be considered.