The psychosocial impact of acne: patients' perceptions

Treatment of acne with isotretinoin: recommendations based on Australian experience

Oral isotretinoin revolutionized acne treatment when it was introduced in 1982 in the USA. However, its use was restricted to patients with severe nodulocystic acne. Today its use worldwide has expanded to treat also patients with less severe but scarring acne who are responding unsatisfactorily to conventional therapies. These recommendations assess the potential for use of oral isotretinoin as a safe and effective treatment for severe nodulocystic acne unresponsive to conventional therapy, and acne of any severity that causes scarring or is associated with psychological distress.

The association between depression and isotretinoin use in acne

OBJECTIVE

The association between isotretinoin and depression has received little attention in the psychiatric literature despite an increasing number of reports in medical journals. The purpose of this paper is to highlight this association, examine the possible link and review the clinical implications.

METHOD

A critical review of the literature pertaining to depression in patients with acne who were treated with isotretinoin was conducted.

RESULTS AND CONCLUSIONS

The causal relationship between isotretinoin therapy and depression has not been clearly established and needs further study. Isotretinoin is likely to have a positive psychological impact for the majority of patients who benefit from such a highly efficacious anti-acne treatment. However, it is important to recognize that depression can occur as an idiosyncratic side-effect that requires urgent and appropriate treatment. Therefore, having a low threshold for detection of this uncommon complication and early psychiatric referral to address both the depression and its contributing factors may prevent serious consequences.

Measuring Adjustment to Chronic Skin Disorders: Validation of a Self-Report Measure

This article describes the development of a questionnaire that assesses problems in adapting to chronic skin disorders, the Adjustment to Chronic Skin Diseases Questionnaire. Patients (N = 442) with different skin disorders completed the original item pool. Principal-components analysis suggested a 6-factor solution that was largely replicated with 2 additional samples of 192 patients with psoriasis or atopic dermatitis and 165 patients with atopic dermatitis. Four of the subscales showed very good internal consistencies, retest reliabilities, and sufficient correlations with expert ratings: Social Anxiety/Avoidance, Itch-Scratch Cycle, Helplessness, and Anxious-Depressive Mood. Two short additional subscales, Impact on Quality of Life and Deficit in Active Coping, showed moderate internal consistencies, but good retest reliabilities. Correlations of the subscales with measures of depression, anxiety, and coping, and meaningful differences between dermatological subgroups support their construct validity. A treatment study showed that changes in some of the subscales correlated with changes in the severity of the skin condition.

Responsiveness of the Acne-Specific Quality of Life Questionnaire (Acne-QoL) to treatment for acne vulgaris in placebo-controlled clinical trials

The Acne-Specific Quality of Life Questionnaire (Acne-QoL) was developed to measure the impact of facial acne across four dimensions of patient quality of life. The main objective of the current study was to evaluate the responsiveness of this instrument. Secondarily, this study provided an opportunity to extend the developer's psychometric validation. The Acne-QoL was utilized in two randomized, double-blind, placebo-controlled studies of the efficacy of Estrostep (norethindrone acetate/ethinyl estradiol) in the treatment of facial acne; a total of 296 Estrostep and 295 placebo patients were evaluated. The Acne-QoL was completed at the beginning, middle (cycle 3), and end (cycle 6) of the 6-month treatment period. The responsiveness of the Acne-QoL was demonstrated through its ability to detect both small (baseline to mid-study) and moderate (baseline to study end) treatment advantages for Estrostep patients. Confirmatory factor analysis supported the subscale structure, and internal consistency estimates were excellent. Convergent and discriminant validity were supported by correlations between Acne-QoL scores and clinical measures that were both in the direction and relative magnitude hypothesized. Finally, item response theory analyses confirmed that each item is highly related to its subscale's latent construct and that each subscale is sensitive across a broad range of the underlying continuum. The results of this evaluation confirm that the Acne-QoL is responsive, internally consistent, and valid.

Prospective study of depressive symptoms and quality of life in acne vulgaris patients treated with isotretinoin compared to antibiotic and topical therapy

There have been recent concerns about the possible association between isotretinoin therapy and depressive symptoms. We conducted a prospective study to evaluate depressive symptoms and quality of life in acne patients having either isotretinoin or antibiotics/topical treatments. There were 215 patients (mean age 20 years) included in the study. Depression, quality of life and acne severity ratings were administered at baseline, 1 month, 3 months and end of treatment or 6 months, and compared between both treatment groups. The changes in the mean depression scores did not differ significantly between both groups (P = 0.62). The incidence of isotretinoin patients with moderate depressive symptoms remained relatively unchanged from baseline. The changes in the quality-of-life measures scores between treatment groups showed no significant difference. No correlation between isotretinoin dose and depression score was found. Although five isotretinoin patients were withdrawn during the study because of worsening of mood, no definite causal relationship was established. This pilot study does not appear to support any direct link between depression and isotretinoin, apart from being a rare unpredictable idiosyncratic side-effect. However, because of the study limitations, a larger study is needed to confirm the findings.

Acne, isotretinoin treatment and acute depression

The association between isotretinoin therapy and depressive symptoms in acne patients has generated much recent interest but has not been systematically explored. A 17-year-old man with acne vulgaris developed symptoms of acute depression two weeks after beginning isotretinoin therapy. The depressive symptoms improved with reduction of isotretnoin dose and treatment with sertraline. Of note, however, is that when the isotretinoin dose was again increased, the depressive symptoms recurred despite clearing of the skin, leading to an unsuccessful suicide attempt. Isotretinoin was finally discontinued and the depression rapidly resolved. Although the effects of hypervitaminosis A may be involved aetiologically, the predictive factors of drug-related depression remain unclear. Significant depressive symptoms that develop during the course of treatment need close monitoring and may necessitate both antidepressant therapy and discontinuation of the drug. Given the uncertain causal relationship between isotretinoin and depression, versus the potential psychological benefits of effective acne treatment, systematic studies exploring the impact of isotretinoin on mood are needed.

Health-related quality of life among patients with facial acne -- assessment of a new acne-specific questionnaire

The psychosocial effects of facial acne are well accepted but until recently few validated instruments existed which were suitable for use in clinical trials. The aim of this study was to assess measurement characteristics (reproducibility, correlation with acne severity, and sensitivity to detect change after acne therapy) of a new acne-specific quality of life instrument, the Acne-QoL. We found that the Acne-QoL is reliable, valid and able to distinguish differences across severity groups and improvement over 16 weeks of standard therapy. The use of the Acne-QoL should aid physicians in understanding the impact of facial acne on young adults, and may be useful in assessing therapeutic effects in acne clinical trials.

Anxiety, depression, and nature of acne vulgaris in adolescents

BACKGROUND

The reported prevalence of acne in adolescence is variable; improved treatment may have modified its prevalence and severity; acne has been related to psychiatric morbidity for many years.

METHODS

Two thousand six hundred and fifty-seven high school students were examined, and adolescents with acne were interviewed about the subject of acne vulgaris. The severity of acne was graded using the Global Acne Grading System (GAGS). The Hospital Anxiety and Depression (HAD) scale was evaluated for one of every two subjects with acne (n = 308) and for the same number of sex-matched control subjects (n = 308) to determine the prevalence of depression and anxiety.

RESULTS

Six hundred and fifteen of the subjects (23. 1%) were determined to have acne. Acne prevalence in girls and boys was 16.1% and 29.2%, respectively (P < 0.001). Two hundred and twenty-five (15.8%) of 1424 boys and only 109 (8.8%) of 1233 girls had moderate or severe/very severe acne (P < 0.001), but the GAGS scores in the groups of boys and girls with acne were not significantly different. The acne and control groups showed no significant differences in the HAD anxiety and depression subscale scores. The HAD anxiety subscale scores of girls were significantly higher than those of boys in the acne group. The severity of acne was not correlated with the HAD anxiety or depression subscale scores.

CONCLUSIONS

Acne results in higher anxiety in adolescent girls. Although acne and moderate/severe acne are more common in adolescent boys, the severity of acne was found to be similar in boys and girls with acne. Adolescent girls are more vulnerable than boys to the negative psychological effects of acne.

Quality of life assessments in dermatology

This review describes the many ways in which skin disease can adversely affect the quality of life (QOL) of patients with skin disease. Measurement of this impact is required for clinical and health service research, and may be valuable in clinical practice and in the evaluation of new drug therapy. Methods of measuring QOL in dermatology are described. These include general health measures, dermatology specific measures such as the Dermatology Life Quality Index (DLQI), the Dermatology Quality of Life Scales (DQOLS), the Dermatology Specific Quality of Life (DSQL), and Skindex, and disease specific measures such as the Psoriasis Disability Index (PDI), the Psoriasis Life Stress Inventory (PLSI), and the Acne Disability Index (ADI). Instruments used for measuring QOL in children (the Children's Dermatology Life Quality Index (CDLQI)) and for measuring the impact of atopic dermatitis on the families of affected children (the Dermatitis Family Impact (DFI) questionnaire) are described. Reasons are given for the use of such measures in clinical practice.

Most topical tretinoin treatment is for acne vulgaris through the age of 44 years: an analysis of the National Ambulatory Medical Care Survey, 1990-1994

BACKGROUND

Topical tretinoin is effective treatment for both acne and photoaging. This creates a problem for insurers that cover medication costs, because treatment of acne is often covered but treatment of photoaging is not. The age distributions of patients with acne or photoaging are likely to be very different. Therefore, one approach insurers can use is an age cutoff for covering the cost of topical tretinoin therapy.

OBJECTIVE

Our purpose was to determine at what age patients are more likely to receive tretinoin for treatment of acne vulgaris versus other conditions to provide a rational basis for insurers to set coverage cutoffs.

METHODS

National Ambulatory Medical Care Survey data for the years 1990 to 1994 were analyzed to ascertain the age distribution of acne vulgaris office visits and treatment with topical acne agents including tretinoin. These data were compared to office visits and tretinoin treatment of wrinkles, solar elastosis, and other conditions.

RESULTS

The mean age (+/- standard deviation) of patients seen for acne vulgaris was 24.3 +/-11.5 years old. The age distribution of topical tretinoin treatment paralleled the age distribution of acne. Tretinoin treatment of acne and of nonacne conditions were equal at an age of 44.

CONCLUSION

The distribution of outpatient visits for acne treatment is skewed toward older patients and persists beyond age 40. A rational age cut-off for coverage of topical tretinoin treatment is 40 years.

Acne. What every pediatrician should know about treatment

Acne is one of the most common and easily treated diseases of adolescents. Scarring can be prevented in most cases with early and vigorous treatment. But such treatment requires patience, skill, and a commitment to good counseling.

Acne in Victorian adolescents: associations with age, gender, puberty and psychiatric symptoms

OBJECTIVES

This study aimed to examine the associations between the frequency and severity of self-reported acne and age, gender, puberty and psychiatric symptoms in Victorian adolescents.

METHODOLOGY

A sample of secondary schoolchildren in Victoria, Australia were surveyed using a computerized questionnaire. Developmental and psycho-social factors associated with acne were recorded and analysed using logistic regression.

RESULTS

The Victorian Adolescent Health Survey (1992) recorded the frequency and severity of self-reported acne in 2491 students. Frequency of acne increased with age and pubertal development. For females commencement of menstruation was associated with increased frequency of acne. Asian born male students were less likely to report acne than Australian born males. Acne severity was coded into mild (students reporting acne sometimes on back or face) and moderate (students reporting acne often on face or back). Students reporting moderate acne were more likely to report a high level of psychiatric symptoms and were in the later stages of puberty.

CONCLUSIONS

This study confirms an association between the frequency and severity of self-reported acne and stage of pubertal development. It showed also that students reporting moderate acne were more likely to report psychiatric symptoms of depression and anxiety.

Descriptive epidemiology of acne vulgaris in the community

Acne is a common skin condition. No universally accepted standardized classification system for acne vulgaris exists, although there is a strong need for it. Thus, the clinical definition of acne has been unclear in many studies. The reported prevalence of acne varies from 35 to over 90% of adolescents at some stage. In some studies the prevalence of comedones approaches 100% in both sexes during adolescence. The prevalence of acne varies between sexes and age groups, appearing earlier in females than in males, possibly reflecting the earlier onset of puberty. There is a greater severity of acne in males than in females in the late teens, which is compatible with androgens being a potent stimulus to sebum secretion. The prevalence of acne at a given age has been shown to be highly dependent on the degree of sexual maturity. Acne commonly shows a premenstrual increase in women. Some studies have detected seasonal variability in acne vulgaris, with the colder months associated with exacerbation and the warmer months showing improvement. Other studies have not confirmed these findings. Several studies that have investigated the psychosocial impact of acne have had conflicting results. The prevalence of severe acne has decreased over the past 20 years due to improved treatment. The general prevalence figure for acne may be confounded by treatment and this factor needs to be accounted for when collecting data.

Psychologic effects of vitiligo: a critical incident analysis

BACKGROUND

Qualitative and quantitative studies have shown that cutaneous diseases can have significant effects on psychologic well-being and social functioning in a variety of interpersonal situations.

OBJECTIVE

Our purpose was to assess the nature and extent of the social and psychologic difficulties associated with vitiligo using a combination of qualitative and quantitative methods.

METHODS

Six hundred fourteen members of the U.K. Vitiligo Society completed a questionnaire that included the 12-item version of the General Health Questionnaire (GHQ) and an open-ended question concerning the effects of the disease on their life.

RESULTS

Thirty-five percent of the respondents scored above the threshold on the GHQ. Analysis of the qualitative data indicated that vitiligo affects lives in a variety of ways consistent with perceived stigma and that some categories of response (such as avoidance of activities and negative reactions by others) were associated with higher GHQ scores.

CONCLUSION

Many persons with vitiligo show indications of significant distress that are related to specific types of social encounters and emotional disturbance.

Evaluating health-related quality of life in patients with facial acne: development of a self-administered questionnaire for clinical trials

Although psychosocial aspects of skin diseases are well known, disease-specific questionnaires validated for use in clinical trials are not available to assess the impact of facial acne on health-related quality of life or to evaluate therapeutic change. Development of such an instrument was undertaken and included item generation, reduction and pilot-testing phases. By interviewing acne subjects and dermatologists and literature review, 168 possible items were identified. Next, 165 acne subjects identified which items affected them and rated importance on a 5-point scale. Reduction to a brief questionnaire was performed by evaluating patient-perceived importance and factor analysis; four domains were identified (self-perception, role-emotional, role-social, acne symptoms). After pilot-testing for comprehension in acne subjects, further revisions were made to improve clarity and applicability. The resulting instrument takes 10 minutes to complete, and consists of 24 questions assessing how acne affected certain aspects of patients' lives during the past week on a 7-point scale. Thus, an instrument with excellent content validity was developed to assess health-related quality of life in patients with facial acne, and is comprised of statistically meaningful items of importance to patients. Other measurement characteristics are being assessed in a recently initiated study to evaluate test-retest reliability and responsiveness to therapy.