ABSTRACT
Background:
Acne scars commonly occur in almost 95% of adolescents having acne. Depression and the psychosocial impact of acne have been studied by previous researchers but there are few studies on acne scar patients.
Objectives:
To study the prevalence of depression, body image, and quality of life in patients with acne scars and the correlation of depression with body image and quality of life.
Material and Methods:
Around 81 patients above 18 years of age clinically diagnosed as having different grades of acne by a dermatologist were assessed for depression using Becks Depression Inventory, Body image concern inventory, and Dermatology Life Quality Index and included in the study after being informed consent.
Results:
The mean duration of acne was 6.03 ± 2.9 years, and acne scar was 2.88 ± 1.2 years. Nearly 93% of our sample had an equal preponderance of Grade 1 and Grade 2 acne scars. 31 (38.27%) patients had clinical depression with a total mean BDI score of 16.8 ± 9.7. 15 (18.5%) and 7 (8.6%) patients had moderate and severe depression respectively. Only 5 (6.17%) patients reported significant body image disturbances. All patients reported a very large effect on the quality of life due to flaws in facial appearance leading to feelings of embarrassment and impairment in sexual activities. Depression was significantly associated with grade 1 and 2 scars, body image disturbances, and quality of life.
Conclusions:
There is a high prevalence of depression in patients with acne scarring which needs to be detected and treated. Liaison with a psychiatrist would improve the outcome.
Keywords: Acne scars, body image, depression, grading of acne scar, the morphology of acne scar, quality of life
Acne vulgaris affects at least 90-100% of adolescents[1] and young adults[2] Major complications of acne are scarring and psychosocial distress which persists long after the active lesions have disappeared[3] Several studies have reported anxiety and depression in acne vulgaris patients. As it is commonly seen during adolescence the impact of acne scars on body image and appearance has been well documented.[4] For many patients, acne may lead to permanent scarring and disfigurement, further aggravating the existing psychosocial aspects of this condition.[5] Facial scarring due to acne affects both sexes equally and may occur in up to 95% of people who develop acne.[6] Acne and its sequelae can negatively impact an individual’s intrapsychic, psychosocial, and vocational functioning.
It has been known for a long time that acne scarring can cause depression. Cotterill et al. reported depression in 13% to 19% of their cases. The presence of depression is also a risk factor for suicide.[7] Khan et al. reported a 38% prevalence of depression in their sample of 50 patients.[8] A higher prevalence was reported by Robaee et al. where 82.6% of their respondents gave feelings of depressive symptoms due to the appearance of acne.[9] Other researchers have reported a lower prevalence of 25.6%[10] and 14.1% of depression in patients with acne.[11]
Reducing the psychosocial impact of acne and improving the quality of life is considered one of the guiding principles for its clinical management. As acne scar is a sequel to chronic acne, the impact of the same on emotional well-being definitely needs to be looked into. Hence, we decided to study the prevalence of depression, body image disturbances, quality of life in patients with acne scars, and the association between depression with body image disturbances and quality of life as we did not find any Indian data documenting the same.
METHODS
Study design: This was a descriptive cross-sectional study, which was initiated in the outpatient department of dermatology of a general hospital after permission from the institutional ethics committee. [IEC -2; EC/162/2017, dated 13/01/2018].
Sample size: The dermatology OPD has a specialized Acne OPD once a week and convenient sampling was used to calculate sample size by the formula:
where, Z = 1.96, p is the prevalence of depression in acne scar patients, and q is (100-p)
N = Total no. of cases available for study, L = Level of the confidence interval to be kept between 10-20% of p = 10% of 25 = 2.5
= (1.96)2 25 x 75 x 100/(2.5)2 × 99 + (1.96)2 x 25 x 75
= 720300/7821.75 = ~81. Hence the sample size was 81 patients.
Inclusion Criteria
All the patients clinically diagnosed as having acne scars diagnosed by the dermatologist as per the Acne Qualitative scarring grading system[12] and all grades of acne scar were included in the study.
Age above 18 years.
Those who were willing to participate and gave their consent for the study.
Exclusion Criteria
Patients with active acne.
Patients of acne scars with co-morbid skin conditions like Psoriasis, Lichen planus, eczema, etc.
Acne patients with a known history of mental illnesses and disabilities, chronic medical or surgical conditions.
Patients were recruited with informed consent as per inclusion and exclusion criteria. The grading and description of the morphology of the acne scars were done by the dermatologist. The scars were graded as per increasing severity from Grade 1 to 4 along with their clinical features, which included whether they were atrophic or hypertrophic scars. The atrophic scars were further described as to whether they were ice pick, boxcar, and rolling scars.
Tools
All patients were interviewed with a specially prepared proforma which enquired into the socio-demographic details, acne details, and scales used to determine the aims of the study.
Becks depression inventory
This is a self-administered tool for screening and assessing possible depression in the normal populations as well as rating the severity of depression in adolescents and adults. It has 21 items rated on a four-point scale ranging from 0-3. The maximum total score is 63.[13]
Body image concern inventory
The body image concern inventory scale is a 19-item 5-point Likert rated self-report measure of body image perception as dysmorphic.[14] Scores can range from 19 to 95, with higher scores representing higher levels of body image disturbances and 72 is the clinical cut-off score.
Dermatology Life Quality Index (DLQI)
DLQI is a 10-item 4-point Likert rated scale that measures the impact of skin disease on adult patients’ quality of life. Higher scores are associated with greater impairment of quality of life.[15]
All scales which were administered to the patients were translated into vernacular languages and validated before use.
Statistics
Descriptive statistics with frequency distribution were used to study the prevalence of depression, body image disturbances and quality of life. The association of depression with body image disturbances, and quality of life was done with Pearson’s correlation coefficient while grading and number of acne scars was done using the Chi-square statistic. Two-tailed P values where P < 0.5 was considered significant for all statistical analysis. Graph pad Instab was used for all statistical analysis.
RESULTS
Sociodemographic variables
Our sample of 81 patients consisted of 38 (46.9%) males and 43 (53%) females in the age range 18-34 years, all educated with secondary and above, with nearly 70% working and unmarried, and coming from lower middle socioeconomic strata.
Acne scar duration and grading
In our study, we found the mean duration of acne to be 6.03 ± 2.9 years while the mean duration of acne scar was 2.88 ± 1.2 years. Nearly 93% of our sample had an equal preponderance of Grade 1 and Grade 2 acne scars. There were no patients with Grade 4 scars.
Morphology, number, and size of acne scars
When our patients were assessed on the basis of morphological acne scar grading, then nearly 37 (45%) patients had boxcar and rolling scars respectively as compared to others. Only 32 (39.50%) patients had >50 acne scars on their faces. Facial acne was seen in all as compared to other body sites. [Table 1]
Table 1.
Acne Scar Variables
| Acne scar Variables | Number of patients n=81 (%) |
|---|---|
| Duration of acne in years | |
| Mean±SD | 6.03±2.912 |
| Duration of acne scar | |
| Mean±SD | 2.88±1.29 |
| Acne scar grading (qualitative) | |
| Grade 1 | 37 (45.67%) |
| Grade 2 | 39 (48.14%) |
| Grade 3 | 5 (6.17%) |
| Morphological grading of acne scar | |
| Icepick | 2 (2.46%) |
| Boxcar | 37 (45.67%) |
| Rolling | 37 (45.67%) |
| Hypertrophic | 5 (6.17%) |
| Number of acne scars | |
| <50 | 4 (60.49%) |
| 50-100 | 32 (39.50%) |
| Site of acne scars | |
| Face | 81 (100%) |
| Others | 24 (29.62%) |
Acne scars and depression
On assessing all the patients for the prevalence of depression as per BDI then nearly 31 (38.27%) patients had clinical depression. The total mean BDI score was 16.8 ± 9.7. Thus, more than 1/3rd of our patients were suffering from depressive symptoms which were undiagnosed. Moderate and severe depression was seen in 15 (18.5%) and 7 (8.6%) patients respectively [Table 2].
Table 2.
Prevalence and Severity of Depression as per Beck’s Depression Inventory
| Depression as per BDI | Number of patients n=81 (%) |
|---|---|
| Present | 31 (38.27%) |
| Absent | 50 (61.72%) |
| Total BDI Score | |
| Mean±SD | 16.81±9.708 |
| Severity of Depression as per BDI | |
| Normal | 14 (17.28%) |
| Mild mood disturbance | 36 (44.44%) |
| Borderline clinical depression | 10 (12.34%) |
| Moderate Depression | 15 (18.51%) |
| Severe Depression | 7 (8.64% |
There was a highly statistically significant association between BDI scores and Grade 1 and Grade 2 acne scars [χ2 = 14.5, df = 2, P value < 0.0007]. Patients who were depressed had more Grade 1 (27%) and Grade 3 (4%) scarring as compared to those who were not; Grade 2 (40%) scarring was more common in those without clinical depression [Table 3].
Table 3.
Association of Depression and Grading of Acne Scar
| Depression as per BDI | Grade 1 (n=37) | Grade 2 (n=39) | Grade 3 (n=5) | Chisq (df) | P |
|---|---|---|---|---|---|
| Clinical depression Absent | 15 (18.51%) | 32 (39.50%) | 2 (2.46%) | 14.56 (2) | 0.0007** |
| Clinical depression Present | 22 (27.16%) | 7 (8.64%) | 3 (3.70%) | ||
| Total | 37 (45.68%) | 39 (48.14%) | 5 (6.17%) |
** Very significant
When the patients were assessed for the association between depression and a number of acne scars then no significant association was seen. [χ2 = 4.8, df = 2, P value < 0.09] [Table 4].
Table 4.
Association of Depression and Number of Acne Scars
| Depression as per BDI | Number Of Acne Scars | Chi Sq (df) | P | |
|---|---|---|---|---|
|
| ||||
| <50 | 50-100 | |||
| Clinical depression Absent | 38 (46.91%) | 11 (13.58%) | 4.81 | 0.09 |
| Clinical depression Present | 11 (13.58%) | 21 (25.92%) | ||
| Total | 49 (60.49%) | 32 (39.50%) | ||
Acne scars and body image
The total mean BICI score was 46.60 ± 15.81. and only 5 (6.17%) patients had a score of more than 72 which was the cut-off score as compared to others.
Acne scars and quality of life as per DLQI
The total mean DLQI score was 16.09 ± 4.04 and impairment was reported in pain due to lesions and itching, embarrassment, and impairment in social and sexual activities. Surprisingly our patients reported on items of DLQI that due to facial acne, they could not enjoy foreplay and touching and also gave feelings of embarrassment due to flaws in facial appearance.
Correlation of depression with body image and quality of life
On analyzing the study population for correlation of depression as per total BDI scores with body image (total BICI score), and quality of life (total DLQI Score) we found a positive correlation between depression and body image concern (r = 0.4537, P = 0.0001) and negative correlation between depression and quality of life (r = -0.7204, P = 0.0001) [Table 5].
Table 5.
Correlation of Depression with Body Image and Quality of life with Pearson’s Correlation Coefficient
| Total BDI Score | BICI Total Score (n=81) | DLQI Total Score (n=81) | ||
|---|---|---|---|---|
|
|
|
|||
| r | P | r | P | |
| 0.4537 | 0.0001*** | -0.7204 | 0.0001*** | |
DISCUSSION
Acne scar duration
Several researchers have found acne duration to be ranging from 6 months to 5 years.[16] with the mean duration of acne being 32.2[3] or 44.2 months.[17] The presence of acne scar usually increases with acne duration and reaches a peak after a person has had acne for 2–3 years.[18] Brown et al. had a mean duration of 7.7 years with the range of acne scar being 4 months to 64 years,[19] which is much higher than our mean of 2.8 years of acne scar. The most common reason for scarring as suggested by researchers is the inflammatory reaction at the pilo sebaceous gland which could be prevented by treatment of early inflammation in acne lesions.[20] Contrary to our findings, Hazarika and Archana had a higher prevalence of patients having grade 2 acne scars (70%) and 11% grade 1 acne scarring,[21] Lei et al.[22] had 21 patients of grade 3,18 patients with grade 2 and 11 patients with grade 1 scarring.
Morphology of acne scars
Our findings about the morphologic type of acne scarring are different from Jacob et al. who had 60%–70% icepick scars with 20-30% boxcar scars and 15-25% rolling scars in their sample.[23] We had more the boxcars and rolling scars among the atrophic scars and only 5 patients had hypertrophic scars. An atrophic scar is an indented scar that heals below the normal layer of skin tissue. Atrophic scars form when the skin is unable to regenerate tissue. As a result, it leaves behind imbalanced scarring. The hypertrophic scar formation occurs because the skin produces ‘inferior’ tissue at the region of the inflamed blemish. This doesn’t have the same structure as healthy tissue and therefore becomes thicker and sits above the surrounding skin.
Number of acne scars
Most researchers have found a number of scars similar to our findings. Some found facial acne scars of less than 50 in 81.8% of their sample,[24] others reported that only 12.5% had 50 -100 acne scars.[25] Nearly 40% of our sample had acne scars between 50-100 which is higher than others. One of the reasons could be that there is a delay in early treatment and help-seeking behaviors for acne which would be a lower priority as it is not life-threatening and thus this would result in an increase in scarring.
Site of acne scars
The site of acne scars was the face followed by the back and chest which is in keeping with the other researchers.[3,6,18,25] Some reported facial acne in 60-65% of patients, whereas 32-37% had multiple site involvement of the face, chest, and back together.[19,21] On studying the various sites of facial involvement a study reported that 30.8% of White/Caucasian women had scars on their cheeks, 28.0% had over the chin as compared to 58.4% of non-White/Caucasian women who had cheeks involved, and acne in the chest area was significantly more common for White/Caucasian (46.7%) than non-White/Caucasian women (30.7%).[25] Others reported that the malar region was the most frequently involved (80%), followed by the frontal region (31.5%), back (17%), anterior chest (8.2%), and mentioning region (6.4%).[24] Though we did not study localization over the face, the majority of our patients had scars on the cheeks and forehead. Facial acne is more common because there are many sebaceous glands in these areas of the skin.
Acne scars and depression
BDI has been universally used to diagnose depression and is also used to rate the severity of depressive symptoms in clinical research. It is known that acne scarring can cause depression and is a risk factor for suicide.[7] A similar finding was noted by Khan et al. who reported a 38% prevalence of depression in their sample of 50 patients.[8] A higher prevalence was reported by Robaee et al. where 82.6% of the respondents gave feelings of depressive symptoms due to the appearance of acne.[9] Several researchers have found the total mean BDI score to be less than our sample. Mishra et al. noted the mean BDI score to be 13.30 + 9.30,[26] whereas Kaymak et al. found a mean BDI score of 9.77 ± 6.62.[27] There are very few studies available regarding the severity of depression as most researchers have commented on the prevalence of depressive symptoms in acne.[8,11] Researchers have found that the risk of suicidal ideation maybe two to three times that of their unaffected peers in cases of severe acne.[11,28]
When we studied for the association between depression and acne scar grading there was a significant association. Other researchers have also noted a positive relationship between the severity of depression and the severity of acne scarring.[8] There is a dearth of literature regarding the association between a number of acne scars and depression, as most studies have correlated depression with qualitative acne scar grading and morphological acne scar grading. As per our findings, there was no significant association which could be interpreted as whether the scars are less or more than 50, the number may not matter but the grade of scarring definitely impacts the mind and the person’s outlook.
Acne scars and body image
Surprisingly dissatisfaction with appearance was not so prevalent in our patients as compared to findings in the literature. Tasoula et al. reported that 1/3rd of adolescents with acne had poor body image. This study also revealed that impairment in body image due to peer pressure was noticed in 19.9% of mild acne, 40.9% of moderate, and 60.7% of severe acne.[29] The BICI Items evaluate dissatisfaction with appearance, checking and camouflaging of perceived appearance defects, reassurance seeking about physical appearance, social concerns, and avoidance related to appearance defects which were not seen to a greater degree in our sample.
The majority of our patients gave higher scores on the items like use of cosmetic materials to improve appearance, feeling of shame about some part of the body, looking for flaws in appearance, comparing one’s appearance with others, avoiding going to social situations because of appearance and fear of being judged by others, avoiding looking at oneself in mirror, etc., but the scores were less than 72. Five patients who had a score of more than 72 had reported a Likert rating of 4 and 5 on most of the above items. They also had whole-face involvement, the greater number of acne lesions, higher severity of acne scarring, and a longer duration of scars.
Some researchers found body image satisfaction could be unrelated to acne severity.[30] Poor body image may result in depression, social anxiety and inhibition, and poor self-esteem, illustrating the impact of body image perception on quality of life.
Acne scars and quality of life as per DLQI
The itch which was reported by our patients is a common concomitant symptom of acne lesions. Tasoula et al. also reported itching in almost 25% of respondents having facial acne.[29] Other researchers found that the majority of patients were affected by DLQI questions two, five, and nine, i.e., 36% felt self-conscious, 24% felt that it affected their social activities, 18% felt that scarring interfered with their going out or shopping, etc.[31] We had a high mean score on DLQI question nine (1.87) which asked about sexual difficulties which are contrary to the findings of others.[31] A lower total mean DLQI score has also been reported by 5.61 ± 4.3,[31] 6.7 ± 0.7,[22] 7.21 ± 4.82[32] which are very low as compared to our findings.
Lei et al. found that 8 (16%) patients had no impairment in quality of life, 17 (34%) had mild impairment, 13 (26%) patients had moderate impairment whereas a very large impairment was seen in 11 (22%) patients and only 1 (2%) patient had extremely large impairment in their quality of life.[22] However, in our study, we did not get any impairments in mild, moderate, and extremely large categories.
Correlation of depression with body image and quality of life
Not only does acne result in emotional distress, the anxiety evoked by acne can aggravate the skin condition itself, thereby creating a vicious cycle. We found that due to depression there was more body image concern and impaired quality of life in our patients. Many researchers feel that psychosocial problems such as low self-esteem, anxiety, depression, and a decrease in social relationships in patients with acne are due to disorder of self-body image.[10] Once the patient has developed belief systems and cognitive distortions leading to high body image disturbance, putting the patient at a higher risk for depression and body dysmorphic disorder, the grade of acne which is the inciting cause for this paradoxically becomes immaterial.[33]
Limitations
We had some limitations as only patients seeking medical help at a tertiary care center were included. We did not use standard diagnostic criteria for diagnosing the prevalence of depression. Using structured clinical interviews would be more helpful in giving the extent of the psychopathology in acne scar patients.
CONCLUSIONS
The results of this study imply that there is a high prevalence of depression in patients with acne scarring along with impairment in quality of life. Awareness about depression and psychosocial distress in acne and acne scars among physicians is important and a liaison with a psychiatrist is necessary for the early identification of depression in these patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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