The Impact of Acne Scarring on Quality of Life, Willingness-to-pay, and Time Trade-off: A Cross-sectional Analysis

Abstract

Objective

We sought to evaluate the impact of the presence of acne scarring in patients with acne vulgaris on quality of life as assessed by the Dermatology Life Quality Index (DLQI) and the Cardiff Acne Disability Index (CADI); disease severity using the Investigator’s Global Assessment of Acne (IGA); and health utility measures including willingness-to-pay, time trade-off, time spent on concealment, and percent of income willing to exchange for resolution of disease.

Methods

We conducted a cross-sectional, single-institution survey.

Results

In total, 94 patients with acne vulgaris participated, of which 53.2 percent had acne scarring and 46.8 percent did not. The presence of acne scarring was associated with higher DLQI, CADI, and IGA scores. Utility measures including willingness-to-pay, time trade-off, concealment time, and percent of income willing to exchange for resolution of disease were similar for participants with and without scarring. For participants with and without scarring, a greater impairment of quality of life as assessed by the DLQI was positively correlated with WTP25, percent of monthly income, IGA, and the CADI.

Limitations

As the study design was single-site and cross-sectional, and therefore results may not be generalizable.

Conclusion

The presence of acne scarring significantly impacts quality of life. A greater impairment of quality of life in patients with acne vulgaris correlates positively with severity of acne and some measures of health economics. Interventions to minimize or prevent acne scarring may reduce psychosocial burden of disease.

Acne vulgaris is the most common dermatologic condition in the United States and may lead to permanent scarring in up to 95 percent of individuals affected.¹ Maladaptive thought processes, negative body image, low self-esteem, social stigmatization, and avoidant social behaviors that develop during active acne are prolonged in patients with acne scarring.¹ Compared to patients with acne vulgaris alone, patients with acne scarring more frequently feel regret, self-blame, and hopelessness.¹ Such feelings of embarrassment, self-consciousness, and poor self-esteem can lead to psychosocial disability.² The aim of this study was to evaluate the impact of acne scarring on quality of life and assess willingness-to-pay (WTP), time trade-off (TTO), and time spent on concealment as methods to quantify burden of disease.

METHODS

This single-site, cross-sectional study included eligible participants 18 years of age or older with acne vulgaris presenting to a dermatology clinic from February through December 2021. A survey questionnaire was offered in English and Spanish and collected demographic characteristics and utility measures including: WTP in a month for 50-percent (WTP50) and 25-percent (WTP25) reduction of skin disease; TTO in hours per day for complete resolution of skin disease; daily time spent concealing the disease (eg, makeup); percentage of monthly income willing to exchange for complete resolution of skin disease; and quality of life as assessed by the Dermatology Life Quality Index (DLQI) and the Cardiff Acne Disability Index (CADI).³ A board-certified dermatologist estimated disease severity using the Investigator’s Global Assessment of Acne (IGA).³ The study was approved by the Boston University Institutional Review Board, and informed consent was obtained from all participants.

RESULTS

A total of 121 individuals completed the survey out of 153 approached (response rate=79%). Participants with a diagnosis of rosacea (n=27) were excluded to minimize confounding. Participants included those diagnosed with acne vulgaris with (53.2%) and without (46.8%) acne scarring. Demographic characteristics were similar between groups (Table 1). Participants with acne scarring had higher mean DLQI scores (11.9 vs. 6.4, P<0.001), higher CADI scores (8.1 vs. 5.3; P<0.001), and higher IGA scores (3.0 vs. 2.1; P<0.001) than participants without acne scarring (Table 2).

TABLE 1.

Demographic characteristics of acne vulgaris patients diagnosed with acne scarring (n=50) and without acne scarring (n=44)

	W/SCARRING	W/O SCARRING	P-VALUEa
Age, n (%)
18–24	15 (30.0)	13 (29.5)	0.12
25–34	24 (48.0)	24 (54.5)
35–44	11 (22.0)	4 (9.1)
45+	0 (0.0)	3 (6.8)
Sex, n (%)
Male	9 (18.0)	8 (18.2)	1.00
Female	41 (82.0)	38 (81.8)
Race, n (%)
American Indian/Alaska Native	0 (0.0)	2 (4.5)	0.21
Asian	2 (4.0)	0 (0.0)
Black/African American	4 (8.0)	3 (6.8)
White	27 (54.0)	18 (40.9)
Other/Missing	17 (34.0)	21 (47.7)
Hispanic or Latino, n (%)
Yes	32 (64.0)	32 (72.7)	0.39
No	18 (36.0)	12 (27.3)
Married Status, n (%)
Married	21 (42.0)	14 (31.8)	0.16
Single	29 (58.0)	27 (61.4)
Other	0 (0.0)	3 (6.8)
Employment Status, n (%)
Employed	35 (70.0)	29 (65.9)	0.83
Unemployed	15 (30.0)	15 (34.1)
Education, n (%)
<High School	9 (18.0)	5 (11.4)	0.82
High School	16 (32.0)	17 (38.6)
College	22 (44.0)	19 (43.2)
Graduate	3 (6.0)	3 (6.8)
Income
<$50,000	38 (76.0)	33 (75.0)	1.00
$50,000–$100,000	12 (24.0)	11 (25.0)

^aP-values were calculated using Fisher’s exact tests.

TABLE 2.

Health utility measures of acne vulgaris patients diagnosed with acne scarring (n=50) and without acne scarring (n=44).

MEASURES	W/SCARRING (MEAN ± SD)	W/0 SCARRING (MEAN ± SD)	P-VALUEa
DLQI	11.9 ± 6.6	6.4 ± 5.4	<0.001*
CADI	8.1 ± 3.3	5.3 ± 3.6	<0.001*
WTP25b	$72.30 ± $55.27	$74.43 ± $78.37	0.88
WTP50c	$123.50 ± $88.27	$114.55 ± $102.65	0.65
TTOd (hours)	2.7 ± 1.6	2.4 ± 2.5	0.54
Concealment timee (minutes)	31.4 ± 21.1	26.0 ± 22.7	0.24
Percent of incomef	14.5% ± 16.0%	18.4% ± 23.8%	0.36
IGA	3.0 ± 0.7	2.1 ± 1.1	<0.001*

Abbreviations: CADI, the Cardiff Acne Disability Index; DLQI, dermatology life quality index; IGA, Investigator’s Global Assessment of Acne; SD, standard deviation; TTO, time trade-off; WTP, willingness-to-pay

*Indicates a statistically significant difference.

^aP -values were calculated using independent sample t-tests.

^bWillingness-to-pay in a month for 25% improvement in skin disease.

^cWillingness-to-pay in a month for 50% improvement in skin disease.

^dHours per day willing to exchange for complete resolution of skin disease.

^eDaily time spent concealing skin disease (e.g. makeup).

^fPercent of monthly income willing to exchange for a therapeutic cure.

Within the last month, participants with acne scarring were more likely to feel aggression, frustration, or embarrassment from their acne compared to patients with acne but without acne scarring (96.0% vs. 72.7%; P=0.003, Table 3). Similarly, participants with acne scarring were more likely to report that their acne interfered to some degree with their daily social life, social events, or relationships in the last month than participants without acne scarring (96.0% vs. 59.1%; P<0.001), with 24 percent of participants with acne scarring reporting a severe impairment in all activities. When queried on feelings about the appearance of their skin over the last month, 72.0 percent of participants with acne scarring were either “usually concerned” or “very depressed and miserable” compared to 45.5 percent of participants without acne scarring (P=0.006). Eighty-two percent of participants with acne scarring felt their acne is currently “a major problem” or “the worst it could possibly be” compared to 43.2 percent of those without acne scarring (P<0.001).

TABLE 3.

The Cardiff Acne Disability Index (CADI) responses of acne vulgaris patients diagnosed with acne scarring (n=50) and without acne scarring (n=44).

MEASURES	W/SCARRING (MEAN ± SD)	W/O SCARRING (MEAN ± SD)	P-VALUEa
Aggressive, frustrated, or embarrassed in the last month due to acne
Not at all	2 (4.0)	12 (27.3)	0.003*
A little	26 (52.0)	19 (43.2)
A lot	8 (16.0)	9 (20.5)
Very much indeed	14 (28.0)	4 (9.1)
Acne in the last month interfered with daily social life, social events, or relationships
Not at all	2 (4.0)	18 (40.9)	<0.001*
Occasionally, in some activities	27 (54.0)	16 (36.4)
Moderately, in most activities	9 (18.0)	6 (13.6)
Severely, in all activities	12 (24.0)	4 (9.1)
Avoided public changing facilities/wearing swimming costumes in the last month due to acne
Not at all	19 (38.0)	28 (63.6)	0.09
Occasionally	23 (46.0)	12 (27.3)
Most of the time	5 (10.0)	3 (6.8)
All of the time	3 (6.0)	1 (2.3)
Feelings about appearance of skin over the last month
Not bothered	0 (0.0)	7 (15.9)	0.006*
Occasionally concerned	14 (28.0)	17 (38.6)
Usually concerned	25 (50.0)	15 (34.1)
Very depressed and miserable	11 (22.0)	5 (11.4)
How bad is acne right now
Not a problem	0 (0.0)	5 (11.4)	<0.001*
A minor problem	9 (18.0)	20 (45.5)
A major problem	30 (60.0)	16 (36.4)
The worst it could possibly be	11 (22.0)	3 (6.8)

^aP -values were calculated using Fisher’s exact tests.

*Indicates a statistically significant difference.

Utility measures, including WTP25, WTP50, TTO, concealment time, and percent of income willing to exchange for resolution of disease were similar between groups (Table 3). For participants with acne scarring, a greater impairment of quality of life as assessed by the DLQI was positively correlated with increased WTP25, percent of monthly income, IGA, and CADI (rs=0.299, P=0.04; rs=0.446, P=0.002; rs=0.426, P=0.002; and rs=0.828, P<0.001, respectively). For participants with acne scarring, quality of life as assessed by the DLQI did not correlate with WTP50, TTO, or concealment time. In contrast, for participants without acne scarring, quality of life was positively correlated with increased WTP25, WTP50, percent of monthly income, TTO, concealment time, IGA, and CADI (rs=0.498, P<0.001; rs=0.546, P<0.001; rs=0.350, P=0.03; rs=0.318, P=0.04; rs=0.640, P<0.001; rs=0.471, P=0.001; and rs=0.797, P<0.001; respectively).

DISCUSSION

Our results highlight the negative impact of acne scarring on quality of life, as participants with acne scarring had higher scores on the DLQI, the CADI, and the IGA compared to those without scarring. When analyzing individual questions of the CADI, participants with acne scarring were more likely to report feeling aggression, frustration, or embarrassment in the last month, interference with social life, and “very depressed and miserable” than participants without scarring, suggesting a greater psychosocial impact in participants with acne scarring compared to those without. These results have been corroborated in other studies which similarly found higher DLQI and CADI scores in patients with acne scarring.^4,5 In our study, quality of life as assessed by the DLQI was positively correlated with both the CADI and disease severity using the IGA, supporting that greater severity of disease leads to higher impact on quality of life. Underrepresentation in research, limited health literacy, lack of established guidelines and insurance coverage for treatment, and variable treatment success remain barriers for patients with acne scarring; however, interventions to minimize or prevent acne scarring may reduce psychosocial burden of disease supporting benefits of treatment.¹

To the best of our knowledge, our study is the first to examine the impact of acne scarring on health utility measures including WTP, TTO, and concealment time using patients with acne vulgaris without scarring as a control. Interestingly, despite worse quality of life associated with acne scarring, WTP25, WTP50, TTO, concealment time, and percent of income willing to exchange for resolution of disease were similar between groups. These findings warrant further investigation. Notably, our study was conducted at the largest safety net hospital in New England with a high proportion of socioeconomic disadvantaged patients. WTP and percent of income willing to exchange for resolution of disease may not be accurate proxies of disease burden for these populations. Indeed, low income individuals are more likely to forgo non-emergency healthcare services and utilize trade-off thinking resulting in consistent consumption decisions.⁶ Despite this, for both patients with and without acne scarring, quality of life as assessed by the DLQI positively correlated with both WTP25 and percent of monthly income willing to exchange for resolution of disease. Further research delineating results by type of scarring (i.e. post-inflammatory hyperpigmentation, ice pick scars, box pick scars, keloids) and location of scarring (face, trunk) may provide further clarification.

CONCLUSION

Our results shed light on the psychosocial impact of acne scarring from the patient’s perspective. Acne scars exert a substantial negative impact on quality of life and psychosocial wellbeing. In our study, the presence of acne scarring in participants with acne vulgaris was associated with worse quality of life as measured by the DLQI and the CADI, and disease severity with the IGA. Similarly, our results support a greater psychosocial impact in participants with acne vulgaris with scarring compared to those without. Efforts to minimize acne scarring may reduce psychosocial burden of disease. Utility measures including willingness-to-pay, time trade-off, concealment time, and percent of income willing to exchange for resolution of disease were similar for participants with and without scarring; however, a greater impairment of quality of life as assessed by the DLQI was positively correlated with WTP25, percent of monthly income, IGA, and the CADI suggesting quality of life correlates with disease severity and some measures of health economics in patients with acne vulgaris. Limitations of our study include its cross-sectional, single-center design. Further research investigating the psychosocial impact of acne scarring by acne scarring subtype and location may provide useful information to better emotionally support our patients.