Abstract
Abstract
Objectives
The presence of acne can significantly impact patients’ health-related quality of life (HRQoL); however, the correlation between patient-reported HRQoL impairment and clinician-evaluated severity has been unclear. The objective of the study was to evaluate HRQoL in patients with different acne severity using generic, dermatology-specific and acne-specific instruments and investigate the correlation between clinical severity and HRQoL.
Design
Data for the cross-sectional survey were extracted from March 2017 to December 2018. The convenient sampling strategy was used to select participants.
Setting
The study was conducted at the Department of Dermatology, Qilu Hospital, Shandong University.
Participants
A total of 1056 outpatients participated in the survey, and 962 patients were analysed in the study.
Primary and secondary outcome measures
The generic instrument (EuroQol 5-Dimensions 5-Levels, EQ-5D-5L), dermatology-specific instrument (Dermatology Life Quality Index, DLQI) and acne-specific instrument (Cardiff Acne Disability Index, CADI) were administered to assess HRQoL and the Global Acne Grading System was used to measure clinical severity.
Results
The mean health state utility (HSU) EQ-5D-5L score of 0.96 (SD: 0.06), a total DLQI score of 6.84 (SD: 4.88) and a total CADI score of 5.72 (SD: 2.81). Patients with moderate and severe acne showed greater impairment compared with patients with mild acne, as evidenced by significantly lower HSU scores (−0.017 and −0.066) and higher DLQI (1.457 and 2.043) and CADI scores (0.726 and 1.685). Clinical severity was weakly correlated with HRQoL scores for all acne severities (rs=−0.131 to 0.167).
Conclusions
Acne is associated with significant HRQoL impairments, especially in terms of psychosocial functioning. It is very important to incorporate HRQoL assessment into clinical practice in future research, and dermatology-specific and acne-specific HRQoL instruments should be used in combination to assess the health status of acne patients.
Keywords: Acne, Clinical Decision-Making, Patient Reported Outcome Measures
STRENGTHS AND LIMITATIONS OF THIS STUDY.
Use generic instrument, dermatology-specific instrument and acne-specific instrument to comprehensively assess the HRQoL of acne patients.
Patient’s clinical activity was reported by doctors rather than relying on the patient’s responses, thus avoiding inclusion bias and ‘recall bias’.
The data collection was conducted in one hospital; therefore, it may not be representative of the acne patient population in China.
Introduction
Acne, a common skin disease, has an impact on approximately 85% of adolescents,1,3 exhibiting a diverse array of clinical manifestations that span from mild comedonal disease to severe haemorrhagic and ulcerative lesions accompanied by scarring.4 The presence of acne can result in the development of secondary lesions, including scars, excoriations, post-inflammatory erythema and dyspigmentation, which have the potential to endure for an extended period, even throughout an individual’s lifetime.5 6 These manifestations can significantly impact various aspects of a patient’s life, such as their emotions, personal relationships and social interactions, and have been linked to an increased risk of suicide, depression and unemployment.6,9
Traditionally, the management of acne has heavily relied on objective clinical severity grading systems,10 such as Acne Severity Index, the Leeds technique and the Global Acne Grading System (GAGS).11 12 Clinicians formulate treatment plans and evaluate treatment effects based on observable lesion types (comedones, papules, pustules, nodules), distribution and inflammation intensity and other characteristics. However, relying solely on clinical severity cannot fully reflect the disease burden of acne patients. The subjective experience of patients, as assessed by health-related quality of life (HRQoL) instruments, is becoming increasingly important. HRQoL encompasses an individual’s physical, psychological, social function and marital state, providing a comprehensive assessment of the overall influence of an illness and its treatment from the patient’s perspective.13 It is an essential measure to supplement evidence by considering outcomes from the patient’s perspective and integrating them into routine clinical practice and research.14
Some studies demonstrate a connection between them,6 15 while others suggest that the impairment of HRQoL is not dependent on clinical severity.16 17 Ideally, treatment outcomes should encompass both clinical improvement and enhancement of quality of life.18 Therefore, investigating the relationship between HRQoL and clinical severity in acne patients is crucial to ensure a more comprehensive assessment of the disease burden.19 Moreover, evaluating this relationship helps identify patients with significant discrepancies, thereby facilitating the provision of patient-centred diagnostic and therapeutic care. This study aims to comprehensively evaluate HRQoL in patients with acne of varying clinical severity using multiple HRQoL instruments, including generic, dermatology-specific and acne-specific measures and to investigate the correlation between physician-assessed clinical severity and patient-reported HRQoL.
Methods
Study design and population
A cross-sectional survey was undertaken at Qilu Hospital of Shandong University, China, spanning from March 2017 to December 2018. Convenience sampling was used to enrol outpatients seeking treatment for acne at the dermatology department. Recruitment is conducted immediately after a patient’s clinical consultation. The clinician assesses their eligibility based on inclusion and exclusion criteria. After the patient provides written informed consent, the clinical doctor conducts a face-to-face investigation of the patient.
Inclusion criteria necessitated patients to be at least 16 years of age and to have been diagnosed with acne by a clinician. The exclusion criteria were as follows: (1) refusal to provide informed consent, (2) inability to comprehend the questionnaires, (3) a history of severe comorbidities such as malignant tumours or mental illnesses and (4) hearing or vision impairments that hindered the patients’ ability to respond to questions. All participants were invited to participate in face-to-face interviews, and informed consent was obtained from each participant prior to the interviews. The study was approved by the Ethics Committee Scientific Research of Qilu Hospital of Shandong University (Reference No. KYLL-2018–195), and the research adhered to the tenets of the Declaration of Helsinki.
The survey used in the research comprised three distinct sections. The initial section encompassed socio-demographic characteristics (such as age, gender, residence, educational attainment, occupation and marital status), clinical characteristics (such as duration of acne) and the subjective well-being of patients. The second section was dedicated to assessing HRQoL, which involved three instruments: a generic measure (EuroQol 5-Dimensions 5-Levels, EQ-5D-5L), a dermatology-specific measure (Dermatology Life Quality Index, DLQI) and an acne-specific measure (Cardiff Acne Disability Index, CADI). We also used WHO-5 to investigate the subjective well-being of patients. The third section centred on evaluating the clinical severity of the patients, which was assessed by a physician using the GAGS.
Patient and public involvement
Participants were not involved in the design, conduct, reporting or dissemination plans of our research.
HRQoL measurements
The EQ-5D-5L is a generic, preference-based instrument for measuring HRQoL. The descriptive system consists of five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension offers five levels of response, ranging from no problems to extreme problems, which generate 3125 unique health states.20 The Chinese version of EQ-5D-5L and the Chinese-specific scoring algorithm of EQ-5D-5L were used in this study.21 The theoretical health state utility (HSU) score ranges from −0.391 to 1, with a score of 1 indicating full health and a score of 0 representing being dead. Scores less than 0 indicate a health status worse than death.22
The DLQI is the most widely used dermatology-specific instrument for measuring the HRQoL of dermatology patients in clinical trials.23 It is a 10-item questionnaire with a 1-week recall period. The DLQI assesses the impact of skin disease on symptoms and feeling, daily activities, leisure, work or school, personal relationships and the side effects of treatment. Each item is assessed using a 4-point scale, ranging from ‘not at all /not relevant’ to ‘very much’. The cumulative scores of items yield a total score that ranges from 0 to 30, with higher scores indicating more deterioration of HRQoL.24
The CADI is a concise questionnaire developed to assess the HRQoL in adolescents and young adults with acne.25 It consists of five items, with each question answered on a 4-point Likert scale ranging from 0 to 3, resulting in a total score range of 0 to 15. Questions are used to assess psychological and social consequences, truncal acne, feelings about the appearance and the patient’s assessment of their acne severity, based on the impact experienced over the previous month. Higher scores on the CADI indicate more severely affected HRQoL.26
Clinical severity measurement
The GAGS is the standard objective assessment to measure acne severity in clinical practice. It involves dividing the face, chest and upper back into six areas: the forehead, right cheek, left cheek, nose, chin and torso (chest and upper back combined). Each acne lesion is described and scored as a comedo (one point), papule (two points), pustule (three points) or nodule (four points). The local score for each anatomic area is determined by multiplying the score of the most severe lesion by an area factor (1–3). The local scores of the six areas are then added together to obtain the total score (0–52) and the severity of acne is graded as mild (1–18), moderate (19–30), severe (31–38) and very severe (more than 38).12 In this study, the severity was defined total scores of 1–18 as mild, 19–30 as moderate and more than 31 as severe.
Subjective well-being measurement
The WHO-5 is widely used to assess subjective psychological well-being and is comprised of five positive items that pertain to positive mood, vitality and general interests. Each item is scored from 5 (all of the time) to 0 (none of the time), and the raw scores theoretically range from 0 (absence of well-being) to 25 (maximal well-being). A total score of less than 13 indicates the possibility of depression in the participant.27
Statistical analysis
Statistical analysis was conducted to summarise the sociodemographic and clinical characteristics of the participants in this study. Descriptive statistics, including frequencies and percentages for categorical variables and means and SD for continuous variables, were used to summarise data. The normality of the HRQoL scores was tested using the Kolmogorov-Smirnov test. Disparities in the participants’ characteristics and HRQoL scores among the three groups were compared using the χ2 test for categorical variables and the Kruskal-Wallis test for continuous variables.
In order to assess the differences in HRQoL scores between patients with mild acne (reference population) and those with moderate and severe acne, multivariable linear regressions were used. These regressions were adjusted for various socio-demographic factors including age, gender, residence, educational attainment, marital status and occupation, as well as clinical characteristics such as disease duration and subjective well-being.
The Spearman’s rank correlation was used to assess the relationship between clinical severity measures and HRQoL instrument. Furthermore, the correlation between the generic instrument and the dermatology-specific and acne-specific instruments was also evaluated using Spearman’s rank correlation coefficient. The strength of correlation was determined based on the following thresholds: |rs|<0.20 (very weak), 0.20≤|rs|<0.40 (weak), 0.40≤|rs|<0.60 (moderate), 0.60≤|rs|<0.80 (strong) and 0.8≤|rs|<1.00 (very strong). All statistical analyses were performed using SPSS V.20.0 (IBM Corporation, Armonk, New York, USA). A two-tailed p value<0.05 was considered statistically significant.
Results
Characteristics of patients
A total of 1056 patients were initially invited to participate in the interview, with six patients declining. Four patients who initially agreed to take part in the study withdrew after completing the sociodemographic section of the questionnaire. Among the 1046 patients who were successfully interviewed, 84 were excluded due to incomplete responses on the questionnaire. A valid sample of 962 patients who completed all HRQoL questionnaires was subjected to analysis.
Table 1 presents a comprehensive overview of the sociodemographic and clinical characteristics of the acne patients, stratified by their clinical severity. The average age of the patients was 22.4 years (SD=4.2), with the majority being female (67.9%). A significant proportion of the patients hailed from urban regions (73.6%) and slightly over half possessed a university degree (51.6%). The majority of the patients were unmarried (89.5%) and a considerable portion were students (67.3%). Furthermore, more than half of the patients reported an acne duration of less than 1 year.
Table 1. Characteristics of patients with acne.
| Characteristics | Total (n=962) | Mild (n=764) | Moderate (n=172) | Severe (n=26) | P value |
|---|---|---|---|---|---|
| N (%) | N (%) | N (%) | N (%) | ||
| Gender | <0.001 | ||||
| Male | 309 (32.1) | 195 (25.5) | 92 (53.5) | 22 (84.6) | |
| Female | 653 (67.9) | 569 (74.5) | 80 (46.5) | 4 (15.4) | |
| Age in years (Mean±SD) | 22.4±4.2 | 22.7±4.1 | 21.6±4.5 | 19.8±3.7 | <0.001 |
| 16–20 | 352 (36.6) | 249 (32.6) | 84 (48.8) | 19 (73.1) | |
| 21–25 | 429 (44.6) | 365 (47.8) | 60 (34.9) | 4 (15.4) | |
| ≥ 26 | 181 (18.8) | 150 (19.6) | 28 (16.3) | 3 (11.5) | |
| Residence | 0.002 | ||||
| Rural area | 254 (26.4) | 188 (24.6) | 52 (30.2) | 14 (53.8) | |
| Urban area | 708 (73.6) | 576 (75.4) | 120 (69.8) | 12 (46.2) | |
| Educational attainment | <0.001 | ||||
| High school and below | 220 (22.9) | 153 (20.0) | 52 (30.2) | 15 (57.7) | |
| Junior college | 158 (16.4) | 125 (16.4) | 31 (18.0) | 2 (7.7) | |
| University degree | 496 (51.6) | 405 (53.0) | 83 (48.3) | 8 (30.8) | |
| Graduate degree and above | 88 (9.1) | 81 (10.6) | 6 (3.5) | 1 (3.8) | |
| Marital status | 0.070 | ||||
| Single | 861 (89.5) | 675 (88.4) | 162 (94.2) | 24 (92.3) | |
| Married | 101 (10.5) | 89 (11.6) | 10 (5.8) | 2 (7.7) | |
| Occupation | 0.003 | ||||
| Students | 646 (67.2) | 506 (66.2) | 119 (69.2) | 21 (80.8) | |
| Employed | 316 (32.8) | 258 (33.8) | 53 (30.8) | 5 (19.2) | |
| Duration of disease | 0.013 | ||||
| <1 year | 492 (51.1) | 411 (53.8) | 73 (42.4) | 8 (30.8) | |
| 1–3 years | 211 (21.9) | 161 (21.1) | 41 (23.8) | 9 (34.6) | |
| ≥3 years | 259 (26.9) | 192 (25.1) | 58 (33.7) | 9 (34.6) | |
| Subjective well-being | 0.022 | ||||
| WHO-5 scores<13 | 208 (21.6) | 153 (20.0) | 45 (26.2) | 10 (38.5) | |
| WHO-5 scores≥13 | 754 (78.4) | 611 (80.0) | 127 (73.8) | 16 (61.5) | |
| GAGS scores (Mean±SD) | 14.2±6.6 | 11.6±3.8 | 22.8±3.5 | 34.7±3.8 | <0.001 |
GAGS, Global Acne Grading System.
Analysis of the GAGS scores revealed that out of the total sample, 764 patients had mild acne, 172 had moderate acne and 26 had severe acne. Compared with patients with mild acne, those with moderate and severe acne were more likely to be men (25.5% vs 53.5% vs. 84.6%, respectively), younger (22.7 years vs 21.6 years vs 19.8 years, respectively) and less educated, with a higher likelihood of residing in rural areas (24.6% vs 30.2% vs. 53.8%, respectively).
Patient self-reported health problems
The self-reported health problems of patients with different clinical severity of acne are presented in online supplemental figures 1–3. For the EQ-5D-5L (online supplemental figure 1), anxiety/depression emerged as the most frequently reported health problem, followed by pain/discomfort. For the DLQI (online supplemental figure 2), symptoms and feelings were the most impaired dimension, followed by leisure. As for the CADI (online supplemental figure 3), patients reported increased limitations for the assessment of acne severity and feelings about appearance. Using multivariable adjusted linear regression (table 2), we found that patients with moderate and severe acne had the most limitations in the dimension of symptoms and feelings in the DLQI (0.460, p<0.001; 0.576, p=0.033). Among all CADI dimensions, patients with moderate acne reported more considerably impaired feelings about appearance, while patients with severe acne reported more impairment in avoiding public changing facilities.
Table 2. Multivariable adjusted linear models of change in HRQoL scores associated with clinical severity*.
| Outcome variable | Moderate | Severe | ||||
|---|---|---|---|---|---|---|
| Coefficient† | 95% CI | P value‡ | Coefficient§ | 95% CI | P value‡ | |
| EQ-5D-5L HSU Score¶¶ | −0.017 | −0.029, 0.006 | 0.001 | −0.066 | −0.094, 0.037 | <0.001 |
| DLQI**** | ||||||
| Symptoms and feeling | 0.460 | 0.237, 0.683 | <0.001 | 0.576 | 0.045, 1.107 | 0.033 |
| Daily activities | 0.407 | 0.174, 0.639 | 0.001 | 0.298 | −0.256,0.852 | 0.291 |
| Leisure | 0.243 | 0.010,0.477 | 0.041 | 0.246 | −0.309,0.801 | 0.384 |
| Work or school | 0.167 | 0.014,0.321 | 0.033 | 0.261 | −0.105,0.627 | 0.162 |
| Personal relationships | 0.047 | −0.140,0.234 | 0.622 | 0.416 | −0.029,0.861 | 0.067 |
| Side effects of treatment | 0.132 | −0.006,0.269 | 0.061 | 0.245 | −0.083,0.573 | 0.143 |
| Total score | 1.457 | 0.568,2.345 | 0.001 | 2.043 | −0.074,4.159 | 0.048 |
| CADI†††† | ||||||
| Psychological consequences | 0.168 | 0.035,0.300 | 0.013 | 0.257 | −0.058,0.572 | 0.110 |
| Social consequences | 0.132 | −0.001,0.265 | 0.052 | 0.224 | −0.093,0.541 | 0.166 |
| Avoided public changing facilities | 0.090 | −0.067,0.248 | 0.261 | 0.528 | 0.153,0.904 | 0.006 |
| Feeling about the appearance | 0.141 | 0.007,0.274 | 0.039 | 0.352 | 0.035,0.670 | 0.030 |
| Assessment of their acne severity | 0.195 | 0.064,0.327 | 0.004 | 0.323 | 0.010,0.637 | 0.043 |
| Total score | 0.726 | 0.210,1.242 | 0.006 | 1.685 | 0.455,2.915 | 0.007 |
All models used the mild patients as the reference population and adjusted for age, gender, residence, educational attainment, marital status, occupation, duration of disease, subjective well-being.
Coefficients represent the average difference in HRQoL scores between the mild patients and the moderate patients, after adjusting for covariates.
p<0.05 is considered significant (in bold).
Coefficients represent the average difference in HRQoL scores between the mild patients and the severe patients, after adjusting for covariates.
The EQ-5D-5L HSU is scored on −0.39 (worse than death) to 1 (perfect health), with higher scores indicating better HRQoL.
The DLQI is scored on 0 (no impairment) to 30 (more severe impairment), with higher scores indicating worse HRQoL.
The CADI is scored on 0 (no impairment) to 15 (more severe impairment), with higher scores indicating worse HRQoL.
CADI, Cardiff Acne Disability Index; DLQI, Dermatology Life Quality Index; EQ-5D-5L, EuroQol 5-Dimensions 5-Levels; GAGS, Global Acne Grading System; HRQoL, health-related quality of life; HSU, health utility score.
HRQoL of patients with different clinical severity
The descriptive statistics for the instruments used to assess HRQoL are presented in table 3. The mean HSU score of EQ-5D-5L was 0.96 (SD: 0.06), while the total score of DLQI was 6.84 (SD: 4.88) and the total score of CADI was 5.72 (SD: 2.81). There were significant statistical differences in all instrument scores among different acne severity groups (all p<0.001). Compared with patients with mild acne, those suffering from moderate and severe acne had significantly lower EQ-5D-5L score and higher DLQI and CADI scores (online supplemental table 1). Furthermore, it was observed that patients with severe acne experienced the most substantial impairments in HRQoL. The HRQoL of patients with different clinical severity of acne by each characteristic is listed in online supplemental table 2.
Table 3. Descriptive statistics of the different HRQoL instruments.
| Instruments | Theoretical range | Observed range | Total | Mild | Moderate | Severe | P value |
|---|---|---|---|---|---|---|---|
| EQ-5D-5L | −0.39,1.00 | 0.40,1 | 0.96 (0.06) | 0.96 (0.06) | 0.95 (0.07) | 0.90 (0.10) | <0.001 |
| DLQI | 0,30 | 0,29 | 6.84 (4.88) | 6.60 (4.79) | 7.72 (5.00) | 8.19 (6.02) | 0.007 |
| CADI | 0,15 | 0,15 | 5.72 (2.81) | 5.60 (2.75) | 6.11 (2.85) | 6.62 (3.77) | 0.016 |
CADI, Cardiff Acne Disability Index; DLQI, Dermatology Life Quality Index; EQ-5D-5L, EuroQol 5-Dimensions 5-Levels; HRQoL, health-related quality of life.
Multivariable adjusted linear models, while controlling for sociodemographic and clinical characteristics, demonstrated a consistent trend (table 2). Patients presenting with moderate and severe acne exhibited significantly lower HSU scores than those with mild acne (−0.017 and −0.066) and higher DLQI total scores (1.457 and 2.043) and CADI total scores (0.726 and 1.685), indicating more impairment.
Correlation of clinical severity with patients’ HRQoL
Table 4 presents the Spearman’s rank correlation coefficients for comparing clinical severity scores and patients’ HRQoL scores, indicating weak correlations (rs=−0.131 to 0.167). Online supplemental table 3 illustrates the correlations between generic, dermatology-specific and acne-specific instruments. Specifically, the EQ-5D-5L HSU score displays moderate negative correlations with both the DLQI total score (rs=−0.349) and the CADI total score (rs=−0.339). A strongly significant correlation (rs=0.736) is observed between the dermatology-specific and acne-specific instruments. Among the dimensions of EQ-5D-5L, ‘anxiety/depression’ exhibited significant correlations with both the DLQI (rs=0.327) and CADI total scores (rs=0.350).
Table 4. Spearman’s rank correlation between clinical severity instrument (GAGS) and HRQoL instruments.
| Instruments | Correlation | P value |
|---|---|---|
| EQ-5D-5L HSU Score | −0.131 | <0.001 |
| DLQI | ||
| Symptoms and feeling | 0.157 | <0.001 |
| Daily activities | 0.101 | 0.002 |
| Leisure | 0.109 | 0.001 |
| Work or school | 0.062 | 0.054 |
| Personal relationships | 0.053 | 0.098 |
| Side effects of treatment | 0.104 | 0.001 |
| Total score | 0.136 | <0.001 |
| CADI | ||
| Psychological consequences | 0.073 | 0.023 |
| Social consequences | 0.086 | 0.007 |
| Avoided public changing facilities | 0.085 | 0.008 |
| Feeling about the appearance | 0.097 | 0.003 |
| Assessment of their acne severity | 0.167 | <0.001 |
| Total score | 0.147 | <0.001 |
CADI, Cardiff Acne Disability Index; DLQI, Dermatology Life Quality Index.
Discussion
To the best of our knowledge, this is the first study in China to comprehensively assess the HRQoL in patients with different severity of acne and its correlation with clinical severity. The study revealed the considerable negative impact of acne on patients’ HRQoL, with patients reporting significantly worse HRQoL on all generic, dermatology-specific and acne-specific instruments, as severity increased. This finding is consistent with previous studies reporting impaired HRQoL in this population.28 29 The mean score for the patients with acne was 0.96 (SD: 0.06) based on the EQ-5D-5L, which was higher than the norm of the Chinese population (0.94, SD: 0.138),30 and also higher than those reported in a recent Hungarian study (0.87)31 and a Singaporean study (0.89).32 In terms of dermatology-specific instrument and acne-specific instruments, the mean DLQI score in our study was 6.84 and the mean CADI score was 5.72. These scores are consistent with the ranges commonly reported in the literature for acne patients using these instruments. For example, studies from India reported mean DLQI scores of 5.60±5.88 and mean CADI scores of 4.10±3.56,33 while research from Egypt found mean DLQI scores of 9.8±5.5 and mean CADI scores of 6.0±3.2.34 The observed differences may be attributed to the application of different country-specific EQ-5D-5L tariffs, the potential varying compositions of acne severities within the patient sample and the differing response patterns of the questionnaires across different countries. Furthermore, this study found that patients with moderate and severe acne had significantly lower HRQoL than patients with mild acne, which was consistent with previous studies.28 Previous research showed that mild and moderate acne mainly manifests as papules and pustules, whereas severe acne is characterised by numerous nodules and cysts that can lead to scarring. That may lead to more dissatisfaction with appearance, embarrassment and lack of self-confidence in patients with acne.11 12
The study revealed that the anxiety/depression dimension was the predominant problem reported by acne patients based on the EQ-5D-5L, consistent with prior evidence indicating that 46.3–69.4% of acne patients exhibit anxiety or depressive symptoms.35 Moreover, this dimension exhibited a moderate correlation with the total scores of both CADI and DLQI. Acne can be a devastating disease for many patients, especially adolescents, who are particularly vulnerable socially and psychologically, as it manifests on visible body parts and may result in considerable scarring.36 Beyond physical symptoms, acne profoundly impacts psychological well-being, contributing to body image dissatisfaction and social stigma.37 Patients with acne experience social, psychological and emotional burdens comparable to those with chronic disabling conditions like asthma, epilepsy, diabetes and arthritis.38 However, the psychological aspects of acne are often neglected in treatment, which may consequently result in poor treatment adherence and patient dissatisfaction.39 Our findings underscore the critical importance of routinely assessing psychological and social functioning in acne patients to identify those requiring additional support. In the future, brief psychological screening and the integration of psychosocial support services for acne patients should be considered as part of comprehensive clinical management.
The worsened HRQoL in patients with acne was observed, whether they were mild, moderate or severe. In clinical practice, physicians often use clinical severity to evaluate the impact of acne on patients. However, the correlation between clinical severity and HRQoL in patients with acne is inconsistent.9 While some studies found a correlation between HRQoL and acne severity,640,42 other studies found no correlation.17 43 This inconsistency can be attributed to factors such as small sample size, use of non-validated outcome instruments and patients’ particular environment (eg, personal, social and occupational).44 45 Furthermore, patients’ subjective perception, self-assessment and coping strategies regarding acne contribute to differences in HRQoL. Notably, individual psychological resilience, attitudes toward appearance and prior experiences with acne can profoundly modulate disease impact. As evidenced in the literature, individuals with mild acne may report severe psychological disability due to heightened appearance-related distress, whereas those with more severe physical manifestations might exhibit greater adaptation.30 46 This heterogeneity emphasises that the true burden of acne exceeds the clinicians' assessment of the severity of acne.47 Therefore, comprehensive acne management must incorporate routine HRQoL assessments using validated instruments alongside clinical evaluation.
The correlation analysis revealed a moderate correlation between the generic instrument (EQ-5D-5L) and both dermatology-specific (DLQI) and acne-specific (CADI) instruments, whereas a strong correlation was found between the dermatology-specific and acne-specific instruments. This can be explained by the differences in the nature and measurement properties of the instruments. As a generic instrument, the EQ-5D-5L is widely applicable across types and severities of disease and different medical treatments or health interventions, but exhibits limited sensitivity to dermatology-specific HRQoL impairments.24 48 In contrast, dermatology-specific and acne-specific instruments were developed to capture acne or skin disease-related quality of life.48 The DLQI encompasses the primary dimensions covered by dermatology-specific instruments, but it lacks the granularity of the CADI in assessing critical acne-related concerns such as appearance dissatisfaction, bullying experiences and scar anxiety.23 Conversely, the disease-specific focus of the CADI limits its cross-condition comparability, a gap that is filled by the EQ-5D-5L. The finding indicates that these instruments are complementary but dissimilar. Relying solely on a single generic, dermatology-specific or acne-specific instrument alone would not adequately capture the unique HRQoL faced by patients with acne. Incorporating multiple instruments in the HRQoL assessment of patients with acne may provide a more comprehensive understanding of their HRQoL status.
While our study provides valuable insights into the HRQoL of acne patients, there are several limitations that should be acknowledged. First, the study only recruited patients from one hospital in China, which may not adequately reflect the diversity of acne patients across different regions and healthcare settings within China. In the future, large-scale and multicentre studies should be carried out to improve the validity and generalisability of the findings. Second, although our study included a range of HRQoL instruments, there may be other relevant measures that we did not consider. Therefore, future studies should incorporate more additional HRQoL instruments from different dimensions to comprehensively evaluate the impact of acne on HRQoL. Third, the cross-sectional design limits the assessment of the changes in HRQoL of patients over time. We are unable to assess the changes in HRQoL of patients as the disease progresses. Further longitudinal studies are needed to help reveal the long-term impact of acne on HRQoL in patients.
Conclusion
Our study indicates that acne is associated with a significant impact on patients’ HRQoL, especially in terms of psychosocial functioning. These findings highlight the importance of incorporating HRQoL assessment into the routine clinical evaluation and considering the different instruments and their relevance to HRQoL of acne patients in future research. Therefore, using a combination of dermatology-specific and acne-specific HRQoL instruments may provide a more comprehensive understanding of the overall health status of individuals living with acne.
Supplementary material
Acknowledgements
We acknowledge the Qilu Hospital of Shandong University for supporting this study. Thanks to all the participants for their contribution to this study.
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-091036).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants and this study involves human participants and this study was screened and approved by the Ethics Committee Scientific Research of Qilu Hospital of Shandong University (No. KYLL-2018-195). Participants gave informed consent to participate in the study before taking part.
Patient and public involvement: Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Data availability statement
Data are available upon reasonable request.
References
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