The Burden of Acne Vulgaris on Health-Related Quality of Life and Psychosocial Well-Being Domains: A Systematic Review

Abstract

Background

Acne vulgaris (acne) is a common dermatological condition that can profoundly affect psychosocial well-being. Health-related quality of life (HRQoL) is an important outcome measure to assess the burden of acne in research and clinical practice.

Objective

This systematic review aimed to identify, critically appraise, and synthesize current evidence on the effects of acne on HRQoL and other psychosocial outcomes.

Methods

Structured searches of PubMed and Web of Science were conducted to identify studies measuring any HRQoL or psychosocial outcome in patients with acne vulgaris (all ages). Eligible studies were those that included ≥ 50 patients with acne, measured HRQoL or psychosocial outcomes as primary endpoints, were conducted in Europe and North America, and were published in English from 1 January 2014 to 30 April 2024. Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools.

Results

In total, 101 studies were deemed eligible for inclusion. They varied widely in terms of study design, population, outcomes, and quality, but overall demonstrated the adverse impacts of acne on HRQoL, mental health outcomes, and the lived experiences of people with acne. Despite their heterogeneity, studies frequently found that acne predominantly affected the emotional and psychological domains of HRQoL, and was particularly burdensome to adults, females, and those with more severe acne.

Conclusions

This review collated the spectrum of impacts that acne vulgaris can impose on psychosocial well-being, and highlighted the need for consensus outcome measures to streamline future research and improve clinical practice.

PROSPERO Registration

CRD42024539174.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40257-025-00983-3.

Key Points

The burden of acne in research and clinical practice is often measured using health-related quality of life (HRQoL) or psychosocial outcomes; however, heterogeneity in the design, population, outcomes, and quality of studies in acne vulgaris is common.

Despite this, studies demonstrate the adverse impacts of acne on HRQoL, mental health outcomes, and the lived experiences of people with acne.

Acne has a large impact on the emotional and psychological domains of HRQoL scales, and imposes a greater burden on adults, females, and those with more severe acne.

Introduction

Acne vulgaris (or acne) is a common dermatological condition characterized by chronic inflammation of the pilosebaceous unit [1]. The epidemiology of acne is complex and there is great variability among estimations of its incidence and prevalence [2]. The most recent Global Burden of Disease Study estimated that there were 240million people with acne worldwide in 2021, equating to an age-standardized prevalence of 3.1% [3]. Although acne is often considered a disease of puberty and is most prevalent in adolescents and young adults (with an estimated prevalence of 9.8% among those aged 10–24 years), a substantial proportion of people will continue to live with acne or develop the condition later in adulthood [1, 3, 4].

While not life-threatening, acne is nevertheless a burdensome condition that accounted for 5.13 million disability-adjusted life years (DALYs) worldwide in 2021 [3]. When compared with other skin diseases, the global burden of acne was similar to that caused by atopic dermatitis (5.62 million DALYs) and scabies (5.32 million DALYs), and greater than that attributed to psoriasis (3.69 million DALYs) [3]. Factors that contribute to the overall burden of acne include the physical effects of its symptoms and sequalae (e.g., pain, scarring), the direct healthcare costs of acne management, and the indirect costs associated with loss of productivity [5]. However, the burden of acne is most often related to its negative effects on psychosocial and mental health outcomes, including but not limited to anxiety, depression, self-esteem, and stigmatization [5].

Given that acne can profoundly impact emotional and social well-being, health-related quality of life (HRQoL) is an important outcome measure to assess the burden of acne, and the effectiveness of acne treatment, in research and clinical practice [6–9]. A wide range of patient-reported outcome measures (PROMs) have been developed to evaluate the effects of acne on HRQoL, and previous reviews have sought to collate and critically appraise these instruments [10–12]. By using a broader scope than previous studies, this systematic literature review aimed to characterize the spectrum of ways that acne can impact HRQoL and psychosocial well-being, and identify the HRQoL domains and mental health outcomes that are most affected in patients with acne vulgaris.

Methods

Literature Search and Selection

This systematic literature review is registered with PROSPERO (CRD42024539174) and was conducted and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 statement [13]. Briefly, structured searches of the PubMed and Web of Science bibliographic databases were conducted on 30 April 2024 to identify studies that evaluated HRQoL and psychosocial outcomes in patients with acne vulgaris. The search strategies included terms related to acne vulgaris, in combination with key terms related to HRQoL and mental health outcomes. The searches were limited to English-language publications since January 1994 (the year that the Dermatology Life Quality Index [DLQI] was first published [14]), and excluded animal studies, congress abstracts, case reports, comments, editorials, guidelines, letters, protocols, study guides, and reviews (i.e., systematic reviews and meta-analyses, literature reviews, scoping reviews, prospective reviews, narrative reviews, and book reviews). Full search strategies for the PubMed and Web of Science database searches are provided in Supplementary Tables S1 and S2, respectively.

After the database searches were conducted, our systematic review protocol was amended to capture the most recent, robust, and relevant studies in this field. We limited eligible studies to those published within the last 10 years (i.e., since January 2014), those that included ≥ 50 patients with acne vulgaris, and those that measured HRQoL or psychosocial outcomes as primary endpoints. To further reduce the number of hits and synthesize data from a culturally similar acne population, we also limited this review to studies conducted in Europe and North America. A review of the impact of acne vulgaris on patients from other regions is planned for a separate publication.

With these amended inclusion criteria, the titles and abstracts of the database search results were screened for eligibility by two independent reviewers (K.H.P. and C.I.). In addition, included publications reported on any type of interventional or noninterventional study that measured any HRQoL or psychosocial outcome in patients of all ages with acne vulgaris. Studies of patients with other forms of acne (e.g., acne fulminans, acne inversa, drug-induced acne) were excluded. This review was not designed to evaluate the effect of interventions on psychosocial or HRQoL outcomes; however, interventional studies were included (with no particular eligibility criteria for interventions or comparators/controls), focusing on their baseline data.

Data Extraction and Synthesis

After title and abstract screening, full-text versions of articles identified as potentially relevant were retrieved to confirm their inclusion based on the eligibility criteria above. The following data were extracted from studies deemed eligible after full-text review:

• Article citation details (author, year, title, journal, volume, and page numbers).

• Study design, study identifiers (as applicable), country.

• Study population (including key eligibility criteria for patients with acne vulgaris).

• Study cohorts/subgroups and sample sizes.

• Key patient characteristics (including age, sex, race/ethnicity, Fitzpatrick skin phototype).

• Acne severity (including how severity was assessed and by whom).

• Location of acne and presence of acne sequelae (e.g., scarring, hyperpigmentation).

• Outcome measures (including the method/instrument used to assess HRQoL or psychosocial outcomes, and data collected using this method/instrument).

Data were extracted from all acne study cohorts and subgroups (e.g., patients stratified by age, sex, acne severity) for which HRQoL or psychosocial data were available. As noted above, only baseline data of interest were collected from interventional studies, to capture the baseline impact of acne vulgaris. Data were extracted into an Excel spreadsheet by two independent reviewers (K.H.P. and C.I.); all conflicts were resolved by the two reviewers, without the need for adjudication by a third independent reviewer.

Risk of bias in each study was assessed by one independent reviewer (K.H.P.) using the Joanna Briggs Institute (JBI) critical appraisal tools [15]. These include quality checklists for cross-sectional, cohort, and case–control studies [16], case series [17], quasi-experimental studies [18], randomized controlled trials (RCTs) [19], and qualitative research [20], which subsequently allow a level of comparison between studies of different methodological designs. Each of these checklists contain a series of questions that assess methodological quality on the basis of study type, answered as either “yes,” “no,” “unclear,” or “not applicable.” In line with previous systematic reviews [21–23], included studies were deemed to be high quality if ≥ 70% of checklist items were marked “yes,” moderate quality if ≥50% and < 70% of items were marked “yes,” and low quality if < 50% of items were marked “yes.”

We expected considerable heterogeneity between the studies captured in our systematic review; therefore, a narrative synthesis of data was anticipated. The primary outcomes of interest in this review were the range of methods and instruments used to assess HRQoL and psychosocial outcomes, and the impact(s) captured by these methods and instruments. Included studies were grouped by outcome measure and/or methods used, and summarized using descriptive statistics. The impact of acne on HRQoL and psychosocial well-being in key patient subgroups (e.g., age, sex, acne severity) were described when sufficient data were available.

Results

Study Selection

In total, the PubMed and Web of Science database searches returned 4734 records published from 1 January 1994 to 30 April 2024 (Fig. 1). After the removal of duplicate records and studies published before 2014, the titles and abstracts of 2070 articles were screened for eligibility, and 231 were retained for full-text review. A further 121 records were excluded after re-screening the full-text articles, resulting in 110 included articles that reported on 101 unique studies.

Fig. 1.

PRISMA 2020 flow diagram. Figure adapted from Page MJ, et al. [13]. PRISMA, Preferred ReportingItems for Systematic reviews and Meta-Analyses; QoL, quality of life

Study Characteristics

As expected, our literature searches captured a broad range of studies that measured HRQoL and/or psychosocial outcomes in patients with acne vulgaris (Table 1). The 101 included studies varied widely in terms of study design, acne population, sample size (ranging from 50 to 9.05 million people with acne), outcome measures, and methodological quality. Most included studies had a cross-sectional design (63 studies), followed by quasi-experimental studies (14 studies), RCTs (12 studies), cohort studies (5 studies), case series (3 studies), qualitative research (3 studies), and 1 case–control study. Using JBI critical appraisal tools selected on the basis of study type, most included studies were deemed to be of high (66 studies) or moderate (31studies) methodological quality.

Table 1.

Key characteristics of included studies

Study	Study designa	Acne population	Acne sample size (n)	HRQoL or psychosocial outcome measure(s)	Study qualityb
Adkins 2023 [126]	Cross-sectional study	Aged ≥ 16 years, current symptoms of acne	650	FSQ	Moderate
Ajdacic-Gross 2016 [112]	Cross-sectional study	Aged 35–66 years, self-reported acne	474	ORs for mental disorders	High
Altunay 2020 [25]	Cross-sectional study	Aged ≥ 18 years, diagnosed acne	213	DLQI, EQ-5D, EQ-VAS, HADS	High
Andersen 2022 [107]	Cross-sectional study	Aged 18–35 years, severe acne warranting treatment	4945	MDI, SF-12	High
Andrese 2016 [26]	Quasi-experimental study	Aged 14–35 years, diagnosed acne	82	DLQI	Moderate
Baldwin 2024 [103], Graber 2024 [104]	Quasi-experimental study	Aged ≥ 9 years, facial non-nodular moderate-to-severe acne (IGA score 3–4)	253	ASIS, EPQ	High
Ballanger 2023 [142]	Cross-sectional study	Aged ≥ 12 years, self-reported truncal acne	1001	Web-based survey	Moderate
Barbieri 2021 [143]	Qualitative study	Women aged 18–40 years, moderate-to-severe acne	50	Semi-structured interview	High
Basra 2018 [105]	Cross-sectional study	Aged 12–19 years, diagnosed acne	105	T-QoL	High
Beisert 2020 [129]	Cross-sectional study	Women aged 18–51 years, diagnosed acne	90	Body Attitudes Questionnaire, RSES, SSEI-SF, Whitley Sexual Satisfaction Inventory	High
Bień 2024 [141]	Cross-sectional study	Aged ≥ 18 years, history of acne ≥ 1 year	202	MLCDP	High
Brauer 2019 [137]	Case series	Aged 15–20 years and acne diagnosed from 1991 to 2005, prescription for minocycline	167	Incidence of urgent psychiatric referrals	High
Bray 2019 [110]	Quasi-experimental study	Aged 16–30 years, diagnosed acne and indicated for oral isotretinoin	56	LOT-R, MAACL-R, WHOQOL-BREF	High
Burris 2014 [99]	Cross-sectional study	Aged 18–25 years, mild-to-severe acne	156	AQOL	High
Callendar 2014 [57], Gorelick 2015 [58], Tanghetti 2014 [59]	Cross-sectional study	Women aged 25–45 years, self-reported acne (≥ 25 facial lesions)	312	Acne-QoL, PHQ-4, investigator-developed questionnaire	High
Campos-Muñoz 2023 [48]	Cross-sectional study	Aged 4–16 years, diagnosed acne	53	CDLQI	Moderate
Cartwright 2023 [144]	Cross-sectional study	People of color with self-reported acne	106	Web-based survey	Moderate
Chernyshov 2018 [27]	Cross-sectional study	Aged ≥ 16 years, diagnosed acne	150	DLQI, CADI	High
Chernyshov 2023 [145]	Cross-sectional study	Aged > 12 years, diagnosed acne	601	Investigator-developed survey	Moderate
Chilicka 2017 [28]	Quasi-experimental study	Women aged 19–29 years, diagnosed facial acne	101	DLQI, Skindex-29	High
Chilicka 2020a [29]	RCT	Women aged 18–25 years, mild-to-moderate papulopustular acne	120	DLQI, Skindex-29	High
Chilicka 2020b [136]	Cross-sectional study	Women aged 19–24 years, mild acne	150	DS14, FTAS, SWLS	High
Cretu 2023 [76]	Cross-sectional study	Medical students with self-reported acne	71	CADI	Moderate
Dashko 2019 [30]	Cross-sectional study	Women aged 18–35 years with acne	119	DLQI, Reactivity-Personal Anxiety Inventory	Moderate
Davern 2018 [31]	Cross-sectional study	Aged ≥ 18 years, self-reported acne in the previous 2 months	271	DLQI, Day-to-Day Discrimination Scale, HADS, Physical Health Questionnaire	High
de Vries 2022 [77]	Cross-sectional study	Aged ≥ 18 years, with or recently recovered from self-diagnosed acne	362	CADI	High
Desai 2017 [78]	Cross-sectional study	Aged 11–18 years, self-reported acne	274	CADI	High
Dréno 2015 [79]	Cross-sectional study	Women aged ≥ 25 years, diagnosed acne	374	CADI	High
Dréno 2019 [80]	Cross-sectional study	Aged > 15 years, diagnosed acne	1048	CADI, SF-12	High
Dréno 2021 [102]	Cross-sectional study	Adults with diagnosed acne	207	AI-ADL	Moderate
DuBois 2019 [32]	Quasi-experimental study	Aged ≥ 12 years; moderate or severe acne (IGA score 3–4); Asian, Latin American, or Black/African American ethnicity	50	CDLQI, DLQI	High
Đurović 2021 [49]	Cross-sectional study	Secondary school students, self-reported acne	249	CADI, CDLQI	Moderate
Esaa 2021 [113]	Cross-sectional study	Aged ≥ 5 years, diagnosed acne	527	PROMIS	High
Fabbrocini 2014 [34]	RCT	Aged 14–28 years, receiving systemic and topical acne treatment, GAGS score 1–39, CADI score > 7	160	CADI, DLQI	High
Fabbrocini 2018 [146]	Qualitative study	Aged 12–17 (adolescents) or ≥ 18 years (adults), moderate-to-severe acne	50	Semi-structured interview	High
França 2017 [35]	Cross-sectional study	People with acne and PIH	50	CADI, DLQI	Moderate
Gisondi 2023 [33]	Cross-sectional study	Aged ≥ 18 years, self-reported acne during the previous 12 months	2452	DLQI	Moderate
Gollnick 2015 [81]	Quasi-experimental study	Patients with moderate-to-severe facial inflammatory acne, indicated for topical therapy	5131	CADI	Moderate
Grimaldi 2023 [36]	Cross-sectional study	Patients treated with topical and systemic therapy for acne	178	BRS, DLQI, HADS, PSS	Moderate
Gupta 2014 [114]	Cross-sectional study	Dermatology outpatient visits in patients with acne	5447	ORs for ADHD and anxiety or depressive disorders	High
Harper 2019 [60]	RCT	Women aged 18–58 years, moderate or severe acne (EGSS score 3–4)	287	Acne-QoL	High
Hekmatjah 2021 [115]	Cross-sectional study	Diagnosed acne, receiving isotretinoin or oral antibiotics	9,046,894	K6, PHQ-2	High
Herrero-Zazo 2018 [138]	Cohort study	Aged 15–20 years and diagnosed with acne from 1991 to 2005	27,641	Incidence of severe mental illness	High
Hornsey 2021 [61]	Cross-sectional study	Aged 18–50 years with acne	204	Acne-QoL, CompAQ, Skindex-16	Moderate
Ip 2021 [89]	RCT	Aged 14–25 years, diagnosed acne and received prescription treatment in the past 6 months	53	PHQ-4, Skindex-16	High
Jankowska 2023 [37]	Quasi-experimental study	Aged 17–40 years, diagnosed acne	200	BDI, CADI, DLQI, SWLS	High
Janowski 2014 [86]	Cross-sectional study	Aged 16–82 years, diagnosed acne	58	Skindex-29	Moderate
Kainz 2016 [38]	Quasi-experimental study	Women aged ≥ 20 years, diagnosed with mild-to-moderate acne, indicated for 20% azelaic acid cream	251	DLQI	High
Kircik 2020 [62]	RCT	Aged ≥ 9 years, moderate or severe acne (EGSS 3–4)	1614	Acne-QoL	High
Kostecka 2022 [116]	Cross-sectional study	Aged < 35 years, present or previous acne diagnosis	1329	HADS	High
Kridin 2023 [117]	Cohort study	Diagnosed acne, receiving isotretinoin or oral antibiotics	151,416	HRs for psychiatric disorders	Moderate
Lappas 2022 [125]	Cross-sectional study	Aged > 16 years, referred to mental health services for isotretinoin initiation	57	Risk of suicidality	High
Leskelä 2024 [111]	Cross-sectional study	Aged 46 years, diagnosed acne	150	AIS, BDI-II, GAD-7, STAI, 15D-HRQoL	High
Liasides 2015 [63]	Cross-sectional study	Aged ≥ 18 years, diagnosed acne	119	Acne-QoL, FSQ	High
Lindberg 2014 [106]	Cross-sectional study	Aged 18–84 years, self-reported acne	500	SF-36	Moderate
Lukaviciute 2017 [39]	Cross-sectional study	Aged 18–70 years, diagnosed acne	255	DLQI, HADS, severity of suicidal ideation	High
Lukaviciute 2020 [118]	Case-control study	Aged 18–70 years, diagnosed acne	283	HADS, prevalence of suicidal thoughts	Moderate
Marron 2019 [130], Marron 2020 [131]	Cross-sectional study	Patients with diagnosed acne	326	Prevalence of body dysmorphia	High
Martínez-García 2020 [40]	Cross-sectional study	Aged ≥ 16 years, diagnosed acne (LRAG score ≥3)	62	DLQI, HADS	High
Marty 2024 [147]	Qualitative study	Patients with open social media posts regarding their acne	10,251	Frequency of encountered difficulties in social media posts	High
McLellan 2018 [64]	Cross-sectional study	Patients referred to dermatologists for acne	690	Acne-QoL	Moderate
Miller 2024 [119]	Cohort study	Aged 12–18 years, prescribed isotretinoin for acne	606	Frequency of psychiatric diagnoses or symptoms	Moderate
Milutinović 2017 [87]	Cross-sectional study	Aged ≥ 18 years, diagnosed acne	53	Skindex-29	Moderate
Misery 2015 [134]	Cross-sectional study	Aged 15–24 years, self-reported acne	1375	Investigator-developed questionnaire	High
Misery 2020 [108]	Cross-sectional study	Aged ≥ 15 years, self-reported acne	482	EQ-5D, EQ-VAS, investigator-developed questionnaire	Moderate
Nagpal 2019 [41]	Cross-sectional study	People with self-reported acne	61	DLQI	High
Neumeister 2021 [42]	Quasi-experimental study	Aged ≥ 14 years, diagnosed mild to moderate acne (LRAG score ≥ 4)	273	CDLQI, DLQI	High
Pagliarello 2015 [88]	Cross-sectional study	Aged > 18 years, diagnosed acne	195	SF-12, Skindex-29	High
Paljarvi 2022 [120]	Cohort study	Aged 12–27 years, diagnosed acne	382,340	Incidence of neuropsychiatric disorders/events	High
Paller 2024 [127]	Cross-sectional study	Aged 8–17 years, diagnosed chronic acne (duration ≥ 6 months), at least moderate severity	381	PROMIS	High
Pochynok 2018 [82]	Cross-sectional study	University and school students, self-reported acne	258	CADI	Low
Poláková 2015 [83]	RCT	Aged 12–25 years, mild-to-moderate acne (IGA score 2–3), prescribed adapalene 0.1% gel for ≥ 2 months	111	CADI	Moderate
Pyne 2023 [65], Santer 2023 [66]	RCT	Women aged ≥ 18 years, diagnosed facial acne indicated for oral antibiotics, IGA score ≥ 2	410	Acne-QoL, EQ-5D	High
Reljić 2014 [50]	Cross-sectional study	High school students with self-reported acne	228	CDLQI	Low
Rencz 2022 [109]	Cross-sectional study	Aged ≥ 18 years, diagnosed acne	83	General health status (0–100 VAS), ICECAP-A	High
Richter 2017 [43]	Quasi-experimental study	Women aged 20–45 years, diagnosed mild-to-moderate acne (ISGA score 2–3)	53	DLQI	High
Rokowska-Waluch 2016 [135]	Cross-sectional study	Aged 18–34 years, diagnosed acne	80	SRRS	High
Sadowsky 2020 [91]	Cross-sectional study	Aged 12–17 years, diagnosed acne	60	Skindex-Teen, investigator-developed teen impact scale	High
Sampogna 2017 [44]	Cross-sectional study	Aged ≥ 18 years, diagnosed acne	202	DLQI	High
Schut 2022 [132]	Cross-sectional study	Aged ≥ 18 years, diagnosed acne	236	Prevalence of body dysmorphia	High
Secrest 2020 [90]	Case series	Aged ≥ 12 years, diagnosed acne	57	Skindex-16	High
Shields 2024 [121]	Cross-sectional study	Aged ≥ 18 years with acne	200	PROMIS	Moderate
Silverberg 2014 [122]	Cross-sectional study	Aged < 18 years, self-reported severe acne	NR	ORs for mental health outcomes	Moderate
Šimić 2017 [100]	Quasi-experimental study	Aged 13–25 years, diagnosed moderate-to-severe acne	127	APSEA, BDI, DSQL, PSS, STAI	Moderate
Singam 2019 [123]	Case series	Hospitalized patients, primary or secondary diagnosis of acne	31,131	ORs for hospitalization due to mental health disorders	High
Skroza 2018 [67]	Cross-sectional study	Aged 12–25 (adolescents) or > 25 years (adults), diagnosed mild-to-severe acne	1167	Acne-QoL	High
Stein Gold 2019 [68]	RCT	Females aged ≥ 13 years, diagnosed moderate-to-severe acne (EGSS 3–4)	865	Acne-QoL	High
Stein Gold 2023 [69]	RCT	Aged ≥ 13 years, diagnosed moderate or severe acne (EGSS 3–4)	309	Acne-QoL	Moderate
Stinco 2016 [98]	RCT	Patients with mild-to-moderate facial acne (GAGS score 10–30)	240	AQOL	High
Szepietowska 2022a [45], Szepietowska 2022b [139], Szepietowska 2022c [128]	Cross-sectional study	Aged 15–19 years, self-reported acne	547	DLQI, 6-ISS, PSQ, TAS-20	High
Szepietowska 2023 [46], Szepietowska 2024 [140]	Cross-sectional study	Patients with diagnosed acne	104	ACIPS, CADI, DLQI, HADS, 6-ISS, SHAPS, TEPS	High
Szepietowski 2018 [148]	Cross-sectional study	Aged 15–24 years, self-reported acne	3099	Online survey	Moderate
Tan 2021 [47], Tan 2022 [149]	Cross-sectional study	Aged 13–40 years, receiving prescription treatment for acne	1309	CDLQI, CompAQ, DLQI, quantitative survey	High
Tavecchio 2020 [150]	Cross-sectional study	Aged 12–21 years with acne	2327	Investigator-developed survey	Low
Tolino 2020 [71]	Quasi-experimental study	Patients treated with oral isotretinoin for severe acne or moderate acne resistant to other systemic treatments	100	Acne-QoL	Moderate
Tolino 2021 [70]	RCT	Aged > 16 years, mild-to-moderate papulopustular acne	100	Acne-QoL	Low
Tros 2023 [133]	Cross-sectional study	Aged 13–24 years, receiving treatment for acne	105	RSES, frequency of body dysmorphic disorder	High
Tyring 2020 [72]	RCT	Aged ≥ 9 years, moderate or severe acne (EGSS 3–4)	1640	Acne-QoL	High
Ugonabo 2021 [124]	Cohort study	Aged 12–35 years, diagnosed acne, prescribed isotretinoin or antibiotic therapy	72,855	Prevalence of psychiatric disorders	High
Zaenglein 2020 [73]	Quasi-experimental study	Aged 12–45, acne with ≥ 5 facial nodules	166	Acne-QoL	High
Zauli 2014 [101]	Quasi-experimental study	Aged > 10 years, newly diagnosed facial acne	100	APSEA	Moderate

15D-HRQoL, 15-dimension health-related quality of life; 6-ISS, 6-Item Stigmatization Scale; ACIPS, Anticipatory and Consummatory Interpersonal Pleasure Scale; Acne-QoL, Acne-specific Quality of Life questionnaire; ADHD, attention deficit hyperactivity disorder; AI-ADL, Acne Impact on Adult Daily Life questionnaire; AIS, Athens Insomnia Scale; APSEA, Assessments of the Psychological and Social Effects of Acne; AQOL, Acne Quality of Life scale; ASIS, Acne Symptom and Impact Scale; BDI, Beck Depression Inventory; BRS, Brief Resilience Scale; CADI, Cardiff Acne Disability Index; CDLQI, Children’s Dermatology Life Quality Index; CompAQ, Comprehensive Acne Quality of Life Scale; DLQI, Dermatology Life Quality Index; DSQL, Dermatology-Specific Quality of Life; DS14, 14-item Type D Scale; EGSS, Evaluator’s Global Severity Score; EPQ, Expert Panel Questionnaire; EQ, EuroQol; FSQ, Feelings of Stigmatization Questionnaire; FTAS, Framingham Type A Scale; GAD, Generalized Anxiety Disorder; GAGS, Global Acne Grading System; HADS, Hospital Anxiety and Depression Scale; HR, hazard ratio; HRQoL, health-related quality of life; ICECAP-A, ICEpop CAPability measure for Adults; IGA, Investigator Global Assessment; ISGA, Investigator Static Global Assessment; JBI, Joanna Briggs Institute; K6, Kessler 6-Item Psychological Distress Scale; LOT-R, Life Orientation Test Revised; LRAG, Leeds Revised Acne Grading; MAACL-R, Multiple Affect Adjective Checklist Revised; MDI, Major Depression Inventory; MLCDP, Major Life Changing Decision Profile; NR, not reported; OR, odds ratio; PHQ, Patient Health Questionnaire; PIH, post-inflammatory hyperpigmentation; PROMIS, Patient-Reported Outcome Measures Information System; PSQ, Perceived Stigmatization Questionnaire; PSS, Perceived Stress Scale; RCT, randomized controlled trial; RSES, Rosenberg Self-Esteem Scale; SF, Short Form; SHAPS, Snaith-Hamilton Pleasure Scale; SRRS, Social Readjustment Rating Scale; SSEI, Sexual Self‐Esteem Inventory; STAI, State-Trait Anxiety Inventory; SWLS, Satisfaction with Life Scale; TAS-20, Toronto Alexithymia Scale; TEPS, Temporal Experience of Pleasure Scale; T-QoL, Teenagers' Quality of Life; VAS, visual analog scale; WHOQOL, World Health Organization Quality of Life

^aStudy design reflects the JBI critical appraisal checklist selected to assess methodological quality and risk of bias

^bStudies were assessed for risk of bias using the JBI critical appraisal tools [15], and were categorized as high quality (≥ 70%), moderate quality (50–69%), or low quality (< 50%) based on of the percentage of items marked “yes” on the JBI checklist used (selected based on study design)

We observed considerable heterogeneity in the acne populations included in each study (Table 1). Patient demographic and clinical characteristics varied with respect to age (ranging from children to older adults), sex (13 studies included females only), how acne vulgaris was identified (e.g., self-reported, clinically diagnosed, not reported), and if/how acne severity was assessed (e.g., self-reported, not reported, or assessed using a variety of severity scales, including the Global Acne Grading System [GAGS], Investigator's Global Assessment [IGA], and Leeds Revised Acne Grading [LRAG]). It should be noted that acne severity scales commonly grade facial acne and relatively few assess the severity of truncal acne [24]. The location of acne was infrequently reported among the studies included in our review.

Included studies also used a broad range of methods and outcome measures to evaluate the HRQoL and psychosocial impact of acne vulgaris (Table 1). We grouped these studies into three main categories: (1) studies that used acne-specific, dermatology-specific, and/or generic HRQoL instruments to assess the effects of acne on general health and emotional, social, and physical functioning; (2) studies that used other instruments or methods to evaluate specific mental health outcomes (e.g., anxiety and depression, stigmatization, self-esteem, neuropsychiatric disorders); and (3) studies that used other qualitative or quantitative methods to elicit the lived experiences of people with acne vulgaris. Each of these groups are discussed in the following subsections; several studies used a combination of methods and outcome measures to assess the HRQoL and psychosocial impact of acne vulgaris, and are subsequently discussed across multiple subsections.

Impact of Acne Vulgaris on HRQoL

Overall, 67 studies used one or more HRQoL instruments to evaluate the effects of acne vulgaris on general health and well-being. A wide range of PROMs were used in these studies, ranging from acne- or dermatology-specific instruments (e.g., DLQI, Acne-specific Quality of Life questionnaire [Acne-QoL]), to generic HRQoL questionnaires (e.g., Short Form [SF-36, SF-12] and EuroQol [EQ-5D, EQ-VAS] instruments). Study data for the four most used PROMs are discussed below, and studies that used alternative HRQoL instruments are summarized in Table 2.

Table 2.

Other HRQoL instruments used to assess the impact of acne vulgaris among included studies

Outcome measure	Domains and scoring	Validated	Unique studies in review (n)	References	General findings in acne populations
Dermatology- or acne-specific HRQoL instruments
Acne Quality of Life scale (AQOL) [156]	Domain: Social impact Scoring: 9 items rated 0–3; higher scores indicate greater QoL impairment	✓	2	[98, 99]	AQOL scoring methods were inconsistent between studies; mean scores ranged from 0.2 to 5.4 AQOL scores were higher with increasing acne severity
Assessments of the Psychological and Social Effects of Acne (APSEA) [157]	Domains: Psychological and social impact Scoring: 6 items rated on 4-point scales and 9 items rated on 0–10 VAS; higher scores indicate greater QoL impairment	✗	2	[100, 101]	APSEA scoring methods were inconsistent between studies; mean scores ranged from 44.9 to 84.3 APSEA scores were higher in females versus males, and with increasing acne severity
Comprehensive Acne Quality of Life Scale (CompAQ) [151]	Domains: Symptoms, social (judgement by others), social interactions, psychological/emotional, treatment concerns Scoring: 20 items rated 0–8; total score 0–160 (higher scores indicate greater QoL impairment)	✓	2	[47, 61]	Mean CompAQ total scores of 82.1–87.3 across studies CompAQ scores were higher in patients with facial and truncal acne versus facial acne only CompAQ domain scores were highest for psychological/emotional and treatment concerns
Acne Impact on Adult Daily Life questionnaire (AI-ADL) [102]	Domains: Relationships with others, economic consequences, impact on work, impact on daily life/sexuality/libido Scoring: 14 items rated 0–5; higher scores indicate greater QoL impairment	✓	1	[102]	Mean AI-ADL scores ranged from 19.1 (mild burden) to 35.4 (severe burden) across subgroups AI-ADL scores were higher with increasing acne severity
Acne Symptom and Impact Scale (ASIS) [158]	Domains: Signs, emotional impact, social impact Scoring: 17 items rated 0–4; higher scores indicate greater QoL impairment	✓	1	[103]	ASIS scores tended to be higher for items related to emotional impact and lower for items related to social impact
Dermatology Specific Quality of Life (DSQL) [159]	Domains: Physical symptoms, activities of daily living, social, work/school, self-perception Scoring: 28 items rated 0–4; domain score 0–4, total score 0–20 (higher scores indicate greater QoL impairment)	✓	1	[100]	It was unclear how DSQL scores were measured in this study; therefore, no clear conclusions can be drawn
Expert Panel Questionnaire (EPQ) [104]	Domains: Emotional functioning, social functioning, activities of daily living Scoring: 11 items rated 0–4; higher scores indicate greater QoL impairment	✗	1	[104]	EPQ scores tended to be higher for items related to emotional and social functioning, and lower for items related to activities of daily living
Teenagers’ Quality of Life questionnaire (T-QoL) [105]	Domains: Self-image, physical well-being and future aspirations, psychosocial impact and relationships Scoring: 18 items rated 0–2; total score 0–36 (higher scores indicate greater QoL impairment)	✓	1	[105]	Mean T-QoL total score of 11.6 Mean T-QoL domains were greater for self-image domain (6.8 out of 16) versus psychosocial impact/relationships (3.5 out of 12) and physical well-being/future aspirations (1.4 out of 8)
General HRQoL instruments
Short Form questionnaires (SF-36, SF-12)	SF-36 [160]: Domains: physical function, role physical, bodily pain, general health, vitality, social functioning, role emotional, mental health Scoring: 36 items rated 0–100; lower scores indicate greater QoL impairment	✓	1	SF-36: [106]	SF-36: SF-36 domain scores tended to be lower for the general health, mental health, and vitality domains SF-36 scores were lower in patients with severe versus mild acne
	SF-12 [161]: Domains: Mental component summary (MCS), physical component summary (MPS) Scoring: 12 items rated 0–100; domain scores < 50 indicate below-average mental or physical health	✓	3	SF-12: [80, 88, 107]	SF-12: Average MCS scores of 39.1–51.2 across studies; PCS scores of 55.4–57.3 MCS scores tended to be lower in females versus males, in patients aged > 20 versus ≤20 years, in untreated versus treated patients, and with increasing acne severity
EuroQol instruments (EQ-5D, EQ-VAS) [162]	Domains: Mobility, self-care, usual activities, pain/discomfort and anxiety/depression Scoring: 5 items rated 1–5 (higher scores indicate greater QoL impairment); VAS rated 0–100 (lower scores indicate worse overall health)	✓	4a	[25, 65, 108, 109]	One study reported overall EQ-5D scores of 0.86–0.89 across subgroups One study reported EQ-5D domain scores of 1.02–1.59; domain scores were higher for anxiety/depression versus other domains Mean VAS scores of 68.8–79.0
World Health Organization Quality of Life (WHOQOL-BREF) [163]	Domains: Physical health, psychological well-being, social relationships, environment Scoring: 26 items rated 1–5; domain scores 0–100 (lower scores indicate greater QoL impairment)	✓	1	[110]	Mean WHOQOL-BREF domain scores ranged 67.7–82.3 WHOQOL-BREF scores were lowest for the psychological and social relationships domains
14-Item Physical Health Questionnaire [164]	Domain: Somatic symptoms Scoring: 14 items rated 1–7; total score 14–98 (higher scores indicate more frequent somatic symptoms)	✓	1	[31]	Mean total score of 44.76, indicating moderate impact of somatic symptoms
15-Dimension HRQoL instrument (15D) [165]	Domain: Overall HRQoL Scoring: 15 items rated 1–5; single index score of 0–1 (higher scores indicate better HRQoL)	✓	1	[111]	Mean 15D score was 0.92; not significantly different versus people without acne (OR 0.48 [95% CI 0.04–5.28])

CI, confidence interval; HRQoL, health-related quality of life; OR, odds ratio; QoL, quality of life; VAS, visual analog scale

^aOne study did not explicitly use the EQ-VAS but assessed general health status using a 0–100 VAS [109], so it was assessed alongside studies that used the EQ-VAS

Dermatology Life Quality Index

In total, 26 studies evaluated acne-related quality of life (QoL) using the DLQI (23 studies [25–47]) and/or the Children’s DLQI (CDLQI; 6 studies [32, 42, 47–50]). The DLQI is a 10-item questionnaire that evaluates the impact of skin diseases on six HRQoL domains (symptoms and feelings, daily activities, leisure, work and school, personal relationships, and treatment) in patients aged ≥ 16 years [14]. For those aged 4–16 years, the 10-item CDLQI was similarly designed to evaluate the effects of skin diseases on symptoms and feelings, leisure, school and holidays, personal relationships, sleep, and treatment domains [51, 52]. In both questionnaires, the impact of acne on each item is rated on a 4-point scale from 0 (not at all/not relevant) to 3 (very much), yielding total scores of 0–1 (no effect on QoL), 2–5 (small effect on QoL), 6–10 (moderate effect on QoL), 11–20 (very large effect on QoL), and 21–30 (extremely large effect on QoL). Both instruments are validated and recommended for HRQoL assessment in people with acne [10], and are the most widely-used PROMs in dermatology for their respective age groups [53–56].

In studies that reported mean or median DLQI scores, averaged total scores ranged from 2.8 (small impact on QoL) to 23.3 (extremely large impact on QoL) across acne cohorts (Fig. 2a) [25, 27–31, 34, 35, 37, 38, 40–43, 45–47]. These data are consistent with studies that presented only DLQI score frequency distributions, which similarly showed that the self-reported impact of acne vulgaris varied widely between individuals [26, 32, 33, 36, 39]. The highest DLQI total scores were reported in studies of women, including a study of 101 women with diagnosed facial acne (mean score of 22.6) [28], a randomized interventional study of 120 women with mild-to-moderate papulopustular acne (mean scores of 22.3–23.3 across treatment arms) [29], and in a subgroup of 78 women with acne duration of 1–5 years (mean score of 22.2) [30]. In studies that reported mean or median CDLQI scores in children or adolescents with acne, averaged total scores ranged from 3.6 (small impact on QoL) to 15.1 (very large impact on QoL) across cohorts (Fig. 2b) [47–50].

Fig. 2.

Average DLQI (a) and CDLQI (b) scores in studies of patients with acne vulgaris. Includes studies that reported mean or median DLQI/CDLQI scores in patients with acne vulgaris; lines represent the median of data shown. N values in the key refer to the total number of patients with acne in each study with DLQI/CDLQI scores reported. DLQI/CLDQI total scores range from 0 to 30, with higher scores indicating greater impact on quality of life. CDLQI domain scores range from 0 to 3 for the school/holidays, sleep, and treatment domains; 0 to 6 for the symptoms/feelings and personal relationships domains; and 0 to 9 for the leisure domain. CDLQI, Children’s Dermatology Life Quality Index; DLQI, Dermatology Life Quality Index

In studies that reported DLQI scores in acne subgroups, the impact of acne on QoL tended to be greater in females versus males, and correlated with acne severity (Fig. 2a) [38, 39, 42, 45, 47]. Other subgroup analyses additionally found that DLQI total scores were higher in patients with facial and truncal acne versus facial acne alone [47], in patients aged <20 years versus older adults [26, 38], in patients with an acne duration of 1–5 years versus < 1 year [30], and in patients who had actively sought treatment for their acne versus those who had not [27]. Similarly, in studies that reported CDLQI scores by subgroup, the impact of acne on QoL tended to be greater in females versus males (Fig. 2b) [42, 49], in patients with facial and truncal acne versus facial acne alone, and with increasing acne severity [47]. Several studies also reported that acne tended to impact the symptoms/feelings or personal relationships domains of the DLQI [28, 41, 47], and symptoms/feelings or leisure domains of the CDLQI (Fig. 2b) [47–50] more than other domains.

Acne-Specific Quality of Life Questionnaire

Fourteen studies assessed HRQoL in patients with acne using the Acne-QoL questionnaire [57–73]. The Acne-QoL instrument comprises 19 items that rate the impact of facial acne using 7-point scales from 0 (extremely) to 6 (not at all), yielding total scores ranging from 0 (extreme impact on QoL) to 114 (no impact on QoL) [74, 75]. Acne-QoL evaluates four domains of HRQoL: self-perception (five questions; score range 0–30), role-emotion (five questions; score range 0–30), role-social (four questions; score range 0–24), and acne symptoms (five questions; score range 0–30). The Acne-QoL is a validated and recommended acne-specific HRQoL instrument for use in clinical trials and clinical practice [10].

In studies that reported Acne-QoL total scores, mean scores ranged from 35.5 to 61.6 (out of 114) across cohorts, with lower scores indicating a greater overall impact of acne on HRQoL (Fig. 3) [70, 71, 73]. Studies with subgroup analyses additionally showed that the burden of acne was greater in females versus males [64, 67], and in adults versus adolescents [67]. An observational study also reported lower mean Acne-QoL total scores in patients with facial acne versus facial plus truncal acne or truncal acne only [64]; however, since the Acne-QoL instrument was primarily developed for facial acne, these data may reflect the need for a comprehensive HRQoL scale that incorporates truncal acne.

Fig. 3.

Average Acne-QoL scores in studies of patients with acne vulgaris. Includes studies that reported mean Acne-QoL scores in patients with acne vulgaris; lines represent the median of data shown. N values in the key refer to the total number of patients with acne in each study with Acne-QoL scores reported. Acne-QoL total scores range from 0 to 114, with lower scores indicating greater impact on quality of life. Acne-QoL domain scores range from 0 to 30 for the self-perception, role-emotion, and symptoms domains; and 0 to 24 for the role-social domain. Acne-QoL, Acne-specific Quality of Life

Mean Acne-QoL scores were generally similar across the four domains, ranging from 8.0 to 21.2 for self-perception, 8.9 to 21.5 for role-emotion, 9.6 to 20.4 for role-social, and 9.7 to 20.1 for acne symptoms scores (Fig. 3) [58, 60–63, 66, 68, 69, 72, 73]. The lowest Acne-QoL domain scores (indicating greater impact on QoL) were reported in a subgroup of 26 women with severe acne [60], while the highest scores (indicating lower impact on QoL) were reported in two phase 3 trials of 309 patients aged ≥ 9 years with moderate-to-severe acne [69]. Variation in Acne-QoL domain scores may be explained by differences in study cohorts, because subgroup analyses have shown that mean Acne-QoL domain scores were lower in females versus males [62], in adults versus adolescents [68], and in patients with severe versus moderate acne [60]. Two unique studies reported on the effect of race/ethnicity on acne-related QoL [57, 58, 62]; taken together, mean Acne-QoL domain scores were comparable between white and Black patients with similar acne severity, and were comparatively lower for Hispanic and Asian/other subgroups.

Cardiff Acne Disability Index

Fourteen studies used the Cardiff Acne Disability Index (CADI) to assess the impact of acne on HRQoL [27, 34, 35, 37, 46, 49, 76–83]. CADI is a five-item questionnaire developed for teenagers and young adults with acne, and evaluates feelings and symptoms, personal relationships, the avoidance of swimming, feelings about appearance, and the perceived severity of acne [84, 85]. Each item is ranked on a 4-point Likert scale from 0–3, yielding total scores of 0 (no impairment) to 15 (maximal QoL impairment). CADI is a validated and widely accepted instrument to assess the HRQoL impact of acne [10, 85].

Mean or median CADI scores ranged from 2.8 to 8.6 (out of 15) across studies, indicating a mild-to-moderate impact of acne on daily activities and QoL (Fig. 4) [27, 34, 35, 37, 46, 49, 76–83]. The lowest CADI total score was reported in a cohort of school students with self-assessed acne [82], while the highest was reported in a randomized study of patients aged 14–28 years receiving systemic and topical treatment for mild-to-severe acne [34]. Data from studies with subgroup analyses additionally suggest that QoL impairment due to acne is greater (i.e., higher CADI total scores) in females versus males [46, 49, 77, 82], in adults versus adolescents [80, 82], with increasing acne severity [77–79], and in patients actively seeking treatment for acne versus those who do not [27]. In studies that reported individual CADI item scores, the impact of acne tended to be greater for item 1 (feelings and symptoms), item 4 (feelings about appearance), and item 5 (perceived acne severity), when compared with item 2 (personal relationships) and item 3 (avoidance of swimming) [27, 49, 76, 82].

Fig. 4.

Average CADI scores in studies of patients with acne vulgaris. Includes studies that reported mean or median CADI scores in patients with acne vulgaris; lines represent the median of data shown. N values in the key refer to the total number of patients with acne in each study with CADI scores reported. CADI total scores range from 0 to 15 and item scores range from 0 to 3, with higher scores indicating greater impact on quality of life. CADI, Cardiff Acne Disability Index

Skindex Instruments

In total, 9 studies assessed HRQoL in patients with acne using Skindex instruments, including Skindex-29 (5 studies [28, 29, 86–88]), Skindex-16 (3 studies [61, 89, 90]), and Skindex-Teen (1 study [91]). The Skindex-29 questionnaire evaluates the impact of skin diseases on emotions (10 items), functioning (12 items), and symptoms domains (7 items); the frequency of experiences described in each item are ranked on a 5-point scale from “never” to “all the time” [92, 93]. In comparison, Skindex-16 is a brief version of Skindex-29 which similarly evaluates emotions (7 items), functioning (5 items), and symptoms (4 items), but ranks the burden of each item on a 7-point scale from “never bothered” to “always bothered” [93, 94]. In both Skindex-29 and Skindex-16, responses are transformed to a linear scale from 0 (never/never bothered) to 100 (all the time/always bothered), and Skindex domain and overall scores are calculated as the average [92–94]. Skindex-Teen is a 21-item questionnaire that evaluates psychosocial functioning (16 items) and symptoms (5 items); the frequency of each item is ranked on a 5-point scale from 0 (never) to 4 (all the time), yielding total scores from 0 to 84 [95]. All three Skindex instruments have been validated; however, Skindex-29 is the most widely used, and is the only Skindex instrument recommended for the measurement of HRQoL in acne [10].

After removing 4 studies that appeared to calculate Skindex scores using alternative methods than those summarized above [28, 29, 61, 86], average Skindex-29 or Skindex-16 total scores ranged from 30.7 to 55.4 out of 100 (Fig. 5) [87–90]. Based on Skindex-29 score cutoffs, proposed using anchor-based methods [96, 97], these scores suggest that the overall impact of acne on patient HRQoL ranged from moderate to severe across studies. The lowest overall Skindex score was reported in an observational study of 195 adults with clinically diagnosed acne (mostly mild or moderate in severity) [88], while the highest was reported in a randomized study of patients aged 14–25 years receiving prescription acne treatment (suggestive of more severe acne) [89]. The presence of acne tended to impact the emotions domain of the Skindex-29 and Skindex-16 instruments (average domain scores of 36.4–76.6) more than the functioning and symptoms domains (average domain scores of 15.7–44.1 and 23.0–41.3, respectively) [87–90]. Subgroup analyses suggest that Skindex-29 and Skindex-16 scores were generally comparable between males and females [88, 90], but increased in patients with increasing acne severity [88].

Fig. 5.

Average Skindex-29 or Skindex-16 scores in studies of patients with acne vulgaris. Includes studies that reported mean or median Skindex scores in patients with acne vulgaris; excludes four studies in which the methods used to calculate Skindex scores were unclear [28, 29, 61, 86]. Lines represent the median of data shown; n values in the key refer to the total number of patients with acne in each study with Skindex scores reported. Skindex total and domain scores range from 0 to 100, with higher scores indicating greater impact on quality of life

Other HRQoL Outcome Measures

In addition to the DLQI, Acne-QoL, CADI, and Skindex instruments, we identified several other PROMs that were used to evaluate the impact of acne on HRQoL (Table 2). These included the Acne Quality of Life scale (AQOL; used in 2 studies [98, 99]), Assessments of the Psychological and Social Effects of Acne (APSEA; 2 studies [100, 101]), Comprehensive Acne Quality of Life Scale (CompAQ; 2 studies [47, 61]), Acne Impact on Adult Daily Life questionnaire (AI-ADL; 1 study [102]), Acne Symptom and Impact Scale (ASIS; 1 study [103]), Dermatology Specific Quality of Life (DSQL; 1 study [100]), Expert Panel Questionnaire (EPQ; 1 study [104]), and Teenagers’ Quality of Life questionnaire (T-QoL; one study [105]). In addition, 11 studies evaluated the impact of acne vulgaris using generic HRQoL instruments, including the SF-36 or SF-12 (4 studies [80, 88, 106, 107]), EQ-5D or EQ-VAS (4 studies [25, 65, 108, 109]), World Health Organization Quality of Life (WHOQOL-BREF; 1 study [110]), 14-item Physical Health Questionnaire (1 study [31]), and 15-dimension HRQoL instrument (15D; 1 study [111]).

Details of these HRQoL instruments (including domains and scoring), and the key findings from studies that used these PROMs, are summarized in Table 2. Data generated from these instruments were generally consistent with results from the more common acne- or dermatology-specific PROMs, and indicated an overall moderate impact of acne vulgaris on HRQoL. Studies using these PROMs similarly showed that acne tended to affect the psychological/emotional domains of HRQoL more than other domains, and was more burdensome among females and in patients with increasing acne severity.

Impact of Acne Vulgaris on Other Psychosocial Outcomes

In total, 44 unique studies used other PROMs or methods to evaluate the effects of acne vulgaris on specific mental health outcomes (Table 3). These studies investigated a range of outcome measures, which we categorized as anxiety and depression (27 studies [25, 30, 31, 36, 37, 39, 40, 46, 57–59, 89, 100, 107, 108, 111–124]), suicidality and self-harm (8 studies [39, 117–120, 123–125]), stigmatization (6 studies [31, 46, 63, 126–128]), body image/dysmorphia (5 studies [121, 129–133]), mood changes/disorders (5 studies [110, 112, 120, 123, 124]), sleep disorders (5 studies [111, 120–122, 134]), stress (4 studies [36, 100, 134, 135]), substance use/abuse (3 studies [112, 119, 123]), life satisfaction (3 studies [37, 121, 136]), self-esteem (2 studies [129, 133]), sexual activity/satisfaction (2 studies [129, 134]), and other neuropsychiatric disorders/events (10 studies [112, 114, 117, 119, 120, 122–124, 137, 138]). One study each also evaluated alexithymia [139], anhedonia [140], capability well-being [109], major life-changing decisions [141], type A and type D personality patterns [136], psychological distress [115], and resilience [36] in people with acne vulgaris.

Table 3.

Impact of acne vulgaris on mental health outcomes

Instrument/method used	Unique studies in review (n)	References	General findings
Anxiety and depression
Hospital Anxiety and Depression Scale (HADS)	8	[25, 31, 36, 39, 40, 46, 116, 118]	Anxiety: Mean HADS anxiety scores of 6.1–11.4 (out of 21) across studies, indicating none to moderate anxiety symptoms One study estimated the prevalence of anxiety symptoms (based on HADS) in patients with acne was 38.2% (adjusted OR versus controls without acne, 3.43 [95% CI 2.24–5.23]) HADS anxiety scores tended to be higher in females versus males, and with increasing acne severity Depression: Mean HADS depression scores of 2.5–9.0 (out of 21) across studies, indicating none to mild depressive symptoms One study estimated the prevalence of depressive symptoms (based on HADS) in patients with acne was 21.9% (adjusted OR versus controls without acne, 3.46 [95% CI 1.99–5.99]) HADS depression scores were generally comparable between females versus males, and with increasing acne severity
Prevalence/risk of anxiety or depressive disorders	8	[112, 114, 117, 119, 120, 122–124]	Estimated prevalence of anxiety disorders of 10.4–19.0% across studies/subgroups Estimated prevalence of depression and major depressive disorder ranged 6–13.5% and 3.0–4.6%, respectively Two studies reported ORs for anxiety disorders (versus general population) of 1.32 (95% CI 1.05–1.66) and 1.72 (1.70–1.76) One study found that the odds of early anxiety disorders were higher among males with acne (OR 1.59 [95% CI 1.08–2.32]) One study reported an adjusted OR for hospitalization due to anxiety disorders (versus controls without acne) of 9.54 (95% CI 7.87–11.56) One study reported ORs for anxiety and depression in patients with severe acne (versus no severe acne) of 3.45 (95% CI 2.16–5.50) and 2.46 (1.17–5.19), respectively
Patient Health Questionnaire (PHQ-2, PHQ-4)	3	PHQ-4: [57–59, 89]	PHQ-4: Mean PHQ-4 scores of 4.0–5.3 (out of 12) across studies, indicating mild to moderate depression and anxiety symptoms PHQ-4 scores were higher for Asian and white patients versus Hispanic and Black patients
		PHQ-2: [115]	PHQ-2: An overall mean PHQ-2 score of 0.6 (out of 3) was reported in one study, indicating that most patients screened negative for depressive disorder PHQ-2 scores were lower in patients receiving isotretinoin versus oral antibiotics
Beck Depression Inventory (BDI, BDI-II)	3	[37, 100, 111]	Two studies reported mean BDI scores of 7.3–7.4 (out of 63), indicating no depression One study estimated the prevalence of moderate/severe depressive symptoms (BDI-II score ≥ 14) in patients with acne was 18.9% (OR versus controls without acne, 2.16 [95% CI 1.36–3.34]) One study found that BDI scores were higher in females versus males with acne
State-Trait Anxiety Inventory (STAI)	2	[100, 111]	It was unclear how STAI scores were measured in one study; therefore, no clear conclusions could be drawn One study reported mean STAI-state and STAI-trait scores of 37.9 and 39.4 (out of 80), respectively, indicating anxiety levels within the normal range This study found that STAI scores were higher in females versus males with acne
Patient-Reported Outcome Measures Information System (PROMIS)	2	[113, 121]	One study reported mean PROMIS anxiety and depression scores of 48.0 and 45.9 (out of 100), respectively, indicating symptoms within the normal range One study found that depression and anxiety were among the most important PROMIS domains among people with acne, in addition to body image, appearance, and life satisfaction
EQ-5D anxiety/depression item	1	[108]	53.5% of patients with acne had moderate anxiety/depression (versus 27.5% of people without skin diseases) 5.6% of patients with acne had extreme anxiety/depression (versus 3.3% of people without skin diseases)
Generalized Anxiety Disorder (GAD-7)	1	[111]	The prevalence of anxiety symptoms (GAD-7 score ≥ 7) in patients with acne was 10.2% (OR versus controls without acne, 1.12 [95% CI 0.59–1.97])
Major Depression Inventory (MDI)	1	[107]	Median MDI scores were 6 (out of 50) across acne subgroups, indicating no depression in most patients The prevalence of depression was 1.9–2.7% across acne subgroups (versus 2.0% in healthy controls)
Reactivity-Personal Anxiety Inventory	1	[30]	Mean reactive anxiety scores of 48.3–59.7 across acne subgroups, indicating severe reactivity anxiety Mean personal anxiety scores of 53.2–69.4 across acne subgroups, indicating severe personal anxiety Reactivity-Personal Anxiety Inventory scores were higher in patients with longer acne duration (1–5 versus < 1 years)
Neuropsychiatric disorders not otherwise specified
Prevalence/risk of other neuropsychiatric disorders and related events	10	[112, 114, 117, 119, 120, 122–124, 137, 138]	Key findings from selected studies: One study reported an adjusted OR for any primary/secondary mental health diagnosis (versus controls without acne) of 4.95 (95% CI 4.52–5.42) One study reported an OR for any neuropsychiatric outcome (versus general population) of 1.46 (95% CI 1.43–1.50), and significantly increased odds of personality disorders (OR 1.50 [1.38–1.63]) and behavioral disorders (OR 1.27 [1.22–1.33]) One study reported an OR for ADHD (versus controls with other dermatological conditions) of 2.34 (95% CI 1.06–5.14); another study reported an OR for ADD/ADHD in severe acne (versus no severe acne) of 2.09 (95% CI 1.19–3.67) One study reported an adjusted OR for hospitalization due to any mental health disorder (versus controls without acne) of 13.02 (95% CI 11.75–14.42), and significantly increased odds of hospitalization due to adjustment disorders, attention deficit/conduct/disruptive behavior disorders, developmental disorders, impulse control disorders, infancy/childhood/adolescent disorders, personality disorders, and schizophrenia/other psychotic disorders
Suicidality and self-harm
Prevalence/risk of suicidality or self-harm	8	[39, 117–120, 123–125]	Estimated prevalence of suicidal behavior of 0.5–12.9% across studies/subgroups (lower estimates for suicidal attempt, higher estimates for suicidal ideation) One study found that the risk of self-harm or suicide was present in 42.1% of patients referred for psychiatric assessment prior to isotretinoin prescription One study reported an OR for non-fatal self-harm (versus general population) of 0.95 (95% CI 0.89–1.01) One study reported an adjusted OR for hospitalization due to suicide and self-inflicted injury (versus controls without acne) of 2.47 (95% CI 0.61–9.99) One study reported an adjusted OR for suicidal ideation (versus controls without acne) of 3.63 (95% CI 1.71–7.72)
Stigmatization
Feelings of Stigmatization Questionnaire (FSQ)	2	[63, 126]	FSQ scoring methods were inconsistent between studies; mean scores of 74.0–116.3 (out of 192) FSQ scores were higher (indicating greater stigma) in females versus males, in patients with a formal acne diagnosis versus without, in patients with a long-term comorbidity versus without, and in patients with a mental health comorbidity versus without
6-Item Stigmatization Scale (6-ISS)	2	[46, 128]	Mean 6-ISS total scores of 1.68–3.36 (out of 18) across studies (versus 0.55 in controls without acne) 6-ISS item scores were highest for item 1 (“Others are not attracted to me due to my skin”) and item 2 (“I think that others start at my skin) versus other items 6-ISS scores were higher (indicating greater stigma) in females versus males, and were significantly correlated with acne severity
Day-to-Day Discrimination Scale	1	[31]	Mean score of 24.5 out of 75 Perceived stigma was significantly and positively associated with HRQoL (DLQI), psychological distress (HADS), and somatic symptoms (14-item Physical Health Questionnaire)
Perceived Stigmatization Questionnaire (PSQ)	1	[128]	Mean PSQ total scores were 2.15 (out of 5) in two acne subgroups (versus 2.12 in controls without acne) PSQ scores were higher (indicating greater stigma) for the absence of friendly behavior domain versus the confused/staring behavior and hostile behavior domains
PROMIS	1	[127]	Mean PROMIS Pediatric Stigma score was 44.3 in patients with acne, indicating mild stigma
Body image/dysmorphia
Prevalence/risk of body dysmorphic disorder	3	[130–133]	Estimated prevalence of body dysmorphic disorder of 8.6–16.9% across studies/subgroups One study reported an adjusted OR for body dysmorphic disorder (versus healthy controls) of 6.90 (95% CI 4.21–11.29)
Body Attitudes Questionnaire	1	[129]	It was unclear how Body Attitudes Questionnaire scores were measured in this study (mean score 3.5); therefore, no clear conclusions could be drawn
PROMIS	1	[121]	Body image and appearance were the PROMIS domains rated the most important to the lived experience of people with acne, followed by life satisfaction, depression, and anxiety
Mood changes/disorders
Prevalence/risk of mood disorder	4	[112, 120, 123, 124]	One study reported that the prevalence of mood disorders of 9.5–10.0% across acne subgroups Two studies reported ORs for mood disorders (versus general population) of 1.29 (95% CI 1.05–1.59) and 1.53 (1.49–1.58) One study found that the odds of mood disorders were higher among males with acne (OR 1.76 [95% CI 1.27–2.45]) One study reported an adjusted OR for hospitalization due to mood disorders (versus controls without acne) of 14.73 (95% CI 13.23–16.39)
Life Orientation Test Revised (LOT-R)	1	[110]	Mean LOT-R score of 14.0 (out of 24), indicating moderate optimism
Multiple Affect Adjective Checklist Revised (MAACL-R)	1	[110]	Mean MAACL-R negative and positive mood trait T-scores of 56.2 and 59.7, respectively, indicating lower mood than published means of matched community samples
Sleep disorders
Prevalence/risk of sleep disorders	3	[120, 122, 134]	One study reported that 65.4% of people with acne experienced fatigue upon waking (adjusted OR versus controls without acne, 1.43 [95% CI 1.19–1.71]) One study reported an OR for sleep disorders (versus general population) of 2.00 (95% CI 1.91–2.10) One study reported an OR for insomnia in patients with severe acne (versus no severe acne) of 1.85 (95% CI 1.09–3.11)
Athens Insomnia Scale (AIS)	1	[111]	Mean AIS score of 2.8 (out of 24), indicating no insomnia
PROMIS	1	[121]	Fatigue was among the least important PROMIS domains among people with acne, in addition to work impairment and anger
Stress
Perceived Stress Scale (PPS)	2	[36, 100]	It was unclear how PSS scores were measured in both studies; therefore, no clear conclusions could be drawn One study reported high PSS stress levels in 18% of patients, normal levels in 55%, and low PSS stress levels in 27%
Social Readjustment Rating Scale (SRRS)	1	[135]	Mean SRRS score was 185 in patients with acne (versus 154 in healthy controls), indicating a moderate level of stress SRRS scores tended to be higher (indicating greater stress) in patients with severe acne versus mild or moderate acne
Frequency/odds of stress	1	[134]	Feelings of stress among patients with acne: 17.9% never, 64.1% sometimes, 18% daily Adjusted OR for stress (versus controls without acne): 1.98 (95% CI 1.59–2.46)
Substance use/abuse
Prevalence/risk of substance use or dependence	3	[112, 119, 123]	One study reported that 1% of patients had a psychiatric diagnosis for a substance use disorder prior to isotretinoin initiation One study reported an OR for substance abuse/dependence (versus general population) of 1.17 (95% CI 0.89–1.54); odds of substance abuse/dependence were higher among males with acne (OR 1.64 [95% CI 1.15–2.33]) One study reported adjusted ORs for hospitalization due to alcohol- and substance-related disorders (versus controls without acne) of 2.63 (95% CI 2.06–3.35) and 3.35 (2.59–4.32), respectively
Life satisfaction
Satisfaction with Life Scale (SWLS)	2	[37, 136]	Mean SWLS score of 17.1–22.1 (out of 35) across studies, indicating low-to-average levels of life satisfaction One study found that SWLS scores in patients with acne were significantly lower (indicating lower life satisfaction) versus people without acne
PROMIS	1	[121]	Life satisfaction was among the most important PROMIS domains among people with acne, in addition to body image, appearance, depression, and anxiety
Self-esteem
Rosenberg Self-Esteem Scale (RSES)	2	[129, 133]	It was unclear how RSES scores were measured in one study (mean score 2.9); therefore, no clear conclusions could be drawn One study reported a mean RSES score of 19.9 (out of 30), indicating average self-esteem RSES scores were lower (indicating lower self-esteem) in patients who screened positive for body dysmorphic disorder versus those who screened negative
Sexual activity/satisfaction
Sexual Self‐Esteem Inventory-Short Form (SSEI-SF)	1	[129]	It was unclear how SSEI-SF scores were measured in this study (mean score 4.5); therefore, no clear conclusions could be drawn
Whitley Sexual Satisfaction Inventory	1	[129]	It was unclear how sexual satisfaction scores were measured in this study (mean score 2.6); therefore, no clear conclusions could be drawn
Frequency/odds of sexual activity	1	[134]	Sexual activity among patients with acne: 37.5% never, 16.9% not currently, 19.7% occasionally, 25.9% at least weekly Adjusted OR for less sexual activity (versus controls without acne): 0.61 (95% CI 0.51–0.74)
Alexithymia
Toronto Alexithymia Scale (TAS-20)	1	[139]	Mean TAS-20 total score of 53.1 (out of 100); mean TAS-20 domain scores were 19.7 for difficulty identifying feelings, 19.1 for externally oriented thinking, and 15.2 for difficulty describing feelings TAS-20 scores were not significantly different between people with versus without acne, and was not correlated with acne severity 30.3% of patients with acne had alexithymia (TAS-20 score ≥ 61), 24.4% had intermediate alexithymia (TAS-20 score 52–60), and 45.4% had no alexithymia (TAS-20 score < 52) Alexithymia was more common among females versus males with acne
Anhedonia
Anticipatory and Consummatory Interpersonal Pleasure Scale (ACIPS)	1	[140]	Mean ACIPS total score of 80.2 (out of 102), indicating low levels of anhedonia ACIPS scores correlated with acne severity, but there was no significant difference in ACIPS scores between females versus males
Snaith-Hamilton Pleasure Scale (SHAPS)	1	[140]	Mean SHAPS score of 1.6 (out of 14), indicating low hedonic capacity/hedonic tone 20.2% of patients had anhedonia (SHAPS score > 2); anhedonia was more common in males versus females SHAPS scores were higher (indicating more severe anhedonia) in males versus females, and were correlated with acne severity
Temporal Experience of Pleasure Scale (TEPS)	1	[140]	Mean TEPS score of 80.8 (out of 108), indicating higher levels of pleasure Mean TEPS anticipatory and consummatory domain scores were 44.9 (out of 60) and 35.9 (out of 48), respectively TEPS scores were not significantly different between males versus females, and were not correlated with acne severity
Capability well-being
ICEpop CAPability measure for Adults (ICECAP-A)	1	[109]	Mean ICECAP-A score of 0.68 (out of 1), indicating lower capability well-being than the general population
Major life-changing decisions
Major Life Changing Decision Profile (MLCDP)	1	[141]	Mean MLCDP total score was 5.4 (out of 128), indicating low impact of acne on major life-changing decisions MLCDP social domain scores were significantly greater (indicating greater impact on social decisions) in females versus males MLCDP total scores were correlated with acne severity
Personality types (Type A, Type D)
Framingham Type A Scale (FTAS)	1	[136]	Mean FTAS score was 0.77 (out of 1), indicating a type A behavior pattern FTAS scores in patients with acne were significantly higher (indicating type A behavior pattern) versus people without acne
14-Item Type D Scale (DS14)	1	[136]	Mean DS14 negative affectivity and social inhibition domain scores were 17.7 and 13.8 (out of 28), respectively, indicating type D personality DS14 scores in patients with acne were significantly higher (indicating type D personality) versus people without acne
Psychological distress
Kessler 6-Item Psychological Distress Scale (K6)	1	[115]	Mean K6 score of 3.3 (out of 24), indicating lower levels of psychological distress Mean K6 scores were lower (indicating lower distress) in patients receiving isotretinoin versus oral antibiotics
Resilience
Brief Resilience Scale (BRS)	1	[36]	39.3% of patients reported low resilience (BRS score 1–2.99 out of 5), 42.7% normal resilience (BRS score 3.00–4.30), and 18.0% high resilience (BRS score 4.31–5.00)

CI, confidence interval; DLQI, Dermatology Life Quality Index; HADS, Hospital Anxiety and Depression Scale; OR, odds ratio; PROMIS, Patient-Reported Outcome Measures Information System; SWLS, Satisfaction with Life Scale; VAS, visual analog scale

The studies used a variety of methods to evaluate these outcomes, including disease-specific PROMs (e.g., the Hospital Anxiety and Depression Scale [HADS]) and analyses that estimated the prevalence or risk of mental health outcomes in people with acne vulgaris (Table 3). Comparisons and conclusions are difficult to draw due to considerable heterogeneity among studies; however, these data collectively suggest that people with acne may be susceptible to several mental health issues. For instance, a large cohort study including 382,340 patients with acne found that an acne diagnosis was associated with increased odds of 1-year incident adverse neuropsychiatric outcomes (odds ratio [OR] 1.46 versus sex-, age-, and race-matched controls without acne), including sleep disorders (OR 2.00), anxiety disorders (OR 1.72), mood disorders (OR 1.53), personality disorders (OR 1.50), and behavioral disorders (OR 1.27) [120]. Several studies also reported that the impacts of acne vulgaris on selected mental health outcomes were greater in females versus males and with increasing acne severity. In particular, a cross-sectional study of 9417 children and adolescents aged < 18 years estimated that patients with severe acne had significantly increased odds of psychological comorbidities versus those without severe acne, including anxiety (OR 3.45), depression (OR 2.46), attention deficit disorder/attention deficit hyperactivity disorder (OR 2.09), and insomnia (OR 1.85) [122].

Other Qualitative and Quantitative Studies

Twelve studies used alternative qualitative or quantitative methods to capture patient perspectives on the impacts of acne vulgaris (Table 4) [59, 91, 108, 142–150]. Most of these studies used investigator-developed surveys or semi-structured interviews to elicit patient feedback, while one analyzed social media posts to identify key challenges faced by people living with acne vulgaris [147]. Participants in these studies frequently reported that acne vulgaris was detrimental to emotional/psychological well-being, body image/self-esteem, and social functioning, which is consistent with the HRQoL domains and mental health outcomes that were most often impacted in studies using PROMs. In studies that reported subgroup analyses, the self-reported burden of acne vulgaris tended to be greater in females versus males [142, 150], in adults versus adolescents [146], and with increasing acne severity [142].

Table 4.

Studies that evaluated the HRQoL or psychosocial impact of acne of vulgaris using other qualitative or quantitative survey methods

Study	Key methods	Key findings
Ballanger 2023 [142]	Internet survey of 1001 adolescents and young adults with truncal acne Survey evaluated self-perceived impact of truncal acne on daily life and QoL	68.4% of participants were concerned about their truncal acne sometimes/often/all the time, and 38.7% reported a heavy or very heavy impact of truncal acne on their QoL Frequency of concern and impact of acne on QoL were greater in females versus males, and with increasing acne severity
Barbieri 2021 [143]	Semi-structured interview of 50 women with moderate-to-severe acne Interviews elicited participants’ perspectives on their experiences with and treatment for acne	Participants often reported that acne caused concerns about appearance, affected mental and emotional health, and impacted everyday life
Cartwright 2023 [144]	Web-based survey of 501 people with skin of color, including 106 people with acne Survey collected data on the impact of skin conditions on mental health and QoL, and perspectives on skin care products and dermatology care	70.8% of people with acne received negative comments from persons close to them 62.3% felt unattractive because of acne 54.7% felt distressed by noticeable facial acne 51.9% edited social media photos because of acne 50.9% were concerned that their acne won’t go away 44.3% felt that acne prevented their participation in social activities 40.6% felt their acne was uncontrollable 34.9% were bullied because of acne 28.3% felt anxiety caused by acne 24.5% felt depressed because of acne
Chernyshov 2023 [145]	Study of 601 patients with acne from nine countries in Europe One group of patients (n = 443) assessed the relevance of 97 items concerning the impact of acne on daily life (selected on the basis of clinical expert consensus) Another group of patients (n = 158) reported on how acne influences different aspect of their life, without a pre-developed list of topics	Overall, the most relevant items according to both groups included: “I am dissatisfied with self-appearance” “I wish I looked better” “I am upset about having facial acne” “I worry that my skin condition may get worse” “I need to use makeup” “I feel lacking in self-confidence”
Fabbrocini 2018 [146]	Semi-structured interview of 34 adolescents and 16 adults with moderate-to-severe acne and prescribed topical treatment Interviews explored patient experiences of acne and its impact on HRQoL, and their experience of topical treatments for acne	Acne impacted seven main areas of HRQoL: emotional functioning, social functioning, relationships, leisure activities, daily activities, sleep, and school/work The proportion of patients reporting impacts for each HRQoL concept was higher among adults versus adolescents
Marty 2024 [147]	Public social media posts were collected from patients with skin diseases and caregivers, including 20,282 posts from 10,251 patients with acne Social media posts were analyzed to identify key themes, encountered difficulties, and unmet medical needs	Common difficulties reported among patients with acne: 53% reported fear or management of adverse events 42% reported negative self-image 23% reported fear or management of disease flares/progression/recurrence 20% reported wandering, therapeutic impasse, or ineffective treatments 18% reported psychological impact 16% reported acceptance of disease 15% reported need for sharing, feedback, or exchanges with others 15% reported need for knowledge or information about treatment 2% reported impact on daily activities 1% reported fear, consideration, or management of symptoms
Misery 2020 [108]	Investigator-developed questionnaire completed by patients with skin diseases, including 482 patients with acne Questionnaire included items related to the psychological impact of skin diseases	53.1% reported feeling withdrawn because of acne 32.4% reported difficult relations with partners because of acne 36.5% reported that acne impacts their sexual life 40.3% reported sleep disturbances because of acne
Sadowsky 2020 [91]	Investigator-developed question completed by 60 adolescents with acne aged 12–17 years The question, “how much does your acne affect your life?” was rated on a 9-point Likert scale	Mean score of 3.0; modest correlation with Skindex-Teen score
Szepietowski 2018 [148]	Online survey of people aged 15–24 years, including 3099 people with acne Respondents with acne were asked “how do you perceive your acne today?”	53.8% considered acne to be a minor problem, 29.7% a major problem, 16.5% not a problem, and 8.4% a burden
Tan 2022 [149]	Online survey of 694 patients with facial and truncal acne Survey explored the impact of facial and truncal acne on psychological well-being and QoL	Facial and truncal acne mainly impacted emotional well-being, acceptability to self and others, and social functioning domains of HRQoL Feeling embarrassed and unattractive were among the most common emotions associated with facial and truncal acne
Tanghetti 2014 [59]	Investigator-developed question completed by 208 women with facial acne Respondents were asked about the degree of troublesomeness for specific acne signs and acne overall, and their feelings about acne	82.7% reported that their acne symptoms were troublesome (10.1% very severely, 28.8% severely, 34.6% moderately, 8.7% mildly, 0.5% not troublesome, 17.3% not applicable) 77.4% reported feeling embarrassed when thinking about their acne 76.9% reported feeling less confident because of acne 76.9% reported feeling self-conscious because of acne 76.0% reported feeling frustrated when thinking about their acne
Tavecchio 2020 [150]	Investigator-developed survey of 2327 patients with acne aged 12–21 years Respondents were asked about the impact of acne on QoL	97% reported that acne causes awkwardness with the other sex, 65% at school, 54% with friends, and 8% with relatives (23% reported no problem) 45% reported that acne “often” limits social life, 26% “sometimes”, 16% “always”, 13% “never" 33% reported that acne “often” negatively influences self-esteem, 27% “rarely”, 24% “never”, 16% “always” The reported impact of acne on QoL was greater among females versus males

HRQoL, health-related quality of life; QoL, quality of life

Discussion

This systematic review aimed to characterize the current body of evidence on the impact of acne vulgaris on HRQoL and psychosocial outcomes. Our literature searches captured a diverse range of studies that assessed HRQoL using a variety of instruments and methods, and/or evaluated the relationships between acne vulgaris and specific mental health outcomes. Overall, current evidence suggests that acne vulgaris predominantly affects the emotional and psychological domains of HRQoL, and is particularly burdensome to adults, females, and those with more severe acne.

Our findings are consistent with recent reviews that have highlighted the broad range of PROMs used to assess acne-related QoL in research and clinical practice [10–12]. In particular, a task force established by the European Academy of Dermatology and Venereology (EADV) aimed to review the PROMs currently available for QoL assessment in acne [10], while a systematic review by the Acne Core Outcomes Research Network (ACORN) evaluated the methodological quality of common acne-specific, dermatology-specific, and generic HRQoL instruments [12]. Similar to the present study, the EADV task force found that the DLQI, CADI, Acne-QoL, Skindex-29, SF-36, and CDLQI were the most widely used HRQoL instruments in current literature, and recommended the use of these PROMs on the basis of available evidence and expert opinion [10]. However, the ACORN review found that the majority of current HRQoL instruments lack sufficient evidence to confirm their content validity and internal structure, and could only recommend two instruments—the Acne-Q and CompAQ—on this basis [12]. CompAQ and Acne-Q are relatively new PROMs (first published in 2018 and 2019, respectively) [151, 152]; as such, none of the 101 studies included in our review used the Acne-Q instrument, and only two used CompAQ [47, 61], to assess HRQoL in patients with acne vulgaris.

Despite the diversity of the studies included in our review, we identified some consistent themes and findings to describe the psychosocial effects of acne vulgaris. First, acne tended to have greater impact on the emotional and social domains of most HRQoL instruments when compared with other (e.g., physical and functional) domains. This was supported by the results of other studies that reported relationships between acne and specific mental health outcomes (e.g., anxiety, body dysmorphia, stigmatization), and surveys in which patients shared the detrimental effects of acne on their emotional well-being, self-esteem, and social functioning. These observations are also consistent with a previous review that identified reduced general well-being, negative self-perception, psychological consequences (e.g., anxiety, depression), and negative effects on social behaviors among the major impacts experienced by people with acne vulgaris [11]. Furthermore, several studies in our review found that the impacts of acne correlated with acne severity, and that the psychosocial burden of acne was greater for females versus males and adults versus younger people. The latter finding is particularly noteworthy and suggests that while acne is more prevalent among adolescents [3, 4], the often chronic and relapsing course of adult acne may be more detrimental to patient QoL [67]. Others have suggested that feelings of anxiety, depression, low self-worth, and social isolation due to acne may be magnified in adulthood, based on the perception that acne is a common and temporary experience during adolescence [63, 143].

Although this systematic review was designed to illustrate the wide range of methods and instruments used to assess HRQoL and psychosocial outcomes in acne research, the heterogeneity between included studies was a key limitation of our study. Differences in study design, population, methods, outcomes, and quality consequently limited our ability to draw clear comparisons between studies, and precluded meta-analyses to quantify the impact of acne vulgaris on psychosocial outcomes and patient QoL. This observation highlights the need for consistent methods and reporting in future acne research, particularly with respect to how acne is diagnosed in study participants, and the location and severity of their acne. For example, although the United States Food and Drug Administration recommend the IGA scale to assess acne severity and treatment effectiveness in clinical trials [153], our review found that acne severity was measured using a range of different methods in current research, if it was reported at all.

The data generated from our review also demonstrate a need for consensus methods that reliably evaluate the impact of acne vulgaris—and the effectiveness of acne treatments—on outcomes that matter most to patients. To that end, ACORN was formed to establish core domains, outcomes, and instruments that will standardize acne assessments in future research and clinical practice [9]. In particular, ACORN identified HRQoL and appearance-related concerns as specific domains of importance that should be measured when assessing acne and incorporated into acne research [8]. ACORN also reviewed the impacts of acne on HRQoL and the PROMs used to assess those impacts [11, 12], and developed CompAQ in line with regulatory guidelines and feedback from patients and clinical experts [151]. Although CompAQ is one of only two PROMs that are currently recommended for use based on psychometric properties and validation (in addition to the Acne-Q) [12], our review suggests that their uptake in acne research has been slow so far. Moreover, these instruments lack validated score descriptor bands which may limit their interpretability and utility in clinical practice, while others have indicated that a general lack of validated short-form PROMs for acne is an important barrier to real-world implementation [12]. To ensure consistency across the field, future acne-related QoL instruments must balance psychometric rigor for use in clinical trials, with pragmatic factors that enable their adoption in routine clinical practice [154, 155].

Conclusions

This systematic review summarizes a large body of evidence to describe the impacts of acne vulgaris on HRQoL and psychosocial outcomes. These studies not only highlight the wide range of ways that acne vulgaris can affect patient health and well-being, but also the need for consensus methods and outcome measures to streamline future research and improve clinical practice.

Supplementary Information

Below is the link to the electronic supplementary material.

Declarations

Funding

The development of this manuscript and the open access fee were supported by Sanofi.

Conflicts of interest

A.M.L. has served as an advisory board member and consultant for Alliance, Almirall, Galderma, Glenmark, Eligo Bioscience, L’Oreal, La Roche-Posay, Novartis, and Viatris; provided unrestricted educational talks for Almirall, Beiersdorf, Galderma, LEO Pharma, L’Oreal, and La Roche-Posay; and received sponsorship to attend educational dermatology meetings from Almirall, LEO Pharma, and L’Oreal. V.B. has served as an advisory board member for AbbVie, Beiersdorf, Cantabria Labs, Galderma, Ganassini, General Topics, L’Oreal, Menarini, Mylan, Novartis, Sanofi, and UCB; received research grants from AbbVie and Ganassini; and received speaker’s honoraria from AbbVie, Beiersdorf, Cantabria Labs, Galderma, Ganassini, General Topics, L’Oreal, Menarini, Mylan, Novartis, and UCB. V.D. and E.P. are employees of Sanofi. J.K.L.T. has served as an advisory board member for Abbott, Cutera, Derm-Biome, Galderma, Sanofi, and Sun Pharma; a consultant for Bausch Health, Boots Walgreens, Galderma, Linio Biotech, L’Oreal, and Pierre Fabre; an independent contractor for Novartis and Pfizer; an investigator for Cutera and Galderma; a speaker for Bausch Health, Galderma, L’Oreal, and Pierre Fabre; and is a co-copyright holder of the Comprehensive Acne Quality of Life Scale (CompAQ), with usage fees donated to the Acne Core Outcomes and Research Network (ACORN).

Data availability

Data available within the article or its supplementary materials.

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Code availability

Not applicable.

Author contributions

All authors participated in the conception and design of the systematic review, the analysis and interpretation of the results, the drafting and critical review of the manuscript, and gave final approval of the version for publication. All authors agree to be accountable for the accuracy and integrity of all aspects of the published work.