Abstract
Introduction
Acne vulgaris is a common inflammatory skin disorder that imposes substantial psychosocial and quality-of-life burden. While most guidelines focus on facial involvement, acne frequently affects the trunk, which further exacerbates symptoms and impairs health-related quality of life (HRQoL). Emerging evidence suggests that combined facial and truncal acne is associated with greater disease severity and psychological distress, yet real-world data remain limited. This study evaluates the prevalence of truncal acne and the HRQoL burden associated with facial acne alone, truncal acne alone, and combined facial/truncal acne in a large secondary-care cohort.
Methods
A retrospective analysis was conducted using an ethically approved UK dermatology database (2001–2020) comprising 2038 patients. Acne severity was assessed using the Leeds photometric scale and subsequently categorized as mild, moderate, or severe disease. All patients completed the Dermatology Life Quality Index (DLQI) and Hospital Anxiety and Depression Scale (HADS).
Results
Among validated cases, 36.3% had facial acne alone, 1.7% truncal acne alone, and 61.9% combined facial/truncal involvement. Patients with combined disease exhibited significantly higher total DLQI scores than those with facial acne alone (p = 0.025). DLQI item analyses demonstrated greater symptom burden (question 1; p = 0.048) and work/study impairment (question 7; p = 0.031) in patients with facial/truncal acne. Total HADS scores were also significantly elevated in this group (p = 0.047), independent of acne severity, indicating increased psychosocial distress.
Conclusions
Our prevalence of truncal acne (63.6%, including both truncal-only and combined facial–truncal disease) exceeds previous reports of approximately 50%. The presence of truncal involvement in addition to facial acne was associated with significantly greater health-related quality-of-life impairment compared with facial acne alone. These findings highlight the need for proactive assessment of truncal acne lesions and guideline recommendations addressing truncal acne. Improved recognition and tailored treatment, potentially including agents suitable for facial and truncal acne, may help mitigate the substantial burden associated with acne.
Keywords: Truncal acne, Facial acne, Quality of life, DLQI, HADS, Retinoids, Trifarotene, Secondary care dermatology
Key Summary Points
| While truncal acne is common, it remains underrecognized in routine assessment and is not consistently addressed with truncal-specific treatment algorithms in major guidelines. |
| This study evaluated the prevalence and health related quality of life (HRQoL) burden resulting from facial or truncal acne alone, and combined facial/truncal disease. |
| When facial and truncal acne coexist, greater symptom burden and functional impairment occur compared with that associated with facial acne alone. |
| These findings highlight the importance of proactive assessment of truncal involvement and continued refinement of guideline recommendations to optimize management of truncal acne. |
Introduction
Acne is associated with marked negative psychosocial impact from both active lesions and resulting sequelae (scarring and pigmentation) [1]. Although most studies and evidence-based guidelines concentrate on facial acne, it is increasingly recognized that acne can extend beyond the face to involve the trunk (shoulders, back, and chest) and this has been reported in approximately 50% of patients [2–4]. The pathophysiology of acne on the trunk is thought to be similar to that on the face; however, concomitant involvement of both face and trunk has been associated with greater disease severity and worse psychosocial impact [2]. The impact on health-related quality of life (HRQoL) may also differ according to acne location and severity in different age groups [1, 2].
The aim of this study was to determine the prevalence of truncal acne and to assess differences in health-related quality of life and psychosocial burden among patients with facial acne alone, truncal acne alone, and combined facial and truncal acne within a large UK secondary-care cohort. In addition, we sought to evaluate the independent effects of acne severity and anatomical distribution on HRQoL.
Methods
This study evaluated the prevalence and HRQoL burden resulting from facial or truncal acne alone, and combined facial/truncal disease in a large single-center retrospective cohort of patients attending a secondary care dermatology unit in the UK. This study was conducted using data from an ethically approved NHS clinical database (REC reference: 21/NE/0158), with approval from the Research Ethics Committee and Health Research Authority. All participants provided informed consent, and all data were anonymized prior to analysis. The database comprised anonymized records from 2001 to 2020 and included 2038 consenting patients with a mean age of 23 years. Patients with potential confounding comorbidities were excluded, including polycystic ovary syndrome, metabolic syndrome, obesity, drug-related acne, and other clinically significant endocrine or systemic disorders that could influence acne severity or psychosocial outcomes. After exclusion of incomplete data and cases with confounding comorbidities or acne-inducing medications, 1906 cases were validated for analysis.
Patients completed the Hospital Anxiety and Depression Scale (HADS) and the Dermatology Life Quality Index (DLQI). Acne site was recorded and severity assessed using the Leeds photometric scale, scores from this were subsequently divided into mild, moderate, and severe disease for analyses. Statistical analyses were performed using STATA MP version 19.5 and IBM SPSS Statistics version 30.
To assess statistically significant differences by acne severity and lesion location, multiple linear regression analysis was employed. Intergroup pairwise comparisons were conducted using the Bonferroni post hoc test and Bartlett’s test for equal variances. Multiple linear regression was selected to evaluate the independent effects of severity and location while controlling for potential confounders. The Bonferroni correction was applied to control for the increased risk of type I error associated with multiple testing (α = 0.05). Bartlett’s test verified homogeneity of variances across groups. Model assumptions, including linearity, normality of residuals, and independence of observations, were examined to ensure validity of parametric inference.
Results
Patient characteristics are presented in Table 1. Of the validated cohort, 832 were male and 1074 female; 695 patients were adolescents (< 18 years) and 1211 were adults (≥ 18 years). Overview of acne location is presented in Table 2. Facial acne alone affected 692 patients (36.3%), a combination of facial and truncal acne (including back and chest) occurred in 1181 (61.9%) patients, and truncal acne alone was reported by 33 (1.7%) patients. Among these, 522 patients had moderate-to-severe acne and 421 had mild disease.
Table 1.
Patient characteristics in acne database in secondary care dermatology unit in the UK from 2001 to 2020
| Result | |
|---|---|
| Total number of patients | 2038 |
| Total number of validated patients | 1906 (93.5%) |
| Total number of adolescents (< 18 years) | 695 (36.5%) |
| Total number of adults (≥ 18 years) | 1211 (63.5%) |
| Male | 832 (43.7%) |
| Female | 1074 (56.3%) |
Table 2.
Location of acne in patients within acne database in secondary care dermatology unit in the UK from 2001 to 2020
| Acne location | n (%) |
|---|---|
| Facial acne only | 692 (36.3%) |
| Combined facial + truncal acne | 1181 (61.9%) |
| Truncal acne only | 33 (1.7%) |
The impact of acne extent and severity on the HADs and the DLQI including the individual items in the latter were assessed. Patients with combined facial and truncal acne exhibited significantly higher total DLQI scores compared with those with facial acne alone (p = 0.025, 95% CI −21.21 to −1.13). Multiple linear regression analysis revealed that the DLQI question 1 score, assessing pain, itch, and stinging, was significantly higher among patients with facial/truncal acne than those with facial acne alone (regression coefficient = 1.2, standard error = 0.5, p = 0.048, 95% CI 0.01–2.40, R2 = 0.50). Likewise, the DLQI question 7 score, reflecting the impact of acne on work or study, was significantly elevated in patients with facial/truncal involvement (regression coefficient = 1.02, standard error = 0.3, p = 0.031, 95% CI −1.90 to −0.08).
Gender and age differences in anatomical distribution and psychosocial burden are summarized in Table 3. Significant gender differences were observed in anatomical distribution. Facial acne was statistically more common in female than male individuals, although the absolute difference was small (98.1% versus 96.0%; OR 0.46, 95% CI 0.26–0.82; p = 0.017). In contrast, truncal acne was significantly more prevalent in male (76.1%) compared with female (54.1%; OR 2.70, 95% CI 2.22–3.28; p < 0.001) individuals. Similarly, combined facial and truncal acne occurred more frequently in male (72.1%) than female (52.2%; OR 2.36, 95% CI 1.95–2.86; p < 0.001) individuals.
Table 3.
Gender and age differences in acne distribution and psychosocial burden
| Anatomical distribution (gender) | Male N = 832 |
Female N = 1074 |
Odds ratio (95% CI) | p-Value |
|---|---|---|---|---|
| Facial acne | 96.0% | 98.1% | 0.46 (0.26–0.82) | 0.017 |
| Truncal acne | 76.1% | 54.1% | 2.70 (2.22–3.28) | < 0.001 |
| Combined acne | 72.1% | 52.2% | 2.36 (1.95–2.86) | < 0.001 |
| Psychosocial burden (gender) | Male % (n) |
Female % (n) |
Odds ratio (95% CI) | p-Value |
|---|---|---|---|---|
| DLQI ≥ 6 |
47.4% (180/380) |
57.5% (328/570) |
1.50 (1.16–1.93) | 0.002 |
| HADS ≥ 16 |
22.5% (75/334) |
34.4% (177/514) |
1.81 (1.32–2.48) | < 0.001 |
| Psychosocial burden (age) | Adolescents % (n) |
Adults % (n) |
Odds ratio (95% CI) | p-Value |
|---|---|---|---|---|
| DLQI ≥ 6 |
59.6% (233/391) |
69.7% (382/548) |
1.56 (1.19–2.05) | 0.002 |
| HADS ≥ 16 |
19.6% (68/347) |
37.6% (184/489) |
2.47 (1.77–3.45) | < 0.001 |
DLQI ≥ 6 indicates moderate-to-severe quality-of-life impairment. HADS ≥ 16 indicates clinically significant psychological distress. Adolescents defined as 12–18 years; adults > 18 years. Odds ratios calculated with male individuals (gender analyses) and adolescents (age analyses) as reference groups. Invalid DLQI (> 30) and HADS (> 42) scores were excluded. Odds ratios calculated with male individuals as the reference group for gender analyses and adolescents as the reference group for age analyses
Despite the higher prevalence of truncal and combined acne in male individuals, female individuals demonstrated significantly greater psychosocial burden. After exclusion of invalid questionnaire scores, moderate-to-severe quality-of-life impairment (DLQI ≥ 6) was observed in 57.5% of female compared with 47.4% of male (OR 1.50, 95% CI 1.16–1.93; p = 0.002) individuals. Clinically significant psychological distress (HADS ≥ 16) occurred in 34.4% of female versus 22.5% of male (OR 1.81, 95% CI 1.32–2.48; p < 0.001) individuals.
Age-stratified analysis further demonstrated greater psychosocial burden among adults (> 18 years) compared with adolescents (12–18 years). Following exclusion of patients younger than 12 years and invalid scores, clinically significant psychological distress (HADS ≥ 16) was present in 37.6% of adults compared with 19.6% of adolescents (OR 2.47, 95% CI 1.77–3.45; p < 0.001). Moderate-to-severe quality-of-life impairment (DLQI ≥ 6) was also more common in adults (69.7%) than adolescents (59.6%; OR 1.56, 95% CI 1.19–2.05; p = 0.0017).
Discussion
These findings indicate that facial and truncal acne confer greater symptom burden and functional impairment than facial acne alone. Moreover, independent of acne severity, total HADS scores were significantly higher in patients with combined facial and truncal acne compared with those with facial acne only (p = 0.047), suggesting greater psychosocial distress in patients with more extensive disease involving more than one site.
The higher overall DLQI scores observed in patients with combined facial and truncal acne were primarily attributable to greater impairment in symptom-related domains and in work or study functioning, as reflected by significantly higher scores for DLQI questions 1 and 7. Although practical challenges associated with managing acne over larger body surface areas and potential lifestyle impacts may plausibly contribute to this burden, these factors were not directly measured in the present study and therefore cannot be inferred from the available data. Additional analyses examining gender and age differences in acne distribution and psychosocial burden were exploratory and provide contextual information on demographic patterns within the cohort.
Our prevalence of truncal acne (63.6%) exceeds previous reports of approximately 50% [3, 4] and highlights the substantial burden associated with acne extending beyond the face. These data underscore that HRQoL impairment increases with both severity and anatomical extent of disease, supporting the view that truncal acne remains underrecognized and under-treated.
Our findings are consistent with those reported by Dréno et al., who demonstrated a significantly greater quality-of-life burden in individuals with combined facial and truncal acne compared with facial acne alone in an international, population-based survey [9]. In contrast to their cross-sectional survey approach, our study provides real-world data from a large secondary-care cohort and demonstrates that the increased psychosocial burden associated with truncal involvement persists independently of acne severity. While Dréno et al. employed truncal-specific quality-of-life instruments [9], previous publications have also described the development of truncal-acne-specific scoring systems and a comprehensive quality-of-life measure for facial and torso acne (CompAQ) [10, 11]. These instruments may provide greater anatomical sensitivity when assessing site-specific burden. However, at the time of study design, such tools were not routinely implemented or available within our clinical service. Our use of the DLQI therefore reflects real-world clinical practice, where it remains the most widely adopted and feasible standardized instrument [12].
Current UK National Institute for Health and Care Excellence (NICE) guidelines structure recommendations primarily according to acne severity rather than anatomical site and do not provide truncal-specific algorithms [5]. International guidance from the Global Alliance to Improve Outcomes in Acne and the 2024 American Academy of Dermatology (AAD) guidelines emphasize a multimodal, severity-based approach incorporating topical retinoids, benzoyl peroxide combinations, and systemic therapies where indicated [13, 14]. More recently, the 2025 EuroGuiDerm evidence-based guideline has reinforced a structured, stepwise strategy that prioritizes combination topical therapy and restricts systemic antibiotic duration to support antimicrobial stewardship [15]. Until recently, there were limited topical treatments licensed specifically for truncal acne, and patients with more extensive disease were commonly managed with oral antibiotics or combination topical therapies. The topical retinoid trifarotene, a selective retinoic acid receptor-γ agonist, has demonstrated efficacy and a favorable safety profile in large-scale clinical trials involving patients with both facial and truncal acne [6, 7]. Given its license for truncal acne and tolerability across larger body surface areas, trifarotene represents a potential therapeutic option within a broader management strategy that may also include other topical acne treatments, hormonal therapies, and systemic treatments, depending on disease severity and patient factors. Such an approach aligns with contemporary international guideline recommendations emphasizing limited-duration systemic antibiotic use and combination therapy to reduce antimicrobial resistance. [13–15]
This study has several limitations:
The patient cohort studied was predominantly Caucasian, meaning results may not be transferable to other ethnicities.
The data were collected at the point of referral into a secondary-care-dedicated acne service and patients would have received some treatment prior to their new patient appointment. However, for those who had previously received systemic therapies, this may have resulted in an underestimate of truncal acne.
Acne sequelae, including scarring and acne-induced pigmentation, were captured within the database; however, these were not formally graded or incorporated into the present statistical analyses. Consequently, their independent contribution to patient-reported quality-of-life outcomes could not be determined. To mitigate the impact of sequelae on HRQol, patients were asked to complete questionnaires specifically in relation to their active acne, rather than any clinical sequelae present.
As this was a cross-sectional, baseline assessment, we were unable to examine subsequent changes in treatment or their potential impact on quality-of-life outcomes.
Treatment adherence was not assessed in this study, and therefore its potential influence on quality-of-life outcomes could not be evaluated.
Although truncal-acne-specific scoring systems and comprehensive facial-and-torso quality-of-life instruments have previously been developed, these were not routinely implemented within our clinical setting at the time of study design. The use of the DLQI, while pragmatic and reflective of routine practice, may therefore have limited sensitivity to truncal-specific psychosocial impacts.
Conclusions
Patients with combined facial and truncal acne experience greater HRQoL impairment compared with those with facial acne alone, driven by both symptom severity and functional impact. Our findings also demonstrate that psychosocial burden varies according to demographic factors, with greater impairment observed in female individuals and adults despite a higher prevalence of truncal involvement among male individuals, highlighting the importance of considering both anatomical distribution and patient demographics when assessing acne severity and treatment needs. As patients may not always volunteer information about truncal lesions, clinicians should proactively assess truncal involvement and tailor management accordingly. Continued refinement of guideline recommendations and increased awareness of truncal disease may help mitigate its underestimated psychosocial and clinical burden.
Acknowledgements
We thank the participants of the study.
Medical Writing/Editorial assistance
Medical writing assistance was provided by Tom Gallagher PhD at Jack’s The Cat, funded by Galderma.
Author contribution
Yalda Salari: data analysis, manuscript drafting. Moe Latt: data collection and interpretation. Eva Lau: database management and analysis. Alison M Layton: study conception, supervision, critical revision of manuscript. All authors approved the final manuscript.
Funding
No funding was received for the study itself. The Rapid Service and Open Access fees were funded by Galderma.
Data availability
The anonymised datasets generated during and/or analyzed during the current study are available in line with approved ethics from the corresponding author on reasonable request.
Declarations
Conflict of interest
Professor Layton has served as advisor on clinical trial development or as a consultant for Alliance, Almirall, L’Oreal, Beiersdorf, La Roche Posay, Galderma pharma, Eligo, Novartis on subjects related to acne. She has also provided unrestricted educational talks for Almirall, Beiersdorf, Galderma Pharma, Leo, L’Oreal, La Roche Posay, on subjects related to acne. Yalda Salari has nothing to disclose. Moe Latt has nothing to disclose. Eva Lau has nothing to disclose.
Ethical approval
This study was conducted using data from an ethically approved NHS clinical database (REC reference: 21/NE/0158), with approval from the Research Ethics Committee and Health Research Authority. All participants provided informed consent, and all data were anonymised prior to analysis.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Data Availability Statement
The anonymised datasets generated during and/or analyzed during the current study are available in line with approved ethics from the corresponding author on reasonable request.