Acne-related quality of life among adolescents and adults: a cross-sectional study in Antananarivo, Madagascar

Abstract

The current study analysed factors associated with alteration of quality of life (QoL) in people with acne. The impact of acne on QoL was related to consultation in dermatology, stress, acne scarring and severe forms according to Global Evaluation Acne scale.

Dear Editor, Acne negatively affects patients’ quality of life (QoL).¹ It would be of great use to have tools to assess its psychosocial effects, as considering these factors could enhance the quality of care and avoid negative psychological effects in patients with acne. This study aimed to assess the QoL of people with acne and to determine factors associated with impaired QoL.

A cross-sectional study was conducted from June to October 2023. Two groups of people with acne were included in this study: one grouping patients seen in consultation at the Department of Dermatology at the University Hospital Antananarivo, Madagascar, and the other grouping people with acne encountered in a large market in the capital of Madagascar. Participants with vitiligo, melasma, psoriasis, lupus erythematosus, or other skin conditions or other health conditions (pregnancy, etc.) that interfere with acne QoL were excluded from this study.

Sociodemographic parameters were assessed, including age, gender, marital status, education level, profession and socioeconomic level. The socioeconomic level was calculated according to the Socioeconomic Position Indices (SEPIs) based on the formula: SEPISs = age − 6 × EL − 4 × PC + 55 (EL = education level and PC = professional category). SEPIs ranges from 0 to 100, and is classified as lower class (1–35); lower middle class (36–54); middle class (55–67); upper middle class (68–80); and upper class (>80).

Clinical parameters were assessed including age of onset, risk factors (nutritional, environmental, hormonal, genetic factors, medication intake, stress assessed by Perceived Stress Scale-10), clinical form of acne, topography, presence of scar lesions and severity of acne [assessed with the Global Evaluation Acne (GEA) scale]. Therapeutic parameters were also assessed, including topical, systemic treatment, peeling and use of artisanal products.

The QoL of participants was assessed by Cardiff Acne Disability Index (CADI) and Dermatology Life Quality Index (DLQI). CADI contains a five-item questionnaire, and each answer is scored from 0 to 3. The score is calculated by summing the score of each answer. The higher the score, the more the QoL is impaired.² The DLQI is a dermatology-specific tool for measuring health-related QoL, consisting of 10 items and including 6 dimensions (symptoms and feelings, daily activities, leisure, work and school, personal relationships and treatment), with four possible responses to each item. Responses are calculated for the total DLQI score, which is 0–30. The higher the score, the lower the quality of life.³

Statistical analysis was performed using Epi Info 7.2.5.0. software. Student’s test, χ² and Fisher’s exact test were used for ­quantitative and qualitative variables, respectively. P ≤ 0.05 was considered statistically significant.

Participants were informed about the purpose of this study, and written informed consent was obtained. To maintain confidentiality, data manipulation was carried out anonymously.

A total of 100 participants (50 patients with acne seen in dermatology consultation and 50 people with acne encountered in a large market in the capital of Madagascar) were included in this study, with a mean (SD) age of 24 (6.18) years; 72 were female participants. Among 100 participants, 81 were single and 19 were married; 45 were students, 38 worked in the tertiary sector and 13 were unemployed.

Facial involvement was seen in all, associated with truncal involvement in 31 participants. According to GEA scale, the majority of participants had acne grade 3 (n = 34), followed by grade 4 (n = 29), grade 2 (n = 21) and grade 5 (n = 13). Acne scarring was observed in 63 participants. Aside from persistent pigmented macular scars, 22 presented with rolling atrophic and 4 with keloidal scars. In this study, 57% (n = 57) of participants had received only local treatment (benzoyl peroxide, tretinoin, adapalene, etc.), while 4% had been treated by oral retinoid. Among 50 patients seen by dermatology, 33 were satisfied with their treatment and 17 were not satisfied.

The QoL of patients seen in dermatology consultation was more impaired than in participants not seen in consultation (P = 0.00). No significant correlation was found between sociodemographic parameters and participants’ QoL. Participants who declared stress as an aggravating factor had more impaired QoL than those who did not (CADI, P = 0.03; DLQI, P = 0.02). Acne scarring and severe forms of acne (grade 4 and 5) were associated with impaired QoL (Table 1).

Table 1.

Correlation between demographics, clinical parameters and Cardiff Acne Disability Index (CADI) score

Demographic and clinical parameters	CADI score ≤7	CADI score >7	P-value
Socioeconomic level
Lower class	10	8
Lower middle class	22	11
Middle class	13	13
Upper middle class	9	12	0.5
Upper class	1	1
Age of onset of acne (years)
<20	47	8
20–30	7	36	0.77
>30	1	1
Nutritional factors
Sweet foods
Yes	42	32
No	13	13	0.28
Dairy productsa consumption
Once daily	25	33
Two to three times weekly	10	2	0.01
Less than once weekly	20	10
Environmental factors
Sunlight exposure
Yes	50	41
No	5	4	0.48
Smoking
Yes	4	3
No	51	42	0.46
Stress (PSS-10)
High level (27–40)	38	40
Moderate level (14–26)	13	3	0.03
Low level (0–13)	2	2
Excessive hygiene
Yes	23	23
No	32	22	0.18
Use of greasy cosmetics
Yes	16	17
No	39	28	0.18
Topography of lesions
Face	18	8
Face and upper cervical	4	3
Face and lower cervical	23	13	0.16
Face and truncal	10	21
Scar lesions
Dyschromia	44	19
Dyschromia + rolling atrophic	11	22	<0.001
Dyschromia + keloidal scars	0	4
Acne severity (GEA)
Grade 1	3	0
Grade 2	10	5
Grade 3	25	9
Grade 4	10	19	0.00
Grade 5	1	12
Therapeutic parameters
Topical treatment	18	39
Topical + systemic treatment	9	29	0.04
Without treatment	4	1

Bold values indicate significance at P < 0.05. GEA, Global Evaluation Acne; PSS-10, Perceived Stress Scale (10-item). ^aDairy products: milk, cheese, yogurt, butter, milk powder.

The current study analysed factors associated with alteration of QoL in people with acne. The impact of acne on QoL was related to consultation in dermatology, stress, acne scarring and severe forms according to GEA.

The mean CADI score was 6.6, with 45% (n = 45) of participants reporting a negative impact of acne on QoL. The mean DLQI score was 9.48, with 36% (n = 36) of participants reporting that acne had an important impact on their QoL; 7% (n = 7) reported a more important effect (according to DLQI score). Our result is different than that reported by Morshed et al., who reported a mean CADI score of their total cohort of 4.5.¹ Our findings confirm that acne significantly impairs self-esteem and QoL.

In this study, we found a relationship between dairy product consumption and poor QoL. However, statistical analysis was not conducted according to the category of dairy consumption. Recent systematic reviews confirm that dairy intake, especially skimmed milk, is associated with increased acne prevalence and severity.⁴

In this study, nodulocystic acne was correlated with impaired QoL, according to CADI (P = 0.02). This finding highlights the profound psychological impact of severe acne, which is consistent with studies demonstrating that patients with nodulocystic acne are at an increased risk of depression, anxiety and social withdrawal.^5,6 In our study, all participants presented facial involvement. Upper or lower cervical area involvement associated with facial acne was statistically associated with impaired QoL according to CADI score (P = 0.02). Our result is consistent with that reported by Tan et al.⁷ The visibility of facial acne is not the sole factor in acne-related psychosocial distress. Although the impact of facial acne on attractiveness is thought to be a primary concern, the face and trunk each contribute to overall attractiveness in both sexes.⁸ Atrophic and/or hypertrophic scars associated with dyschromia significantly impaired participants’ QoL according to CADI score (P < 0.001) and DLQI score (P = 0.007) in our study. Similarly, as stated by Dreno, impaired QoL was recorded in participants complaining of acne marks or scars compared with those without similar complaints, regardless of age group (P < 0.001).⁹ This may be explained by the fact that scars are more visible and enduring than acne itself. Concerning therapeutic parameters, our result is consistent with literature which found impairment of QoL in patients who had actively sought treatment for their acne vs. those who had not.¹⁰

Acne is more than simply an aesthetic issue. Even though our sample size was small, our findings suggest that dermatologists should pay attention to both the dermatological aspect and, more importantly, to the mental state and QoL of patients with acne.

Author contributions

Fandresena Arilala Sendrasoa (Conceptualization, Data curation, Investigation, Methodology, Writing—original draft, Writing—review & editing [lead]), Kanto Jessica Randrianamparany (Data curation, Investigation, Methodology, Writing—original draft [equal]), Lala Soavina Ramarozatovo (Validation, Visualization, Writing—review & editing [equal]), and Fahafahantsoa Rapelanoro Rabenja (Supervision, Validation, Visualization [equal])

Funding sources

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Conflicts of interest

The authors declare no conflicts of interest.

Data availability

The data underlying this article are available in the article.

Ethics statement

All study procedures were performed in accordance with the Ethics Committee of the University Hospital Joseph Raseta Befelatanana, Antananarivo, Madagascar, and conducted in accordance with the Declaration of Helsinki.

Patient consent

Written patient consent for publication was obtained.