C. Zip, MD, FRCPC
Department of Medicine, University of Calgary, Calgary, AB, Canada
Optimal acne therapy must take into account not only acne type and severity, but also the impact of this skin disorder on the patient’s quality of life. Several validated instruments have been used to measure quality of life in acne patients. By using these instruments, acne patients have been shown to experience levels of social, psychological and emotional distress similar to those reported in patients with asthma, epilepsy and diabetes. Several studies have demonstrated that the disability caused by acne can be mitigated by effective therapy.
Acne vulgaris, quality of life
The psychological burden associated with acne was described years ago by Sulzberger and Zaidens1: “There is probably no single disease which causes more psychic trauma, more maladjustment between parents and children, more general insecurity and feeling of inferiority and greater sums of psychic suffering than does acne vulgaris.” Despite general acceptance of the psychosocial impact of acne, measurement of its effect on quality of life (QOL) has only begun in recent years. This article will review the methods used to measure QOL in acne patients and what we have learned from this research.
Measurement of QOL
QOL is generally measured using validated questionnaires. Several instruments have been designed: for use in many different diseases, for skin disorders only, or for one particular disease such as acne. General health measures, which can be used to assess many diseases, include the Short-Form 36 (SF-36) and the General Health Questionnaire. These can be used to compare the impact of skin disease with that of diseases affecting other systems. Dermatology-specific measures include the Dermatology Life Quality Index (DLQI)2 and Skindex.3 These are more sensitive indicators of the impact of skin disease on QOL and they can be used to compare one skin disease with another. Acne-specific QOL instruments include the Acne Disability Index (ADI)4 and the Cardiff Acne Disability Index (CADI).5 The CADI was derived from the ADI as a short, five-item questionnaire that could be used in clinical practice. Other acne-specific measures include the Acne-Specific Quality of Life (Acne-QOL) questionnaire,6 which is designed for assessment of facial acne. A recently described four-item condensed version of the Acne-QOL7 was developed for use in routine clinical practice. The Acne Quality of Life (AQOL) scale8 focuses on the social and vocational aspects of acne. Greater impairment of QOL, as measured by the AQOL, was associated with greater levels of anxiety and depression in one study.9
Why Measure QOL?
Measuring the impact of acne on quality of life allows us to understand the disease from the patient’s point of view. In clinical research, new medications are increasingly being evaluated according to their impact on QOL, which is in addition to the traditional approach of assessing only treatment safety and efficacy. In clinical practice, understanding how a patient’s life is impacted by acne can help in selecting the most appropriate treatment for that patient and may enhance compliance.10
How Acne Impacts QOL Compared with Other Diseases
Although acne is sometimes considered to be unimportant in comparison with other medical conditions, the associated morbidity is significant. Mallon, et al.11 measured QOL in 111 acne patients using the DLQI, Rosenberg’s measure of self-esteem, a version of the General Health Questionnaire, and the SF-36. The acne patients described levels of social, psychological and emotional problems that were as great as those reported by patients with asthma, epilepsy, diabetes, back pain or arthritis. Lasek, et al.12 reported that adults with acne experienced functional and emotional effects comparable with those of patients who have psoriasis. Beattie, et al.13 used the Children’s Life Quality Index and the Children’s Dermatology Life Quality Index to evaluate patients aged 5–16 years with various skin diseases and compared them with children suffering from other chronic medical conditions. Health-related QOL impairment in children with skin disease was at least equal to that experienced by children with other chronic illnesses, but atopic dermatitis and psoriasis caused greater disability than did acne.
Acne Severity and QOL
Studies have failed to show a strong association between acne severity and QOL.9,11,14 Hence, it is difficult to ascertain the extent of disability caused by a given severity of acne, as QOL is dependent on a host of correlating factors that are as yet poorly understood. Rapp, et al.15 reported that trait anger, the tendency to experience an angry mood easily, was significantly related to global and skin-related QOL, as well as to satisfaction with treatment. Furthermore, Krehci-Manwaring, et al.16 proposed that dispositional social sensitivity in acne patients was independently associated with poorer social functioning and QOL.
Age, Gender and QOL
Lasek, et al.12 reported greater overall effects on QOL in older adult acne patients regardless of disease severity, with similar effects on both sexes. Jones-Caballero, et al.17 also found that older patients had a worse acne-related QOL, although its influence was small. In this study, women experienced greater QOL impairment, although acne was significantly more severe in men. In a recent study18 of Scottish teenagers aged 15–18 years, 11% of those with self-reported acne perceived their lives to be significantly affected by their acne. The rate of variance in this perception was negligable between the sexes.
Impact of Acne Treatment on QOL
Several studies have shown improvement in QOL with effective acne treatment.17,19,20 Using the SF-36, the DLQI, Rosenberg’s measure of self-esteem, and a version of the General Health Questionnaire, Newton, et al.20 monitored the QOL of patients who were referred to a dermatology clinic for acne treatment. As the clinical acne grade significantly improved with treatment, so did QOL, as measured by the four instruments used. Clinical and patient-assessed outcomes were most improved in isotretinoin treated patients. Two recent studies21,22 have shown that instruction in appropriate cosmetic use enhances QOL in female acne patients.
Acne can profoundly impact quality of life. As its effect on QOL does not always correlate with acne severity, the disability caused by acne must be taken into account when individualizing treatment. Effective acne therapy is associated with significant improvement in the quality of life of acne patients.
- Sulzberger NB, Zaidens SH. Psychogenic factors in dermatologic disorders. Med Clin North Am 32:669-85 (1948).
- Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 19(3):210-6 (1994 May).
- Chren MM, Lasek RJ, Quinn LM, et al. Skindex, a quality-of-life measure for patients with skin disease: reliability, validity, and responsiveness. J Invest Dermatol 107(5):707-13 (1996 Nov).
- Motley RJ, Finlay AY. How much disability is caused by acne? Clin Exp Dermatol 14(3):194-8 (1989 May).
- Motley RJ, Finlay AY. Practical use of a disability index in the routine management of acne. Clin Exp Dermatol 17(1):1-3 (1992 Jan).
- Girman CJ, Hartmaier S, Thiboutot D, et al. Evaluating health-related quality of life in patients with facial acne: development of a self-administered questionnaire for clinical trials. Qual Life Res 5(5):481-90 (1996 Oct).
- Tan J, Fung KY, Khan S. Condensation and validation of a 4-item index of the Acne-QoL. Qual Life Res 15(7):1203-10 (2006 Sep).
- Gupta MA, Johnson AM, Gupta AK. The development of an Acne Quality of Life scale: reliability, validity, and relation to subjective acne severity in mild to moderate acne vulgaris. Acta Derm Venereol 78(6):451-6 (1998 Nov).
- Yazici K, Baz K, Yazici AE, et al. Disease-specific quality of life is associated with anxiety and depression in patients with acne. J Eur Acad Dermatol Venereol 18(4):435-9 (2004 Jul).
- Dreno B. Assessing quality of life in patients with acne vulgaris: implications for treatment. Am J Clin Dermatol 7(2):99-106 (2006).
- Mallon E, Newton JN, Klassen A, et al. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br J Dermatol 140(4): 672-6 (1999 Apr).
- Lasek RJ, Chren MM. Acne vulgaris and the quality of life of adult dermatology patients. Arch Dermatol 134(4); 454-8 (1998 Apr).
- Beattie PE, Lewis-Jones MS. A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases. Br J Dermatol 155(1):145-51 (2006 Jul).
- Ilgen E, Derya A. There is no correlation between acne severity and AQOLS/DLQI scores. J Dermatol 32(9):705-10 (2005 Sep).
- Rapp DA, Brenes GA, Feldman SR, et al. Anger and acne: implications for quality of life, patient satisfaction and clinical care. Br J Dermatol 151(1):183-9 (2004 Jul).
- Krejci-Manwaring J, Kerchner K, Feldman SR, et al. Social sensitivity and acne: the role of personality in negative social consequences and quality of life. Int J Psychiatry Med 36(1):121-30 (2006).
- Jones-Caballero M, Chren MM, Soler B, et al. Quality of life in mild to moderate acne: relationship to clinical severity and factors influencing change with treatment. J Eur Acad Dermatol Venereol 21(2):219-26 (2007 Feb).
- Walker N, Lewis-Jones MS. Quality of life and acne in Scottish adolescent schoolchildren: use of the Children’s Dermatology Life Quality Index (CDLQI) and the Cardiff Acne Disability Index (CADI). J Eur Acad Dermatol Venereol 20(1):45-50 (2006 Jan).
- Grosshans E, Marks R, Mascaro JM, et al. Evaluation of clinical efficacy and safety of adapalene 0.1% gel versus tretinoin 0.025% gel in the treatment of acne vulgaris, with particular reference to the onset of action and impact on quality of life. Br J Dermatol 139(Suppl 52):26-33 (1998 Oct).
- Newton JN, Mallon E, Klassen A, et al. The effectiveness of acne treatment: an assessment by patients of the outcome of therapy. Br J Dermatol 137(4):563-7 (1997 Oct).
- Hayashi N, Imori M, Yanagisawa M, et al. Make-up improves the quality of life of acne patients without aggravating acne eruptions during treatment. Eur J Dermatol 15(4):284-7 (2005 Jul-Aug).
- Matsuoka Y, Yoneda K, Sadahira C, et al. Effects of skin care and makeup under instructions from dermatologists on the quality of life of female patients with acne vulgaris. J Dermatol 33(11):745-52 (2006 Nov).