Quality of Life in Patients with Acne : A Questionnaire Study

Introduction: Acne vulgaris is a self-limited disorder of the pilosebaceous unit. It is primarily seen in adolescent age group. Acne can present with pleomorphic lesions consisting of comedones, papules, pustules and nodules. Both inflammatory and non-inflammatory acne can produce scarring. It has been found that acne significantly affects selfimage and quality of life. Effective treatment results in improvement of quality of life. Objective: The objective of this study was to find the impairment of quality of life in patients with acne. Materials and Methods: A total of 140 randomly selected patients coming to Dermatology OPD of Bir Hospital with complaints of acne were enrolled. A standard Dermatology Life Quality Index (DLQI) and Cardiff Acne Disability Index (CADI) questionnaires were used. Results: The average score of DLQI in my study was 9.5±5.6 with a minimum score of 0 and maximum score of 25. Similarly, the mean CADI score was 5.9±2.88 with minimum score of 0 and maximum score of 12. This study found acne to be more common in females as compared to males. Most common age group for acne was 16-20 years. Almost half of the patients (46%) complained of flare-ups during summer season. Similarly, majority (60%) of patients could relate to some aggravating factors. Most common aggravating factors were topical medications, fatty foods and stress. Conclusion: Acne is a common skin condition among the adolescents. This study conducted in Dermatology and Venereology Department of Bir Hospital showed that there is invariably some impairment in quality of life in acne patient.


Introduction
A cne vulgaris, a self-limi ng disorder of the pilosebaceous unit, is seen primarily in adolescents.It consists of comedones, papules, pustules, and nodules.Although the disorder is selflimi ng, the scar forma on can be a life-long sequela. 1 The key elements in the pathogenesis of acne are follicular epidermal hyperprolifera on, excess sebum produc on, infl amma on and presence and ac vity of Propionibacterium acne.It has been found that certain foods like milk and hyperglycemic foods can promote the development of acne. 2 There are diff erent methods of classifying acne, but most commonly used are the classifi ca on of the American Academy of Dermatology and Indian authors. 3,4e personal and social consequences of acne mostly commonly aff ect the adolescent age group. 5cne nega vely aff ects quality of life.The level of anxiety and depression directly correlates with the impairment in quality of life.A greater impairment in dermatologic quality of life seems to put the pa ent at an increased risk for anxiety disorder. 6ne can aff ect an individual's health-related quality of life (HRQoL), notably feelings and emo ons, personal rela onships, social life and even chances of employment. 7It has also been found that acne pa ents can have low self-esteem, depression, anxiety, shame/ embarrassment and social avoidance. 5,7,8It is quite surprising that the impact of acne may be equivalent to that of asthma or epilepsy.But on the be er side, eff ec ve treatment results in improvement in quality of life. 9

Materials and Methods
A ques onnaire study was conducted in the Department of dermatology at Bir Hospital, Kathmandu using "Dermatological life quality index" and "The Cardiff Acne Disability Index". 10,11Permission was sought from the ins tu on review board of Na onal Academy of Medical Sciences.Likewise, permission was also obtained from the original authors to use the DLQI ques onnaires.Pa ents were explained about the purpose of the study and the methods used.They were given a wri en consent form regarding the study and only the pa ent willing to par cipate in the study were included.A detailed proforma of the pa ent was fi lled up by the researcher, which included age, sex, level of educa on, profession, severity of acne, dura on of acne, aggrava ng factors and sites of involvement.The pa ents were requested to fi ll the ques onnaire and every precau on was taken to maintain privacy of the pa ent.
A total of 140 randomly selected pa ents were included in the study from January 2010 ll December 2010.Pa ents with acne coming to the dermatology out pa ent department, only on the even days of the week (Monday, Wednesday and Friday) were included in the study.A total of 140 randomly selected pa ents were included in the study.Results were analyzed using SPSS so ware version 17.0 for Windows.Comparison of categorical variables between independent groups was done with Chi-square test.Pearson correla on coeffi cient was used to correlate the scores of two diff erent ques onnaires.A p value of <0.05 was considered sta s cally signifi cant.
The DLQI was calculated by summing the score of each ques on resul ng in a maximum of 30 and a minimum of 0. The higher the score, the more quality of life was impaired.The DLQI can also be expressed as a percentage of the maximum possible score of 30.A banding system has been validated in order to help with the clinical interpreta on of the scores.According to this system, a DLQI score of 0-1, 2-5, 6-10, 11-20, 21-30 indicates no eff ect at all, small eff ect, moderate eff ect, very large eff ect and extremely large eff ect on pa ent's quality of life, respec vely.The ques ons can be classifi ed under 6 headings: symptoms and feelings (ques ons 1-2), daily ac vi es (ques ons 3-4), leisure (ques ons 5-6), and personal rela onships (ques ons 8-9), each with a maximum score of 6. Ques ons regarding work and school (ques on 7) and treatment (ques on 10) have a maximum score of 3.
Similarly, the CADI score was calculated by summing the score of each ques on resul ng in a possible maximum of 15 and a minimum of 0. The higher the score, the more the quality of life is impaired.

Results
A total of randomly selected 140 pa ents with acne were enrolled in this study.The results showed a slight predominance of acne among females (56% vs 44%).The mean age was 19.11±3.41years.The most common age group was noted to be 16-20 years for both sexes.Almost half of the pa ents (46%) noted fl are-up of their acne during summer.More than half of pa ents (60%) noted presence of some aggrava ng factors.The most common aggrava ng factors were topical medicine (16.4%), fa y foods (15%) and stress (4.3%).Majority of pa ent coming to seek consulta on had moderate form (66.4%) of acne in severity and onset of one-year dura on (52.9%).
The average score of DLQI in our study was 9.5±5.6 with a minimum score of 0 and maximum score of 25.The distribu on of pa ent according to DLQI banding is shown in Figure 1.
A large group of pa ents (39.2%) scored between 11-20, which correlated with a very large eff ect on pa ent's life and another signifi cant propor on (32.8%) scored between 6-10, which meant a moderate eff ect on pa ent's life.Only 11 pa ents (7.8%) had no eff ect on their life due to acne whereas six pa ents (4.2%) had an extremely large eff ect on their life.But this study failed to show any signifi cant correla on between DLQI score with age group, sex of pa ent, level of educa on, dura on, severity, or site of acne.
The mean CADI score was 5.9±2.88 with minimum score of 0 and maximum score of 12. Similarly, CADI scores also failed to show any correla on with age  group, sex of pa ent, level of educa on, dura on, severity or site of acne.

Discussion
Many studies have found that the nega ve psychological impact of acne being more in females 14,15 as compared to males, but this study failed to show any such correla on.
[17] It was also noted that the no correla on was established between acne severity with both of the scoring system sugges ng that the impairment in quality of life is dependent on pa ents' percep on rather than the severity.
In contrast to the study done by Finlay and colleagues, this study failed to show any correla on between CADI scores with severity and site of acne. 11 was found that both the ques onnaire systems were equally eff ec ve and comparison of scores from both ques onnaires showed signifi cant correla on (p<0.001)No correla on was noted between the scores in the ques onnaires as compared to the level of educa on, which suggest that certain level of anxiety or impairment may not only depend on peers' exploita on but there are other factors which should be further explored into.
Signifi cant morbidity and decrease in health-related quality of life has been strongly associated with acne.It has also been found that both general prac oners and dermatologists have poor comprehension of the psychological implica ons of skin disease, being insensi ve to their pa ent's emo onal suff ering, and trivializing par cipants' disease. 18This study in some ways inquired into the pa ents' emo ons and suff ering which has not been dealt prior in Bir Hospital.

Conclusion
Acne was more common among adolescents.The common aggrava ng factors were topical medica ons, fa y foods and stress.There was invariably some impairment in quality of life and the impairment was not related to sex, severity or dura on of acne.So, in trea ng pa ents with acne special a en on should be taken on fi nding out the impairment in quality of life and addressing such problem as well.Furthermore, mul -centric studies with larger sample size would be useful in correla ng the impairment of acne in the pa ents.

Figure 1 :
Figure 1: Distribu on of pa ents according to DLQI banding scores.

Financial disclosure:
None.Confl icts of interest to disclosure: None declared.