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Table of Contents 
ORIGINAL ARTICLE
Year : 2022  |  Volume : 67  |  Issue : 3  |  Page : 239-246
Predictors of quality of life in adults and adolescents with acne: A cross-sectional study


1 Department of Dermatology, Sanko University Faculty of Medicine, Gaziantep, Turkey
2 Department of Dermatology, Bahçeşehir University Faculty of Medicine, İstanbul, Turkey

Date of Web Publication22-Sep-2022

Correspondence Address:
Fatmaelif Yıldırım
Department of Dermatology, Sanko University Faculty of Medicine, Gaziantep
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_781_20

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   Abstract 


Background: Acne is becoming more prevalent in adults, particularly women across the globe. Although previous studies have compared clinical and epidemiologic characteristics of adolescent and adult acne, an adequate understanding of the quality of life (QoL) of adult acne patients and associated comorbidities are still lacking. Objectives: We sought to compare the differences between adolescent and adult patient groups, regarding gender, socio-clinico-demographic factors, and comorbid associations, as well as their relatedness with life quality. Methods: This is a cross-sectional study with 1013 acne patients. Data on the severity, onset and location of acne, sex, family history of acne, smoking and alcohol habits, medication history, presence of seborrhea, and other comorbidities were collected. We employed the classification used by the American Academy of Dermatology for assessing acne severity. To assess the QoL in the patients, the Dermatology Life Quality Index (DLQI) score was used. Results: Of the 1013 patients included in this study; 380 (female: 333, male: 47) were adult, and 633 (female: 535 and male: 98) were adolescent cases. The median total DLQI scores of adult and adolescent groups were not significantly different. Our results showed that factors such as age, gender, duration, body mass index, family history, and psychiatric disorders exhibited no impact on QoL in both adolescents and adults. Age of onset was correlated with DLQI scores in the adult group. The main influencers of DLQI in the adult group were allergic disorders, hormonal imbalances, and previous treatment history. Besides, major influencers in adolescent patients were acne severity, acne location, hirsutism, hyperseborrhea, premenstrual exacerbation, menstrual irregularities, previous treatment history, and smoking. Conclusions: The findings of our current study have shown that DLQI has been influenced by different factors in adolescents and adults that should be kept in mind.


Keywords: Acne vulgaris, quality of life, adult acne


How to cite this article:
Yıldırım F, Mert B, Çağatay EY, Aksoy B. Predictors of quality of life in adults and adolescents with acne: A cross-sectional study. Indian J Dermatol 2022;67:239-46

How to cite this URL:
Yıldırım F, Mert B, Çağatay EY, Aksoy B. Predictors of quality of life in adults and adolescents with acne: A cross-sectional study. Indian J Dermatol [serial online] 2022 [cited 2022 Sep 30];67:239-46. Available from: https://www.e-ijd.org/text.asp?2022/67/3/239/356757





   Introduction Top


Acne is the most common form of skin disease among adolescents and young adults, with a prevalence of ~85% in the age range of 12–25 years.[1],[2] Though acne is primarily considered as a disease of teenagers, current research shows that the prevalence of acne in adults is increasing. Age cutoff between adolescent and adult acne is not clearly set but 25 years as an age demarcation is the most frequent option in the literature and adult acne can be defined as the presence of acne lesions over 25 years of age.[3] The onset of acne is age-variable; it could start during adolescence and continue until adulthood (persistent acne), or it might be seen only in the post-adolescent period (late-onset acne). Late-onset acne is thought to be less common than persistent acne.[4]

In addition to the impact of acne on patients' social life, it has been demonstrated by the Dermatology Life Quality Index (DLQI) that acne patients score higher by this assessment than psoriasis patients (DLQI = 11.9 and 8.8, respectively).[5] It has been widely accepted that acne impacts the quality of life (QoL) in adult patients more than their younger counterparts.[6],[7],[8] Nonetheless, the literature consists of conflicting results.[6],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21] Making comparisons between QoL outcomes in adults from different studies is difficult because of differences in the questionnaire design, study setting, and the characteristics of the included study population.[6],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23]

Nonetheless, because of these inconsistencies in results in the literature, we found it necessary to standardize the QoL assessment tools for further scientific studies, as the existing instruments might not capture the impact of adult acne on health-related QoL fully. Richter et al.,[17] validated the use of DLQI in adult female acne patients, concluding that DLQI could be used in clinical trials and/or clinical practice to measure changes of QoL of adult female acne patients. Even so, for other assessment tools such as Cardiff Acne Disability Index (CADI), acne specific-QoL questionnaire, or Skindex, such a validation study does not exist in adult acne.

In this study, we hypothesized that the demographic and socio-clinical characteristics might have different effects on patients' QoL in adolescent and adult acne patients and we compared acne severity relative to comorbidities among the two groups, and their effects on patients' QoL using DLQI in two provinces of Turkey.


   Methods Top


Study design

We performed a cross-sectional study with 1013 acne patients, enrolled between January 2016 and December 2018 from two medical centers located in different cities and regions in Turkey, Medical Park Hospital, Kocaeli (n = 680, 67.2%) and Sanko University Hospital, Gaziantep (n = 333, 32.8%), after the approval by the institutional research and ethics committee. Inform consent was provided to all the adolescent and adult patients admitted to the dermatology outpatient clinic with at least mild acne who agreed to participate in the study. Patients were included in the study without a requirement of naive treatment. Our exclusion criteria were as follows: (1) patients who refused to participate in the study; (2) patients who could not perform the study-related procedures because of an apparent disability; (3) patients with skin diseases that could affect the DLQI measurements. The patients' population was divided into two groups with respect to their ages, as follows: adolescent acne (of age 12–25 years) and adult acne (of age >25 years). The adolescent group consisted of 535 girls and 98 boys, whereas the adult group comprised 333 women and 47 men.

Comprehensive history was taken from each patient by two qualified dermatologists (FEY and BA), and cutaneous examinations were performed for each patient. These include data collection on the severity, onset and location of acne, sex, age, family history of acne, smoking and alcohol habits, medication history, presence of seborrhea, and other accompanying symptoms. We employed the classification used by the American Academy of Dermatology for assessing acne severity, grading the extent of acne as mild, moderate, and severe.[24]

To evaluate the QoL in the patients, the DLQI score was used.[25] The effect of the total DLQI score was graded as follows: rating (0–1), zero impact on patient life; (2–5); minor effect; (6–10); moderate effect; (11–20); very significant effect; and (21–30); extremely significant effect on a patient's life.

Statistical analysis

We applied the Statistical Package for Social Sciences (SPSS; Win Ver 25.0, 2004; SPSS Inc., Chicago, IL, USA) for data analysis. The descriptive statistics presented include frequency, percentage, mean and SD or median, and min–max values. Comparisons between groups were examined using the following: Mann–Whitney U test or independent samples t-test and Kruskal–Wallis test for more than two groups; a Chi-square test was performed for comparison of categorical variables in different groups, and Pearson correlation coefficient for assessing the association between two continuous variables. A P ≤ 0.05 was considered statistically significant.


   Results Top


Patients' demographics and clinical history are included in [Table 1]. Of the 1013 patients included in this study, 380 (female: 333 and male: 47) were adult, and 633 (female: 535 and male: 98) were adolescent cases. There was no significant difference between the adolescent and adult groups regarding sex (P = 0.171; [Table 1]). The mean body mass index was higher (22.8) in the adult group than the adolescent group (21.5), and this slight difference between the two groups was statistically significant (P < 0.001), [Table 1].
Table 1: Acne patients' demographics and clinical information

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DLQI measurements and comparison of effects of characteristics of patients on DLQI among the adult and adolescent groups

In general, the median total DLQI scores of adult [median 6 (min 0–max 29)] and adolescent (median 6 [min 0–max 26]) groups were not significantly different for the majority of the dimensions assessed, ranging from P values of 0.087 to 0.986. However, there was a notable difference regarding the work and study parameters (P = 0.004), [Table 2]. In addition, the distribution of patients according to total DLQI score grading was not different between adults and adolescents [Table 3].
Table 2: Median Dermatology Life Quality Index (DLQI) scores in acne adultorum and acne vulgaris patient groups

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Table 3: Distribution of total patients' DLQI scores in acne adultorum and acne vulgaris patient groups

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Age of onset and acne duration

Patients were classified as the following stages of acne: childhood (0–12), adolescent (12–19), early adult (20–25), and older adult (>25) years of age according to the self-reported age of onset of acne [Table 4]. In the adult group, 39.7% had late-onset acne and 60.3% had persistent acne. The onset of age had no statistically significant effect on DLQI levels (P = 0.073). Acne duration ranged from a minimum of 2 weeks to as long as 29 years in the adult group, whereas it was from 1 month to 16 years in the adolescent patient group. We observed a significant, but the inverse correlation between the age of onset and total median scores of DLQI in the adult patient group [6 (0–26), P = 0.027, correlation coefficient = −0.115]; however, there was no correlation between the age of onset or acne duration, and total scores of DLQI [6 (0–29), P = 0.087] in the adolescent group.
Table 4: Prevalence of acne in patients according to the age of onset

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Localization of acne lesions

Overall, acne lesions were significantly more common in different areas of the vulgaris group, except for the neck of which the adult patients demonstrated a considerably higher spreading of the disease [Table 1].

The median total DLQI scores were significantly higher for acne lesions in the cheek and perioral localizations in adolescent group [(7 (0–29), P = 0.003; 7 (0–29), P = 0.014] than the adultorum group [6 (0–26), P = 0.19; 6 (0–21), P = 0.475, respectively]. Overall, acne localization had a significant effect on the median DLQI scores of the adolescent group, contrary to the adult group, which did not show a measurable effect [Table 5].
Table 5: Relationship between acne patients' socio-clinical information and DLQI scores

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Acne severity

There was no statistically significant difference regarding acne severity between the adult and adolescent patient groups (P = 0.205) [Table 6]. In the adult group, the median DLQI scores were not statistically different among mild, moderate, and severe acne patients, and the disease severity had no statistically significant effect on the DLQI scores (P = 0.558). However, in the adolescent patients, the median DLQI scores were significantly affected by acne severity (P < 0.001) [Table 5].
Table 6: Acne severity between the adultorum and vulgaris patient groups

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Hyperseborrhea

Excessive seborrhea was significantly more common in adolescents than in adult patients (P < 0.001). In the adult group, there was no significant difference between the median DLQI values of patients with and without excessive seborrhea (P = 0.943), whereas, in the adolescent group, the median DLQI of the patients with excessive seborrhea was significantly higher than the patients without excessive seborrhea, P = 0.007 [Table 5].

Hirsutism

No significant difference was found between hirsutism among adolescent and adult patient groups (28% and 23%, respectively, P = 0.096). However, although the median DLQI scores between patients with and without hirsutism did not differ significantly among the adult group (P = 0.685), the hirsutism significantly affected the median DLQI scores of the adolescent group) than the hirsutism-free patients P = 0.03 [Table 5].

Menstrual irregularity

Patients' history of menstrual irregularity was significantly more common in the adolescent patient group (22.6%) than in the adult group (14.1%), (P = 0.002). Likewise, the median DLQI score in the adolescent group was significantly affected but not in the adult group (P = 0.986), [Table 5].

Premenstrual exacerbation

Patients' history of premenstrual exacerbation was significantly more common in the adult patients' group than the adolescent group (P = 0.001). However, this condition was found to have a statistically significant effect on the median DLQI score of the adolescent patient group with median DLQI scores of [7 (0–29)], compared with those without the symptoms [6 (0–24)], (P = 0.004) [Table 5]. In contrast, no significant difference was noted between those with and without premenstrual exacerbation in the adult group.

Hormonal imbalances

There were no statistically significant differences between hormonal imbalances and adult or adolescent patients. In the adolescent group, hormonal imbalances did not show a notable effect on the median DLQI scores, but the scores of the adult group were affected with a resultant higher median DLQI scores (P = 0.04) [Table 5].

Previous treatment history

Our study found no statistical difference between previous treatment history in the adolescent (54.9%) versus the adult group (49.1%), P = 0.075, [Table 1]. However, past acne treatment had a significant impact on the DLQI scores for both adult and adolescent patient groups (respectively, P = 0.016 and P = 0.013), [Table 5].

Family history of acne

In both adult and adolescent patient groups, no statistically significant difference was observed in both patients with a family history of acne and without. Also, there were no differences between the median DLQI scores obtained between patients, both with and without a family history of acne [Table 5].

Allergic diseases

There was no statistically significant difference between the presence of allergic diseases (allergic asthma, allergic rhinitis, food allergy, and atopic dermatitis) in the adult or adolescent patient groups (P = 0.291). However, the presence of allergic disease affected the DLQI score in the adult group, but not in the adolescent group (P = 0.045), [Table 5].

Psychiatric disorders

There was no statistically significant difference concerning psychiatric diseases between the adult and adolescent patient groups, [Table 1]. Also, by comparing the presence of psychiatric disease in adult and adolescent patients, we did not observe a significant effect on DLQI (P = 0.414 versus 0.185), [Table 5].

Smoking

Smoking history was significant in both the adult patient group and the vulgaris group, but it was twice as common in the adult group as the adolescent group (P < 0.001). We determined that smoking had a significant effect on the DLQI scores in the adolescent patient group = 0.004. Meanwhile, smoking did not have a significant effect on the DLQI scores in the adult group (P = 0.605), [Table 5].

Alcohol use

There was no significant difference between the history of alcohol use among the adult or adolescent patient groups, compared with the nonusers (P = 0.137), [Table 1]. Similarly, alcohol history did not have a significant effect on the median DLQI scores of both adult and adolescent groups (P = 0.481, P = 0.398, respectably [Table 5].


   Discussion Top


Acne is a dermatologic condition typically linked with the adolescent population, but the incident is increasing rapidly among adults, especially in women.[26],[27] There are only a few reported studies[28],[29] that compared the sociodemographic and clinical features of adolescent and adult patients among the Turkey population, and none of the studies evaluated adult and adolescent patients with a specific focus on DLQI. In general, the demographic and clinico-social history discussed below, negatively impacted the prevalence and severity of acne among the adolescent and adult populations, as reported by earlier investigators.[30],[31]

The impairment of acne lesions on QoL has been reported in studies involving both adult and the adolescent groups[6],[9],[10],[32],[33] as a chronic condition that impacts the QoL in adult patients with considerable psychological, social, and emotional impacts,[11],[34] attributable to patients proneness to embarrassment, social withdrawal, depression, anxiety, and anger.

Several investigators have reported that older patients were more adversely affected by their acne.[6],[9],[11],[15] Lasek and coworkers,[9] reported that older age had a more significant overall effect on QoL than younger patients. Likewise, their study among Indian acne patients, Hazarika and Rajaprabha[15] showed that the mean DLQI scores were highest among >25-year-old patients, with grade IV acne, severe scars, and post-acne hyperpigmentation. Further, Tan et al.,[11] showed that acne had a more significant effect on QoL among older-aged females,[11],[22] and also reported a significant association between the age of patients and the CADI scoring.

Contrary to those reports, Chowdary et al.[10] reported higher DLQI scores in the age group of 18–21 years, compared with those between 22 and 30 years. Similarly, Kainz et al.,[16] whose study population consisted of only female patients, reported no difference between DLQI scores of those >20 years and <20 years. Also, Richter's group[17] reported age might not affect the change of DLQI scores. Besides, Liasides and coworkers[18] reported that older participants in their study were less affected by their skin condition. Further, Salek et al.[21] reported that the patients' age did not correlate with either the UKSIP or the ADI, but it moderately correlated with the CADI.

Our results revealed no significant difference in the median total DLQI scores between the adolescent and the adult age groups. Although some of the previous studies were consistent with our results, others were not. The distinctions between other reports and ours might be explained by the differences in the QoL assessment tools, study setting, and the characteristics of inclusions in the study populations. Also, since there is no clear definition of adult acne based on the age of onset and there are different age demarcations assigned to adult acne definition in the literature, the different age designation in previous reports might affect results. In our study, we used 25 years as an age demarcation, since it is the most frequent option in the literature.[7] Discordance between the literature and ours might also be due to ethnic differences.

No gender difference in median DLQI scores was noted in this study in both adult and adolescent patient groups. Consistent with our results, several studies[10],[15],[22] also found no significant difference between DLQI responses among males and females with adult acne, indicating both genders were equally affected psychologically for living with acne. On the other hand, Lakshminarayana et al.,[14] reported in their results that adult female acne patients in their study had higher mean DLQI scores than male patients. Reports by other investigators[11],[12],[23] also contradicted our findings, as they reported that acne had a greater effect on adult female patients than on male patients. Thus, the literature results are also controversial regarding the impact of sex on QoL. Other than differences in QoL assessment tools used in the various studies and ethnic differences, psychological factors like perceived stigma might also cause discrepancies in the literature, as one previous study showed that the perceived stigma contributed more to the acne-related QoL than factors such as acne severity, gender, or age.[18]

Further, our study on severity demonstrated no difference between the adolescent and the adult patient groups, which is comparable with findings by other investigators.[28],[35] Although our median total DLQI scores showed no statistically significant differences between mild, moderate, and severe acne in the adult group, the severity in the adolescent group enhanced the DLQI scores. It is believed that in the adolescent population, acne is a more frequent complaint than in an adult group. Thus, it is the severity of acne but not necessarily the existence of the condition that may have a profound effect on the adolescent group. Our results can explain that even one single episode of acne outbreak can impair the DLQI in the adult group, which is consistent with a recent study by Rocha et al.,[13] who confirmed that adult has a high negative impact on the patients' QoL, even when they have mild to moderate acne.

In general, adolescent and adult patients demonstrated weaker significant differences in their DLQI scores, as shown by the same median DLQI scores differences only between the ranges of the two groups in the work/study domains with no significant difference in other aspects of the DLQI measurement. The adolescent patient group seemed to be statistically, more affected than the adult patient group in the work/study domain, but the clinical importance of this marginal statistical difference needs to be elucidated.

We found that the overall past acne treatments increased the DLQI scores for both adolescent and adult patient groups. The effect of previous treatment history on QoL is a parameter that was not evaluated in most of the earlier studies on adult acne. Only Durai and Nair[22] reported a significant association between treatment history and DLQI/CADI scores with a patient group consisting of age group >18. Recent findings showed treatment strategies that reduce the number and size of acne lesions in adolescents could improve patients' QoL,[36] and the assessment QoL tools such as DLQI were employed to evaluate treatment effects in acne.[37]

Studies have shown that individuals with facial acne show poorer self-esteem and body image than if the acne localization is in other areas of the body.[38] Overall, acne lesions in our study were significantly more common in different areas of the adolescent group, except for the neck of which the adult patients demonstrated substantially higher spreading of acne, similar to the finding by Kutlu et al.[28] in Turkey.

Several groups have also found acne distribution to dominate facial areas both for adults and adolescents.[15],[21],[28],[33],[39] Hassan et al.[23] who reported severity of facial acne had a significant association with increased social self-consciousness in women, but not in men. However, other reports indicated that acne localization did not significantly the mean QoL measurement scores in their adult patients[15],[18],[22]; therefore, it did not associate with the QoL in these adult acne populations.

Studies on the direct correlation between allergic disorders and adult acne, as well as DLQI responses, are lacking. Further research would explain whether the treatment response of adult acne patients with allergic diseases is lower and DLQI scores are impaired in adult acne patients by allergic diseases. Our study had limitations; first, it was restricted to a population of patients visiting only two hospitals located in two provinces of Turkey. However, due to the large study size, it provided more accurate median values and smaller margin errors. Second, the DLQI questionnaire was employed for evaluation, which is suitable for the detection of psychosocial problems, but not sufficient for the diagnosis of depression or anxiety without clinical assessment.


   Conclusions Top


The findings of our current study showed that the DLQI scores in adults and adolescents were affected by different factors that could result in poor QoL that should be kept in mind when making decisions in the planning of care for acne patients among different age groups.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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