ARTICLE
According
to epidemiological studies, acne is a common condition affecting 80% of
young people between 12 and 18 years of age. It is also the most
common reason for consultation in private dermatology practices. Yet, paradoxically,
very few studies have been concerned with the profile and therapeutic treatment
of acne patients [1-3]. The aim of this research was firstly to perform,
in 1996, a major national transversal study to define the profile of the
acne patient treated by a dermatologist in private practice by describing
his/her clinical characteristics, the repercussions of his/her acne on his/her
quality of life and the modalities of his/her treatment, and to perform
the study again 4 years later in 2000 using the same methodology
in order to evaluate the evolution of the profiles of acne patients and
the modalities of their treatment.
This method also aimed to form the first step in a longitudinal observation
of acne patients and their therapeutic treatment.
Material and methods
The questionnaires for 1996 and 2000, which were identical, consisted
of four parts.
The aim of the first part was to obtain a description of the demographic
characteristics of patients and their motivation for consulting a dermatologist.
The second part contained a clinical evaluation of the patients' acne.
This questionnaire has been built by 2 dermatologists and confirmed
by one epidemiologist.
The third part evaluated the aesthetic, professional and emotional problems
caused by the patients' acne. The fear of scarring and the loss of confidence
felt by patients was also evaluated. For this, patients were asked to
state their opinion using an analogical scale of 1 to 6, ranging
from "not very important" to "very important". This scale was adapted
for the study but not valided. The fourth part contained the modalities
of the therapeutic treatment patients were receiving for their acne in
terms of medical prescriptions, examinations and complementary treatments.
This study was carried out on 26 November 1996 and 21 November
2000 among all patients consulting the dermatologist on these days
for acne.
If a doctor was not consulting on that particular day, he/she was allowed
to carry out the study one day earlier or one day later: no other days
were acceptable.
Criteria used when selecting the different participating French dermatologists
were the following: age, sex, the town's population, district for obtaining
a representative sample of French dermatologists. The dermatologists were
not identical between 1996 and 2000.
Statistical analysis
The patients' files were then sent to the Biotechnology Evaluation
and Standardization Center in the medical biostatistics department
of the university hospital of Dijon where they were processed and analysed
using the SAS software program. The statistical analysis made use of the
usual parameters, averages and standard deviations for quantitative variables,
and histograms and percentages for qualitative variables. The comparisons
were carried out using chi 2 tests and variance analyses. The threshold
of significance was fixed at alpha risk = 0.05.
Results
In 1996, six hundred and fifty two dermatologists participated in the
study. Their average age was 44 ± 7 years; the percentage
of females was 64.4% (n = 406). 7.8% (n = 49) worked
in towns with fewer than 10,000 inhabitants, 43.0% (n = 269)
in towns with 10,000 to 100,000 inhabitants and 49.2% (n = 308)
in towns with over 100,000 inhabitants. They held an average of 110.5 ± 42.0 consultations
per week, of which 19 ± 12 were for acne, i.e. almost one
in five consultations.
In 2000 and in the same way, 657 dermatologists in private practice,
aged on average 46 ± 7 years, mainly female (70.3%; n = 460)
participated in the study. Of these, 8.0% (n = 52) worked in
towns with fewer than 10,000 inhabitants, 47.7% (n = 309)
in towns with 10,000 to 100,000 inhabitants and 44.2% (n = 308)
in towns with over 100,000 inhabitants. They held an average of 100 ± 35 consultations
per week, of which 20 ± 10 were for acne, i.e. almost one
in five consultations.
No statistically significant difference was found in these criteria between
the 1996 and 2000 groups of dermatologists in private practice.
Demographic characteristics of the patients
The study 2000 involved 2363 patients aged 20.5 ± 7.7
years, the majority of whom were female (63.6%; n = 1479), 33.0%
(n = 457) of whom were taking oral contraception.
In the 1996 study, the number of patients, 2284, was similar. These patients
were comparable with respect to age (21.0 ± 7.6), sex/ratio
(64.4%; n = 1456) and number taking oral contraception (35.2%;
n = 513). A more detailed analysis of age showed that adults
from 18 to 25 years accounted for a quarter of all patients
(23%; n = 536) in 2000 and 24% (n = 548) in 1996
(p = ns).
The socio-professional situation of patients was heterogeneous in both
1996 and 2000, without any significant evolution over the four years (Fig. 1).
Clinical description
For 90.1% (n = 2129) of the patients, acne was the first reason
for consultation in 2000; for 81.2% (n = 1919) of these patients,
this was a follow-up consultation.
These figures were slightly higher than those for 1996, where acne was
the primary reason for 77.7% of consultations. More than three quarters
of consultations were spontaneous consultations on the patient's own initiative
(81.0%; n = 1787) in 2000; there was no significant change compared
with 1996 (81.1%; n = 1723).
Previous treatments before consultation
In 2000, 62.8% (n = 1484) of the patients seen in consultation
had already received systemic previous treatment, versus 58.2%
(n = 1329) in 1996 (Table I).
This previous treatment had been given either by general practitioner
or dermatologist. This reduction concerned mainly the tetracyclines, 74.1%
in 2000 versus 86.9% in 1996. Mild and moderate acne vulgaris
were the most common form of acne seen [55.2% (n = 1305)] by
the dermatologists, far more frequent than nodular acne [10.0% (n = 238)]
with similar frequency between 1996 and 2000.
In 2000, a reduction (p < 0.05) in excoriations (15.8%),
inflammatory scars (13.5%) and non-inflammatory scars (8.8%) was noted
in patients compared with 1996.
Psychological repercussions and quality of life of the patients
In 2000, 74.3% (n = 1755) of the patients felt that their acne
induced an aesthetic problem which they rated 3.6 ± 1.4 on
a scale ranging from 1 for "not very important" to 6 for "very
important". Acne had fewer (p < 0.01) repercussions on quality
of life compared with 1996. But for patients who participated in the 1996
and the 2000 studies, the evaluation on an analogical scale of the
repercussions of their acne on their quality of life remained stable (Table II).
Treatment prescribed by the dermatologist at the
end of the consultation
As Figures 2 and 3
show, there were several variations in the prescription of the dermatologists
between 1996 and 2000.
With regard to topical treatments, dermatologists reduced their number
of prescriptions of topical antibiotics [50.6% versus 39.9% (p < 0.05)],
and benzoyl peroxide [43% versus 36.7% (p < 0.05)].
Although, the number of prescriptions of first generation of topical retinoids
remained stable, the prescription of second generation retinoids (adapalene)
increased (18.3% versus 16.2%).
With regard to prescriptions of systemic treatments at the end of the
consultation, a slight non significant increase was noted in the percentage
of prescriptions of doxycyclin (28.8% versus 26.8%) between 1996
and 2000, and isotretinoin (15.4% versus 18.4%). Conversely, there
was a non significant reduction in the percentage of prescriptions of
minocyclin (18.8% versus 13%). The number of zinc salts and lymecyclin
prescriptions remained stable and there was a slight reduction in the
percentage of hormonal therapy prescriptions. One of the pitfalls of this
study is that it does not permit us to determine the types of combined
therapy (for example oral antibiotic and topical benzoyl peroxyde or/and
retinoid).
The frequency of requests for complementary examinations was unchanged
and remained low [18.1% (n = 408)]. There was a trend towards
reducing the number of prescriptions of complementary treatments (63.4%
versus 76.2%: p < 0.05) and dermatological cleansing
bars (22.8% versus 74.9%), whereas the number of prescrip
tions of moisturizing creams remained stable and prescription was frequent
[65.0% (n = 1112)].
Discussion
Epidemiological studies published in the literature have been essentially
concerned with two areas. Studies have been either devoted to the prevalence
of acne and the clinical profile of acne within well targeted populations
such as young people in a school environment [1-3], acne in adults [4]
and pre-pubescent acne [5], or have been interested in the psychological
profile of the acne patient [6-8].
Thus, very little data can be found in the literature concerning the fashions
of prescription of acne treatments by dermatologists in private practice.
The interest of this present study lies in 3 factors. Firstly, studies
concerned with the day-to day-practice of dermatologists in the treatment
of acne are rare. Secondly, this study involved a large and representative
number of French dermatologists and patients. Thirdly, the study made
use of comparative data collected at the beginning and end of a 4-year
period. One of the potential biases of this study is that the dermatologists
who have participated to the two different studies are not identical.
However, this bias was limited by the fact that the two groups of dermatologists
were similar for the main criteria: age, sex, size of the town.
The profile of the typical acne patient taken in charge by the dermatologists-
essentially a female with an average age of 20 years - has
changed little between 1996 and 2000. A trend towards an increase in the
frequency of acne in adult women noted in several studies was not found
in our study. In 2000 as in 1996, patients most frequently (80%)
came to see the dermatologist of their own accord. They were rarely referred
by their general practitioner. Acne vulgaris with superficial inflammatory
lesions was the most common type seen by the dermatologist; severe nodular
forms accounted for fewer than 15% of consultations with no evolution
of this percentage over the 4 years.
Regarding therapeutic prescription, some interesting points emerged in
the evolution of prescriptions by dermatologists in private practice between
1996 and 2000. For topical treatments, a significant reduction in the
number of prescriptions of antibiotics as well as, to a lesser extent,
benzoyl peroxide was noted. On the other hand, there was an increase in
the number of prescriptions of a new retinoid (adapalene).
Without prejudice as to the frequency of different types of acne (inflammatory
or non-inflammatory) seen on both days of the study, the reduction in
the number of prescriptions of topical antibiotics suggests that dermatologists
in private practice have started to become aware of the risk of the development
of bacterial resistance. In addition, for systemic treatments, the decrease
in the number of prescriptions of minocyclin in favour of doxycyclin seems
indicate that the dermatologists are also taking the severe side effects
of minocyclin into account, even if these are rare. It is interesting
to note that in France in contrast to many parts of the world, oxytetracycline,
tetracycline (first generation) and erythromycin are very rarely prescribed.
Finally, the strict regulations linked to the use of isotretinoin do not
seem to have slowed down the rate at which this drug is prescribed. Indeed,
prescriptions increased between 1996 and 2000. Prescriptions of the 2 other
main systemic treatments (zinc salts and hormonal treatments) remains
stable.
Regarding associated cosmetic treatments, though dermatologists continued
to recommend moisturizing cream to limit the drying side effects of local
treatments, they were less likely to recommend cleansing gels. Finally,
with regard to the repercussions of acne on quality of life, no significant
difference was noted between 1996 and 2000.
CONCLUSION
In conclusion, though the profile of acne patients evolves slightly between
1996 and 2000, therapeutic prescriptions, whether local or systemic treatments,
are notably modified suggesting that information in the literature about
both antibiotic resistance and severe side effects are having an effect.
It would be interesting to perform this study again so as to put in place
an observatory on the evolution of the therapeutic treatment of acne patients.
We thank all the French dermatologists who have participated to these
2 surveys. These surveys were supported by FABRE France.
Article accepted on 14/01/03REFERENCES
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