Patient’s perspective: an important issue not to be overlooked in assessing acne severity

ARTICLE

Auteur(s) : Zeynep Demircay¹, Dilek Seckin¹, Asli Senol¹, Figen Demir²

¹Marmara University School of Medicine Department of Dermatology, Marmara Universitesi Tip Fakultesi Hastanesi, Dermatoloji Anabilim Dali, 34662 Altunizade Istanbul, Turkey
²Marmara University School of Medicine, Department of Public Health, Istanbul, Turkey

accepté le 19 Novembre 2007

Acne is an inflammatory disease of the pilosebaceous unit experienced by almost 80% of adolescents and young adults [1-3]. It is frequently localized on the face, affecting the appearance, which is an important part of overall body image [4, 5]. Moreover, it often begins in puberty, which is an important time for the development of body image, self-confidence and social abilities [4, 6, 7]. Acne patients are prone to psychological problems such as social withdrawal, anger, anxiety and depression [8-12]. In addition, patients with acne have a higher unemployment rate than adults without acne [13].

Evaluating acne patients with only clinical objective measures would not sufficiently reflect the overall morbidity associated with acne [14]. Thus, there is growing interest in using quality of life scales to understand to what extent patients are affected by their acne. The results of previous studies have pointed out that there is not always a correlation between the severity of acne and its impact on quality of life [6, 7, 15-22]. Therefore, supplementing objective measures with tools such as patients’ self assessments and acne-specific quality of life scales may provide insight into the magnitude of the problem. This may, in turn, help us in deciding which treatment is most appropriate for the particular patient.

In this study, we used two different measures of quality of life, one generic, the other acne-specific in a group of acne patients referred to our dermatology outpatient clinic. The following questions were addressed:

• 1) Is there any correlation between the quality of life scales and the physicians’ assessments of acne severity?
• 2) Is there any correlation between the quality of life scales and patients’ assessments of acne severity?
• 3) Which quality of life scale is more sensitive to changes in acne severity?

Materials and methods

The quality of life was assessed by means of the Turkish version of Acne Quality of Life (AQOL) scale [15]. We recently translated the AQOL scale into Turkish and demonstrated the reliability of the Turkish version [23]. The scale consists of 9 questions. These questions include items of self-consciousness, decreased socialization, difficulties with spouse/partner, difficulties with close friends, difficulties with immediate family, feeling like an “outcast”, people making fun of appearance, rejection in romantic relationships and rejection by friends. The answers are scored as “0” not at all, “1” mildly, “2” moderately, “3” very markedly. Total scores range between 0 and 27. Higher scores are associated with a lower quality of life.

Fifty of the patients also filled the questionnaire of Short Form 36 (SF-36) [24]. SF-36 is a generic questionnaire related to general health. It measures 8 separate dimensions of health: physical functioning, role limitations due to pyhsical problems, role limitations due to emotional problems, social functioning, mental health, energy/vitality, pain and general health perception, using a scale from 0 to 100, 0 meaning worst and 100 meaning best possible health.

The patients were examined by a dermatologist using the Global Acne Grading System (GAGS) [25]. Based on GAGS, “0” was considered as none, “1-18” as mild, “19-30” as moderate and “> 31” as severe acne.

In the SPSS 11.5 program, Pearson’s correlation analysis was used for statistical evaluations. p < 0.05 was considered as statistically significant.

Results

Percentage of the female and male patients in the study population was 67% and 33%, respectively. Mean age was 21 ± 4 (range: 14-38), mean duration of acne was 58 ± 36 months (range: 1-180). Eighty-six patients (80%) had been previously treated for their acne. Forty-seven of them had used systemic antibiotics, 38 only topical treatments, 27 cosmetic agents, 5 hormonal treatments and 5 systemic isotretinoin.

The mean GAGS score was 23.7 ± 7.9 (6-44). According to GAGS scores, 29 (27%) of the patients had mild, 58 (54%) had moderate and 20 (19%) had severe acne.

According to the patients’ own assessments, the mean score of disturbance due to acne was 6 ± 2.4 (range: 2-10), the mean score of acne severity was 6 ± 1.9 (range: 3-10) and the mean score of disturbance due to oiliness of the skin was 6 ± 2.6 (range: 1-10). No correlation was found between GAGS scores and any of the patients’ own assessments.

The mean score of the AQOL scale was measured as 13.5 (95% confidence interval, 12.7-14.4). There was no correlation between scores of GAGS and AQOL scale (figure 1). When the acne subgroups of different severity (mild, moderate, severe) were compared, no statistically significant correlation was detected in terms of AQOL scale scores. The AQOL scale correlated with the patients’ own assessments (r = 0.37, p < 0.001 for disturbance due to acne; r = 0.21, p < 0.05 for acne severity; r = 0.23, p < 0.05 for disturbance due to oiliness) (figure 2).

The AQOL scale scores correlated with the subgroups of SF-36 including social functioning, mental health and role limitations due to physical problems (r = – 0.32, p < 0.05; r = – 0.48, p < 0.001; r = – 0.32, p < 0.05 respectively). However, there was no correlation between AQOL scores and the subgroups of physical functioning, role limitations due to emotional problems, energy/vitality, pain and general health perception. There was no correlation between the subgroups of SF-36 and either GAGS score or patients’ own assessments.

Discussion

The recently published data regarding the correlation of objective clinical severity and quality of life measures is conflicting [6, 7, 15-22]. Assessment of quality of life and acne severity with different measures in each study seems to be an additional factor increasing the complexity of this subject.

The AQOL scale, developed by Gupta et al., is a disease-specific measure which may be used to evaluate the relation between acne severity and quality of life in mild to moderate acne patients [15]. The importance of the AQOL scale especially increases where there is inconsistency between the results of quality of life and objective severity scales. For example, in patients whose impairment is much greater than expected from clinical observations, we may lower the threshold for more effective treatment alternatives such as systemic antibiotics or isotretinoin. This approach, which will improve the patients’ adherence and compliance to the treatment, is based on the rationale that psychosocial disability should be taken into account when selecting an acne regimen [27].

Yazici et al. assessed the correlation between objective acne severity, psychiatric parameters such as depression and anxiety and quality of life measures, including AQOL scale and Dermatology Life Quality Index (DLQI) [4]. They found that the AQOL scale correlated positively with psychiatric measures but not with the objective acne severity. Similarly, Ilgen et al. could not find any significant relationship between acne severity and the AQOL scale and DLQI and suggested that acne patients’ quality of life should be evaluated with psychiatric measures other than the AQOL scale and DLQI [22]. We could not find any correlation between the AQOL scale and objective acne severity either. However, the AQOL scale correlated with the patients’ assessment of acne severity. It is not surprising to find a positive correlation between AQOL scale and patient reported severity, since they both reflect the patients’ perceptions of acne. We do not share Ilgen et al.’s opinion that the AQOL scale and DLQI are not good enough to evaluate quality of life in acne patients. On the contrary, we think these tools are valuable in clinical practice since they may be supplementary to objective clinical severity assessments by measuring different aspects of acne. Acne is one of the dermatological diseases in which the prevalence of psychiatric disorders is rather high [12]. These quality of life measures can help to detect any possible underlying psychiatric disturbance which may need further psychological intervention.

Unlike Gupta et al., we also included severe acne patients rather than limiting the study group with mild to moderately affected patients. Depending on the results obtained from this study and our previous validation study of Turkish version of the AQOL scale [23], we think that the AQOL scale may also be used in severe acne patients. Acne-specific quality of life measures have been reported to be more sensitive to changes in acne severity than generic scales [7, 18, 19]. According to our results, the subgroups of SF-36 did not correlate with either objective severity scores or with patients’ own severity scores. However, the numbers of patients responding completely to SF-36 and the AQOL scale were 45 and 107, respectively. Therefore, this small sample size for SF-36 should be taken into consideration while interpreting the results of our study.

Quality of life measures are mostly used for research purposes. In fact, lesion counting, done either by the doctors or the patients themselves, is the most reliable method to evaluate the therapeutic outcome. However, measurement of quality of life has certainly an important supplementary effect in evaluating the effect of treatment, especially from the patients’ point of view. Therefore, quality of life scales should be used more often in our dermatology practice. However, it is hard to decide which quality of life scale should be chosen. Interpreting the results of these scales is a further problem because of the difficulty in integrating these results into clinical practice. Anyhow, patients’ and doctors’ perspectives of acne severity may be different and the assessment should include both objective and subjective measures. The ‘Rule of tens’ proposed for psoriasis by Finlay is a good example of this concept [28]. According to the rule of tens, current severe psoriasis is described as body surface area involved > 10% or Psoriasis Area and Severity Index Score > 10 or DLQI > 10. Until a similar concept is developed for acne, patients’ perception of their acne should not be ignored when making treatment decisions. Quality of life measures are best for this purpose. However, if their use is not practical in a busy out-patient clinics, asking simple questions like “how much are you disturbed by your acne?”, “how severe do you think your acne is?” would improve both our relations with the patients and the therapeutic outcome.

Acknowledgements

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