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*Corresponding Author: Dr.
Manish Pradhan
, Lecturer | Email: drmanishpradhan1@gmail.com
45
Journal of Nobel Medical College
Available Online: www.nepjol.info, www.nobelmedicalcollege.com.np
Volume 7, Number 1, Issue 12, January-June 2018, 45-49
Original Article
The Impact of acne on the quality of life of the patients
attending dermatology outpatient department at
Nobel Medical College Teaching Hospital
Manish Pradhan*1, Chandra Bhal Jha2 and Dipa Rai1
1Department of Dermatology, Nobel Medical College Teaching Hospital,
2Department of Dermatology, Mechi Zonal Hospital
Received: 14th April, 2018; Revised after peer-review: 20th May, 2018; Accepted: 18th June, 2018
Abstract
Background
Acne is a very common distressing skin condition that affects multiple aspects of quality
of life of an individual. It has been illustrated that acne have tremendous effect on an
individual’s self-image and impacts his or her quality of life. The extent of burden of the
disease experienced by the patients seems to be underestimated by the whole medical
fraternity. The aim of the study is to determine the health related quality of life
impairment in acne patients using CADI and to identify various variables that increase the
patients’ susceptibility for quality of life impairment.
Subjects and Methods
This is a hospital based, cross sectional study conducted in the Department of
Dermatology, Nobel Medical College Teaching Hospital from Jan 2017 to December
2017.A total of 202 acne patients were evaluated with CADI. Clinical characteristics were
recorded after history and clinical examination.
Results
Out of total 202 patients enrolled, 56.4% of patient scored a CADI score of (5-9) indicating
moderate quality of life impairment and 15.3% of patient scored a CADI score of 10 or
more indicating severe quality of life impairment. The mean CADI score was 6.82 ± 2.75.
There was positive correlation between the CADI score and impact on quality of life with
grade of acne, which was statistically significant (p<0.001).
Conclusion
Acne is a common skin disease with tremendous adverse effect on the patient’s health related
quality of life. Patients are affected both physically and mentally with this condition.
Key word
Acne vulgaris, clinical grading, Cardiff Acne Disability Index (CADI), impact on quality of life.
Introduction
Acne vulgaris is the most common skin
disease encountered in the general
population, and has considerable impact on
quality of life of the sufferers [1]. It is the
most common dermatological disease for
which patients seek physician care in the
Caucasian, African Americans and Hispanic
populations and the second most commonly
treated dermatological disease in the Asian
population [2]. Because, the lesions of acne
may vary in number and morphology during
Dr. Manish Pradhan,
et.al., Journal of Nobel Medical College
*Corresponding Author: Dr.
Manish Pradhan
, Lecturer | Email: drmanishpradhan1@gmail.com
46
it’s natural course of disease, numerous
measurements have been developed, based
on proper clinical examination and
photographic documentation, to assess the
clinical severity of the disease [3].
A report in the British Medical Journal in
1989 opined that, in a lifetime, a person is
more likely to suffer from acne than any
other disease [4]. Acne impacts profoundly
on the psychosocial development, on the
quality of life, and on career prospects [5].
Acne does ruin beauty and, in some, it
leaves with scars for life. All grades of acne
is very common in young people, with over
90% of males and 80% of females being
affected by the age of 21 years [4,6].
Acne vulgaris is a common distressing skin
disease that does affect all aspects of an
individual’s health-related quality of life
(HRQoL); in particular, personal
relationships, feelings and emotions, sports,
social circle and employment prospects [7].
There is usually a directly proportional
relationship between the clinical severity of
acne and impairment of HRQoL, although
impairment is also dependent upon one’s
‘coping ability’. Moreover, individuals with
minor objective evidence of acne may suffer
severe subjective impairment, greatly
affecting their HRQoL [8]. Although the
psychosocial aspects of acne are well
recognized, there is also evidence
suggesting psychosocial stress itself, may
also exacerbate acne. So until recently, there
have been very few validated scales to
measure HRQoL [9].
Acne vulgaris is a very common skin
condition in Nepal, and it seems to cause
much concern to patients and families alike.
So this study was conducted to highlight the
impact of the quality of life on acne patients.
Materials and Methods
We did a hospital based, cross sectional
study in the outpatient department (OPD) of
Department of Dermatology and
Venerology, Nobel Medical College
Teaching Hospital, Biratnagar, Nepal, over a
period of one year from Jan 2017 to Dec
2017.
Sample selection
Inclusion criteria
• Patients with clinical diagnosis of acne
and 10- 35 years of age.
Exclusion Criteria:
• Acne patients with history of steroids
use and other acne causing drugs.
• Patients with psychiatric illness.
• Age more than 35 years.
• Patients taking anti-acne medications
within last 3 months.
Altogether 202 acne patients were selected
for the study. Diagnosis was made on the
basis of clinical features and classified
depending on type of lesions into: Grade I,
Grade II, Grade III and Grade IV. All these
patients were interviewed using a CADI
questionnaire. The completed forms were
then scored according to the
recommendation made by Motley and
Finlay. The details of the selected patients
were recorded in a prepared Performa.
Cardiff Acne Disability Index (CADI) [10]
The Cardiff Acne Disability Index (CADI)
(Motley and Finlay, 1992) is a short 5 item
questionnaire derived from the longer Acne
Disability Index (Motley and Finlay, 1989).
The Cardiff Acne Disability Index is designed
for use in teenagers and young adults with
acne. It usually doesn’t take much time to
complete. It is self explanatory and can be
simply handed to the patient who is asked to
complete it without the need for detailed
explanation.
Instructions for scoring
The scoring for each answer is given as
follows: (a) 3 (b) 2 (c) 1 (d) 0
The CADI score is ultimately calculated by
adding up the score of each question
resulting in a possible maximum of 15 and a
minimum of 0. The higher the score, more
the quality of life is impaired. The CADI
contains total of 5 questions with a
maximum possible score of 15. These
questions also focuses on symptoms and
feelings, social life, use of public changing
places, psychological and patient’s
perception of the acne severity over the last
1 month prior to consultation. These scores
Dr. Manish Pradhan,
et.al., Journal of Nobel Medical College
*Corresponding Author: Dr.
Manish Pradhan
, Lecturer | Email: drmanishpradhan1@gmail.com
47
were graded as low (0–4), medium (5–9) and
high (10–15). The lower the cumulative CADI
score, the lower the level of disability
perceived by the patient while a reverse is
true. The CADI also identifies area of
concerns in patients suffering with acne.
Statistical Analysis
The results of the study were statistically
analyzed using SPSS version 22. Chi-square
test and one-way ANOVA test were applied
where needed. The level of statistical
significance was set at (p ≤0.05)
Results
Total 202 patients were included in our
study, all of them filled out CADI
questionnaire after written consent. The
mean age of the patients in years were 20.24
± 6.07, with minimum age 11 year and
maximum age 35 year. Out of total patients
102(50.5%) were male and 100(49.5%) were
female. Regarding marital status 62 were
married and 140 were unmarried.
Of the total acne patients, 79(39.1%) were at
school level or had completed SLC level,
65(32.2%) had completed intermediate level,
46(22.8%) bachelors level and 12(5.9%) had
attained their postgraduate degrees. In our
study regarding grading of acne, number of
patients in grade I was 25 (12.4%), number
of patients in grade II was 81(40.1%),
number of patients in grade III was
71(35.1%) and number of patients in grade
IV was 25(12.4%).
Overall Cardiff Acne Disability Index Score:
The mean CADI score was found to be 6.82 ±
2.75 with minimum score of 2 and maximum
13. The mean CADI score was more for
females was (6.83 ± 2.89) and for males (6.81
± 2.62) which was not statistically significant
(p=0.967). Similarly, the score for married
patients were higher (6.98 ± 2.73) than for
unmarried patients (6.75 ± 2.67). However
this was not statistically significant
(p=0.578). The educational status of patient
was analyses for CADI score. The score for
patients in bachelors level were higher (7.57
± 2.83) than patients of SLC, intermediate or
Masters level. However, this difference was
not statistically significant (p=0.158). Of the
four clinical grading of acne evaluated in the
study, the grade IV patient scored highest
score with CADI of (8.92 ± 2.40) followed by
grade III (7.77± 2.17), II (6.35 ± 2.63) and I
(3.56 ±1.26) and it was significant statistically
(p<0.001) as shown in table 1.
Table 1: CADI Score of Acne patients and its analysis for different variables.
Variables Categories
Number (Percentage) CADI Score
(Mean ± S.D.) p-value
Gender
Male
102 (50.5%)
6.81 ± 2.62
0.967
Female
100 (49.5%)
6.83 ± 2.89
Marital Status Married
62 (30.7%
6.98 ± 2.73
0.578
Unmarried
140 (69.3%)
6.75 ± 2.76
Educational status
School Level
79 (39.1%)
6.75 ± 2.83
0.158
Intermediate
65 (32.2%)
6.54 ± 2.65
Bachelors
46 (22.8%)
7.57 ± 2.83
Masters
12 (5.9%)
6.00 ± 2.05
Grading
Grade I
25 (12.4%)
3.56 ± 1.26
<0.001*
Grade II
81 (40.1%)
6.35 ± 2.63
Grade III
71 (35.1%)
7.77 ± 2.17
Grade IV
25 (12.4%)
8.92 ± 2.40
* The test result is significant at P<0.05.
*Corresponding Author: Dr.
Manish Pradhan
, Lecturer | Email: drmanishpradhan1@gmail.com
48
Quality of life impairment
Out of 202 patients in our study, 28.2%(n=57)
scored a CADI score of less than 5
suggesting mild quality of life impairment,
56.4%(n=114) scored a CADI score of 5-9
indicating moderate impairment of quality of
life; whereas 15.3%(n=31) scored a CADI
score of 10 or more indicating severe
impairment in quality of life.
The association between different variables
undertaken in our study and impact on
quality of life according to CADI score is
illustrated in the table no 2. Affect on the
quality of life due to acne shows statistically
significant association between grading of
acne; suggesting higher the grade of acne;
more severe is the impact in quality of life.
Table 2: Analysis of Impact on quality of life according to CADI score.
Variables Categories
Impaired Quality of Life
(Number and percentage)
P-value
Low
Medium
High
Age in years ± SD 19.67±6.07 20.53±6.18 20.26±5.78 0.685
Gender
Male
26 (25.5%)
62 (60.8%)
14 (13.7%)
0.452
Female
31 (31.0%)
52 (52.0%)
17 (17.0%)
Marital Status
Married
15 (24.2%)
37 (59.7%)
10 (16.1%)
0.699
Unmarried
42 (30.0%)
77 (55.0%)
21 (15.0%)
Educational status
School level
25 (31.6%)
40 (50.6%)
14 (17.7%)
0.294
Intermediate
21 (32.3%)
36 (55.4%)
8 (12.3%)
Bachelors
8 (17.4%)
29 (63.0%)
9 (19.6%)
Masters
3 (25.0%)
9 (75.0%)
0 (0.0%)
Grading
Grade I
24 (96.0%)
1 (4.0%)
0 (0.0%)
<0.001*
Grade II
31 (38.3%)
43 (53.1%)
7 (8.6%)
Grade III
2 (2.8%)
55 (77.5%)
14 (19.7%)
Grade IV
0 (0.0%)
15 (60.0%)
10 (40.0%)
Total
57 (28.2%)
114(56.4%)
31(15.3%)
* The test result is significant at P<0.05.
Discussion
Skin diseases can affect virtually all aspects
of patient’s lives. Apart from causing
physical discomfort to the acne sufferers, it
has been demonstrated that, acne influence
the patient’s both social as well as personal
life [11].
There are several published studies
regarding acne and quality of life. Previous
studies have shown that acne is related with
significant morbidity and decrement in
health-related quality of life. Acne has a
considerable psychological impact on
affected individuals [12]. Both general
practitioners and dermatologists were
reported to have poor comprehension of the
psychological implications of skin diseases
on patient’s personal and social circle; being
insensitive to their patient’s emotional
sufferings, and trivializing participant’s
condition [13].
Magin P et al found out that depression was
two to three times more prevalent in acne
patients than that of the general population,
with a reported 8.8% of acne patients having
clinical depression and females were twice
more common than males [14].
In our study, there was no significant
difference between the sexes in the CADI
score and impact on quality of life.
Contradictory to this, Pawin H found out that
adolescent girls were more vulnerable than
boys to the negative psychological effects of
acne [15]. Krowchuk DP et al found out that
acne affected significantly on 11% of
teenagers [16]. However in our study,
impairment of life and CADI score was not
significant with age.
Jones-Caballero M et al and Walker N et al
illustrated positive correlation between
Cardiff acne disability index, impact on
quality of life and clinical severity [17,18].
This match with our results as we found that
quality of life was associated with grading of
acne. In contrast to our result, Aush Gupta et
Dr. Manish Pradhan,
et.al., Journal of Nobel Medical College
*Corresponding Author: Dr.
Manish Pradhan
, Lecturer | Email: drmanishpradhan1@gmail.com
49
al didn’t find any association between
severity of acne and quality of life [19].
No significant correlations were noted
between the level of education obtained and
scores of CADI. This might be the fact that
patients experience certain level of anxiety
and impairment may not only depend on the
peer’s exploitation but rather patient’s own
conscience.
Conclusions
Acne is a common disease with significant
adverse effect on the patient’s health related
quality of life. Patients are affected both
physically and mentally with this condition.
Limitation
Since this study was done on a tertiary
referral centre, the impact on patient’s
quality of life might be overestimated. A
population based survey would help to
identify more accurately the disease’s
impact on general population.
References:
[1] Thomas DR, Psychosocial effect of acne, J
Cutan Med Surg 8: 4 (2004) 3–5.
[2] Halder RM, Holmes YC, Bridgeman-Shah S, A
clinicopathological study of acne vulgaris in
black females. J Invest Dermatol 106 (1996)
888-10.
[3] Witkowski JA, Parish LC, The assessment of
acne: An evaluation of grading and lesion
counting in the measurement of acne. Clin
Dermatol 22 (2004) 394 -7.
[4] Rademaker M, Garioch JJ, Simpson NB, Acne
in school children: No longer a concern for
dermatologists. Br Med J 298(1989) 1217-9.
[5] Hendon J. Acne: A patients' point of view. J
Am Acad Dermatol 51 (2004) S39.
[6] Pearl A, Arrol B, Lello J, Birchall NM, The
impact of acne: a study of adolescents'
attitudes, perception and knowledge. NZ Med
J 111:1070 (1998) 269-71.
[7] Finlay AY. Quality of life assessments in
dermatology, Semin Cutan Med Surg 17
(1998) 291–296.
[8] Finlay AY, Quality of life measurements in
dermatology: a practical guide. Br J Dermatol
136 (1997) 305–314.
[9] Mulder MM, Psychological impact of acne
Vulgaris, Dermatology 203 (2001) 124–130
[10] Motley RJ, Finlay AY. Practical use of a
disability index in the routine management of
acne, Clinical and Experimental Dermatology
17 (1992) 1-3.
[11] Jayaprakasam A, Darvay A Osborne G,
McGibbon D, Comparison of assessment of
severity and quality of life in cutaneous
disease. Clin Exp Dermatol 27 (2002) 306-08.
[12] J. Khoo, “The psychological impact of acne:
patient’s perceptions.” Journal of the
American Academy of Dermatology 32:5
(1995) S26–S30.
[13] Magin PJ, Adams J., Heading GS and Pond
CD, Patients with skin disease and their
relationships with their doctors: a qualitative
study of patients with acne, psoriasis and
eczema. Medical Journal of Australia 190:2
(2009) 190:62–64.
[14] Magin P, Adams J, Heading G. Psychological
sequelae of acne vulgaris: results of a
qualitative study, Can Fam Physician 52
(2006) 978-9.
[15] Pawin H, Chivot M, Beylot C. Living with acne.
A study of adolescents' personal experiences.
Dermatology 215:4 (2007) 308-14.
[16] Krowchuk DP, Stancint T, Keskinen R, Wakjer
R, Bass J, Anglin TM, The psychosocial
effects of acne on adolescents, Pediatric
Dermatol. 8 (1991) 332.
[17] Jones-Caballero M, Chren MM, Soler B,
Pedrosa E, Peñas PF. Quality of life in mild to
moderate acne: Relationship to clinical
severity and factors influencing change with
treatment. J Eur Acad Dermatol Venereol 21
(2007) 219-26.
[18] 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 (2006) 45-50.
[19] Gupta A, Sharma YK, Dash KN, Chaudhari
ND, Jethani S. Quality of life in acne vulgaris:
Relationship to clinical severity and
demographic data. Indian J Dermatol
Venereol Leprol 82 (2016) 292-7.
