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Psychological Impact of Acne on Women
Ruksana Hamid, MD, Anesthesiologist, Directorate of Health services Kashmir
Rayees ul Hamid Wani, MD, Senior Resident, Department of Emergency
Medicine, SKIMS, Soura
Suhail Hamid Wani, Post graduate scholar, Department of Radiodiagnosis, GMC
Srinagar
Ghulam Mustafa Malik, Post graduate scholar, Department of Pathology, GMC
Srinagar
Mohammad Sarwar Mir, Resident Medical Officer, SKIMS
Corresponding Author: Mohammad Sarwar Mir, Resident Medical Officer,
SKIMS
Abstract
Background: It is well-known that acne vulgaris is a common malady of
adolescence.
Objective: To evaluate the level of impact among acne female adolescent students
on their quality of life.
Methods: A total of 200 patients studied. Acne severity was graded using Global
Acne Grading System (GAGS) after the clinical diagnosis. All the patients went
through self administered questionnaire of Cardiff Acne Disability Index (CADI)
to fill out, to assess the reflection of patients’ experiences and perceptions.
Results: The maximum number of patients was in the age group of 16-20 years
(142/200, 71%). The impact on quality of life was more in the age-group of 21-30
years even though in this age group clinical severity of acne was mild to moderate
only.
Conclusion: Study found that women with acne had profound emotional, as well
as, social impact on their quality of life.
Keywords: Acne, Cardiff Acne Disability Index, quality of life.
Introduction
It is well-known that acne vulgaris is a common malady of adolescence and is
easily recognized. It is common enough to be called as physiological process, but
is better recognized disease due to its inflammatory component. It can have
significant psychosocial disturbances as it affects adolescence that is the critical
period during which emotional development and maturity starts taking place.1
Skin plays an important role in socialization, as skin is considered as an organ of
Communication. Cosmetic disfigurement produces social disapproval and increase
in self-consciousness. 2It can result in social poor eye contact, academic under
achievements and psychosocial disturbances especially when skin diseases like
acne occur during adolescence.3 Acne may also be associated with increased levels
of anxiety, anger, depression and frustration. This psychological stress can further
aggravate acne through hormonal changes thereby setting up a vicious cycle. It is
important to have reliable epidemiological data on acne and its psychosocial
impact so that physician can show quantitatively that effective treatment of acne
can have significant benefit to patient’s psychosocial life, apart from physical
benefit to their acne.4
Methods
This study was a cross sectional survey. A total of 200 femlae patients with clinical
diagnosis of acne, aged more than 13 years were enrolled in the study after taking
an informed consent.
A detailed history was also taken according to proforma. The severity of acne was
graded using Global Acne Grading System (GAGS). The patient was then given a
self-administered Cardiff Acne Disability Index (CADI) questionnaire Global Acne
Grading System (GAGS) Acne was graded using GAGS5.
The GAGS considers six locations on face and chest/ upper back with a factor for
each location based on surface area, distribution and density of pilosebaceous
units. (Area factor: forehead-2, right cheek-2, left cheek-2, nose-1, chin-1, chest
and upper back-3). Each of the location was graded separately on 0-4 scale with
the most severe lesion within that area determining the local score. (Grade: 0-no
lesion, 1-comedone, 2- papule, 3-pustule, 4-nodule). Under good light and without
touching, all the manifestations of acne ranging from comedones to nodule were
recorded. Local score is calculated by multiplying area factor with the grade of
most severe lesion within that location. Global score is the summation of all the
local scores.
Cardiff Acne Disability Index (CADI)
All the enrolled patients with acne above the age of 13 years completed CADI
questionnaire made available in local language. It is a detailed questionnaire
designed to assess disability caused by acne.6It consists of five questions, each with
four graded alternative responses (0-3). CADI is calculated by summing up the
score of each question. The higher score indicates the greater disability
experienced and the lower score indicates the lesser level of disability.
Results
Out of 200 patients, The maximum number of patients was in the age group of 16-
20 years (142/200, 71%). Family history of acne was present in 80 (40.0%)
patients. Appearance of facial acne was preceded by application of topical steroids
in 40 (20%) patients.
Table 1: Relationship between acne severity Global Acne Grading System
(GAGS) and gender.
Acne severity
(GAGS)
Males Females Total
Mild 36 23 59
Moderate 34 29 63
Severe and very
severe
16 62 78
Total 86 114 200
P value <0.05(non significant)
Table 2: Relationship between Cardiff Acne Disability Index (CADI)and
duration of acne.
Duration Low Medium High Total
Less than six
months
5 8 13 26
6 months-one
year
12 16 20 48
Greater than
one year
12 45 69 126
Total 38 80 82 200
p=0.001; highly significant
Table 3: Relationship between Global Acne Grading System(GAGS) and
Cardiff Acne Disability Index(CADI).
GAGS Low Medium High Total
mild 11 48 31 90
Moderate 12 18 40 70
Severe and
very severe
3 12 25 40
Total 26 78 96 200
Discussion
Acne has shown significant psychological impact in the previous studies. The
severity ofacne was measured by different grading methods in various studies.
Most of the patients were adolescents as acne is more prevalent in this age group.7
About 40.0 % of patients gave history of acne in parents or siblings. This is in
accordance with various studies which show that genetic factors influence
susceptibility to acne.8 One-fifth of patients had applied topical steroids which lead
to further aggravation of acne. It is due to easy availability and indiscriminate use
of topical steroids and marked transient improvement which ultimately results in
steroid dependence.
Acne may have different psychosocial morbidity according to gender. Our study
showed higher CADI scores in females . This is similar to previous studies which
also found more psychological impact on females. 9Facial disfigurement makes
females present earlier to treatment even for milder acne. The impact on quality of
life was more in the age-group of 21-30 years even though in this age group
clinical severity of acne was mild to moderate only. It may be due to chronicity of
acne and the need of more social interactions at this age. All the patients above 30
years of age had low psychological impact of acne.
Patients with persistent acne were reported to have higher CADI scores.9 This
study
demonstrated a significant relation between GAGS and CADI scores. The impact
on quality of life increased with acne severity. It is consistent with previous studies
which also found the similar findings.9,11 Also patients with higher CADI scores
tend to present with suicidal ideations.
Recommendations
In order to decrease psychological stress associated with acne and to build up self-
esteem,it is the need of hour in a developing country like India to establish acne
clinic with provision of counselors. This need stems out of high patient burden
with low doctor: patient ratio. In order to increase time spent per patient, these
acne clinics with counselors will help achieve the targets. Also the patients can be
involved in group discussions.
Conclusion
Our study confirmed that acne has profound effect on psychosocial behaviour. The
impact on quality of life has been significantly associated with severity of acne,
female gender, age and long disease duration. Clinicians should be aware that early
treatment of acne and avoidance of aggravating factors can prevent significant
psychological morbidity.
Conflict of interest: None
Source of Funding: None
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