Impact of acne on quality of life in young Pakistani adults and its relationship with severity: A multicenter study

Objectives: The current study aimed to determine the effect of acne vulgaris on quality of life of young adults and to assess the correlation between acne severity and impairment of quality of life (QOLI). Methods: In this multi-center cross-sectional study, 163 young adults with acne vulgaris were assessed for severity and quality of life impairment between December 2016 and May 2017 at three tertiary care hospitals. Cardiff Acne Disability Index (CADI) was used to assess the quality of life while the severity of acne measured by Global Acne Grading System (GAGS). Data were collected on standardized forms, with CADI, GAGS scores, and sociodemographic data and analyzed using SPSS version 9. The quantitative variables were presented as means, median and qualitative variables expressed as frequency and percentages. P-value ≤0.05 was considered as statistically significant. Results: Out of 163 patients enrolled in this study, the mean age was 21.6 ± 4.9 years and 124 were females and 39 males. In mild QOLI, 56 (87.5%) cases were affected with mild, 11 (13.4%) with moderate and 1 (1.5%) case had severe acne. While, in moderate QOLI, 8(12.5%) cases were of mild, 60 (73.2%) were moderate and 6 (35.3%) cases affected with severe acne. The severe impairment of QOL noted in 11 (13.4%) moderate and 10 (58.8%) severe acne cases. The relationship between sex was statistically significant, (P<0.001). The result showed significant correlation between severity of acne vulgaris and the quality of life impairment of these patients (P<0.001). Conclusion: This study showed significant correlation between acne vulgaris and quality of life impairment. Cardiff acne disability index has proven to be a reliable tool to assess the quality of life. It is recommended to be used routinely in dermatology clinics to provide tailored treatment to individuals because mild disease may be disproportionately distressing for patients.


INTRODUCTION
prevalence of anxiety and depression. 3,4 The repercussion of acne on quality of life (QOL) is an important element of the morbidity related to acne, and it is the prime consideration while deciding about the initiation of treatments. Literature reported that psychological, emotional and social problems in acne patients are as common as those described by patients with diabetes, epilepsy, asthma or arthritis. 5,6 Currently, there are various acne-specific quality of life instruments exist, like, Acne Disability Index (ADI), the Dermatology-Specific Quality of Life (DSQL) questionnaire and the Cardiff Acne Disability Index (CADI). 4,7 In the current study, we used the Cardiff Acne Disability Index (CADI), because of its simplicity, validity, and reliability. 8 It is user-friendly five-item questionnaire devised in 1989. 4,9 Few prior studies have studied the psychosocial impact and QOL of the acne vulgaris patients and addressed the relationship between acne severity and emotional distress. 1,2,10 However, we need to gather further data in our context with specific cultural norms. We, therefore, identified that there is a need to study the correlation between psychosocial impact and the severity of acne vulgaris in patients, using a reliable and validated tool. It will provide each individual with proper treatment, since even mild diseases can be disproportionately distressing to someone's life.

METHODS
The study is a multi-center cross-sectional study conducted in three different hospitals, named, Liaquat National Hospital, Karachi, and Combined Military Hospital, Lahore, Aga Khan University Hospital, Karachi. This study was conducted after approval by all the three hospital's ethical review committees (CMH, Lahore, LNH and AKUH, Karachi). The study objectives were to determine the effect of acne vulgaris on the QOL of young adults and whether a correlation exists between the impairment of quality of life (QOLI) and acne severity. In this study, young adults with acne vulgaris, reporting to skin clinics of the respective hospitals seen during the study period i.e., between December 2016 and May 2017 meeting inclusion criteria were invited to participate. All the patients with any other chronic skin condition, systemic illness, under any psychiatric treatment, on systemic steroids, or pregnant were excluded from the study. Written informed consent was taken from all the participants. QOL was measured using the CADI, while acne severity was objectively assessed by Global Acne Grading Scoring (GAGS). CADI is a fiveitem questionnaire. Every question has four answers with a score of 0-3. The overall scores are determined by adding scores of all questions with a minimal score of 0 and a maximal score of 15. The 0 to Five score interprets the mild quality of life impairment, 6 to 10 translates moderate, and 11 to 15 indicates severe QOLI. GAGS is a measurable grading system, based on locations, and type of lesions. It divides the areas into 6 different regions. These regions are five on the face, while one on the upper back or chest. These regions give a factor to each region. The nose and chin are given a factor of one while each cheek and forehead are given a factor of two. In addition, a factor of three is for chest/upper back. Scores translated as, one for comedones, two for papules, three for pustules, and four for nodules. Every region score is addition of severity score multiplied by the area factor. The maximum score is 44 and the minimum is one. The one to18 score is reflected as mild, 19 to 30 moderate, and 31 to 38 as severe, while 39 and above as very severe. By taking a prevalence of 12% and precision of 5%, the calculated sample size is 163 patients with the help of WHO software for sample size calculation taking 95% confidence level. 11 Nonprobability convenience sampling was used to raise the sample.
Data were collected using specific standardized forms, with CADI, GAGS scores, and sociodemographic data. Data were analyzed using SPSS version 19. The quantitative variables presented as mean±SD and median while the qualitative variables expressed as frequency and percentages. T-test was used to compare the significance of results for quantitative variables. Chi-square test was used to assess the association between categorical variables. P-value ≤0.05 considered as statistically significant.

DISCUSSION
Healthy skin has a vital role in socialization and enhancing self-confidence. 3,5 There are instances where cosmetic disfigurements produce social disapproval and low self-esteem. 12,13 The medical literature shows an important and complex correlation between skin disorders and psychosocial functioning states of these patients. 14,15 Different studies from various countries assessed the impact of acne on quality of life. 1,8,13 It is very difficult to compare these different studies because of the differences in settings, culture and characteristics of the study population. There are very few studies published to assess the effect of acne on quality of life in our own local context. [16][17][18] The current study was conducted in tertiary care centers of two provinces of Pakistan to get a diverse sample. The study population consisted of young adults, Shams et al, also conducted the study on similar age group. 18 The young adults are usually conscious about their appearances and Shaheen Naveed et al. youth of a country contributes a lot in the progress of the country. It is imperative to be cognizant of the potential detriments to their mental health and to address the issues proficiently. 19 There is variation in mean age group of patients in different studies population and different factors like age, gender and culture of that specific area affects the QOL. 20 A study conducted by Kokandi on adult female university students, with mean age of 24 years, did not find a correlation between acne severity and QOLI ; neither CADI score was associated with disease duration or age of patients. 21 In the current study there were more females than males. It is because females are more conscious about their skin and seek dermatological consultation more frequently. It may also have attributed to more regular use of beauty creams for attaining a fair blemish free complexion, but ending up with increased chances of skin damage and acne. The sex distribution was similar to that seen by El-Hamd et al (Female 60% vs Male, 40%) and Shyam et al. 4,19 On the other hand, Do JE et al found males predominance in their study. 22 The current study demonstrated strong association between gender and QOLI. Females have severe acne than males. This finding is also similar to that seen by Ismail KH et al. 23 These observations were not similar to study by El-Hamd et al who did not find any significant difference between sex and acne grades. 4 The mean global acne grading system score in our study was higher than most of the previous studies. 23 Shams 4,19,20 The total mean CADI score in our study was 6.70, which highlights that the average study population experienced moderate QOLI.
In this study we found a strong association between acne severity and CADI scores. Our results were consistent with those seen by El-Hamd et al, who also found that QOLI is significantly related to severity of acne. 4 23 Yap et al and another study from Hong Kong did not found such association between CADI and acne severity. 8,24 These variations probably reflect the different racial and cultural contexts. 21,25 The results of the current study can serve as an interface for improving the QOL evaluation criteria as well as the measures to be taken for acne patients to prevent them from stress and mental trauma. This study provides an insight about the importance of using an effective measurable validated tool to assess the quality of life impairment in acne patients. It contributes to the studies conducted earlier by addressing the effectiveness of using CADI in our own context and suggests that acne treatment has to be tailored not merely based on grading but also on QOLI. The quality of life issues needs to be sought and addressed in acne vulgaris patients through indepth counseling and psychotherapy.

Limitations of the study:
It was conducted only among adolescent acne patients and may not reflect the findings of whole population. There is a need for future studies comprising all age groups including all provinces with a relatively larger sample size to validate the results of current study.

CONCLUSION
The possible impairment in quality of life in acne patients need to be vigilantly assessed and, should be appropriately addressed. CADI has proven to be a convenient, valid and reliable tool to assess the quality of life within minutes. We recommend it to be used routinely in dermatology outpatient clinics to provide tailored treatment to each individual, as even mild disease may be disproportionately distressing to someone's life. The acne vulgaris management should be based on acne severity and degree of quality of life impairment and it would help to improve the confidence and self-esteem of these patients.