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Background: Acne vulgaris has been documented to impair Quality of Life (QOL) in
adolescents. In Nigeria, quality of life studies in adolescents who have acne
vulgaris are few.
Aims and objectives: To assess QOL impairment
in adolescents who have acne vulgaris. To correlate clinical severity, gender,
history of previous acne treatment, family history with QOL impairment and to
determine what items on the QOL questionnaire are impaired.
Methodology: This was a cross-sectional study on adolescents from four co-educational
secondary schools. Students were clinically evaluated for acne and severity was
graded. Quality of life was assessed using the Cardiff Acne Disability Index
(CADI). Data was analysed using SPSS16. Level of significance was set at
P<0.05.
Results: 574 students were
studied, 48.9% males and 51.0% females. Median QOL was 2 (p=0.033) in
adolescents with and without a family history of acne. Median QOL was 3 for
persons that had a history of previous treatment of acne and 1 (3.00),
P<0.001 in those that did not have a history of previous treatment of acne.
The median quality of life was 2 for mild acne and 3 for moderate/severe acne
and this was significant at P<0.001.
Conclusion: History of previous treatment, severity and family history of acne
impairs QOL but not gender.
Keywords: Acne, Quality of
life, Family history, Treatment and adolescence
INTRODUCTION
Adolescence is defined as the period between ten and nineteen years of
age [1]. This is the period when body and self-image is formed, a time of
concern with physical appearance, when the opinion of peers on body image is
strong [2,3]. There is additional pressure on adolescents to have the perfect
face with the advent of television adverts and cosmetology [4]. Acne vulgaris
is recognized to impact negatively on the quality of life (QOL) of adolescents
[5-12]. Acne affects the face commonly and facial appearance represents an
important aspect of one’s perception of their body image with a resultant
negative impact of facial acne on psychosocial well-being [10,13]. Despite the
high prevalence of adolescent acne and the vulnerability of adolescents to the
psychosocial effects of acne and QOL impairment; little research attention on
QOL has been paid to this age group. Instruments for QOL assessment both
generic and specific have been used in the few studies on adolescents who have
acne [6,7,14-17]. Studies of QOL in Nigerian adolescents who have acne are few
with even fewer reports of specific item affectation with QOL questionnaires
[7,18-20]. The aim of the study was to assess QOL impairment in adolescents who
have facial acne vulgaris. To correlate clinical severity, gender, history of
previous acne treatment, family history with quality of life impairment and to
determine what items on the QOL instrument are impaired.
MATERIALS AND METHODS
This was a cross-sectional population based study of 574 students aged
9-20 years from four co-educational secondary schools in Ibadan, Nigeria.
Permission to carry out the study was obtained from the Ministry of Education
and the various
Cardiff Acne Disability Index (CADI)
The CADI, a well validated disease specific instrument for acne,
designed for use in teenagers and young adults who have acne is made up of five
(5) questions with four responses [8,16,17,23]. The five questions relate to
feeling of aggression, frustration, interference with social life, avoidance of
public changing facilities and appearance of the skin (all over the last month)
and an indication of how bad the acne is now. Walker et al. [8] stratified the
CADI as follows; CADI scores of <4 is interpreted as mild, scores of 5-9 as
moderate and scores of 10-15 as severe impairment of QOL. Data was analyzed
using the Statistical Package for the Social Sciences, (SPSS) version 16 [24].
Univariate descriptive statistics such as means, medians, frequencies and
proportions are presented. Associations between categorical variables were
tested using the chi-square test while differences in means of groups were
tested using the t-test and analysis of variance. Associations between
quantitative variables were tested using Spearman’s correlation coefficient due
to non-normal distribution. Logistic regression analysis was used to identify
predictors of acne and severity of acne, odds ratio and 95% confidence
intervals are reported. Level of significance of all tests was set at
p<0.05.
RESULTS
Socio-demographic characteristics
574 students were studied; 281 (4.8.9%) males and 293 (51.0%) females.
Age of the students ranged from 9-20 years. History of previous treatment of
acne was acknowledged by 312 (54%) of students. Family history of acne was
found in 252 (44%) of the students. On clinical examination, 386 (67.2%)
persons were found to have clinically mild acne, 166 (28.9%) had clinically
moderate acne and only 5 (0.9%) were found to be severe.
Quality of life
The median CADI was 2 with an inter-quartile range of 4. The highest
score was 14 and the lowest was 0 (Table
1).
Summary of CADI
The statistics of the CADI among the gender revealed that, both males
and females had a median Cardiff Quality of Life of 2 with an inter-quartile
range of 4. The highest Cardiff score for males was 13 and the lowest was 0.
The highest was 14 for females and the lowest was 0.
Gender and CADI
Figure 1 shows the overall gender
distribution of the Cardiff scores. Quality of life was impaired in 66.8% of
the adolescents and this occurred in 63.9% of males and in 69.9% of females.
Specific response to CADI
Association between variables and QOL
Significant associations were found for history of treatment and
clinical severity of acne (Table 2a).
The median quality of life was 2 for mild acne and 3 for moderate/severe acne
and this was significant at P<0.001.
Variables that were
significantly associated at the 10% level of significance were entered into a
logistic regression model (Table 2b).
A family history of acne, history of treatment of acne and clinical severity
are the variables that remained significant. Persons with a history of acne
treatment were about 2 times more likely to have an impairment in their quality
of life than persons who had not treated acne (P=0.01). Respondents with
clinically mild acne were 2 times less likely to have impairment in their
quality of life compared to those that have clinically moderate/severe acne.
DISCUSSION
This study revealed a statistically significant impairment of QOL in a
large percentage of the adolescents, showing that, the presence of facial acne
vulgaris negatively impacts on QOL of Nigerian adolescents. This is similar to
the report of the only study of QOL in Nigeria where CADI was used for QOL
assessment in adolescents with acne vulgaris [7] and at variance with a study
from Serbia where QOL was not impaired in most of the adolescents’ studied [6].
In this study, QOL impairment was mild. The mild impairment of QOL in theses
adolescents may have been due to clinical severity of acne being mild in most
of these adolescents. Also, the fact that, their friends had acne may have made
them to be less concerned. Some adolescents in this study demonstrated no
impairment of QOL and this was not unexpected as not everybody is affected by
the appearance of their face especially in this young age group. The results in
this study is comparable to that in other studies of QOL in adolescents acne,
where QOL impairment is found to be mild and QOL was not impaired in some
adolescents [6-8,12].
Specific aspects of QOL affectation
Specific responses to the items on the CADI concerning QOL affectation
revealed embarrassment, aggression and frustration from having acne although,
the percentage report was low. These adolescents may have had these negative
feelings as the face is the most obvious part of any human being and most
people want a smooth face. More females in this study felt embarrassed than the
males. Females are much more likely than males at this age to be interested in
their appearance thus and more embarrassed by blemishes on their face low percentage
report of embarrassment was the result of from other studies [6-8]. However,
Jankovic et al. [6] in their study also found more females reporting
embarrassment from acne. Interference with social life and avoidance of public
facilities was reported by a low percentage of the adolescents. This low
percentage report of interference with social life may be due to the fact that
the predominant form of facial acne in adolescents is mild with minimal
scarring of the face. This study however, reveals that in some adolescents,
presence of acne can led to social inhibition. Social life affectation in a low
percentage of adolescents has also been noted in other studies [6-8]. Avoidance
of public changing facilities for swimming or physical education was not very
much affected in this study with only 15.9% of the adolescents reporting this.
This study is on facial acne vulgaris and the face is already exposed. This may
have been responsible for the low report of avoidance of public changing
facilities. Also, this study did not specifically lookout for how many people
participate in sporting activities. It is not known if this low report of
influence of facial acne vulgaris on of public changing facilities is due to a
low participation in sporting activities. A similar study of QOL in adolescents
with acne vulgaris reported a low response on the item on avoidance of public
changing facilities as in this study [7]. Almost equal proportions of
respondents registered some concern about their skin appearance and saw their
acne as a problem. Of those that saw their acne as a problem, most saw the skin
problem as little. This study shows that, some adolescents with facial acne are
concerned about the appearance of their skin and think their skin is a problem.
It is not unlikely that these adolescents are teased by their peers in school,
making them self-conscious and worried about the appearance of their skin.
Walker et al. [8] in their study reported occasional concern about the skin in
adolescents. However, Ogedengbe et al. [7] in their study reported as in this
study, a high percentage concern about the appearance of the skin. The study by
Walker et al was on Caucasian skin unlike this study and that by Ogedendgbe et
al. [7] which are on dark skin types. The scars of acne tend to be more obvious
on the dark skin. On the item on how bad the adolescents thought their pimples
was now; more than half of the adolescents thought that their pimples was
presently bad. The proportion of females reporting this was slightly higher than
that in the males. A high proportion of adolescents in this study thought that
the pimples on their face were bad despite the clinical assessment of mild acne
in most of them. These adolescents may have felt this way because they did not
have a smooth face which is the desire of most people. Also they may have been
teased by their peers or had uncomplimentary comments made about their face.
The females also may have had a slightly higher percentage report compared to
the males because, although undocumented, females are said to be more
self-conscious and more concerned about their appearance compared to males.
Jancovic et al like in this study noted more female report of how bad the acne
was [6]. Ogedengbe et al. [7] reported a high impairment in this variable. They
thought that, this question allowed for more articulation of thoughts than the
other questions leading to high percentage impairment. On the other hand, in a
study in Scotland, the authors reported a low response of how bad the
adolescents thought their skin was [8]. The reason for this difference in
percentage report maybe due to the fact that, QOL is a subjective phenomenon
which is affected differently in different individuals. Previous studies on QOL
of life in adolescents in Nigeria are at variance with some of the results of
this study [18,19]. Yahaya [18] in Kaduna reported no effect on social life by
acne and in Ife [19], the adolescents were not bothered that they had acne. The
reason for this difference in response between this study and the other
Nigerian studies can be adduced to the use of different instruments. A disease
specific instrument (CADI) was used in this study while non-standardized
instruments were used in the other Nigerian studies. The only Nigerian study
where CADI was used [7] reveals comparable results to this study on some of the
variables assessed.
Relationship between the quality of life and
variables
Severity of adolescent facial acne was found in this study to correlate
with QOL impairment. Severe acne implies more lesions on the face and presence
of inflammatory acne. These groups of adolescents are also more likely to seek
treatment with people constantly commenting on the appearance of their face.
All of this will cumulatively lead to a worse QOL impairment with severe acne.
This study report is at variance with that from Hong Kong, in which, Law et al.
[23] reported no strong correlation between acne severity and QOL impairment
but in agreement with studies from Nigeria and Malaysia [7,10]. There was a
lack of correlation between gender and QOL impairment in this study. This lack
of correlation is difficult to explain in this study. Although as already
discussed above, looking at specific items of QOL impairment, females were
found to be more embarrassed at having acne. Ogedengbe et al. [7] reported no
gender difference in QOL impairment as in this study but Yeung et al. [25] and
Jankovic et al. [6] found females to have a worse QOL than males. Family
history of acne was found to significantly impair QOL. Adolescents, who have a
family history of acne, have seen family members having acne and being treated
for acne. They may have realized that acne is a chronic skin lesion and known
that treatment is not a one off thing. They may also have seen family members who
had severe acne with scarring and may fear having the same lesions. This may
have led to the significant QOL affectation. Other studies on adolescent acne
have not looked at the relationship between family history of acne and QOL
impairment and so it was difficult to compare this finding with another study.
History of previous treatment of facial acne vulgaris was significantly
associated with QOL impairment. It is postulated that, adolescents who have had
treatment may have gotten tired of the long duration it takes for clearance of
acne lesions and this age group is usually not associated with patience. Also,
the cost of treatment may have contributed to this impairment of QOL. There was
no study to compare this finding with as it has not been documented in other
studies of adolescent acne.
CONCLUSION
Facial acne vulgaris is associated with QOL impairment and this
impairment is mostly mild. Specifically, facial acne vulgaris leads to
embarrassment, feelings of aggression, negative feelings about appearance of
the skin and how bad acne on the face is. History of previous treatment of
acne, severity of acne and family history of acne negatively impacts on QOL.
Gender does not influence QOL impairment in adolescents who have acne.
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