Summary

Acne is a common problem in adolescents. Its impact to patient might not be proportionate to the size, number, redness or pain of the skin lesions. The resultant quality of life impairment and psychic sequelae such as depression, eating disorder and body dysmorphic disorder are important.

Literature review was done to examine the impact of acne on patients' quality of life and psyche state. Prudent understanding of our patients by validated questionnaires, observing the associated behaviour changes, individualised counselling and discussion of the nature and method of therapy may optimise their well-beings.

摘要

痤瘡（俗稱暗瘡）是青春期常見的疾病。它對病人的影響不一定與其大小、數量、紅腫和疼痛程度成正比例。對生活質素的損害及在精神上帶來的後果如抑鬱、飲食失調及儀容異常也都是重要的。回顧過去文獻可查驗痤瘡對生活質素及精神狀態的影響。利用有論據支持的問卷審慎地了解我們的病人、觀察其行為改變、個人輔導及與他們討論治療方案都能使他們健康得到最大的裨益。

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Introduction

The following is a real case scenario. A 26-year old young man attended a general practice clinic presenting himself with fever and sore throat. He told his family doctor that he had trouble with acne. The family doctor found that he was suffering from tonsillitis. Appropriate therapy was given for tonsillitis and the young man asked about acne treatment. The family doctor reassured him that acne was "harmless" and would resolve with time. Few days later, this young man's mother also consulted the same family doctor for her illness. She mentioned that her son was not happy with his last consultation. On hearing this, the family doctor worried that his patient's fever had not settled. The mother told the doctor that the tonsillitis had resolved and her son had gone back to work. However he felt that his acne problem had not been managed. In fact, acne was the main reason for his consultation and by chance he also had fever on that day. Acne was perceived by her son as the more serious condition than his having a fever.

Family physicians are often consulted by an adolescent with a pimpled, miserable and having a downcast face. Acne is a common dermatosis in general practice and is the commonest skin problem in adolescents. In the Youth 2000 survey in New Zealand, 67.3% of respondents reported acne.¹ Acne also causes much personal and social difficulties for adolescent students.² An analysis of the 1994 U.S. National Ambulatory Medical Care Survey also showed that acne was the fourth leading principal reason for physicians' office visits among adolescents.³

All these data support the need for family physicians to give more attention and care to their acne patients, both physically and psychologically. In this article, the latter will be discussed and considered in more detail.

Why should we care for patients with acne?

In 1948, Sulzberger and Zaldems first recognised the impact of acne on the mental state of patients: "There is no single disease which causes more psychic trauma, more maladjustment between parents and children, more general insecurity and feelings of inferiority and greater sums of psychic suffering than does acne vulgaris". The influence of acne should be interpreted as a function of patient demographic data, personality, baseline psyche status, attitudes from friends and family, coping skills, but not a mere reflection of the clinical severity.

A special age group: adolescents

The prevalence of acne vulgaris reaches its peak during adolescence when they are undergoing physically, socially and psychologically critical development. The heightened concerns of the body image, self-esteem or self-concept, and the desires for sexuality or dating issues amplify the consequence of lesion severity.⁴ Acne might be devastating enough to incur health-related quality of life (QoL) impairment, psychosocial distress or even psychiatric sequelae.

Diminished quality of life?

In 1948, the World Health Organization defined health as a "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". Since then, the impact of illnesses is acknowledged to be a subject of objective clinical measures of disease condition and patients' self-apprehension of the disability from the disease.⁵

Patients' apprehension affects their lives in many ways. The latter is described by QoL. Literature search showed an explosive increased concern for this regard. When the keyword "quality of life" was searched in MEDLINE database from 1950 to 1965, there was only one related article. But the same search strategy applied from 1966 to 2006 showed a soaring 75,478 articles.

So called "Trivial" dermatological condition such as acne was previously perceived as a mere cosmetic nuisance. Yet, evidences now emerge that acne patients reported comparable levels of diminished QoL as patients with chronic disabling asthma, epilepsy, diabetes, back pain or arthritis did.⁶ Understanding QoL (Table 1) in acne patients has become a popular assessment of therapeutic benefits and an important outcome measurement in clinical practices and researches.

Patient-orientated and consistent assessment is enabled and rendered more accurately with the use of QoL questionnaires. One of these acne-specific QoL questionnaires, Cardiff acne disability index (CADI), was designed for investigating the disability caused by acne in routine management.

The Cardiff acne disability index

CADI, developed by Finaly and Motley, is a simplified version which was purposefully extracted from a longer acne disability index for the ease of busy physicians.

It consists of 5 simple questions and could be completed in 1-2 minutes and patients over a wide range of age and intellectual ability can self-administer it without difficulty. It has been translated into a Cantonese version (see Appendix) and shown be a valid and reliable tool for local use.

Psychological sequalae

For acne patients, the spectrum of psyche outcomes^4,16,18 ranges from diminished self-assurance or self-image, emotional stress, social isolation to anger, anxiety and depression. These psyche problems, although not prevalent, exist among acne patients. The sight of such defacement is jeopardous and can further engender worse psychological and psychiatric consequences which include depression, eating disorder and body dysmorphic disorders (BDD).

(a) Depression

Depression is a major psychiatric comorbidity of acne,¹⁶ and has been demonstrated to lead to suicide.¹⁷ The use of highly efficacious treatment of severe acne, isotretinoin, is still controversial for its association with depression and suicidal behaviour.¹⁸ Although there lacks conclusive evidence, it is importance to figure out the possibility of depression in our acne patients (Table 2).

A review¹⁹ compared 4 screening tools of depression for acne patients:

• Hospital anxiety and depression scale (HAD),
• Brief patient health questionnaire (B-PHQ),
• General health questionnaire-12 item version (GHQ-12), and
• World Health Organization-5 well-being index (WHO-5).

The brief and highly sensitive WHO-5 was recommended as the best screening tool before referring the acne patients for further psychiatric assessment.

(b) Eating disorder

Some patients with acne try to improve their condition with exigent but scathing dieting, for example, restricting meat and fatty food in their diet. This concept is especially deep-rooted in Chinese population because these "hot" foods are blamed for the induction of acne.

Through possible mechanism of decreased serum androgen level during starvation, they succeed in eradicating their acne. However, with strong antipathy for their body image concerns, particular individuals might go further and develop psychiatric disorders like anorexia nervosa²⁰ and bulimia nervosa²¹ (Table 3).

(c) Body dysmorphic disorder (BDD)

Adolescence is when the upsurge of acne vulgaris coincides with the occurrence of personal fable. An imaginary audience 'staring' at their appearances heightened the belief of own uniqueness and consciousness. Dysmorphic concern or the more severe end, the BBD, could be the tragic consequences.

According to Diagnostic and Statistical Manual of Mental Disorders-IV, BDD is a somatoform disorder featured by the preoccupation with a specific body part and the belief that this body part is deformed or defective.

A study showed that BDD is a common psychiatric disorder in acne patients.²² Another study demonstrated that about 8.8% of patients with mild acne were diagnosed with BDD.²³ Patients with particular features deserve our further suspicion for BDD (Table 4).

Conclusion

Acne can be disastrous to individual patients. Apart from the psychological aspects, suffering from acne also impedes the patient's functional abilities. Unemployment, avoidance of normal social activities or backsliding academic performance are possible results.

Clinicians might not be the best assessors of the impact of the disease on the sufferers' daily activities, but the acne patients themselves would be.

Hopefully, compliance and efficacy of the treatment can be optimised through physicians and nurses (i) checking all the tips in the boxes (Tables 1 - 4) attached; (ii) coming-out with better doctor-patient relationship by showing more solicitude and empathy to acne patients; (iii) discussing the possible therapeutic strategies with them; (iv) explaining the possible side-effects, onset time and magnitude of treatment efficiency. Following these suggestions, we might truly be adopting patient centred approach meeting the needs of patients.

Acknowledgements

We thank Prof. A. Y. Finlay, Department of Dermatology, Wales College of Medicine, Cardiff University for his kind permission to attach the Cardiff Acne Disability Index in this article.

Key messages

1. Adolescents with acne deserve our special attention as the impact might be deeper than it appears.
2. Sequelae of acne range from diminished quality of life, to psyche problem like depression, eating disorder and body dismorphic disorder.
3. Quality of life questionnaires provide an additional patient-centered information to medical records, assist our therapeutic decision, and enable consistent comparison across and among patients.
4. Usage of quality of life questionnaire (e.g. Cardiff Acne Disability Index) should be encouraged in clinical management of acne patient.

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References