Acne vulgaris is one of the most common skin disorders, with an estimated prevalence of 90% to nearly 100% among adolescents.1,2 Approximately 40% of affected adolescents require some type of medical intervention.2 For some patients, acne continues to be a problem beyond adolescence, persisting well into adulthood.3-6 It has been reported that more than 70% of patients over age 20 are affected by acne.3,5
Studies on the psychosocial impact of acne have documented dissatisfaction with appearance, embarrassment, self-consciousness and lack of self-confidence.7-11 Furthermore, acne is associated with feelings of anxiety, depression, anger, less satisfaction with the body and lower self-worth.8,12-14 Social dysfunction in relation to acne has also been observed, including concerns about social interactions with the opposite gender, appearances in public, interactions with strangers and reduced employment opportunities.12,15-18 Reducing the psychosocial impact of acne is considered one of the guiding principles for its clinical management.12,16
For many patients, acne may lead to permanent scarring and disfigurement (Figure 1A-1C), further aggravating the existing psychosocial aspects of this condition.19 Facial scarring due to acne affects both sexes equally and may occur in up to 95% of people who develop acne.20 Despite the prevalence and negative effects of acne scarring, relatively little has been published in the literature about its specific psychological effects as a condition separate from acne. Acne and its sequelae can negatively impact an individuals’ intrapsychic, psychosocial and vocational functioning. Therefore, additional data is needed to correlate acne scarring, as a separate entity from active acne vulgaris, with its associated psychological and functional impact. Several quality of life scales have been developed to document the psychological impact of acne.15,21-23 However, a quality of life questionnaire would be a useful tool for assessing the impact of acne scarring and the effectiveness of treating acne scars during clinical trials.24-27
This article provides an overview of a study that aimed to assess the emotional and functional impact of facial scarring. A patient self-report instrument utilizing Likert scales was developed and used. The questionnaire specifically addressed how the presence of acne scarring has affected the emotional and functional status of the affected individual. A review of available quality of life instruments as well as an analysis of relevant aspects of the human spheres of functioning (social, vocational, intrapsychic and sexual) provided guidance for the development of the instrument.
This was a multicenter study across 4 private practice dermatology sites in the United States. Each site recruited 20 to 30 subjects who were male or female, ≥18 years old, with Fitzpatrick skin types I-VI, and any degree of facial acne scarring; but with no evidence of clinically moderate-to-severe active acne activity during the previous 6 months.
The study excluded subjects who had undergone any previous treatments for acne scarring including laser resurfacing, chemical peel, dermabrasion, microdermabrasion, punch excision/graft/elevation, subcision or skin filler specifically used for acne scars. Subjects who had prior excisional facial surgery such as blepharoplasty, face-lift or rhinoplasty less than 1 year prior to study enrollment were also excluded.
Investigator’s Global Assessment Scale
To exclude subjects with clinically moderate-to-severe active acne, investigators evaluated subject’s clinical acne activity based on the 5-point Investigator’s Global Assessment (IGA) Scale for acne vulgaris (Table 1).28
Acne Scar Assessment Scale
A validated 5-point physician-evaluator Acne Scar Assessment Scale (ASAS) was used to rate subjects’ global facial acne scar severity as clear (0), very mild (1), mild (2), moderate (3) or severe (4). See Table 2 for descriptions.29 The study investigators were trained on the use of all assessment scales prior to enrolling any subjects.
Subject Self- Reporting Instrument - Scar Impact Scale
Each enrolled subject completed a 33-question subject self-reporting Scar Impact Scale (SIS) designed to assess the emotional and functional impact of facial acne scarring (Table 3). Subjects completed the SIS during a single office visit.
Photographs for the study were conducted at 1 study site as designated by the sponsor. Each investigator determined if additional photographs were needed as part of their practice policy and procedures. Additional training regarding study-related photography was provided during the site initiation visit.
Descriptive statistics were used for quantitative variables, including mean, median, standard deviation (SD), quartiles, minimum and maximum values to describe their distribution. Frequencies and proportions were used for categorical variables. The study population was divided into 2 strata using the baseline median value of SIS scores. For Fitzpatrick skin type strata analyses, study subjects were grouped into 1 stratum for skin types I-IV or another for skin types V and VI. P-values from Wilcoxon 2-sample tests, assuming normal approximation, were presented to estimate statistical significance. Data was analyzed without imputation and statistical analyses were performed in SAS (version 9.3; SAS Institute Inc., Cary, NC).
The purpose and procedures of the study were explained and subjects were asked about their willingness to participate, including their willingness to sign an informed consent. In some cases, they were asked to sign photography release forms. To comply with Health Insurance Portability and Accountability Act requirements, a separate authorization for disclosure or use of protected health information was signed. Subjects signed an Internal Review Board-approved Informed Consent Form, Photographic Release Form and the Authorization for Use and release of Health and Research Study Information Form prior to any study-related procedures being performed.
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A total of 97 subjects met the inclusion/exclusion criteria and were enrolled in the trial. The mean (SD) age of subjects was 34.9 (11.6) years, and most subjects (71.1%) were female. The majority of subjects were Caucasian (73.7%) and had Fitzpatrick skin type II (35.1%) or III (28.9%). For a summary of subject demographics, see Table 4.
All subjects enrolled in the trial had been identified by investigators to have some degree of facial acne scarring (grade 0-4). The subject population had a mean ASAS score of 2.31 (SD ±0.89), which corresponds to mild to moderate scarring, and a mean IGA (grade 0-4) score of 1.29 (SD ±0.96). Table 5 shows the ASA and IGA disease severity scores.
Analysis of the SIS questionnaire results showed that all subjects enrolled were negatively impacted to a certain degree by their facial acne scarring as well as the severity of their active acne. Study subjects rated the following items as being most negatively impacted due to the presence of acne scarring (corresponding SIS score ≥5): feeling less happy about own body (68.8%), less happy when the face is touched (71.9%), less confident (80.2%), less attractive (84.4%) and most notably, feeling less happy when looking in mirror (85.4%).
Specifically, subjects with an ASAS score above the median (N=37, Table 6), which corresponded to more severe scarring, rated themselves as more anxious, less social, less confident, less in control, less attractive, feeling like life is worse, less happy when looking in mirror, using more cosmetics and less happy when the face is touched compared to those subjects with less severe scarring. Likewise, compared to subjects with an IGA score at or below the median, subjects with an IGA above the median (N=44), corresponding to higher levels of inflammatory acne activity, demonstrated a significantly greater impact with regards to being more angry, being less assertive, doing worse at work/school, feeling less attractive, feeling less relaxed and feeling that life is worse.
Additional subgroup analyses were performed, suggesting that subjects with Fitzpatrick skin types I-IV and female subjects were more negatively impacted by their acne scarring in comparison to the general acne scarring population. Stratified results of the SIS questionnaire revealed that subjects with Fitzpatrick skin types I-IV reported feeling sadder, less social and more argumentative compared to subjects with Fitzpatrick skin types V-VI. Female subjects demonstrated a significantly greater impact with regards to feeling less optimistic, energetic, amorous, assertive, comfortable with others, in control, confident overall and sexually confident. They were also less likely to go out, exercised less and were less happy looking in the mirror or when their face was touched compared to male subjects. They reported feeling more depressed, anxious, sadder and using more cosmetics.
To date, several studies have been published establishing the psychosocial effects of acne,7-11,14,18,28 but very few have explored the negative impact caused by post-acne scarring. The results of the present study confirm that acne scars have a substantial negative impact on the overall social and functional well-being of affected individuals. An overwhelming 85.4% of study subjects revealed they were unhappy looking at themselves in the mirror, with 84.4% feeling less attractive, as a result of their acne scars.
Although there are some detectable differences between groups (ie, women were affected differently than men, subjects with more severe scarring reported greater distress along several parameters and lighter skin types manifested psychological symptoms differently than darker skin types), the underlying conclusion is the same: acne scarring has a profound negative impact on patients; therefore, effective therapies to prevent and ameliorate the occurrence of acne scarring can be essential and pivotal in the prevention of debilitating psychosocial effects.
New and improved methods for treating atrophic acne scars are being developed.30,31 The dermal filler Bellafill (Suneva Medical, Inc.) was recently approved by the FDA for treating atrophic acne scars. Further studies are warranted to assess the benefits of acne scar correction.
Several study limitations are recognized with the present study. The measures employed self-reporting instruments and do not necessarily assess or report functional status objectively. The assessments reflected only a single sampling of mood or function, with no comparator group, and thus may be subject to sample bias colored by the events during a brief moment in time.
Acne scars have a substantial negative impact on the overall social and functional well-being of affected individuals. Interventions to improve the objective appearance of individual’s acne scars may be life enhancing and in some individuals, lifesaving.
Dr. Fried is in practice in Yardley, PA.
Dr. Werschler is in practice in Spokane, WA.
Dr. Berson is in practice in New York and is also with the department of dermatology at Weill Medical College of Cornell University, New-York Presbyterian Hospital in New York, NY.
Dr. Del Rosso is in practice in Las Vegas, NV.
Acknowledgement: This study was supported by Suneva Medical, Inc., Santa Barbara, CA. The authors acknowledge the editorial assistance of Dr. Carl S. Hornfeldt and Dr. Vivien L. Nguyen during the preparation of this manuscript.
Disclosure: Dr. Fried is a consultant for Valeant, Neutrogena and Johnson & Johnson.
Dr. Werschler is a consultant and investigator for Suneva Medical Inc.
Dr. Del Rosso is a consultant for Suneva Medical Inc. and has received grants from the company.
Dr. Berson is a consultant for Suneva Medical Inc.
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