A study of psychological impact of acne vulgaris on quality of life using CADI & DLQI scoring in patients attending dermatology OPD in tertiary care hospital

Introduction

Acne Vulgaris is the leading reason for visiting a dermatologist. It is a chronic inflammatory disease of pilosebaceous units,1 with seborrhea, comedones, papules, pustules, and in more severe cases nodules and pseudocysts.2

The face, back & chest are the most commonly affected sites. Post‐inflammatory macules, pigment changes and scarring also occur. The severity of acne depends on the level of their sebum secretion. Multiple factors have been implicated in causing acne vulgaris. However the basic cause of it is unknown. The various factors implicated are 2 androgens, sebaceous hyperplasia with seborrhea, altered cornification & differentiation, inflammation & immune response, diet etc

Acne is associated with depression, anxiety, and low self-esteem thus impacting the quality of life.

There are a variety of general health related quality of life indices & acne specific health related quality of life. DLQI is specific for evaluating dermatological patients. It consists of 10 questions based on disease symptoms, feelings, daily activities, type of clothing, social or physical activities, exercise, job/ education, interpersonal relationship, marriage relationship and treatment.

CADI is only related to acne, containing 5 questions about last month. This is based on -feelings, interference with social life and interaction with the opposite gender, avoidance of public spaces, appearance of skin and perceived severity of state of disease.

Objectives

To Determine the Impact of Acne Vulgaris on Quality of Life or in simple terms, well-being using two different scoring systems i.e. CADI & DLQI

Materials and Methods

It is a hospital based cross-sectional study. 500 patients of age group 15-30 with acne vulgaris diagnosed on the basis of clinical morphology presenting to Dermatology Outpatient Department were studied. The patients were explained regarding the objectives as well as the method of study. Informed written consent was obtained from all patients. A complete history, clinical examination was done in all patients as per proforma.

A baseline ‘global acne grading system’ was performed. Photograph was taken for documentation. All patients were required to complete pre-structured questionnaire based on acne specific - Cardiff acne disability index (CADI) and skin disease specific -Dermatological life quality index (DLQI).

Results

A total of 500 patients clinically diagnosed as acne vulgaris were studied in a tertiary care hospital. Age group between 15 & 30 were studied. Majority of the patients belonged to the age group 21 - 25. Mean age in this study is 21.45 ± 2.220 years. Out of 500 acne vulgaris patients 376 were females, amounting to 75.2%. Thus females were the majority in this study compared to male (124, 24.8%).

Majority of the patients (88.4%) age of onset were between 15 - 20 years. Mean age of onset → 18.57 years with SD of 1.500. Family h/o acne vulagaris were positive in only 35% of the patients in this study. Out of the remaining 65.4%, majority were mother and sister. Majority of the patients in this study were students (91.2%). Remaining were coolie by occupation (8%), followed by home maker and teacher.

Face was the most common site involved in the patients with acne vulgaris in this study (98.6%). Chest and upper back were rarely involved. In this study, comedones were present in 96.4% of patients, papules in 46.8%, pustules in 4.6%, nodules and cyst in 1%.

According to global acne grading system, 80% of the patients were mild. 19% moderate and remaining 1% severe. Triggering factors for acne vulgaris were diet (4.6%), cosmetics (4%), stress (2.8%), sweating (1.4%) and smoking in 1.2%.

Based on DLQI scoring, majority had very large effect on quality of life (76%) and 2% had extremely large effect on quality of life (Table 2). Mean DLQI is 13.29. Mean CADI score is 7.57. Majority had medium impact in quality of life (86%). 12.4% had high impact and 1.6% had low impact on quality of life (Table 3).

1% of the patients studied with mild grade acne & 25% with severe acne had small effect on QoL based on DLQI. 80% of the patients with small effect on QoL had mild acne. 84% with moderate effect had mild acne. 50% with severe acne had very large effect on QoL. 77.8% with extremely large effect on QoL had moderate acne based on GAGS. DLQI is significantly related to global acne grading system. p=0.0001 (chi square test) r=.119 (Pearson’s correlation).

1.8% of the patients studied with mild grade acne had low effect on QoL based on CADI. 87.5% of the patients with low effect on QoL had mild acne. 83.5% with medium effect had mild acne. 50% with severe acne had medium effect & another 50% had high effect on QoL. 53.2% & 43.5% with high effect on QoL based on CADI had mild & moderate acne respectively based on GAGS. CADI is significantly related to GAGS p=0.0001 based on chi square test and r=0.218 based on Pearson’s correlation.

CADI and DLQI scoring system correlated significantly according to Pearson’s correlation r=0.221 (Table 4) & highly significant based on Fischer’s test (p < 0.0001).

Figure 1

PredominantlyComedones, Grade 1 Acne Vulgaris with medium CADI & moderate DLQI

Figure 2

Nodules, papules over the cheeks andcomedones and papules over the forehead with low effect CADI & small effect DLQI

Figure 3

Nodulocystic acne with very large effect DLQI & medium CADI

Discussion

The mean age of the study population was 21.45 years (ranging from 15 to 30 years with SD = 2.220). Age correlated with the global acne grading system in our study (p=0.0001, chi square test). Many studies like Walker and Lewis-Jones et al, Hanisah et al, Jankovic et al, Pawin et all, Uslu 3, 4, 5, 6, 7 et al included age group of 13 to 18 years of age whereas Rapp et al, Jones‑Caballero et al, Ismail et all included age group from 11 years 8, 9, 10 and few studies age group ranging above 17 years. 11, 12 Acne commonly involves the face and in our study facial acne was most common (493, 98.6%). Study done by Martin et al showed that the QoL worsened with increasing severity of facial acne. 13 Hassan et al also reported QoL was affected by the severity.14

Majority of the type of lesions (Table 1) present were comedones (482, 96.8%) & papules (46.8%). A Study done by Tasoula et all showed lower prevalence of comedones compared to our study. 15

There was no gender difference between CADI (p=0.711) & DLQI (p=0.803) score based on chi square test in this study. Study by Cotterill et al 16 showed that females had higher scores, which was also seen in another study by Halvorsen et al.17

The mean DLQI score was 13.29 i.e. very large effect on QOL with majority (79.8%) having mild grading of acne (GAGS) in our study compared to study done by Walker and Lewis-Jones with low mean CADI score (1.9) and good correlation. 3 In the study done by Shahin et al 18 Mean CADI score was 8.34 with medium effect and our study it was 7.57. Correlation of the scores and acne severity was also showed by another study done by Srivastava et al. 19 Study done by Gupta et al showed no association of QoL with acne severity. 20

There was highly significant correlation between global acne grading system with CADI & DLQI scores. (r=0.218, r=0.119 respectively, Pearsons correlation). Majority had moderate to large effect (DLQI - 99%), & medium to high effect (CADI- 98.4%) on QoL in this study.

Our present study shows significant correlation between QoL & age based on DLQI score. (p=0.017, chi square test). CADI did not correlate (p=0.789). Study by Pruthi and Babu showed impact of acne on physical and psychosocial aspect of life. 21 But a Study by Salek et al showed no association of age and QoL. 22

We observed that there was no correlation between triggering factors with acne & scoring in our study. Commonest triggering factors for acne was diet (4.6%) followed by cosmetics (4.0%). In a study done by Ismail et al acne was associated with milk and Icecream intake. 23

Limitations of this study is that, we do not know what impact acne has on patients who do not choose or cannot come to hospitals for consultation. Therefore, there is a need to replicate this study in community setting to explore the findings to all acne patients.

Conclusion

Our study has showed strong correlation between the QoL and acne and age based on DLQI score which might be due to the effect of social and occupational functioning. Majority of the patients in this study had moderate or medium effect on QoL. Increased severity of acne was directly proportional to the impairment of quality of life.

These scoring indices measuring the quality of life changes gave a small insight into the impact of acne from a patient’s outlook thus significantly interfering with social functioning and bringing about impairment in quality of life.

The strength of our study was large number of acne patients surveyed from 15-30 years age mostly students, giving an approximate estimation of psychometric morbidity with hospital based data. To promote patients satisfaction & QOL it’s also recommended to set up supportive groups in dermatology department & hospitals. Hence the disability caused by acne must be taken into account when individualizing treatment by health professionals and include QoL measurements to provide better care.

Conflict of Interest

There are no conflicts of interest in this article.

Source of Funding

None.