Acne Takes a Toll on Women’s Mental Health, Quality of Life

Almost half of women with moderate or severe acne had appearance-related concerns that affected their social, professional, and personal lives, including behavior-altering effects, a small survey showed.

The results showed that 24 of 50 women expressed concern about their appearance — acne made them self-conscious, and many reported intrusive thoughts about their appearance and how much attention other people exhibited toward the women’s acne.

Many patients also expressed frustration with clinical management, including finding a dermatologist who made them feel comfortable and with identifying effective treatment, reported John S. Barbieri, MD, of the University of Pennsylvania in Philadelphia, and colleagues, in JAMA Dermatology.

“The results of this qualitative study highlight that acne has multifaceted quality-of-life consequences in women,” the authors stated. “Although acne is often viewed as a disease of adolescence, more than 50% of women experience acne in their 20s and more than 35% in their 30s.”

“Many patients described frustration with finding a dermatologist with whom they were comfortable and with identifying effective treatments for their acne,” the authors added. “In contrast, those who thought their dermatologist listened to their concerns and individualized their treatment plan reported higher levels of satisfaction.”

The study added to the evidence that acne has negative health-related quality-of-life consequences in patients of all ages, according to the authors of an accompanying editorial.

“The similarity of the findings of Barbieri et al to larger international studies supports a consistent theme among patients with acne,” wrote Diane Thiboutot, MD, of Pennsylvania State University College of Medicine in Hershey, and colleagues. “They were a representative reflection of what women with acne experience regarding acne-related appearance concerns, judging the effectiveness of treatment, and determining what is important to measure in a clinical trial setting.”

Patient preferences often are not considered in the development of acne treatment plans, Thiboutot and colleagues said. However, efforts are underway to adopt more patient-centered approaches to assessing treatment efficacy in clinical trials of acne and other skin diseases.

“Ensuring access to care and identifying optimal treatment approaches for women with acne are needed to reduce the burden and improve outcomes in this population,” they added. “This rigorously conducted qualitative study of women’s perspective in their lived experience with acne represents an important contribution to the field of designing patient-reported outcome measures that reflect what is important to patients.”

Multiple studies have documented the adverse quality-of-life effects of acne among adolescents, but few studies have explored the lived experience of acne in adults, Barbieri and colleagues noted. Because acne often persists into adulthood, understanding adult women’s perspectives on acne and its treatment can help guide clinical management.

The study involved patients, ages 18 to 40, with moderate or severe acne, recruited from clinics at the University of Pennsylvania Health System and from a private dermatology clinic in Cincinnati. Research coordinators conducted confidential telephone interviews with study participants, during which two types of qualitative data were collected: free listing (first word that comes to mind about different aspects of acne and its management) and open-ended, semi-structured interviews. Patients also provided an overview of their medical and acne histories.

Treatment history for the study population included topical retinoids (78%), spironolactone (70%), oral antibiotics (60%), topical antibiotics and combined oral contraceptives (43% each), and isotretinoin (41%). Analysis of free-listing responses showed that the most salient terms associated with treatment success were “clear skin” (salience index 0.67) and “no scarring” (0.09). The most salient terms associated with treatment-related adverse effects were “dryness” (0.67), “redness” (0.21), and “burning” (0.14).

During the structured interviews, participants “consistently noted that their blemishes made them highly aware of their appearance,” the authors reported. The responses and comments allowed researchers to identify five themes: concerns about appearance, mental and emotional health, everyday life impact, successful treatment, and interactions with the healthcare system.

The authors offered representative comments associated with each theme. For example, one participant said of acne’s impact on everyday life, “It prevents me from doing the things that I love to do. It prevents me from leaving my house. It prevents me from getting my mail without makeup on. It pretty much prevents me from doing anything without makeup on, so it 100% affects my entire life.”

With regard to different treatments, participants considered topical retinoids helpful for certain types of acne, but some cited barriers to use, such as dryness and peeling and limiting sun exposure. Most participants considered oral antibiotics inappropriate treatment, primarily because of limited-term effectiveness. Participants treated with spironolactone generally considered it their most effective therapy. Negative comments commonly related to prolonged time to onset of activity and adverse effects, including irregular menstrual cycles, increased need to urinate, lightheadedness, and headaches.

Patients experienced with isotretinoin found it effective but potentially disruptive to everyday living because of need for multiple forms of contraception, frequent blood work, and adverse effects. Others described it as a last-resort treatment, noting the potential side effects.

The authors acknowledged several limitations of the study: relative severity of the participants’ acne; possibly limiting generalizability of the results to other patient populations; inability to compare responses by acne distribution, such as truncal versus facial only; and incomplete demographic data.