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Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

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Open Access  Full Text Article                                                                                                                                                   Research Article

Effect of Acne Vulgaris and its Impact on Quality of Life of Adolescents in Bengaluru

Shabnam^1,*, Basharat Rashid², Mohd Nazir Mannan³, Anisur Rahman⁴

^1, Assistant Professor, Department of Tahaffuzi wa Samaji Tib (Preventive and Social Medicine), Markaz Unani Medical College & Hospital, Kozhikode, Kerala, India

² Medical Officer, Department of AYUSH, Health and Medical Education, Govt. of Jammu and Kashmir, India

³ Assistant Professor, Department of Ilmul Advia (Pharmacology), Markaz Unani Medical College & Hospital, Kozhikode, Kerala, India

⁴ Associate Professor, HOD Dept. of Ilmul Advia, Markaz Unani Medical College & Hospital, Kozhikode, Kerala, India

INTRODUCTION

Physical appearance is important in our society and influences the way in which we are perceived by others. The skin is the most visible organ of the body and determines, to a large extent, our appearance with a wide function in social and sexual communication¹. Acne vulgaris is one of the most common skin disorders^{2, 3}. Acne vulgaris is a common skin disease affecting up to 80% of adolescents and many adults at some stage. it is associated with a considerable psychological impairment which is comparable with certain chronic diseases like asthma, epilepsy, diabetes and arthritis^{2, 3}. Acne patients are prone to low self-esteem, low confidence and social dysfunction which may lead to anxiety, depression, obsessive compulsive disorder and sometimes suicidal ideation⁴. Also prevalence of acne in school children reported ranges from 30-100% depending on age⁵. More severe acne has been suggesting to be associated with increased anxiety, depression symptoms and impact on patient life⁶.

The psychosocial affect of acne was first recognized in 1948 when Sulz Barger Zalden mentioned that there is no single disease which causes more psychic trauma and more maladjustment between parents and children more general insecurity and feeling of inferiority and greater sums of psychic assessment than acne vulgaris. Acne is strongly associated with depression and anxiety⁷.

Quality of life (QoL) is a general term which includes a feeling of joy and satisfaction with life. WHO defines QoL as the “individual's perception of their position in the context of culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns” ⁴. Acne vulgaris is a chronic inflammatory disease of the pilosebaceous follicles, common in adolescents, characterized by Comedones, papules, pustules, cysts, nodules, and occasionally scars⁹. The term acne is derived from the Greek word 'acme' which means 'prime of life'. Although generally considered to be a benign, self-limiting condition, acne may cause severe psychological problems or disfiguring scars that can persist for a lifetime¹⁰.

According to Ibn-Sina, Buthūr-i- Labaniyya (acne vulgaris) are small white eruption on the nose and cheeks which resemble a condensed drop of milk¹¹. According to Qarshi it is a Muta‘addid (contagious) disease in which small white eruption appears on face nose and cheeks, on pressing a cheesy material expressed out from it¹². Causes of these eruption is a mādda-i-ṣadīdiya (suppurative material) which comes towards skin surface due to bukharat-i-badan (vapours of the body/abnormal heat)¹¹. According to Hakeem Ajmal Khan, sometimes small pointed eruption appears on the face, neck, chest, cheeks and nose. These eruptions are hard and red in colour. When these eruptions become mature they excrete keel and some amount of pus¹³. According to classical Unani literature, Buthūr (eruptions) is a type of waram (inflammation). The difference is only in size. Buthūr is a small awram¹⁴. If any organ is unable to excrete out fudlat (morbid matters) from the skin or other organ disposed there fudlat towards this organ, and the organ is unable to dispose the waste, it results in nutū’ (eminence) or elevation in an organ. If this elevation does not rupture the skin or mucous membrane then it is known as waram, and if the elevation is crushed it is known as buthūr. Buthur which are on the face and nose and are non-itching, they are known as labaniyya (milky eruption) or ṣadīdiya (suppurative)¹⁵.     

MATERIALS AND METHODS:

The present study was conducted by the department of Tahaffuzi wa Samaji Tib (Preventive and Social Medicine), National Institute of Unani Medicine, Bengaluru. The aims and objectives of the study were to assess the prevalence of acne vulgaris and its impact on the quality of life and to study socio-demographic factors, family history and lifestyle associated with the disease.

The study population comprised of school children of age group 12-18 years (adolescents) of selected area of Bengaluru. The duration of the study was one year, from January 2017 to December 2017. The sample size was calculated as 200 using formula = Z²_α/2 ×P× (1 ̶ P) ×D÷E² where P is the prevalence or proportion of event of interest for the study (P=70% taken from the previous studies), E is the precision or margin of error (E= 10% of P), Z _α/2 is normal deviation at a 5% level of confidence (=1.96) and D is the design effect (which is 1 for simple random sampling).

Ethical Clearance: Before starting the study, a comprehensive protocol was prepared and put in for obtaining clearance from the Institutional Ethics Committee (IEC) of NIUM, Bengaluru. After getting ethical clearance with IEC No: NIUM/IEC/2015-16/019/TST/04 study was conducted.

Data was collected from a selected area of Bengaluru using simple random sampling method.   A pretested structured questionnaire consisting of various questions and aspects regarding socio-demographic profile, acne vulgaris and the assessment of quality of life was administered to the respondents fulfilling inclusion criteria. Quality of life assessment data was obtained by using Cardiff Acne Disability Index (CADI), Children’s Dermatology Life Quality Index/ Dermatology Life Quality Index (CDLQI/DLQI) and Acne grading was calculated by using GAGS.

The Global Acne Grading System

Socio-economic status of the parents was calculated by using Kuppuswamy’s socioeconomic status scale 2014. Measurement of the study variables included age, sex, gender, language spoken, and assessment of acne vulgaris in school children. Acne was graded in to mild, moderate and sever based on GAGS.

CDLQI is a general questionnaire to assess the quality of life. It consists of 10 questions about disease symptoms and feelings (question 1&2), leisure (question 4,5 & 6), school or holidays (question 7), personal relationships (question 3 &8), sleep (question 9), and treatment (question10). The scoring of each question is as follows: Very much = 3, Quite a lot = 2, Only a little = 1, Not at all = 0, Question unanswered = 0, Question 7: “Prevented work or studying” = 3. Its domain is from zero (without any effect on quality of life) to 30 (extremely large effect on quality of life). The CDLQI was calculated by summing the score of each question resulting in a maximum of 30 and a minimum of 0. The higher the score, the more quality of life is impaired.

Interpretation: 0-1 = No effect on child’s life, 2-6 = Small effect, 7-12 = Moderate effect, 13-18 = Very large effect, 19-30 = extremely large effect. 

The CDLQI/DLQI and CADI questionnaires were both copyright protected, so prior permission was granted from the University and authors before their use. The CDLQI was calculated by summing the score of each question, resulting in a maximum of 30 and a minimum of 0. The CADI questionnaire was specific for acne and contained 5 questions. The CADI score is calculated by summing the scores of each question, resulting in a maximum of 15 and a minimum of 0, from 0-3 leading to a total score of 0-15. The CADI score was graded as low (0-4), medium (5-9) and high (10-15). A higher score showed a very large impact on quality of life. Both questionnaires were copyright protected, so prior permission was granted from the University and authors before their use. CDLQI was administered to adolescents age less than 16 years of age, while DLQI was administered to adolescents age 16 or above.

RESULTS:

A total number of 200 patients between the age of 11 to 18 years were taken in study. Patients were divided into 4 groups of which a maximum of 56.5% were among patients between 15-16 years followed by 32.5% of age group 13 to 14 years and 7% of patients of age group 17-18 years.  Out of total number of 200 patients, 46% of patients were male and 54% of patients were female. In this study, out of 200 adolescents 36% of adolescents were dark and 64% were fair complexion. 69% were non vegetarian and 31% were vegetarian (Table 1).

Table 1: Association of demographic variables with Acne according to Respondents

Table 2: CADI distribution according to gender of Respondents

CADI scores showed that acne had a low effect in 40.8% of patients, majority had a medium effect in 44.3%, and a high effect in 14.9% (Table 2).

Table 3: CDLQI distribution according to of respondents

 P<0.001**, Significant, Fisher Exact Test

Acne had no effect on 9.8% of patients, small effect in 13.2%, moderate effect in 22.9%, very large effect in 20.7% and extremely large effect in 32.8% (DLQI scores) (Table 3).

Table 4: CDLQI/DLQI distribution according to GAGS of respondents

P<0.001**, Significant, fisher exact test

The severity of acne has a direct impact on quality of life. 

DISCUSSION:

Acne is more common in adolescent females, confirming previous findings that it is common¹⁶. However, the prevalence of acne has been reported to be lower in some studies¹⁷. This study found that 56.5% of subjects (113) were in the age group of 15-16 years, which is in line with Jancovic et al., finding that acne prevalence is higher at this age of 16 and 17 years¹⁸. Balakrishnan et al., also reported that acne is a chronic disease affecting 85% of teenagers¹⁹.

This study found that 52.5% (105) of the study population were females, while 47.5% were males (95). This is in line with previous studies conducted by Ismail et al., and Chinese in 2012, which reported that acne in adolescents was predominant in males and adult acne was common in females^{20, 21}.

Our study found that 85.1% (148) of students had mild acne, with 10.9% (19) having moderate acne, 1.7% (3) having severe and 2.3% (4) having very severe acne.  Comparative studies conducted by Yahya et al., and Kaduna et al,. and Hanisha et al.,¹⁶ in Malaysian adolescents showed 93.1% and 90.2% frequency of mild acne respectively. Tan et al.,²² found a near equal prevalence of moderate/severe acne (48.6%) and mild (51.4%) in Singaporean adolescents.  Agheai et al., and Mallon et al found more moderate/severe grades of acne (84%) than mild grades (16%) in hospital-based studies ²³. In the UK this is not unexpected, as persons with more severe diseases are likely to seek medical intervention, thus hospital-based studies are likely to yield more severe forms of acne compared to community-based ones such as ours. Same as in the UK are likely to yield more severe forms of acne than community-based ones, as people with more severe diseases are likely to seek medical intervention.

The overall CADI score was 44.3% (77), indicating a mild degree of disability from acne. Similar values were obtained in some community-based studies¹⁶, while higher scores were obtained by Motley and Finlay ²⁴ in the UK and Oakley ²² in New Zealand, respectively. Several reasons may be adduced for the relatively higher CADI scores in the two latter studies, which were hospital-based: Firstly, hospital-based studies have a higher concentration of persons with more severe grades of acne compared to community-based surveys. Secondly, the ages of patients in hospital-based surveys are varied compared to the exclusively adolescent age of fore mentioned community-based studies. Another factor may be cultural and/or racial; the studies with higher CADI scores were conducted in Western societies.²⁴ The studies with higher CADI scores were conducted in Western societies²⁴.

Our study showed that the impact of acne on quality of life was proportional to its severity. These results are in agreement with similar studies where both acne and severity are self-reported^{25, 23, 26, 27, 28, 16, 29, 30}.  

The correlation between CADI and GAGS was found to be significant (p<0.001). This is in line with previous studies conducted by Hanisha et al.,¹⁶ who reported that severity of acne correlates strongly with quality of life. However, Law et al ³⁵ reported that the correlation between GAGS and CADI was weak.

This study found that acne had a moderate to extremely large effect on quality of life in patients with acne, similar to Safizedeh H et al., and Haritha et al., who found a moderate to very large effect in adolescents (Table 3).

This study found that Acne vulgaris had a medium effect 44.3% (77) on adolescents based on CADI score, indicating a high psychosocial burden. Hanish et al., reported that patients felt aggressive, frustrated or embarrassed as a result of having acne¹⁶.

A study done in the psychiatry OPD of a medical institution in New Delhi found significantly higher psychiatric morbidity in patient with acne vulgaris. Similarly, in our study, a significant correlation of GAGS score with CDLQI/DLQI (p<0.001) and CADI (p<0.001) was found. The result showed that acne has an impact on quality of life³⁶.

This study has a few limitations, such as limited to a small geographical location, over reporting in a cross sectional study design. These limitations limit the causality of relations, as the sample size was less than many other studies. Additionally, the results cannot be generalized to the entire city.

CONCLUSION:

Thus, it may be concluded that evaluation of the quality of life in patients with acne is important as it helps in the pharmacological as well as psychological treatment of these patients in a more effective and integrated way. Further Health education is needed in our secondary schools and society to ensure that adolescents understand their disease and know what treatments are available and from whom they should seek advice. A Health professional should be aware that early acne treatment can prevent the progression of the disease and its complication.

REFERENCES:

1. Vilar GN, Santos LA, Filho JFS. Quality of life, self-esteem and psychosocial factors in adolescents with acne vulgaris. A Bras Dermatol. 2015; 90 (5):622-9. https://doi.org/10.1590/abd1806-4841.201533726

2. Behn PN, Aggarwal A, Srivastava G. Practice of dermatology. Edi 9 New Delhi: CBS Publishers and distributors 2002:408-411

3. Mcphee SJ, Papadakis MA. Lange current Medical Dignosis and Treatment. Edi 49. New Delhi:Mc graw Hill Medical, 2010:120-122.

4. Samanthula H, Kodali M. Acne and quality of life- A study from a tertiary care centre in south India. Journal of dental and medical science. 2013; 6(3):59-62. https://doi.org/10.9790/0853-0965962

5. Yeung C, Teo LHY, Xiang LH, Chan HHL. A community based epidemiological study of acne vulgaris in Hong Kong adolescents. ACTA Derm Venereol. 2002; 82:104-107. https://doi.org/10.1080/00015550252948121

6. Tasoula E, Gregorious S, Chalikiyas J, Lazarou D, Danopoulous I, Katsambas A et al. The impact of acne vulgaris on quality of life and psychic health in young adolescent in Greece.Result of population survey. An bras Dermatol 2012; 87(6):863-867. https://doi.org/10.1590/S0365-05962012000600007

7. Rubin MG, Kim K, Logan AC. Acne vulgaris mental health and omega-3 fatty acids: A Report of cases. Lipid in health and disease 2008; 7(36):1-3 https://doi.org/10.1186/1476-511X-7-36

8. Ghaderi R, Saadatjoo A, Ghaderi F. Evaluating of life quality in patients with acne vulgaris using generic and specific questionnaires. Dermatology research and practice. 2013; 1-6. https://doi.org/10.1155/2013/108624

9. Bagatin E, Timpano DL, Guadanhim LRD, Nogueira VMA, Terzian LR, Steiner D et al. Acne vulgaris: prevalence and clinical forms in adolescents from São Paulo, Brazil. An Bras Dermatol. 2014; 89(3):428-35. https://doi.org/10.1590/abd1806-4841.20142100

10. Tahir MC. Pathogenesis of acne vulgaris simplified. Journal of Pakistan association of dermatologist 2010; 20-93-96

11. Sina I. Al Qanoon Fil Tib (urdu translation by Kantoori sayed ghulam hasnain), New Delhi:Idara kitab Us shifa, YNM:1432.

12. Qurshi H M. Jamiul Hikmat. New Delhi:Idara kitabushifa 2011:994,995.

13. Jeelani G. Makhzane Hikmat. Vol.2. New Delhi: Ejaz Publication,1996:689

14. Almaseehi, Ibne Alqaf AFA. Kitabal Umda Fil jarahat. Vol1. New Delhi:CCRUM; YNM:146

15. .Siddiqi MMH, Jafari AHS. Tarjuma Daqa-i-Qulilaaj.vol.1.Deoband: Mukhtar press; YNM: 478-80.

16. Hanisah A, Omar K, Shah SA, "Prevalence of acne and its impact on the quality of life in school -aged adolescents in Malaysia," Journal of Primary Health Care, 2009; 1:20-25. https://doi.org/10.1071/HC09020

17. Aktan S, Ozmen E, Sanli B. Anxiety, depression, and nature of acne vulgaris in adolescents. Int J Dermatol. 2000; 39(5):354-357. https://doi.org/10.1046/j.1365-4362.2000.00907.x

18. Jankovic S, Vukicevic J, Djordjevic S, Jankovic J, Marinkovic J. Quality of life among schoolchildren with acne: Results of a Crosssectional study. Indian J Dermatol Venereol Leprol 2012; 78:454-8. https://doi.org/10.4103/0378-6323.98076

19. Balkrishnan R, Kulkarni AS, Cayce K, et al. Predictors of healthcare outcomes and costs related to medication use in patients with acne in the United States. Cutis 2006; 77(4):251-5.

20. Ismail KH, Mohammad Ali KB. Quality of life in patients with acne in Erbil city. Health and quality of life outcomes 2012; 10(60):1, 2, 4. https://doi.org/10.1186/1477-7525-10-60

21. Yiwei S, Wang T, Zhou C. Prevalence of Acne Vulgaris in Chinese Adolescents and Adults: A Community-based Study of 17,345 Subjects in Six Cities: Acta Derm Venereol 2012; 92:40-44. https://doi.org/10.2340/00015555-1164

22. Oakley AM. The Acne Disability Index: usefulness confirmed. Australas J Dermatol. 1996; 37(1):37-39. https://doi.org/10.1111/j.1440-0960.1996.tb00992.x

23. Mallon E, Newton JN, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br J Dermatol. 1999; 140(4):672-676. https://doi.org/10.1046/j.1365-2133.1999.02768.x

24. Motley RJ, Finlay AY. Practical use of a disability index in the routine management of acne. Clin Exp Dermatol. 1992; 17 (1):1-3. https://doi.org/10.1111/j.1365-2230.1992.tb02521.x

25. Walker N, Lewis Jones MS. Quality of life and acne in Scottish adolescent children: use of the Children's Dermatology Life Quality Index (CDLQI) and the Cardiff Acne Disability Index (CADI). J Eur Acad Dermatol Venereol. 2006; 20:45-50. https://doi.org/10.1111/j.1468-3083.2005.01344.x

26. Poli F, Dreno B, Verschoore M: An epidemiological study of acne in female adults: Results of a survey conducted in France. JEADV 2001, 15:541-545. https://doi.org/10.1046/j.1468-3083.2001.00357.x

27. Pawin H, Chivot M, Beylot C, Faure M, Poli F, Revuz J, Dréno B. Living with acne. A study of adolescents' personal experiences. Dermatology. 2007; 215:308-14. https://doi.org/10.1159/000107624

28. Finlay AY and Khan GK, Dermatology life quality index (DLQI) A simple practical measure for routine clinical use clinical and experimental Dermatology volume 1994; 19(3):210-216. https://doi.org/10.1111/j.1365-2230.1994.tb01167.x

29. Abdel-Hafez K, Mahran AM, Hofny ER, Mohammed KA, Darweesh AM, Aal AA. The impact of acne vulgaris on the quality of life and psychological status in patient from upper Egypt. Int J Dermatol. 2009; 48:280-5. https://doi.org/10.1111/j.1365-4632.2009.03838.x

30. Gupta MA, Gupta AK. Psychiatric and psychological co-morbidity in patients with dermatologic disorders: epidemiology and management. Am J Clin Dermatol.2003; 4:833-42. https://doi.org/10.2165/00128071-200304120-00003

31. Ilgen E, Derya A. There is no correlation between acne severity and AQOLS/DLQI scores. J Dermatol. 2005; 32:705-10. https://doi.org/10.1111/j.1346-8138.2005.tb00829.x

32. Girman CJ, Hartmaier S, Thiboutot D, Johnson J, Barber B, DeMuro-Mercon C, et al. Evaluating health related quality of ife in patients with facial acne: development of a self administered questionnaire for clinical trials. Qual Life Res. 1996; 5:131-8. https://doi.org/10.1007/BF00540020

33. Niemeier V, Kupfer J, Demmelbauer-Ebner M, Stangier U,Effndy I, Gieler U. Coping with acne vulgaris. Evaluation of the Chronic Skin Disorder Questionnaire with acne. Dermatology. 1998; 196:108-15. https://doi.org/10.1159/000017842

34. Salek MS, Khan GK, Finlay AY. Questionnaires techniques in assessing acne handicap: reliability and validity study. Qual Life Res. 1996; 5:131-8. https://doi.org/10.1007/BF00435978

35. Law MP, Chuh AA, Lee A, Molinary N.Acne prevalence and beyond: acne disability and its predictive factors among Chinese late adolescent in hong kong.clin Exp dermatol 2010; 35(1):16-21. https://doi.org/10.1111/j.1365-2230.2009.03340.x

36. Kokandi A, Evaluation of acne quality of life and clinical severity in acne female adults. Dermatology research practice; doi 10.1155/2010/410809 (2010). https://doi.org/10.1155/2010/410809