J Clin Aesthet Dermatol. 2025;18(3):71–73.
by Henriette De La Garza, MD; Nicole Trepanowski, MD; Rene Flores, MD, MPH; Poom Visutjindaporn, MD, MSc; Nicole Patzelt, MD; and Neelam A. Vashi, MD
Drs. De La Garza, Trepanowski, Visutjindaporn, Patzelt, and Vashi are with the Department of Dermatology at the Boston University School of Medicine in Boston, Massachusetts. Additionally, Dr. Vashi is with the Dermatology Institute of Boston in Boston, Massachusetts. Dr. De La Garza is also with the Department of Internal Medicine at Lahey Hospital and Medical Center in Burlington, Massachusetts. Dr. Flores is with the Department of Surgery at Massachusetts General Hospital in Boston, Massachusetts.
FUNDING: No funding was provided for this article.
DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.
ABSTRACT: Objective: We sought to evaluate the impact of the presence of acne scarring in patients with acne vulgaris on quality of life as assessed by the Dermatology Life Quality Index (DLQI) and the Cardiff Acne Disability Index (CADI); disease severity using the Investigator’s Global Assessment of Acne (IGA); and health utility measures including willingness-to-pay, time trade-off, time spent on concealment, and percent of income willing to exchange for resolution of disease. Methods: We conducted a cross-sectional, single-institution survey. Results: In total, 94 patients with acne vulgaris participated, of which 53.2 percent had acne scarring and 46.8 percent did not. The presence of acne scarring was associated with higher DLQI, CADI, and IGA scores. Utility measures including willingness-to-pay, time trade-off, concealment time, and percent of income willing to exchange for resolution of disease were similar for participants with and without scarring. For participants with and without scarring, a greater impairment of quality of life as assessed by the DLQI was positively correlated with WTP25, percent of monthly income, IGA, and the CADI. Limitations: As the study design was single-site and cross-sectional, and therefore results may not be generalizable. Conclusion: The presence of acne scarring significantly impacts quality of life. A greater impairment of quality of life in patients with acne vulgaris correlates positively with severity of acne and some measures of health economics. Interventions to minimize or prevent acne scarring may reduce psychosocial burden of disease.
Keywords: Acne, acne scar, scarring, acne vulgaris, quality of life, dermatology life quality index, willingness to pay, time trade-off, the Cardiff Acne Disability Index, Investigator’s Global Assessment, DLQI, WTP, TTO, CADI, IGA, disease burden, health utility measures
Introduction
Acne vulgaris is the most common dermatologic condition in the United States and may lead to permanent scarring in up to 95 percent of individuals affected.1 Maladaptive thought processes, negative body image, low self-esteem, social stigmatization, and avoidant social behaviors that develop during active acne are prolonged in patients with acne scarring.1 Compared to patients with acne vulgaris alone, patients with acne scarring more frequently feel regret, self-blame, and hopelessness.1 Such feelings of embarrassment, self-consciousness, and poor self-esteem can lead to psychosocial disability.2 The aim of this study was to evaluate the impact of acne scarring on quality of life and assess willingness-to-pay (WTP), time trade-off (TTO), and time spent on concealment as methods to quantify burden of disease.
Methods
This single-site, cross-sectional study included eligible participants 18 years of age or older with acne vulgaris presenting to a dermatology clinic from February through December 2021. A survey questionnaire was offered in English and Spanish and collected demographic characteristics and utility measures including: WTP in a month for 50-percent (WTP50) and 25-percent (WTP25) reduction of skin disease; TTO in hours per day for complete resolution of skin disease; daily time spent concealing the disease (eg, makeup); percentage of monthly income willing to exchange for complete resolution of skin disease; and quality of life as assessed by the Dermatology Life Quality Index (DLQI) and the Cardiff Acne Disability Index (CADI).3 A board-certified dermatologist estimated disease severity using the Investigator’s Global Assessment of Acne (IGA).3 The study was approved by the Boston University Institutional Review Board, and informed consent was obtained from all participants.
Results
A total of 121 individuals completed the survey out of 153 approached (response rate=79%). Participants with a diagnosis of rosacea (n=27) were excluded to minimize confounding. Participants included those diagnosed with acne vulgaris with (53.2%) and without (46.8%) acne scarring. Demographic characteristics were similar between groups (Table 1). Participants with acne scarring had higher mean DLQI scores (11.9 vs. 6.4, P<0.001), higher CADI scores (8.1 vs. 5.3; P<0.001), and higher IGA scores (3.0 vs. 2.1; P<0.001) than participants without acne scarring (Table 2).
Within the last month, participants with acne scarring were more likely to feel aggression, frustration, or embarrassment from their acne compared to patients with acne but without acne scarring (96.0% vs. 72.7%; P=0.003, Table 3). Similarly, participants with acne scarring were more likely to report that their acne interfered to some degree with their daily social life, social events, or relationships in the last month than participants without acne scarring (96.0% vs. 59.1%; P<0.001), with 24 percent of participants with acne scarring reporting a severe impairment in all activities. When queried on feelings about the appearance of their skin over the last month, 72.0 percent of participants with acne scarring were either “usually concerned” or “very depressed and miserable” compared to 45.5 percent of participants without acne scarring (P=0.006). Eighty-two percent of participants with acne scarring felt their acne is currently “a major problem” or “the worst it could possibly be” compared to 43.2 percent of those without acne scarring (P<0.001).
Utility measures, including WTP25, WTP50, TTO, concealment time, and percent of income willing to exchange for resolution of disease were similar between groups (Table 3). For participants with acne scarring, a greater impairment of quality of life as assessed by the DLQI was positively correlated with increased WTP25, percent of monthly income, IGA, and CADI (rs=0.299, P=0.04; rs=0.446, P=0.002; rs=0.426, P=0.002; and rs=0.828, P<0.001, respectively). For participants with acne scarring, quality of life as assessed by the DLQI did not correlate with WTP50, TTO, or concealment time. In contrast, for participants without acne scarring, quality of life was positively correlated with increased WTP25, WTP50, percent of monthly income, TTO, concealment time, IGA, and CADI (rs=0.498, P<0.001; rs=0.546, P<0.001; rs=0.350, P=0.03; rs=0.318, P=0.04; rs=0.640, P<0.001; rs=0.471, P=0.001; and rs=0.797, P<0.001; respectively).
Discussion
Our results highlight the negative impact of acne scarring on quality of life, as participants with acne scarring had higher scores on the DLQI, the CADI, and the IGA compared to those without scarring. When analyzing individual questions of the CADI, participants with acne scarring were more likely to report feeling aggression, frustration, or embarrassment in the last month, interference with social life, and “very depressed and miserable” than participants without scarring, suggesting a greater psychosocial impact in participants with acne scarring compared to those without. These results have been corroborated in other studies which similarly found higher DLQI and CADI scores in patients with acne scarring.4,5 In our study, quality of life as assessed by the DLQI was positively correlated with both the CADI and disease severity using the IGA, supporting that greater severity of disease leads to higher impact on quality of life. Underrepresentation in research, limited health literacy, lack of established guidelines and insurance coverage for treatment, and variable treatment success remain barriers for patients with acne scarring; however, interventions to minimize or prevent acne scarring may reduce psychosocial burden of disease supporting benefits of treatment.1
To the best of our knowledge, our study is the first to examine the impact of acne scarring on health utility measures including WTP, TTO, and concealment time using patients with acne vulgaris without scarring as a control. Interestingly, despite worse quality of life associated with acne scarring, WTP25, WTP50, TTO, concealment time, and percent of income willing to exchange for resolution of disease were similar between groups. These findings warrant further investigation. Notably, our study was conducted at the largest safety net hospital in New England with a high proportion of socioeconomic disadvantaged patients. WTP and percent of income willing to exchange for resolution of disease may not be accurate proxies of disease burden for these populations. Indeed, low income individuals are more likely to forgo non-emergency healthcare services and utilize trade-off thinking resulting in consistent consumption decisions.6 Despite this, for both patients with and without acne scarring, quality of life as assessed by the DLQI positively correlated with both WTP25 and percent of monthly income willing to exchange for resolution of disease. Further research delineating results by type of scarring (i.e. post-inflammatory hyperpigmentation, ice pick scars, box pick scars, keloids) and location of scarring (face, trunk) may provide further clarification.
Conclusion
Our results shed light on the psychosocial impact of acne scarring from the patient’s perspective. Acne scars exert a substantial negative impact on quality of life and psychosocial wellbeing. In our study, the presence of acne scarring in participants with acne vulgaris was associated with worse quality of life as measured by the DLQI and the CADI, and disease severity with the IGA. Similarly, our results support a greater psychosocial impact in participants with acne vulgaris with scarring compared to those without. Efforts to minimize acne scarring may reduce psychosocial burden of disease. Utility measures including willingness-to-pay, time trade-off, concealment time, and percent of income willing to exchange for resolution of disease were similar for participants with and without scarring; however, a greater impairment of quality of life as assessed by the DLQI was positively correlated with WTP25, percent of monthly income, IGA, and the CADI suggesting quality of life correlates with disease severity and some measures of health economics in patients with acne vulgaris. Limitations of our study include its cross-sectional, single-center design. Further research investigating the psychosocial impact of acne scarring by acne scarring subtype and location may provide useful information to better emotionally support our patients.
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- Hayashi N, Miyachi Y, Kawashima M. Prevalence of scars and “mini-scars”, and their impact on quality of life in Japanese patients with acne. J Dermatol. 2015;42(7):690–696.
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