Assessment of Body Image Disturbance, Self-Esteem and Quality of Life among Adolescents and Young Adults with Acne in a Tertiary Care Facility of India.

Background: Impact of acne on the psychological aspect among adolescents and young adults is poorly understood and many times goes unnoticeable. Aim: To assess body image disturbance, self-esteem, quality of life among adolescents and young adults with acne. Materials and
Methods: A cross sectional survey on 250 adolescents and young adults aged 13-25 years in Dermatology OPD of a tertiary care hospital, was performed. Severity of acne, body image disturbance, self-esteem, and quality of life were assessed using standardized tools like IGA scale, BIDQ, RSES, and TAQOL respectively.
Results: A majority of the participants, 163 (65%), were aged 20-25 years, in which 141 (56.4%) were male, 237 (94.8%) were unmarried, 192 (76.8%) were residing in urban area, 142 (56.8%) were graduate/post-graduate, 173 (69.2%) were students and 113 (45.2%) belonged to upper middle class of socio-economic status. More than half, 137 (54.8%), had a family history of acne, 228 (91.2%) had oily skin, 166 (67.4%) had normal nutritional status, 154 (61.6%) had moderate form of acne whereas 80 (32%) had severe acne. The mean BIDQ score was 3.05 (SD = 0.89); 169 (67.60%) had normal self-esteem and 174 (69.64%) had mild impairment in quality of life. Severity of acne had significant association with body image disturbance (P = 0.007) and quality of life (P = 0.001) but not related with self-esteem.
Conclusion: The results revealed body image disturbance and impaired quality of life among adolescents and young adults with acne which draws the attention of dermatologists towards unidentified psychological aspects of acne during treatment. However, the majority of them revealed normal self-esteem in the study. Copyright:

Introduction

Appearance is a priority and influences how we perceive ourselves and also how we are perceived by others. Skin has a great role in self-perception and social interaction.[1]

Acne is one of the most common skin problems among adolescents and young adults aged 13–25 years.[234] Factors like follicular hyperkeratinization, microbial colonization, with Propionibacterium acnes, sebum production, and complex inflammatory mechanisms play an important role in the development of acne.[5] It can be mild, moderate or severe depending upon the type and number of lesions. Most people believe that acne is caused by chocolate, fried foods, candies, anything else in usual diet, the result of constipation, a sign of sexual activity or the lack of it.[67]

Previous studies have shown the increasing burden of the disease worldwide.[891011] Although acne is not life-threatening, it is a leading cause for visits to a dermatologist and has potential to affect body image, self-esteem, and quality of life. Body image disturbance is the individual's dissatisfaction, dysfunction and distress related to their own body image. This type of disturbance has been reported among acne patients.[12] Self-esteem can be defined as the individual's confidence and satisfaction of self. Low self-esteem is being evident among acne patients.[1314] The impact of acne on social, emotional, and vocational aspects of quality of life has been highlighted in some of the studies. A number of studies have found depression, low self-esteem, social impairment, body dysmorphic disorder, personality disorders, as well as negative impact on personal relationships, sports activities, and employment opportunities in teens and young adults with acne.[13151617]. As per the literature review, the complex interplay of body image disturbance, self-esteem, and quality of life among acne patients and associated factors have not been discussed in Indian scenario. It is necessary to reveal the combined effect of these three psychosocial parameters for wholesome management of acne. Moreover, effective treatment of acne is accompanied by improvement in self-esteem, body image, social assertiveness, and self-confidence.[15] Thus, this study aims to assess body image disturbance, self-esteem, and quality of life changes in adolescents and young adults with acne, which gives insight into the impact of acne from a patient's perspective, and can also measure treatment success.

Materials and Methods

The descriptive study was conducted cross sectionally on 250 adolescents and young adults with acne (grade 1–5 on IGA scale), aged 13–25 years who visited Dermatology OPD of a tertiary care hospital at New Delhi, able to read or write Hindi/English, had no other co-morbidity and willing to participate, were enrolled during the period of July 2017 to December 2017. Ethical permission was obtained from institute ethics committee. Informed written consent was taken from the subjects above 18 years and parents/guardians for children below 18 years. Assent was taken from the subjects below 18 years. Socio-demographic profile (age, sex, marital, residency, education, occupation, and socio-economic status) and clinical profile (duration of acne, age of onset of acne, number of visits to doctor for acne, family history of acne, skin type, cleaning behavior, acne grade, BMI) of participants was obtained. Participants were assessed for acne severity on IGA scale, grade ranging from 0 to 5 (Grade 0 or 1 - “None to mild,” Grade 2 or 3 – “ Moderate acne,” Grade 4 or 5 – “Severe acne”) by the researcher under supervision of a dermatologist. The standardized tools to assess body image disturbance (BIDQ) in which scoring was done by calculating mean of seven items scaled from 1 to 5 (<2.5 mild disturbance, 2.5 to 3.5 moderate, >3.5 severe disturbance), self-esteem (RSES), which is a 10-item 4-point Likert scale ranging from strongly agree to strongly disagree. and acne quality of life (TAQOL), which is a 15-point questionnaire with scoring 0–45 (0 to 15 - Mild, 16 to 30 – Moderate, 31 to 45 – Severe), were translated and re-translated into Hindi, validated and administered through structured interview technique after taking permission from the respective authors.

Data collected were coded and summarized into a Microsoft Excel 2010 spreadsheet and analysis was done using SPSS version 16.0. Descriptive statistics such as frequencies, percentage and measures of central tendencies were used. In inferential statistics both parametric and non-parametric tests were used. Parametric tests such as the t-test and one-way ANOVA with multiple comparisons using bonferroni correction were used. Non-parametric tests such as Chi-square, Fisher's exact test (if any category had sample size ≤5), and Kruskal-Wallis equality-of-populations rank test with multiple comparisons using the dunn test if any category had sample size ≤5. At p < 0.05, it was considered as statistically significant.

Results

A total of 163 (65%) of the participants belonged to the age group 20–25 yrs. More than half, 141 (56.4%), were males, 237 (94.8%) were unmarried, 192 (76.8%) were residing in urban areas, 173 (69.2%) were students, and 113 (45.2%) belong to the upper middle class of socio- economic status [Table 1]. More than half, 137 (54.8%), were found to have a family history of acne, 228 (91.2%) had oily skin, and 166 (67.4%) had normal nutritional status [Table 1]. Majority, 154 (61.6%), of them were having moderate forms of acne [Figure 1]. The mean BIDQ score was 3.05 (SD = 0.89) which indicates moderate body image disturbance among subjects [Table 2]. Most of them, 168 (67.6%), had normal self-esteem [Figure 2] and 174 (70.0%) had mild impairment in acne quality of life [Figure 3]. The association of severity of acne, body image disturbance, self-esteem, quality of life, and selected socio-demographic and clinical variables were calculated as secondary objectives of the study. Severity of acne was significantly higher in male (p = 0.001) and rural (p = 0.011) subjects. Those with moderate form of acne had an earlier age of onset compared to those with mild form of acne (p = 0.022). With increase in severity of acne, the frequency of face washing/day was also found to be increasing significantly (p = 0.003). Table 3 depicts that participants with severe form of acne had significant increase body image disturbance (p = 0.007). No association was found between severity of acne and self-esteem. Moderate impairment in quality of life was significantly higher among participants with severe form of acne [Table 4]. The body image disturbance has statistically significant association with occupation (p = 0.012) and number of visits to doctor (r = 0.192, p = 0.002). Also the self-esteem is found to be related with sex, area of residence, and socio-economic status. The quality of life has statistically significant association with area of residence and number of visits to doctor (p = 0.010, p = 0.013).

Table 1

Socio- demographic clinical variables of participants n=250

Socio - demographic variables	Frequency (%)
Age (in years)
13-19	87 (34.8)
20-25	163 (65.2)
Sex
Male	141 (56.4)
Female	109 (43.6)
Marital
Married	13 (5.2)
Unmarried	237 (94.8)
Area of residency
Rural	58 (23.2)
Urban	192 (76.8)
Education
Up to secondary education	44 (17.6)
Senior secondary education	64 (25.6)
Graduate/post graduate (PG)	142 (56.8)
Occupation
Student	173 (69.2)
Private job/Govt job	51 (20.4)
Others	26 (10.4)
Socio-economic status (se-status)
Upper class (UC)	27 (10.8)
Upper middle class (UMC)	113 (45.2)
Lower middle class (LMC)	83 (33.2)
Upper lower class (ULC)	27 (10.8)
Clinical variables	Frequency (%)
Family history (father/mother/sibling)	137 (54.8)
Yes	113 (45.2)
No
Skin type
Oily	228 (91.2)
Dry	8 (3.2)
Normal	14 (5.6)
Nutrition (BMI)
Underweight (<18.5)	61 (24.4)
Normal (18.5-24.9)	166 (66.4)
Overweight (25-29.9)	23 (9.2)
Acne grade
1	17 (6.8)
2	60 (24.0)
3	92 (36.8)
4	46 (18.4)
5	37 (14.0)
Clinical variables	Mean±SD
Duration of acne (in years)	3.69±2.38
Age of onset in (in year)	16.90±3.10
Number of visits to Doctor (for acne)	2.18±2.47
Cleaning behaviour (frequency of face washing/day)	3.40±1.68
Duration of acne (in years)	3.69±2.38

Figure 1

Severity of acne

Table 2

Body image disturbance among adolescents and young adults with acne n=250

Variable	Minimum	Maximum	Median	Mean SD
BIDQ score	1.28	5	3.14	3.05±0.9

Figure 2

Self-esteem among adolescents and young adults with acne

Figure 3

Quality of life among adolescents and young adults with acne

Table 3

Association of severity of acne with body image disturbance n=250

Variables	Body image disturbance Mean±SD	P*
Severity of acneΩa
Mild	2.68±0.80	0.007*	#0.655
Moderate	2.96±0.87		∆0.037*
Severe	3.29±0.90		Ω 0.026*

*Significant at P<0.05, Ω = one way ANOVA, ªbonferroni. Post-hoc analysis: #=between mild and moderate group, Δ=between mild and severe group, Ω=between moderate and severe group

Table 4

Association of severity of acne with quality of life n=250

Variables	Quality of life Frequency (%)		P*
	Mild impairment	Moderate impairment
Severity of acneα
Mild	13 (81.2)	3 (18.8)	0.001*
Moderate	121 (78.6)	33 (21.4)
Severe	41 (51.2)	36 (45.0)

Significant at P<0.05, α = Chi-square (Fisher’s exact)

Discussion

Major findings of the study revealed that acne has an adverse effect on body image and quality of life of adolescents and young adult, which dermatologists should include in their treatment strategies to prevent psychological repercussions of acne.

Regarding severity of acne, males were having more severe (41.1%) form of acne as compared to females (20.1%, P = 0.001). With similar study population, Skroza Nevena et al. conclude the presence of severe form of acne among males.[18] Similar finding was shown in other studies.[115] It may be due to the role of androgens and other hormones in male. However, some researchers found no gender difference in terms of acne severity.[19]

In the present study, the BIDQ score was found to be 3.05 (SD = 0.89), which indicates prevalence of moderate body image disturbance among adolescents and young adults with acne. In line with this finding, many studies have proved the existence of body image disturbance and dissatisfaction among acne patients[202122] using different scales.

Majority of the researchers have found lower self-esteem among acne patients.[232425] But in this study, only 6.8% were having low self-esteem; majority (67.6%) had normal self-esteem. When compared to the present study results, Dilek unal[20] in a case controlled study in the age group 12-17 years presented that there was no significant difference in social anxiety levels and self-esteem between the study (with acne) and control groups.

Nair et al. (2015)[26] demonstrated that 75% of acne patients were having mild impairment in quality of life as assessed by TAQOL, which is in congruence with present study findings. Similarly, Durai and Nair (2015)[27] also reported low effect on quality of life with DLQI and CADI.

Al-Kubaisy et al. showed that acne occurred significantly in males and at younger age (p < 0.0001), which is similar to the present study findings.[28] In the present study, severity of acne was not associated (p = 0.05) with nutrition (BMI) and family history, similar results revealed by LaRosa et al.[29] and Sharma[5] whereas a number of studies[30] revealed the association of higher chance of having acne with maternal or paternal history of acne and consumption of chocolate (BMI), which might be because of difference in dietary pattern between India and European countries. The present study also revealed that severe form of acne was significantly higher in rural (48.3%) as compared to urban (27.1%), which may be due to the fact that those with severe form of acne only would come to a tertiary care hospital. However more exploration is required to establish this fact. Most of the Indian authors have talked about the prevalence of acne, but none has focused on acne prevalent in rural and urban. A few studies has considered other factors affecting acne severity like a systematic review on epidemiology of acne showing no relationship between acne severity and face washing per day which opposes the present study findings.[29]

The present study is supported by the findings of BP Raju[3132] and Sharma[5] that quality of life is significantly impaired in patients with severe acne vulgaris whereas Gupta et al.[33] reported no correlation between the severity of acne and an impaired quality of life. This can be explained as this study had a small sample size and less reliability on the self-reported quality of life. A study by Zulfiqar and Rana (2016)[34] revealed a significant positive correlation between severity of acne and appearance distress, which is congruent with the present study finding. Thus, it shows that with increase in severity of acne, impairment in body image also increases. Hence, the result draws attention towards providing psychological treatment for the acne patients.

In the present study, body image disturbance, self-esteem, and acne quality of life were assessed using standardized tools and structured interview techniques to gain in depth information. However, it was a single centric study, qualitative data was not analyzed and acne-specific self-esteem assessment tool was not used, which limits the generalizability of the study findings. Further qualitative data can be explored on myths, boons, and factors influencing the attitude of adolescents with acne towards approaching the health-care facility. Based on the study findings and literature review, it is recommended to provide screening for psychiatric comorbidities to adolescents and young adults with severe acne.

Thus, this study will provide a strong base to focus on improvement of body image, self- esteem, and quality of life in adolescents and young adults with acne as a part of management along with pharmacological therapy.

Conclusion

The study findings reveal that adolescents and young adults with acne have body image disturbance and impaired quality of life, which draw the attention of dermatologists to take care of the psychological aspect of acne during the treatment period. However, the majority of subjects in the study possess normal self-esteem.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.