U p to 85% of adolescents develop acne — a time in many people’s lives that is already difficult. You probably have many patients unhappy about the significant scarring or dyspigmentation caused by their acne.

But what about the psychosocial effects of acne on your patients? Studies show that many of our acne patients are suffering from depression and poor self-esteem, which are harder to detect than the physical manifestations of their acne. That’s why early evaluation and treatment of acne, along with appropriate follow-up and adjustments in therapy, are extremely important in achieving successful control of acne and enhancing quality-of-life for your patients. Ask patients questions about how they’re feeling and observe their behaviors during examinations to help determine what kind of psychosocial effects their condition is having on them.

Challenges We Face
Unfortunately, professional treatment is often delayed because of:
• use of over-the-counter (OTC) products that may not adequately control acne.

• disinterested parents who believe that acne is “normal in kids” and will resolve.

• Parent’s concern regarding treatment-related costs (doctor visits, medications, etc.).

• inadequate education regarding unsubstantiated “acne myths” such as the effects of diet (eating chocolate) and hygiene (frequently washing, using abrasive cleansers). In one U.S. survey of 178 acne patients and their relatives, 32% believed dietary factors (especially chocolate) exacerbated acne and 62.5% believed dirt was the cause of the dark color of “blackheads.”

We need to educate patients and parents about the importance of early treatment for acne so patients can be helped with the physical and mental effects of the condition.

Psychosocial Impact of Acne Vulgaris
Several studies have demonstrated acne vulgaris’s significant negative impact on quality of life. Although most patients with acne don’t have severe inherent personality disorders, a majority of patients do suffer from major psychosocial effects of acne including anxiety, depression, frustration, anger, preoccupation with acne, embarrassment, reduced self-esteem, decreased confidence and social withdrawal. (See “Quality of Life Factors in Acne Vulgaris,” on page 42.) Interference with social relationships, decreased participation in social activities and negative impact on employment have also been described. A survey of 625 patients aged 18 to 30 years demonstrated a 76% higher unemployment rate among males (16.2% versus 9.2% of controls) and a 64% higher rate among females (14.3% versus 8.7% of controls).

More severe psychological abnormalities may be present in isolated cases, including obsessive-compulsive behavior related to perceived appearance, body dysmorphic disorder, habitual facial excoriation (acne excoriee), eating disorders (such as bulimia nervosa), delusional syndromes and suicidal thoughts. Mild to moderate (non-cystic) facial acne has been reported as second only to severe psoriasis in prevalence of associated clinical depression. In addition, active suicidal ideation was higher among acne patients (5.6% to 7.2%) than among the general medical population (2.4% to 3.3%).

In some cases, as the treating physician, you may not recognize the extent of psychosocial impact. For example, mild acne may be associated with significant depression or anxiety. Another contributing factor is the characteristic difference between physicians and patients in their “global assessments” of improvement, reported in studies evaluating the efficacy of various therapies. In many cases, patients don’t perceive as great a degree of improvement as you may see as the clinical investigator. Physicians grade the actual response based on monitoring lesion count reductions over time. However, the perspective of many patients is that they still see some visible acne lesions and they want “the acne to be gone.”

Emotional Impact of Chronic Disease
The phenomenon of developing a “career of patienthood” early in life has been described in the literature in relationship to acne. Physical presence of acne, psychosocial factors, time intrusion factors and financial burden are significant for patients, and in many cases for other family members. As the doctor, you must consider these factors, especially since treatment of a common disorder such as acne may be perceived as less interesting or challenging. Patients will detect the attitude of their physician who exhibits a “matter-of-fact” demeanor and a perfunctory approach to patient management. You and your staff are major components of the “support system” of acne patients.

Effectively managing acne usually requires long-term physician visits, so patients must believe their physician cares about them and their disease. Unfortunately, not all initial physician encounters are perceived as favorable by patients. One survey of 900 acne patients demonstrated that approximately 25% believed their primary physician wasn’t interested in or sympathetic to their acne. Less than 20% of those seeking assistance consulted their primary physician about their acne. Many believed nothing could be done, a perception often based on previously inadequate treatment (including heavily advertised OTC products).

Patient Support System
For all these reasons, developing a support system is essential for acne patients. The psychological impact of acne on patients depends at least partially on the perceptions and attitudes of those closest to them. Members of this “inner circle” of intimates, usually family members, may either assist or detract from a patient’s abilities to adjust to his disease.

A parent who focuses too heavily on the presence of his child’s acne may magnify the perception of the disease, giving the patient the impression that the entire world around him is also focused on his acne and appearance. Parents who express rational concern and support, without allowing their child to become manipulative, provide an environment conducive to better psychological adjustment to acne. Adult patients who have accepting spouses or partners report easier psychological adjustment and a better overall sense of well-being.

Impact and Selection of Acne Therapy
In addition to psychological support, patients need clinical support. Effective acne therapy has been shown to significantly diminish the negative psychological and social impact inflicted by acne. Patient assessments of psychosocial factors such as social interaction, overall mental health, emotional status, self-esteem and energy level correspond with variations in disease severity. Continued improvement in patient-assessed outcomes and quality of life has been correlated with decreased acne severity due to acne treatment, with progressive improvement reported over 4 to 12 months.

The most important factors correlating with success of acne therapy are:
• avoiding irritation
• complying with therapy
• adequate duration of consistent use.

Informing patients regarding a reasonable response to treatment and reasons for follow-up evaluation are vital. The success of therapy is dependent on patient compliance. Initial response to therapy and response to adjustments in treatment generally occur over a period of 6 to 8 weeks.

In adolescent patients, early initiation and maintenance of comedolytic therapy is important since multiple comedonal lesions are usually present. Topical retinoid therapy is valuable in enhancing the response to other topical and systemic agents. The comedolytic effect of retinoid therapy appears to alter the follicular “microclimate,” allowing other agents to achieve enhanced benefit. Appropriate use of topical and/or oral agents in combination with topical retinoid therapy completes the treatment protocol.
Of course, you’ll need to choose the best vehicle for these topical agents depending upon your patient’s skin type (dry, oily, sensitive, etc.) and vehicle “texture” preference.

Although your patient may not achieve peak benefit from therapy for 3 to 4 months, significant clinical improvement may be apparent within the first 2 to 6 weeks. As comedonal lesions “loosen” from therapy, especially with topical retinoid agents, comedone extraction expedites visible improvement in overall appearance.

Some physicians don’t fully appreciate the value of topical retinoids, when used alone or in combination with other therapies (benzoyl peroxide, antibiotics), in reducing inflammatory acne lesions. It’s widely accepted that the primary lesion in the pathogenesis of acne is the microcomedone. As dermatologists, we’ve long recognized that topical retinoids [tretinoin (Avita, Renova, Retin-A); adapalene (Differin); tazarotene (Tazorac)] are effective comedolytic agents.

The “disconnect” occurs when the clinician treats a patient with predominantly inflammatory acne and loses track of the concept that inflammatory acne lesions once began as microcomedones, and may only sometimes pass through a clinically evident closed comedonal phase. Direct anti-inflammatory activity caused by a variety of mechanisms and pathways has also been reported with topical retinoids. The presence of erythema related to inflammatory acne may dissuade some clinicians from prescribing a topical retinoid because of a concern regarding irritation associated with topical retinoid use in some patients.

All three of the available topical retinoids approved for acne have been shown in several studies to reduce development of both comedonal and inflammatory lesions. For example:

• adapalene 0.1% gel and tretinoin 0.05% cream produced comparable reductions in both non-inflammatory and inflammatory acne lesions during a 10-week trial using once daily application (n=384); the median percentage reduction in non-inflammatory lesion counts exceeded 50% after 10 weeks and inflammatory lesion counts decreased approximately 25% at 6 weeks and 40% at 10 weeks for both agents.

• tazarotene 0.1% cream applied once daily was shown in two 12-week trials (n=424) to produce a median lesion count reduction ranging between 40% to 50 % for both non-inflammatory and inflammatory lesions.

These results support the paradigm that topical retinoid use is an important component of initial acne therapy and a significant part of the foundation for long term therapeutic success (maintenance therapy).

Topical retinoids may be effectively used in combination with other agents for acne treatment, including topical preparations and oral antibiotics. Studies have demonstrated “compounded efficacy” for acne when a topical retinoid is used in combination with either benzoyl peroxide (cleanser or gel) (Triaz, Benzac, Brevoxyl, Clinac BPO) or a topical antibiotic, like clindamycin (Cleocin, Clindagel) or combination products (Benzaclin, Duac). Benzoyl peroxide has also proven effective in patients undergoing antibiotic therapy for acne, significantly reducing the proliferation and emergence of antibiotic-resistant Propionibacterium acnes strains — a factor that may impact therapeutic efficacy in at least some patients. Some effective topicals that can help reduce both inflammatory and non-inflammatory acne lesions include sulfacetamide 10%-sulfur 5% (Plexion, Sulfacet-R) and azelaic acid (Azelex, Finevin).

Caring for the Whole Patient
It’s important to consider both the physical and psychosocial affects of acne vulgaris. Both must be addressed in order to provide a full array of care for our acne patients.