Quality of life
Issues of QoL are rarely discussed among Asian communities. It is also not a priority among clinicians in most Asian countries, particularly those countries with lower socioeconomic status. Asian populations are generally more stoic and will not readily discuss their psychological and mental wellbeing with others. In certain communities in Asia, it is considered rude to openly discuss personal problems, especially when related to psychological, mental and sexual wellbeing. Japanese and natives of Borneo are particularly stoic in this regard19.
There are a number tools to measure the impact of acne on QoL. These tools generally comprise a series of questions to measure social and psychological wellbeing. These questionnaires can be either a general tool, dermatology-specific, or acne-specific tool. The majority of studies used the dermatology-specific and acne-specific tools. The most common dermatology-specific tool used is the Dermatology Life Quality Index (DLQI), and the most common acne-specific tool is the Cardiff Acne Disability Index (CADI)20, 21.
There is a scarcity of studies in Asia related to the QoL of acne patients. Some studies were carried out in the community, concentrating on QoL among school children and adolescents. Others were carried out among patients of dermatology and aesthetic clinics, concentrating on QoL among acne sufferers who actively seek medical treatment.
Dermatology Life Quality Index
Studies using general dermatology QoL tools were mainly carried out in dermatology and aesthetic clinics using the DLQI. This tool comprises 10 questions measuring six domains: symptoms and feelings; daily activities; leisure; work and school; personal relationships; and treatment20. The minimum score is 0 and maximum is 30. A score of 0–1 signifies no effect at all on the patient’s life; 2–5, a small effect on the patient’s life; 6–10, a moderate effect; 11–20, significant effect; and 21–30, extremely great effect on patient’s life.
The author has conducted and published a study determining the QoL among patients with acne in Sarawak, Malaysia11. This study involved 200 patients with acne aged 16 years and over of age from three dermatology clinics in Sarawak. The mean DLQI score was 4.1. This translates to a mild impairment on QoL. Similarly, in Japan the mean DLQI score for patients attending dermatology clinics was 4.022. In comparison, a study carried out in Iran noted that the mean DLQI was 6.4, which translates to moderate impairment on QoL among Iranian patients attending skin clinics in Kerman city23. This is similarly noted in an urban Indian study12.
When a comparison is made between these studies and those carried out in Western populations, it was noted that QoL impairment among Asian acne patients was much lower. Studies in European countries showed that the majority of patients with acne attending dermatology clinics have moderate to severe QoL impairment. The mean DLQI was between 7.0 and 17.713, 24, 25.
[pull_quote align=”left” ]When analysis was carried out to determine the relationship between quality of life impairment and acne severity, all the studies failed to show a direct correlation[/pull_quote]
In the author’s study, it was found that the most severe impairment was seen in the symptoms and feelings domain of the DLQI11. The majority of patients in that study felt embarrassed and self-conscious about their acne. This was worsened by the fact that acne appears on the face and is therefore highly visible. The least affected domain in the DLQI was the relationship domain. This is expected as Asians are less likely to reveal their sexual problems to others.
When analysis was carried out to determine the relationship between QoL impairment and acne severity, all the studies failed to show a direct correlation11, 23. The author’s study found a positive correlation between DLQI and mild acne, but it became insignificant once it was more severe11. The acne severity in that study was assessed using the Global Acne Grading System (GAGS). An Iranian study also found no correlation between QoL and acne severity. This emphasises that QoL impairment is independent of acne severity assessed by the treating physician, but most likely dependent on the patients’ perception of their acne and coping mechanisms with regard to their condition. Patients with good coping mechanisms and high acceptance of their condition will experience only mild impairment on QoL.
Cardiff Acne Disability Index
The CADI is one of the most popular acne-specific QoL tools used for research in Asia. This validated questionnaire contains fuve questions21, with a maximum score of 15 and minimum of 0. A score of 0–5 translates to low disability with regard to QoL; 6–10, moderate disability; and 11–15, high disability. Few Asian-specific studies have focused on the community, while others are carried out in the dermatology and aesthetic clinic setting.
A community study among late adolescents in Hong Kong, China, revealed a mean CADI of 2.64. This translates to low impairment on QoL. Another community survey carried out among school-aged adolescents in Malaysia also showed a low impairment of QoL, with a mean CADI of 46. However, when the studies are carried out in the dermatology clinic setting, the impairment was translated as moderate. The author has conducted and published a study among acne patients attending a dermatology clinic in Sarawak, Malaysia11. This study involved 173 patients aged 12 years and over, and using the CADI. It was found that the mean CADI among multi-ethnic patients was 5.1. Similarly, an Iranian study also showed a mean CADI of 5.910, 23. This difference between community surveys and dermatology clinic surveys might be related to the perception and acceptability of patients towards their condition. Those presenting to dermatology clinics are usually more psychologically affected by their condition. They are less likely to accept their condition and therefore have a greater QoL impairment.
Interestingly, the mean CADI score among Asians in the community setting is not dissimilar to that of European patients. The mean CADI scores among adolescents in Europe range between 1.7 and 3.626, 27. In the dermatology clinic setting, the mean CADI was also almost similar to that seen among Europeans. In a French study, the mean CADI was between 5.3 and 5.628. This denotes that QoL impairment as a result of acne among Asians and Europeans are not dissimilar. Asians also suffer psychologically owing to acne.
When an analysis to determine the relationship of CADI and acne severity was carried out, it was noted that all the studies failed to show a direct relationship regardless of whether the studies were done in the community or dermatology clinics. Again, this reiterates the importance of patients’ perception and acceptance of their condition. In a Korean study, it was found that the degree of stress and self-image impairment was related to the subjective severity, rather than the objective severity5.
