Assessment of Negative Emotional State in Patients with Acne. Vulgaris: A Study on the Emotional Impact of Acne

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1 Original Article 22 Copyright University of Medicine, Tirana AJMHS 2014; Vol. 2: Assessment of Negative Emotional State in Patients with Acne Vulgaris: A Study on the Emotional Impact of Acne Brizida Refatllari 1, Admir Nake 1, Loreta Kuneshka 2, Albana Lufi 3, Ferdinand Canaj 4 1 Faculty of Technical Medical Sciences, University of Medicine, Tirana 2 Faculty of Medicine, University of Medicine, Tirana 3 Military Hospital Tirana, Albania 4 University of Sports, Tirana, Albania Abstract Background: Acne vulgaris is a common skin disease whose influence on body image is believed to be an important cause of psychological problems in patients with this disease. Aims: The aim of this study is to compare the frequency of anxiety and depression symptoms between patients with acne vulgaris and healthy individuals and to evaluate the levels of these symptoms in relation to the severity of acne as well as patient's age and sex. Study design: Cross-sectional study. Methods: Ninety-seven patients with acne vulgaris and 88 healthy individuals (without acne) of both sexes, aged years were enrolled in the study from December 2011 to January Depression Anxiety Stress Scale (DASS) was used to assess anxiety and depression symptoms in both groups (patient and control group). Results: Anxiety symptoms were present in 72.2 % of patients and 46 % of controls with a significant difference between the two groups (P<0.05). Depression symptoms were present in 46.8 % of patients and 35.9 % of controls, but the difference was not statistically significant (P >0.05). The level of anxiety and depression symptoms was not significant in relation to severity of disease, sex and age of patients (P>0.05). Conclusions: There is a strong correlation of acne vulgaris with anxiety symptoms. Symptoms of depression in acne patients were not significantly more frequent compared to the control group. The level of anxiety and depression symptoms in patients with acne was not related to the severity of acne, sex and age of patients. Key-words: acne vulgaris, anxiety, depression, symptoms Address for correspondence: Brizida Refatllari, Faculty of Technical Medical Sciences, University of Medicine, Tirana, Tirana, Albania. fbrizida@yahoo.com

2 Refatllari B. et al. Acne Vulgaris 23 INTRODUCTION Acne vulgaris is a skin disease that involves the oil glands at the base of hair follicles. It commonly occurs during puberty when the sebaceous glands come to life as the glands are stimulated by male hormones produced by the adrenal glands of both males and females. Although is it more common during adolescence, a considerable number of those 20 to 40-years-old develop this condition as well. Four primary factors contribute to the development of acne lesions: abnormal desquamation of keratinocytes within the pilosebaceous unit, increased sebum production under the influence of androgens, proliferation of Propionibacterium acnes and inflammation. Skin lesions of acne vulgaris consist of comedones (non-inflammatory lesions), papules, pustules, nodules, cysts, and scars. The lesions of acne occur predominantly on the face and to a lesser extent on the back, chest and upper arms. In younger patients, it mainly affects the face, while in the middle-aged the back is the principal site. Although some consider acne to be just a cosmetic problem, it has significant emotional and psychological effects. Acne patients can experience the negative emotional state of depression, anxiety and stress affecting the quality of their lives (1-5). Adolescents are at the highest risk for mental disturbances from acne. Their individual and social perception will lead to a sense of being tagged that may be followed by depression, anxiety, stress, low self-esteem, fear and guilt. Physical and emotional upheavals that naturally occur at this time of life, can magnify the consequences of acne lesions. Adults who suffer from acne, especially women, may experience a resurgence or new onset acne vulgaris and they also can develop psychiatric and psychological complications. According to a Turkish study, patients with acne were at an increased risk for anxiety and depression compared to the normal population, irrespective of the degree of acne severity (6). Acne patients also report greater levels of anxiety and depression than other dermatology patients and other medical populations. In Kellet's et al. study on 34 patients with acne, depression and anxiety scores in these patients were higher than in those with psoriasis and cancer (1). Considerable clinical depression and anxiety were present in 18 % and 44 % of the patients, respectively. Due to different studies showing the relationship of acne with psychological symptoms, we decided to assess the frequency of anxiety and depression symptoms in acne patients in our country and evaluate the level of these symptoms in relation to severity of acne, sex and age of patients. MATERIAL AND METHODS This cross-sectional study included 97 patients (64 females and 33 males) with acne vulgaris and 88 persons (58 females and 30 males)

3 24 Refatllari B. et al. Acne Vulgaris without acne enrolled from December 2011 to January Adults with other chronic dermatoses and other medical diseases that can lead to symptoms of depression and anxiety were excluded from the study population. The institutional ethical committee approved the study design and informed consent was obtained from all patients and controls. Both patients and controls were divided into two groups according to age: years old and years old. Patients were divided into three groups according to the severity of acne vulgaris that was rated according to a classification developed by Lehmann et al. (7) based on the number and type of lesions. Lesions included non-inflammatory open (blackheads) and closed (whiteheads) comedones, as well as inflammatory papules, pustules, and nodules (8). The severity of acne vulgaris according to Lehmann was graded as mild (<20 comedones or <15 inflammatory lesions or total number of lesions <30), moderate ( comedones or inflammatory lesions or total number of lesions ) and severe acne (> 5 nodules or > 50 inflammatory lesions or total number of lesions >125). The Depression Anxiety Stress Scale (DASS) questionnaire was used to assess the anxiety and depression symptoms in patients and controls. DASS is a 42-item self-administered questionnaire designed to measure the magnitude of three negative emotional states: depression, anxiety and stress (9). In our study, we referred to the anxiety and depression subscales. The anxiety subscale assesses autonomic arousal, skeletal muscle effects, situational anxiety and subjective experience of anxious affect. The depression subscale assesses dysphoria, hopelessness, devaluation of life, self- deprecation, lack of interest/ involvement, anhedonia and inertia. The DASS questionnaire was completed by both groups and both anxiety and depression scores were calculated. Based on the total points, the respondents were divided into five groups regarding their degree of anxiety and depressive symptoms. The degrees of anxiety symptoms were normal (0-7), mild (8-9), moderate (10-14), severe (15-19) and extremely severe (over 20). The degrees of depression symptoms were normal (0-9), mild (10-13), moderate (14-20), severe (21-27) and extremely severe (over 28). Chi-square test and Kendall's tau-b coefficient were used for statistical analysis. Categorical variables are shown as frequencies and percentages. P-values below 0.05 were considered statistically significant. All statistical analyses were performed using SPSS version RESULTS Among patients with acne vulgaris, 64 (59.8 %) were females and 59 (60.8 %) patients were years old. The control group included 88 persons with 65.9 % females 51 (57.9 %) were years old. There was no significant

4 Refatllari B. et al. Acne Vulgaris 25 difference between the two groups (patients and controls) in regard to sex and age (P> 0.05). Anxiety was present in 70 (72.2 %) patients and 45 (46 %) controls with a significant difference between the two groups (P<0.05). Depression was present in 45 (46.8 %) patients and 31 (35.9 %) controls, but difference was not statistically significant (P>0.05). The comparisons of anxiety and depression frequencies between patients and controls are shown in Table patients in the younger age-group (18-25 years), forty two (71.2%) experienced anxiety symptoms and 31 (52.5%) suffered from depression symptoms, while in the those aged 26 to 35 years, anxiety symptoms were present in 28 (73.6%) and depression symptoms in 14 (37%) cases. Our findings did not show any significant difference in the frequency of symptoms between women and men and the two age- groups (P>0.05). Table 1. Comparisons of anxiety and depression of patients and control group Acne Patients n = 97 (%) Control Group n = 88 (%) P-value Anxiety Depression Normal (0-7) 27 (27.8) 47 (53.6) Present ( 8) 70 (72.2) 41 (46) Normal (0-9) 52 (53.2) 57 (64.1) Present ( 10) 45 (46.8) 31 (35.9) <0.05* NS *Chi-square test with significance at p<0.05 In patients with acne, out of 64 females, anxiety and depression symptoms were present in 49 (76.5%) and 31(48.4%) patients, respectively. While among the 33 males, 21 (63.6%) experienced anxiety and 14 (42.4%) depression symptoms. According to the age-group, among Table 2 describes the distribution of anxiety and depression symptoms in the acne group according to gender and age-group.

5 Original Article 22 Copyright University of Medicine, Tirana AJMHS 2014; Vol. 2: Table 2. Distribution of anxiety and depression symptoms in acne patients according to gender and age-group. Characteristics Sex Anxiety Symptoms Present Not present Depression Symptoms Present Not present Female 49 (76.56) 15 (23.44) 31 (48.4) 33 (51.6) Male 21 (21.76) 12 (36.4) 14 (42.4) 19 (57.6) Age group (71.2) 17 (28.8) 31 (52.5) 28 (47.5) (73.6) 10 (26.4) 14 (37) 24 (63.1) In the patients group, 26 (26.8 %) of them experienced a normal level of anxiety symptoms, 28 (28.9%) had a mild level, 23 (23.7 %) experienced a moderate level and 20 (20.6%) had a severe level, while 52 (53.6%) patients had a normal level of depression symptoms, 23 (23.7%) suffered from a mild level, 13 (13.4%) from a moderate level and 9 (9.3 %) from a severe level of depression symptoms. In the patients' group, 43 cases (44.3 %) had mild acne, 31 cases (32%) had moderate and 23 cases (23.7%) had severe acne. The levels of anxiety and depression symptoms according to the severity of acne are shown in tables 3 and 4. The severity of anxiety and depression symptoms did not show a linear relationship with the severity of acne vulgaris (p>0.05).

6 Refatllari B. et al. Acne Vulgaris 23 Table 3. The levels of anxiety symptoms according to the severity of acne The levels of anxiety symptoms Normal Mild Moderate Severe Total Mild 15 ( 15.5) 12 (12.4) 9 (9.3) 7 (7.2) 43 (44.3) Severity of acne Moderate 6 (6.2) 9 (9.3) 8 (8.2) 8 (8.2) 31 (32) Severe 5 (5.2) 7 (7.2) 6 (6.2) 5 (5.2) 23 (23.7) Total 26 (26.8) 28 (28.9) 23 (23.7) 20 (20.6) 97 (100) P > 0.05 Table 4. The levels of depression symptoms according to the severity of acne The levels of depression symptoms Normal Mild Moderate Severe Total Mild 28 (28.8) 10 (10.3) 3 (3.1) 2 (2.1) 43 (44.3) Severity of acne Moderate 15 (15.5) 7 (7.2) 6 (6.2) 3 (3.1) 31 (32) Severe 9 (9.3) 6 (6.2) 4 (4.1) 4 (4.1) 23 (23.7) Total 52 (53.6) 23 (23.7) 13 (13.4) 9 (9.3) 97 (100) P > 0.05

7 24 Refatllari B. et al. Acne Vulgaris DISCUSSION Acne has an association with low self-esteem, shame, difficulties in applying for a job, stress, anxiety and depression symptoms. Our study evaluated emotional disturbances of anxiety and depression in patients with acne vulgaris in comparison to healthy individuals. Anxiety symptoms were significantly higher in patients with acne than in the control group (P<0.05) suggesting that acne patients in our country are prone to develop these symptoms. Depression symptoms were more frequent in patients with acne than in the control group (46.8 % vs %), but the difference was not statistically significant (P>0.05). Similar studies were previously done by different authors and their findings have been diverse. The findings of our study are in agreement with Golchai et al (10) who observed a significant difference in anxiety prevalence between patients and controls with no significant difference in relation to depression. Oczan et al. reported an increased frequency of anxiety and depression among acne patients without any statistically significant difference (11). However, according to some other studies, patients with acne suffered from higher depression scores compared to the control group (12, 13). In some other studies, patients with acne have been reported to suffer from at least mild depressive symptoms (6, 14). The demographic characteristics of our patients' group showed that the majority of adult patients with acne were females. However, there was no significant difference on anxiety and depression between females and males. In contrast to our study, Kellet et al. (1) reported a higher frequency of anxiety and depression among male patients with acne, while several other studies have reported that the frequency of these symptoms was higher in women (15, 16). Similar to our study, some studies have shown that the severity of anxiety and depression was not related to the patient s sex (6, 17). In our study, the symptoms of anxiety and depression were not significantly related to the patient s age. This is in contrast to results of some previous studies where young age is particularly vulnerable to anxiety and depression (17,18 ), but according to Golchai et al. (10) there was no significant difference in incidence of anxiety and depression between the two groups of those 20 and > 20 years old. The findings of this study showed that sex and age were not important indicators of the psychological status in acne patients. Our study did not show any relationship between severity of acne and levels of anxiety and depression symptoms. This means that the severity of acne does not play a significant role in predicting the level of depression and anxiety symptoms in patients with acne vulgaris. Niemeyer et al. (19) found that even though acne caused emotional stress and psychosocial problems, there was no relationship between these factors and the severity of acne. Our results were similar to results of some previous

8 Refatllari B. et al. Acne Vulgaris 25 studies (6, 15), while also different from some other studies that found a positive relationship between the severity of acne and that of anxiety and depression (1, 20, 21). CONCLUSION There is a strong correlation of acne vulgaris with anxiety symptoms while symptoms of depression in acne patients were not significantly more frequent than in controls. We found no significant association correlation between symptoms of anxiety and depression and the severity of acne as well as the sex and age of patients. Acknowledgments: Not available Conflict of Interest disclosure: Not available REFERENCES 1. Kellett SC, Gawkrodger DJ. The psychological and emotional impact of acne and the effect of treatment with isotretinoin. Br J Dermatol 1999;140: Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol 1998;139: Cotterill JA, Cunliffe WJ. Suicide in dermatological patients. Br J Dermatol 1997; 137: Koo JY, Smith LL. Psychologic Aspects of Acne. Ped Dermatol 1991; 8: Van der Meeren, Van der Schaar WW, Van der Hub CM. The psychological impact of severe acne Cutis 1985; 36: Yazici K, Baz K, Yazici AE, Köktürk A, Tot S, Demirseren D, et al. Disease-specific quality of life is associated with anxiety and depression in patients with acne. J Eur Acad Dermatol Venereol 2004; 18(4): Lehmann HP, Andrews JS, Robinson KA, Holloway VL, Goodman SN. Management of acne. Evid Rep Technol Assess 2001; 21(17): Davis EC, Callender VD. A review of acne in ethnic skin: pathogenesis, clinical manifestations, and management strategies. J Clin Aesthet Dermatol 2010;3(4): Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. (2nd Ed) Sydney: Psychology Foundation Golchai J, Khani SH, Heidarzadeh A, Eshkevari SS, Alizade N, Eftekhari H. Comparison of anxiety and depression in patients with acne vulgaris and healthy individuals. Indian J Dermatol 2010;55: Ozcan Y, Ozcan H, Unal S. Personality Characteristics in Patients with Acne Vulgaris. Klinik Psikiatri 2000;3: Öztürk A, Deveci E, Bağcioğlu E, Atalay F, Serdar Z. Anxiety, depression, social phobia, and quality of life in Turkish patients with acne and their relationships with the severity of acne. Turk J Med Sci. 2013;43: Ozturk P, Orhan FO, Dokur N, Ozer A. Assessment of Temperament and Character profile with Anxiety and Depression in Patients with Acne. Balkan Med J 2013; 30: Ng CH, Tam MM, Celi E, Tate B, Schweitzer I. Prospective study of depressive symptoms and quality of life in acne vulgaris patients treated with isotretinoin compared to antibiotic and topical therapy. Australasian J Dermatol. 2002;43:

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