Evaluation of the quality of life in adolescents with acne Procena kvaliteta života kod adolescenata sa aknama

Background/Aim. Acne is well recognized condition that adversely affects quality of life (QoL) of the patients. The aim of this study was to determine the self-reported prevalence of acne and its main characteristics in high school pupils, and to assess their QoL. Methods. The cross-sectional study conducted in May 2011 comprised 440 pupils from Serbia (281 from Belgrade and 159 from Užice). Participation in the study was voluntary and anonymous. Two questionnaires were administered: a short demographic questionnaire, and Children's Dermatology Life Quality Index (CDLQI). Internal consistency was assessed using the Cronbach’s alpha while item-total score correlations were assessed using Spearman's correlation analysis. Results. The majority of the study population (84.3%) were girls, and 15.7% were boys. The total mean age of the pupils was 16.48 ± 0.55 years. A total of 228 (51.8%) pupils self-reported their acne with significantly higher prevalence in Užice (73.6%) than in Belgrade (39.5%). The mean CDLQI score was 3.55 with the similar quality of life impairment in adolescents from the two cities. The mean Cronbach’s alpha was 0.83. There was a statistically significant positive correlation between the mean overall CDLQI score and CDLQI subscale scores that ranged from 0.401 to 0.841. Conclusion. Our study confirmed that acne is associated with impairment in QoL that is in accordance with previous studies performed on teenagers. The CDLQI is a reliable and valid measure, and can be used as a practical tool for measuring the impact of acne on patients’ QoL.


Introduction
Acne is a chronic inflammatory, multifactorial skin disorder of the pilosebaceous unit that usually occurs in adolescence affecting nearly all teenagers to some degree 1 .The clinical picture can vary significantly from mild comedonal acne to fulminant systemic disease.
It is well recognized that acne adversely affects quality of life (QoL), and that can leave physical and emotional scars that can persist throughout the life of the affected person 2 .Loney et al. 3 showed dermatological-related social anxiety of acne patients to be negatively associated with intention to participate in sport/exercise, self-esteem and health related QoL.
As there is not always a correlation between the severity of acne and its impact on QoL, it can be helpful for dermatologists to use either global or specific QoL measures to determine the psychological impact of acne on patients 4 .
Within the last few decades health-related QoL of patients has become an important factor of patient care, and several dermatologic and acne-specific measures have been created to assist in acne research, management, and care 5 .
The aim of this study was to determine the self-reported prevalence of acne and its main characteristics in high school pupils, and to assess their QoL.

Methods
The cross-sectional study conducted in May 2011 comprised 440 pupils from Serbia (281 from Belgrade and 159 from Užice).We used convenience sampling.Participation in the study was voluntary and anonymous.The informative consent in the written form was obtained from pupils' parents.The response rate was 74.7% (281/376) in Belgrade and 75.7% (159/210) in Užice.Two questionnaires were administered -a short questionnaire including questions about demographic and disease characteristics, and Children's Dermatology Life Quality Index (CDLQI).
CDLQI is a skin disease specific questionnaire that was used to assess acne-related QoL in pupils 6 .It is a one-page questionnaire comprising 10 questions covering all aspects of quality of life.The questions are graded from 0-3, with a possible maximum score of 30 with higher scores representing worse QoL.According to the instructions for use if two or more questions are left unanswered the questionnaire is not scored.Questions about symptoms, feelings, embarrass-ment, clothes, hobbies, daily activities at school and leisure time, as well as issues related to sleep, personal relationships and treatment were asked.A total of 199 out of 228 (87.3%) pupils with acne filled the questionnaire properly and were included in the analysis.We used the Serbian version of the CDLQI 7 .
All statistical analysis was performed using the Statistical Package for the Social Sciences, SPSS version 17.0 (SPSS Inc., Chicago, IL, USA).A two-tailed probability value of 0.05 or less was considered significant.The differences between variables were assessed by χ 2 or t-test.Internal consistency was assessed using the Cronbach's alpha while item-total score correlations were assessed using Spearman's correlation analysis.

Results
A total of 440 pupils from the two high medical schools in Serbia (one from Belgrade and another from Užice) participated in this study.Demographic characteristics of the pupils are presented in Table 1.
The majority of the study population (84.3%) were girls, and 15.7% were boys.The total mean age of the pupils was 16.48 ± 0.55 years, with significantly older pupils from Užice (p < 0.001).A total of 228 (51.8%) pupils selfreported acne with significantly higher prevalence in Užice than in Belgrade for the entire sample and for the females.
Disease characteristics of the high school pupils who reported acne and answered questions are presented in Table 2.
The difference between two cities was observed in acne duration and problems related to skin appearance.Acne duration less than 1 year had 51.4% of adolescents and 1 year more 48.6% with significantly longer duration among pupils from Belgrade compared to those from Užice.The most of adolescents had problems caused by skin appearance with significantly higher levels of concern among those from Belgrade than those from Užice.
The mean overall CDLQI score in acne self-reported pupils was 3.55 ± 4.14 with the similar quality of life impairment in adolescents from the two cities.
There was a statistically significant positive correlation between the mean overall CDLQI score and CDLQI subscale scores that ranged from 0.401 to 0.841 (Table 3).
The highest correlation with the mean overall CDLQI score was observed for subscales "symptoms and feelings" (0.841) and "leisure activities" (0.746) and the lowest correlation was observed for "sleep" (0.401).The value of the Cronbach's alpha for CDLQI was 0.83.
The vast majority (74.4%) of acne affected adolescents had CDLQI score < 5 as presented in Table 4, and even in 93% of pupils quality of life impairment was mild (CDLQI < 10).Only 3.5% of the pupils had CDLQI score > 15 with the maximum reported CDLQI score 24 (of possible 30) in one affected individual.

Discussion
Acne vulgaris is a common, chronic, inflammatory skin condition that affects nearly all adolescents to some degree 8 .Although acne is considered as a trivial skin disorder, it has great impact on psychologically fragile period of adolescence.The interaction of acne and psychosocial issues is complex and can elicit negative emotional reactions including depression, anxiety, helplessness and frustration that can lead to impaired functional status and decreased quality of life 2 .prevalence of acne in teenagers differs from study to study and ranges from 41.7% to 93.3% [9][10][11][12][13][14] .It could be explained by methodological differences (such as definition and grading of acne) and population characteristics.In our study 51.8% of the pupils self-reported acne what is in accordance with the findings of Smithard et al. 11 and Rigopulous at al. 9 .The regional difference (Belgrade vs. Užice) in acne prevalence, disease duration and levels of concern caused by skin appearance could perhaps be explained by the cultural differences.The appearance of the skin affects the  patients' overall body image 15 , and therefore they are prone to embarrassment and social withdrawal, depression, anxiety, anger, and even suicidal ideation 16,17 .
Acne has long been recognized to have a significant effect on the QoL of patients.However, no significant correlation between patients' and dermatologists' assessments of acne severity was observed 18,19 .Acne patients usually see their disease as more troubling than their physicians do.The use of standardized subjective QoL measures in routine clinical practice in conjunction with clinical assessment can provide additional information on QoL impairments.It is of great importance to recognize depressive symptoms in acne patients, which sometimes may be concealed or masked by aggression or disruptive behavior 20 and to evaluate the psychological impact of acne and its repercussion on QoL.
We used the CDLQI to evaluate the impact of acne on QoL in adolescents.Ten questions encompass different aspects of a child's life that could be affected by their skin disease, including physical symptoms, such as itching and sleep loss, as well as psychosocial questions regarding friendships, bullying, school performance, sports participation, and enjoyment of vacation.The total mean score of the CDLQI in our study was 3.6 which is somewhat lower in comparison with recently conducted Serbian study 14 , but twice higher than in Scottish study 10 .Relatively lower scores of CDLQI could possibly be explained by the nature of the population studied (population from the community with a predominantly mild form of acne).In addition, the fact that all the pupils completed questionnaires together in the same classroom with their classmates being able to read their answers, might prevent some of them to express their true emotions.
Although the overall mean score of CDLQI is rather low, our study confirms that acne is associated with impairment in QoL.
Internal consistency reliability (Cronbach's alpha = 0.83) and item-to-total correlation (Spearman's rho = 0.40 0.84), were found to be sufficient, indicating that the Serbian version of CDLQI is a reliable questionnaire with good consistency between the items.It provides information about aspects of acne treatment that could be of great assistance to dermatologists to provide effective clinical intervention which could be crucial for maintenance or restoration of psychological well-being of affected individuals.
The strength of our study was a large number of adolescents surveyed from the general population, thus excluding the possibility of referral bias and overestimation of psychometric morbidity with hospital-based data.Cross sectional type of study, however, may introduce biases associated with self-reporting, such as recall bias, and under or overreporting of information.

Conclusion
The present study confirmed that acne is associated with impairment in QoL that is in accordance with previous studies performed on teenagers.We did not find statistically significant difference in QoL between pupils from Belgrade and Užice.
Our results also demonstrated that the Serbian version of Children's CDLQI is a reliable and valid measure, a practical tool for measuring the impact of acne on patients' QoL.