Study analysis

The findings of dissimilar QoL impairment between Asians and Europeans using skin-specific dermatology tools such as the DLQI are not surprising. This is because some of the questions in DLQI are irrelevant in Asian communities, resulting in a lower total points score. However, using acne-specific QoL tools like CADI give a more accurate account to QoL impairment. Thus, it is not surprising to note an almost similar impairment across the board.

A study carried out in India using Skindex, a validated skin diseases QoL tool, and an open-ended interview revealed that acne causes high levels of emotional and social impairment29. This is particularly apparent with regard to feelings of physical discomfort and anger. In a Singaporean study, it was noted that more than half of the school-aged adolescents felt depressed, worried and frustrated with their acne3. Most also have poor self-esteem as a result. Similarly, a Korean study also showed psychosocial impairment in Korean adolescents owing to acne5. They had to cope with stress, depression, self-image problems, interpersonal relationship problems, and daily life disturbances. There is a direct relationship between these problems with the severity and duration of acne. Females had more severe psychosocial problems. Limited social activities and lower employment chances were also seen in Chinese patients with acne30.

When acne scarring is considered, it was noted that Asians with more severe acne scarring have worsened QoL. This is evident in a Thai study, in which the more severe the acne scarring, the more severe the impact on QoL31. The mean DLQI score of that study was 9.0, in which more than half of the patients had severe acne scarring.

Treatment

Proper treatment of acne vulgaris with oral and topical medications are important for patients with acne. Effective treatment of acne will significantly improve QoL impairment in these patients. In a Japanese study using oral antibiotics in the treatment of acne, it was noted that the DLQI improved by 1.9 points and the Skindex by 6.0 points32. The patients improved from moderate QoL impairment to mild impairment. Isotretinoin, which is the gold standard and most effective treatment for acne in many Asian countries, including the Philippines, has markedly improved the quality of life among patients33. A study in Korea showed that isotretinoin treatment improved acne-related QoL using the Assessment of the Psychological and Social Effects of Acne (APSEA) scale, depression using the Beck’s Depression Inventory, and anxiety using the Beck’s Anxiety Inventory34. Nevertheless, there is still ongoing debate about the relationship between isotretinoin and depression. Although the jury is still out, recent evidence suggests that acne is the cause of the depression, rather than isotretinoin35.

Use of facial skin care and make-up for patients with acne is also of utmost importance. Cover-up of acne lesions with cosmetic agents will improve the facial appearance of patients. In a Japanese study, patients who were taught proper use of skincare and cosmetics had a better QoL improvement compared with those who were not36. Using the DLQI, they found a 4.4-point improvement in those who were taught proper technique compared to only a 3.0-point improvement in those who were not.

Laser and light-based therapies can also be adjuncts in the treatment of acne. In many Asian countries, particularly in East Asia, laser and light therapies have been successfully used in the treatment of acne. Laser treatment using a 1450 nm diode laser, and in combination with photodynamic therapy (PDT) using indocyanine green, have been shown to significantly reduce inflammatory acne in Hong Kong and Korea37, 38. Intense pulsed light (IPL) treatment is also useful in reducing both inflammatory and non-inflammatory acne in Japan
and Korea
39, 40. Combining PDT to IPL in Hong Kong showed further improvement in the non-inflammatory acne compared with IPL alone41. Fractional microneedle radiofrequency has been used successfully in Korea to reduce inflammatory acne and in addition, improve acne scars42. The improvement of acne lesions definitely leads to better QoL.

Laser treatment is also widely used in the treatment of acne scarring in Asia. A number of studies in East Asia and South East Asia have shown an improved clinical outcome and QoL among patients with acne scars. Fractional CO2 lasers have significantly improved atrophic acne scarring in China, Hong Kong and Korea43, 44, 45. In order to reduce the downtime associated with fractional such devices, fractional photothermolysis and non-ablative erbium : glass lasers have also been used successfully to reduce acne scars in East Asia46, 47. Diode lasers also improved mild to moderate atrophic acne scars in Singapore48.

Conclusions

QoL impairment of Asian patients with acne is generally mild-to-moderate. It is not dissimilar to European populations, although the emphasis on the treatment of acne in Asia is significantly less. QoL impairment in Asia is not directly related to the severity of acne, but dependent on acceptance and coping mechanisms of the patient. Those with acne scarring have a worsened QoL. Therefore, acne should be addressed properly in Asian communities. Health authorities in Asia should allocate more resources for the treatment of acne.