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Clinical dermatology • Original article

Clinical and Experimental Dermatology

Acne prevalence and beyond: acne disability and its predictive factors among Chinese late adolescents in Hong Kong
M. P. M. Law, A. A. T. Chuh, A. Lee and N. Molinari*
Department of Community and Family Medicine, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; and *Department of Biostatistics, Institut Universitaire de Recherche Clinique, Montpellier, France


Background. Data are lacking on the prevalence of acne, its effects on quality of life (QOL) and the treatment usage among Chinese patients in late adolescence. Aim. To derive data about the prevalence and predictive factors of acne, the disability caused by acne and choice of treatment used by Chinese late adolescents in Hong Kong. Methods. This was a cross-sectional study of a random sample of 389 entrants in a university in Hong Kong, using the Global Acne Grading System (GAGS) to measure the clinical severity of acne and the Cardiff Acne Disability Index (CADI) to measure QOL. Results. The response rate was 99.3%. The prevalence of acne was of 81.5% (95% CI 77.6–85.4%) and coexisted with a high frequency of acne disability at a rate of 81.8% (95% CI 78.1–85.6%). Assessment of the clinical severity of acne did not correlate strongly with the effect on QOL (cs = 0.445, P < 0.001). Over the previous 6 months, 30.3% of subjects had used topical treatments, 3.9% had taken systemic conventional western drugs and 3.2% of the subjects had used traditional Chinese medicine. Multivariate logistic regression was used to explore the predictive factors for acne disability. Female gender (P = 0.002), higher GAGS score (P < 0.001), higher perceived stress (P = 0.01) and willingness to pay Hong Kong$15 000 (£970) for a hypothetical permanent cure (P = 0.03) were positive predictors. Conclusions. Acne is prevalent in Hong Kong and has considerable psychological effects. The association between clinical severity and impaired QOL is not strong.

In the USA, acne vulgaris is the fourth most common reason for patients aged 11–21 years to visit a doctor,1 and accounts for 4% of all visits by patients aged 15– 19 years.2 Studies3–6 have shown that the prevalence of acne varies from 28.9% to 91.3% in adolescent populations. Recent evidence7,8 has shown that acne results in significant psychological problems, such as stigmatization from peers, lower self-esteem, interpersonal
Correspondence: Dr Michelle Law, 4th Floor, Department of Community and Family Medicine, School of Public Health, Prince of Wales Hospital, Shatin, N.T. Hong Kong, China. E-mail: Conflict of interest: none declared. Accepted for publication 6 November 2008

difficulties, anxiety, depression and higher unemployment rates. Severe psychological consequences such as depression, eating disorder and body dysmorphic disorder are common among people with acne.9 Studies on the prevalence of acne and the predictive factors for impaired quality of life (QOL) are important for effective and efficient management of acne. Unfortunately, data are lacking for young people in Hong Kong. To date, the estimation of acne frequency in Hong Kong has been based on studies from other countries and empirical data within Hong Kong. Although the adolescent population of Hong Kong is mainly ethnic Chinese, the lifestyle is mainly western with retention of certain traditional practices. This indicates the importance of an investigation in Hong Kong. To our knowledge, this is the first study of acne prevalence in late adolescents with a confirmed diagnosis of acne in Hong Kong, using an established


Ó 2009 The Author(s) Journal compilation Ó 2009 British Association of Dermatologists • Clinical and Experimental Dermatology, 35, 16–21

(iii) to explore the predictive factor(s) of QOL impairment as a result of acne. The exploratory findings will be useful for other cities in China or other parts of Asia because the effect of common adolescent health problems on QOL is an emerging issue. Subjects with GAGS score > 0 were categorized as the acne group and those with GAGS score of 0 were categorized as the reference group. and only 3 refused to participate. a nonparametric statistical procedure was carried out.16 Willingness to pay questionnaire. The objectives of the study were: (i) to determine the prevalence of acne among Chinese late adolescents in Hong Kong. examining only the facial region can minimize bias due to some study subjects declining adequate exposure for full examination of the chest and upper Prevalence estimates and odds ratios with 95% CI were calculated. 16–21 17 . The GAGS is a clinical grading system for the clinical severity of acne. giving a completion rate of 91. P. would be in the acne group). measuring the degree to which situations over the previous month are perceived as stressful. As stress19 is believed to be an important confounder of acne severity and QOL. method. and (iv) to examine the use of acne treatments and their relationship with the clinical severity of acne and QOL impairment. M. For ease of comprehension in the Cantonese (the predominant dialect in Hong Kong) speaking population. The final sample therefore comprised 389 students [206 boys (53%) and 183 girls (47%)]. Such modification would not jeopardise the validation of our results of logistic regression analysis but would reflect the subjects’ acne severity more accurately. Assuming a 95% confidence interval and error within 5%. the GAGS score was modified (Appendix 1) by extracting the truncal factor of the original GAGS score. Of the 413 recruited subjects.. pronounced truncal lesions without facial counterparts are uncommon11. the parametric alternative was adopted. Law et al. 416 enrolled students were approached. One investigator (ML) was systematically trained and validated by a specialist dermatologist to rate GAGS. The concept of willingness to pay (WTP) for treatment has been used previously for assessing QOL and healthcare usage in dermatology. All entrants were invited to have a general health evaluation within a period of 5 days. Firstly. and question 5 investigates the patient’s (subjective) assessment of current acne severity (Appendix 2).2%. Secondly. 35. From those who consented to participate. even if the subjects in our study did show significant extrafacial acne. Measuring tools Global Acne Grading System. Questions 1–4 address the psychological and social consequences as a result of acne. Statistical analyses Methods Sampling This was a cross-sectional study among entrants to a university in Hong Kong.17 The questions investigate how much patients are willing to pay for a hypothetical cure for their condition. informed written consent was obtained. If the normal distribution hypothesis of a continuous variable was rejected. The study was approved by the Clinical research ethics committee of The Chinese University of Hong Kong. as shown in the descriptive results. giving a response rate of 99. This was justified for the following three reasons. It was assumed that 50% of the subjects would have a score on the Global Acne Grading System10 (GAGS) > 0 (i. Students could freely decide whether or not to participate in the study.3%. Otherwise.15.e. A higher cumulative CADI implies a greater QOL impairment due to acne.12 and assessing only facial lesions with exclusion of severity assessment of chest and back acne will not compromise the assessment of acne severity overall. Higher scores relate to higher stress. the Perceived Stress Scale-4 (PSS-4) was used to measure the stress levels of the subjects. Multivariate Ó 2009 The Author(s) Journal compilation Ó 2009 British Association of Dermatologists • Clinical and Experimental Dermatology. back. 24 students refused the physical examination. Cardiff Acne Disability Index14.13 Thirdly. the cut-off point before and after the GAGS modification was still the same (zero).Acne disability and its predictive factors among Chinese late adolescents • M. In total. a formal translation process was performed following international guidelines. This is a four-item selfreport questionnaire with a five-point scale. The Cardiff Acne Disability Index (CADI) was designed for use in teenagers and young adults to assess the disability caused by acne. In our study. (ii) to investigate the impairment of QOL resulting from acne and its relationship with clinical severity of acne. Each question is provided with four graded responses. a minimal sample size of 384 was estimated. Two WTP questions were used in this study. Perceived Stress Scale-418.

66 2. 95% CI 78. severe.77). severe or very severe’ acne group (P = 0. M.6%–85.03 6.6%) subjects indicated that their QOL were impaired by acne (i. 2. 95% CI 53. P. severe and very severe’ acne (Table 1).5%) of and acne clinical severity and gender is shown in Fig. the acne group (P = 0. How much would you be prepared to pay for this treatment?’). The mean GAGS score for subjects in different categories of acne clinical severity and of gender are shown in Fig. the ‘mild’ acne group (P = 0. IL.5%) With acne (GAGS = 1–32) 317 subjects (81.) The mean CADI for or each category Figure 3 Mean CADI with respect to subjects in different categorization of acne clinical severity and gender. 64 (15. severe or very severe’ acne (Fig..5%) were willing to buy it at ‡ HK$1000 (£65) or above. Within this group.34 9.89 Female Male Both genders 2. 3.228) or the ‘moderate. the reference group (P = 0.1%. CADI > 0.3) were categorized as having ‘moderate.417) individually. or very severe” acne (GAGS = 14–32) 90 subjects (23.219). The correlation became insignificant (cs = 0.19 2.196).022) and the ‘moderate.01 5 6 The mean CADI for all subjects was 2.38 2. 35. The first WTP question asked how much the students would be willing to pay for treatment (‘Imagine that a new product is available for the treatment of acne.003).77 Female Male Both genders Results Prevalence 18. and 338 (81. severe or very severe” acne group (GAGS = 14–32) 0 1 2 0.9%–27. Quality of life Figure 2 Mean GAGS score with respect to subjects in different categorization of acne clinical severity and gender. The GAGS score and CADI weakly correlated [Spearman rank order correlation coefficient (cs) = 0. 317 subjects were categorized as the acne group. Law et al.22 2. 16–21 . Willingness to pay “Mild” acne (GAGS = 1–13) 227 subjects (58.5 2.92 6. Total 389 subjects (100%) Reference group Acne group “None” acne (GAGS = 0) 72 subjects (18. Chicago.1%) • Moderate (GAGS = 14–22): 75 subjects (19.313) for those with ‘moderate.45 10.8%.09 2. severe or very severe’ acne group (P = 0.89 1.4%. Imagine that this product is much more effective than previous treatments and is almost certain to cure your acne.56 3. USA) software.3%) Figure 1 Summary of clinical severity of subjects in this study.96 2.108.4).49 8. P = 0.191. 154 18 Ó 2009 The Author(s) Journal compilation Ó 2009 British Association of Dermatologists • Clinical and Experimental Dermatology. All subjects Acne group (GAGS > 0) “Mild” acne group (GAGS = 1–13) “Moderate.Acne disability and its predictive factors among Chinese late adolescents • M.4%) “Moderate. logistic regression for predictive analysis was performed. All subjects Acne group (GAGS > 0) Reference group (GAGS = 0) “Mild” acne group (GAGS = 1–13) “Moderate.5 7.58 17.88 8 10 12 GAGS score 14 16 18 20 Of the 389 students.89 3. Of the 389 students. 227 subjects (58.008).35– 2. the ‘mild’ acne group (P = 0.37 4.4 3 4 CADI score 4.1–85. 1). The differences in mean GAGS scores between genders were not significant for the study population overall (P = 0.002).3 17. 95% CI 18.64 8.13 1.5% (95% CI 77.004] for subjects with ‘mild’ acne.001). rendering a prevalence rate of 81.3%) • Severe (GAGS = 23–28): 14 subjects (3. severe or very severe” acne group (GAGS = 14–32) 0 2 4 6 7. The mean CADI for girls was significantly higher than for boys for all subjects (P < 0.56 (95% CI 2.4%–63.6%) • Very severe (GAGS = 29–32): 1 subject (0.4) were categorized as having ‘mild’ acne and 90 subjects (23. P = 0.09 9. All analyses were performed with SPSS (SPSS Inc.e. or the acne group (P = 0.

This suggests that the more severe the acne. 53 (16. the less predictive is physician-rated severity in exploring the psychosocial stress and treatment needs of the patient. 83 (92. Of these. The results are shown in Table 2. the main aim of treatment should be optimization of the subjective well-being of patients. behavioural and psychosocial risk factors. reflecting that a significantly larger proportion of subjects in the acne group than in the control group (P = 0.7%) did not use TT.2%) had used traditional Chinese medicine (TCM) to treat their acne. two findings in their treatment-seeking behaviour were surprising.313 0. 87 (95%) of them were in the acne group. independent of other physiological.3%) did not use TCM.23 and Uslu et al. 129 (40.445 0. These results imply that there is a group of patients who could potentially benefit from medical intervention but do not present to clinicians. In the acne group. Another implication from our results to inform better care for patients with acne is the gender issue.7%) were willing to buy it at ‡ HK$1000 (£65). Purvis et al. WTP. Categorisation for clinical severity of acne All subjects ‘Moderate. to report difficulty in accessing medical treatment for acne. This could be due to ignorance of the existence of effective treatments for acne or difficulties in accessing to specialist care.001 0. severe or very severe’ acne group (GAGS = 14–32) ‘Mild’ acne group (GAGS = 0–13) Acne group (GAGS > 0) Discussion Acne is prevalent among late adolescence patients in Hong Kong and results in considerable impairment in QOL. Girls in every category of acne severity had significantly higher CADI than boys. Yeung et al.9%) had used conventional systemic western medicine (SWM) for their acne and 115 (30. Gender.Acne disability and its predictive factors among Chinese late adolescents • M. Secondly. previous treatment of acne was not a significant factor in predicting QOL impairment.002) desired to be free from acne.7%) would pay HK$500 (£32) for it and 135 (42.22 We found that the correlation of GAGS and CADI was further weakened as the subjects’ clinical severity of acne increased. Emphasizing patients’ QOL was shown to enhance patient satisfaction. P.001) or TT (P < 0. M. SWM (P < 0. previous treatment(s) of acne and PSS score were adjusted for the analysis. by an odds ratio of 5.23 stated that over half of their respondents did not know whether effective treatments were available. Our findings were in accordance with Mosam et al.6%) chose not to buy it.3%) would pay HK$500 (£32) for it and 195 (47. 84 (93.2%) did not use SWM and 42 (47. Law et al. The association of the clinical severity of acne and disability induced by it is not strong.20 who found that severity of acne was not significantly correlated with psychological distress.25 who reported a male : female ratio of 3 : 5 for dermatologist visits because of acne. Ó 2009 The Author(s) Journal compilation Ó 2009 British Association of Dermatologists • Clinical and Experimental Dermatology.26 reported that the dermatologist to patient ratio is 1 : 120 000 in Spearman’s q 0. showing a need for genderspecific management protocol for patients with acne. (37. Predictive factors of impaired QOL Multivariate logistic regression analysis for the CADI was performed to confirm the above results.001). As acne is not a life-threatening condition. severe or very severe acne’ but did not actively seek treatment: in the previous 6 months.2%) subjects chose not to purchase it. Treatment history Over the previous 6 months.004 < 0. 16–21 19 . 35. 13 respondents (3. 15 (3. GAGS score.3%) had used (western) topical treatment (TT).001 GAGS.191 0.24 The heightened concerns of self-image echo the study of Stern. The students who had used TCM (P < 0.001) were found to have more severe acne and greater acne disability than subjects who had not sought treatment. The second WTP question asked whether the students thought the drug or a sum of money was more important to them (‘Would you rather receive the cure at no cost to you. 63 subjects preferred a free course of the hypothetical treatment to the money (which is the approximate cost in Hong Kong for a full course of systemic isotretinoin treatment).3 found that students having ‘problem acne’ were more likely. a result that is consistent with the findings of Yeung et al. or would you rather receive HK$15 000 (£955) but never receive the cure?’). Although the students were impaired physically and psychologically.29. Table 1 Correlation of GAGS and CADI with respect to categorisation of acne clinical severity. a significant number of subjects had ‘moderate. Chan et al. If only the acne group was considered. Global Acne Grading System.001).21 Self-rated health by patients has also been shown to bear strong predictive validity for morbidity and mental health. Firstly.374 P < 0. not merely control of the clinical severity as rated by physicians. girls were significantly more willing than boys to pay more for the hypothetical cure (P < 0.108 0.

HK Pract 2006. As there are no local data on acne prevalence and its effects on QOL. TT. Reference group Female N⁄A N⁄A HK$15 000 preferred Non-TCM user Non-SWM user Non-TT user N⁄A Odds ratios (95% CI) 0. 28: 1–5. A closer look at truncal acne vulgaris: prevalence. Practical use of a disability index in the routine management of acne. Department of Dermatology. 2 Stern RS. The psychosocial impact of acne: patients’ perceptions.050–1.102–12. Baum E et al. F. Director of University Health Services. *For the hypothetical cure. Zawar. CADI. 14 Motley RJ.458 1. Acne therapy.288) 1. Aust J Dermatol 1997.05 Table 2 Results of multivariate logistic regression. 35. 145: 274–9. Cox N. Law. Professor A. Global Acne Grading System. 8 Mulder MM.128 0. 16–21 . Y. The public should be informed about the appropriate medical services available to ensure timely treatment. for his strong support for this study. J Drugs Dermatol 2007. Pediatrics 1999.789–1. SWM. Hong Kong and that the locations of dermatology clinics are distributed unevenly. Br J Dermatol 1998. and Dr B.024 (0. Y. Clin Exp Dermatol 1992. NDMVPS Medical University and Research Centre. The prevalence of common skin conditions in Australian school students: 3. Prevalence and severity of facial and truncal acne in a referral cohort. Lee A. Psychosocial impact of acne vulgaris.956) 1.457) (0. Oxford: Blackwell Scientific Publications. N Z Med J 2004. traditional Chinese medicine. N ⁄ A. P. 43. Slap GB. A comparison of current acne grading systems and proposal of a novel system. these odd ratios and P values correspond to the final selection model procedure. A limitation of the study is that the general population was not sampled due to resource constraints. Utilization of physician offices by adolescents in the United States. Int J Dermatol 1997. Tang J. not significant. 104: 35–42. Acknowledgements We thank Dr V. Medication use and sources of care in office-based practice.204 (1. Glazebrook C. TCM. P. Descriptive epidemiology of acne vulgaris in the community. Breathnach S. PSS. for his expert training and validation of the use of GAGS given to M. Cardiff Acne Disability Index. we hope that this exploratory study will provide the foundation for a future population-based study. 11 Ebling FJG. 7: 551–6. Law et al.005 NS NS NS < 0. Williams HC. Dermatology 2001. Marks R. GAGS.870) 1. 10 Doshi A. 6: 597–600. India. 2004. Sigurdsson V. Finlay. Finlay AY. Kilkenny M. Cunliffe WJ. J Am Acad Dermatol 1995. NS.138 1. 7 Koo J. 36: 416–18. these odd ratios correspond to the complete model (without the selection procedure). Watson P. 203: 124–30. and clinical significance. 7th edn (Burns T.001 NS < 0. M. Chinese University of Hong Kong.323) 1. Merlin K. not available. Arch Dermatol 1996. 13 Tan JK.005 < 0. Acne prevalence. University of Wales University of Medicine. Stiller MJ. Plunkett A et al.887 (0. Robinson E. Factors Male GAGS score Amount of money would pay* Preference for money or cure Hypothetical cure preferred Acne treatments used TCM SWM TT PSS score vs. Bikowski JB. knowledge about acne and psychological morbidity in midadolescents: a community-based study.044–4.005–1. Disorders of the sebaceous glands. van Zuuren EJ et al. Department of Dermatology.824–0. 38: 115–25. 17: 1–3. for his kind permission to use and publish the CADI in this study. M.214 (0. 32: S26–30. 20 Ó 2009 The Author(s) Journal compilation Ó 2009 British Association of Dermatologists • Clinical and Experimental Dermatology. had impairment of QOL because of acne.618–3.086) (1. 139: 840–5. Acne: its psychological consequences and management. Zaheer A. Acne vulgaris. References 1 Ziv A. severity. topical treatments. 4 Stathakis V. CADI = 0. 9 Law PM. Evaluation of the relation between a change in clinical acne severity and psychosocial state. 6 Kilkenny M. Perceived Stress Scale. systemic western medicine.043) P < 0. eds). 3 Purvis D. Br J Dermatol 2001. with CADI as dependent variable. Fung K et al. Acne prevalence in secondary school students and their perceived difficulty in accessing acne treatment. 132: 776–80. Fong. 5 Smithard A.15. Chuh AAT. Boulet JR. In: Rook’s Textbook of Dermatology. did not have impairment of QOL because of acne.163 (1.095–1. CADI = 1–15.746) (0. 117: U1018.Acne disability and its predictive factors among Chinese late adolescents • M. 12 Del Rosso JQ. J Drugs Dermatol 2008.

Not a problem Appendix 1. J Am Acad Dermatol 2000. 22: 462–9. Chuh AAT. A little d. The response of skin disease to stress: changes in the severity of acne vulgaris as affected by examination stress. affecting all activities b. Law et al.Y. Modified GAGS scale Ó M. Ferraro KF. Quality of life issues for South Africans with acne vulgaris. perceptions and effects on psychological health among adolescents in Aydin. Acne: prevalence. 39: 298–311. Appendix 2. 39: 774–8. Grove A. 43: 1042–8. Turkey. Abeni D. English version of Cardiff Acne Disability Index 1. Not at all a. Principles of good practice for the translation and cultural adaptation process for patient reported outcomes (PRO) measures: report of the ISPOR task force for translation and cultural adaptation. A community-based epidemiological study of acne vulgaris in Hong Kong adolescents. 17 Motley RJ. Location I: forehead I: right cheek III: left cheek IV: nose V: chin Local score* 2 2 2 1 1 Grade 0: 1: 2: 3: 4: no lesions ‡ 1 comedone ‡ 1 papule ‡ 1 pustule ‡ 1 nodule Global score 0 1–13 14–22 23–28 29–32 Modified GAGS scale ‘None’ ‘Mild’ ‘Moderate’ ‘Severe’ ‘Very severe’ Factor · grade (0–4)* = local score. Teo LH.S. Please indicate how bad you think your acne is now: a. 82: 104–7. Br J Dermatol 2001. Lee A. Woo J. During the last month have you avoided public changing facilities or wearing swimming costumes because of your acne? 4. Moderately. Not at all a. in most activities c. Factors associated with patient satisfaction with care among dermatological outpatients. The worst it could possibly be b. Arch Dermatol 2003. All of the time b. How would you describe your feelings about the appearance of your skin over the last month? 5.) Ó 2009 The Author(s) Journal compilation Ó 2009 British Association of Dermatologists • Clinical and Experimental Dermatology. Very depressed and miserable b. Xiang LH et al. 24: 385–6. Medication and medical service utilization for acne 1995–98. Int J Dermatol 2000. Clin Exp Dermatol 2005. M. Sendur N. frustrated or embarrassed? 2. 26 Chan HH. Mermelstein R. 145: 617–23. 14: 194–8. Martin M et al. Occasionally or in only some activities d. A. Chon SY. Picardi A et al. Vawda NB. Hong Kong Med J 2009. Finlay AY. Chan WM et al. Occasionally concerned d. Kimball AB. Uslu M et al. Usually concerned c. Not at all a. Very much indeed b. A lot c. As a result of having acne. 8: 94–104. J Health Soc Behav 1983. A minor problem d. 30: 6–9. 35. 15 Law MPM. 24 Uslu G. Acta Derm Venereol 2002. 22 Farmer MM. 19 Chiu A. Lewis-Jones. Not bothered a. Occasionally d. 18 Cohen S. Do you think that having acne during the last month interfered with your daily social life. 23 Yeung CK. Teledermatology in Hong Kong: a cost-effective method to provide service to the elderly patients living in institutions. 20 Mosam A. Value Health 2005. Finlay 1995. (Re-adoption of the questionnaire for further research or clinical studies shall be subjected to approval by the copyright holders. Severely. P. A global measure of perceived stress. Most of the time c. 16 Wild D. J Eur Acad Dermatol Venereol 2008. 139: 897–900.Acne disability and its predictive factors among Chinese late adolescents • M. 15: 12–7. social events or relationships with members of the opposite sex? 3. Gordhan AH et al. A major problem c. J Health Soc Behav 1997. 21 Renzi C. Distress and perceived health: mechanisms of health decline. during the last month have you been aggressive. Kamarck T. How much disability is caused by acne? Clin Exp Dermatol 1989. 16–21 21 . 25 Stern RS. Validation of a Cantonese version of the Cardiff Acne Disability Index.

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