Responding to the need for consistent quality of life (QoL) measurement in acne treatment and research, the European Academy of Dermatology and Venereology (EADV) has recommended six new treatment guidelines in three categories.
Led by Pavel Chernyshov, M.D., of Bogomolets National Medical University in the Ukraine, the EADV recommends three dermatology-specific tools, two acne-specific tools and one generic instrument for assessing health-related QoL (HRQoL) in acne.
The guidelines appear in the August issue of the Journal of the European Academy of Dermatology and Venereology.
The guidelines also call for adopting a quality-of-life measure as an integral part of acne management. In response, and in keeping with several national acne guidelines, members of EADV Task Forces on QoL and Patient Oriented Outcomes and on Acne, Rosacea and Hydratenitis Suppurativa reviewed and evaluated the QoL instruments that have been used in acne in recent decades to produce the following recommendations:
- Dermatology Life Quality Index (DLQI)
- Children's Dermatology Life Quality Index (CDLQI)
- Cardiff Acne Disability Index (CADI)
Medical Outcome Study Short Form 36 (SF-36)
"The brevity of the DLQI, CDLQI, CADI and Acne-QoL makes these instruments suitable for use in routine clinical practice," review authors wrote. "Acne-specific instruments may assess HRQoL in both children and young adults." Conversely, authors find that experience with other instruments is too limited to be recommended.
From 186 papers that met selection criteria, researchers culled a total of 24 validated QoL measures used in acne studies between 1980 and November 2016. "In all studies reviewed, the measures used detected impairment of QoL caused by acne," which in severe form may impact QOL comparably to psoriasis, vitiligo, atopic dermatitis and urticaria. In one study, the only skin diseases that exerted a greater psychosocial impact than acne were hyperhidrosis, hirsutism, ectoparasitic infections and bullous diseases.
The scales used most commonly were the dermatology-specific DLQI and the acne-specific CADI (54 and 41 studies, respectively). The CADI and Acne-QoL (also acne-specific; 23 studies) were used far more frequently than the generic SF-36 questionnaire (15 studies). The interventions assessed most frequently included isotretinoin (in 13 studies) and benzoyl peroxide (10 studies).
Clinical trials often use HRQoL assessment as an outcome measure, and indeed most of the publications identified were clinical trials, epidemiologic studies and studies on the creation and/or validation of QoL instruments. "But there are also many reasons to measure HRQoL in clinical practice," wrote Chernyshov and colleagues, although HRQoL assessment in the clinic remains infrequent.3
Outside of clinical trials, contexts in which QoL instruments were used ranged from patient education and adherence efforts to attempts to correlate HRQoL with acne severity, psychological comorbidities and demographic associations. Most studies that addressed acne severity found a positive correlation with QoL scores. However, the fact that a handful of studies found no correlation underscores the need for timely, effective acne treatment – even for patients with less severe acne.
Regarding adherence, being female, married, employed and not paying for prescriptions were associated with higher medication adherence and HRQoL. However, young females with high Skindex-29 scores, and males with low Skindex scores, were especially prone to nonadherence.
As for race, female patients classified as "white" and "black" reported less negative impact on QoL than subjects categorized as "Hispanic" and "Asian/other" in a survey that used the Acne-QoL. White and black subjects also suffered less social-functioning impairment than Asian/other subjects.4
Along with recommending particular QoL instruments, the authors stated that the major impact of acne on QoL documented in the studies reviewed emphasizes the need for patient education programs about living with and treating acne. With acne education lagging behind educational efforts in atopic dermatitis and psoriasis, they wrote, "The creation and critical evaluation of high-quality educational programs should be given priority by organizations that focus on acne, researchers and clinicians."
The heterogeneity of study designs and QoL questionnaires emphasizes the need to develop agreed-upon core outcome measures for use across all studies. The review uncovered many examples of inappropriate use or reporting of QoL measurements in acne. Some studies used unvalidated, study-specific questionnaires; others inaccurately presented titles of QoL instruments, failed to explain the instruments' components and/or used QoL instruments outside their validated age limits. In the latter area, authors of one study used Skindex-29, which is designed for adults, in children as young as 12 years old. Elsewhere, the DLQI, designed for patients over 16 years old, was utilized in children as young as 12 years.
"Such activity reduces the scientific value of published results and may discredit HRQOL assessment." To avoid these problems, review authors exhorted researchers planning studies that include HRQoL assessment to seek "educated input" in this regard. Chernyshov and colleagues also call upon journal editors to set clear standards for reporting HRQoL data.
Nast A, Dréno B, Bettoli V, et al. “European evidence-based (S3) guideline for the treatment of acne - update 2016 - short version,” August 2016. Journal of the European Academy of Dermatology and Venereology. DOI:10.1111/jdv.13776.
Sampogna F, Tabolli S, Abeni D. “Impact of different skin conditions on quality of life,” Giornale Italiano di Dermatologia e Venereologia. June 2013.
Finlay AY, Salek MS, Abeni D, et al. “Why quality of life measurement is important in dermatology clinical practice: An expert-based opinion statement by the EADV Task Force on Quality of Life,” Journal of the European Academy of Dermatology and Venereology. Oct. 24, 2016. DOI:10.1111/jdv.13985
Gorelick J, Daniels SR, Kawata AK, et al. “Acne-related quality of life among female adults of different races/ethnicities,” May 2015. Journal of Dermatology Nurses Association. DOI:10.1097/JDN.0000000000000129