ORIGINAL RESEARCH

A Qualitative Investigation of the Impact of Acneon Health-Related Quality of Life (HRQL):Development of a Conceptual Model

Gabriella Fabbrocini . Sara Cacciapuoti . Giuseppe Monfrecola

Received: November 8, 2017 / Published online: February 12, 2018� The Author(s) 2018. This article is an open access publication

ABSTRACT

Introduction: The negative impact of acne onaspects of health-related quality of life (HRQL)has been demonstrated in many quantitativestudies; however, there has been relatively littlequalitative research exploring the impact ofacne and the use of topical treatment. The studyaimed to explore the impact of moderate–severeacne on HRQL in adolescents and adults withinflammatory and non-inflammatory lesionsand to develop a conceptual model to illustratethe impact. In addition, the study aimed toidentify the attributes of topical acne treat-ments that are most important for patients.Methods: Thirty-four adolescents and 16 adultswith moderate–severe acne who were currently/recently prescribed topical treatment wererecruited in this cross-sectional qualitativestudy in the UK, Italy, and Germany. In-depth,semi-structured telephone interviews exploredpatients’ experiences of acne and the impact it

has on their HRQL, and their experience oftopical treatments for acne. Data were analyzedusing thematic analysis and a conceptual modelwas developed.Results: The analysis identified seven mainareas of HRQL that are affected by acne: emo-tional functioning, social functioning, rela-tionships, leisure activities, daily activities,sleep, and school/work. Also commonthroughout the interviews was the perceptionand reaction to acne from others, whichpotentially had an impact on all areas of HRQL.The conceptual model illustrates the impact onHRQL and the links between HRQL domains.For both adolescents and adults, it was mostimportant for acne treatments to be fast-acting,non-irritating, and non-bleaching.Conclusion: The results of this qualitative studydemonstrate that moderate–severe acne has anextensive impact on adolescents’ and adults’HRQL. The conceptual model illustrates themany areas of HRQL that are affected and drawsattention to the importance of effective treat-ments for acne. The study also highlights topi-cal acne treatment attributes that are mostimportant for patients.Funding: Meda, a Mylan company.

Keywords: Acne vulgaris; Conceptual model;Health-related quality of life; Qualitative;Topical treatment

Enhanced content To view enhanced content for thisarticle go to https://doi.org/10.6084/m9.figshare.5817453.

G. Fabbrocini (&) � S. Cacciapuoti � G. MonfrecolaSection of Dermatology, Department of ClinicalMedicine and Surgery, University of Naples FedericoII, Naples, Italye-mail: gafabbro@unina.it

Dermatol Ther (Heidelb) (2018) 8:85–99

https://doi.org/10.1007/s13555-018-0224-7

INTRODUCTION

Acne is a chronic, inflammatory disease of thepilosebaceous unit estimated to affect 9.4% ofthe global population [1]. By the age of 21 years,80–90% of people are estimated to have hadacne [2]. The primary pathogenic factors areincreased sebum production by the sebaceousgland, alterations in the keratinization process,follicular colonization by Propionibacteriumacnes, and activation of innate immunity fol-lowed by increased inflammation [3]. Signs ofacne include non-inflammatory lesions (openand closed comedones), inflammatory lesions(papules and pustules), and seborrhea (oilyskin). Typically, acne starts in early puberty andis a chronic condition that can last for manyyears [4].

Although acne is not life-threatening orphysically disabling, the negative impact ofacne on health-related quality of life (HRQL)has been demonstrated in many studies ofadults and adolescents with acne [5–7]. In onestudy, pretreatment acne patients reportedsubstantially more pain/discomfort and anxi-ety/depression than a population sample [5]. Inanother study, authors claimed that the HRQLof acne patients is comparable to patients withconditions such as chronic disabling asthma,epilepsy, back pain, and arthritis [6]; this issupported by a literature review that found theHRQL impact of acne was comparable to psori-asis, a condition that causes significant disabil-ity [8]. A small study of adults with acne foundclinically significant anxiety and depression in44% and 18% of the sample, respectively [9],and a large survey of 18-year-olds found thatparticipants with acne had significantly moredepressive symptoms, lower self-attitude andself-worth, more feelings of uselessness, andlower body satisfaction than those without acne[10]. Other psychological effects of facial acne,including embarrassment, impaired self-image,low self-esteem, self-consciousness, frustration,and anger, have been identified in qualitativeresearch [11]. In addition, dermatological-re-lated social anxiety has been shown to be neg-atively associated with intention to participatein sport/exercise, self-esteem, and

dermatological HRQL [12]. A review of studiesexamining the relationship between HRQL andacne in adolescents concluded that acne has anegative impact on HRQL and improvements inacne are associated with improvement in indi-viduals’ self-appraisals, thus highlighting thepotential benefit of effective acne treatments onHRQL [13].

Many treatments for acne are currentlyavailable; guidelines recommend a combinationof a topical retinoid and an antimicrobial agentfor most patients with acne in order to targetboth inflammatory and non-inflammatorylesions [14]. Although acne typically requiresprolonged treatment, poor adherence to acnetherapies has been documented. One largestudy found poor adherence in 50% of partici-pants prescribed treatment for acne; adherencerates reported in Europe were lower than thosereported in the Americas or Asia [15]. Dissatis-faction with treatment has been closely associ-ated with poor adherence [16]. Understandingmore about what drives treatment satisfactionand what patients prefer in terms of their acnetreatment may be important. A conjoint anal-ysis assessing patient preferences for topicaltherapies evaluated five treatment attributes(form, storage, product life, method of applica-tion, and regimen). After using four topicaltreatments for a week each, participants pre-ferred a gel formulation, room temperaturestorage, application with fingers, and a once-daily regimen [17].

Much of the previous research into theimpact of acne on HRQL has used validatedinstruments such as the Acne Quality of Life(Acne-QOL) [18], Dermatology Quality of LifeIndex (DLQI) [19], or the Assessment of Qualityof Life (A-QOL) [20]. Some qualitative studieshave explored the psychological and socialimpact of acne [11, 21, 22]. Qualitative researchmethodologies allow an in-depth investigationinto patients’ experiences and allow us toidentify concepts of importance to patients, interms of HRQL impact and experience of usingtreatment for acne. Qualitative data can be usedto develop conceptual models to illustrate theimpact of a condition and hypothesize linksbetween the concepts. A conceptual model canbe used to guide the choice of what to measure

86 Dermatol Ther (Heidelb) (2018) 8:85–99

and how to measure it, and provide a contextfor the interpretation of findings [23].

The aims of this qualitative study were toexplore the impact of moderate–severe acne onHRQL in adolescents and adults with inflam-matory and non-inflammatory lesions, and todevelop a conceptual model to illustrate thisimpact. The study also aimed to determine theattributes of topical treatments for acne that arethe most important for patients.

METHODS

Study Design

Qualitative methods were used to explore theimpact of moderate–severe acne on adolescents’and adults’ quality of life. Individual interviewswere conducted with acne patients to informthe development of a conceptual model ofpatient-reported HRQL. The research wasdesigned to comply with guidelines for con-ducting research with children and young peo-ple [24]. Ethical approval was provided by SalusIRB, an independent review board, and thestudy was conducted in accordance with theprinciples of the Declaration of Helsinki. Alladult participants provided informed consentprior to participating in the study; parents orguardians of adolescent participants providedinformed consent for their child to participate;adolescents also provided assent.

Participants

Interview participants were recruited through aspecialist recruitment panel in the UK, Italy,and Germany. Participants were eligible if theyhad a self-reported diagnosis of acne vulgaris,were aged 12–17 years (adolescents) or 18 yearsor older (adults), were currently experiencingfacial lesions including papules and/or pustules,and were currently or recently (in the last6 months) prescribed a topical medication foracne. Recruitment aimed for a higher propor-tion of adolescents than adults in each countryto reflect the higher incidence in youngerpeople.

Data Collection Procedures

Semi-structured interview guides were devel-oped following a literature review of HRQL inacne; separate versions were developed for adultand adolescent interviews. The interviewsbegan with a series of sociodemographic andclinical questions followed by a semi-structuredinterview guide exploring patients’ experienceof acne. The interview guide used open-endedquestions to allow participants to sponta-neously describe the ways in which acne affectsthem, e.g., ‘‘what is the most difficult part ofhaving acne?’’, followed by open-ended ques-tions about different areas of HRQL. If notalready reported, specific probe questions werealso asked such as ‘‘how does acne affect yourself-confidence or self-esteem?’’ Interviews alsoexplored participants’ experiences of usingtopical treatment for acne and their views ondifferent aspects of topical therapy. The inter-view guides were modified during the study toincorporate questions on topics mentioned inearly interviews. Interviews were conducted bytelephone; evidence suggests that telephoneinterviews can be used productively in qualita-tive research, including research with children,with no significant differences in the quality ofthe data obtained when compared with face-to-face interviews [25, 26]. Telephone interviewsare also particularly suitable for research ondermatological conditions as they allow partic-ipants to speak freely about their acne withoutfeeling self-conscious that the interviewer cansee their acne. The telephone interviews wereconducted by experienced qualitative research-ers following semi-structured adolescent oradult interview guides. Interviews lasted up toan hour and were audio recorded and tran-scribed verbatim.

Analysis

Data from the interviews were analyzed usingthematic analysis, which uses inductive codingto identify themes across a dataset [27]. Tran-scripts were systematically coded using a quali-tative software tool (MAXQDA). A codingframework was developed and discussed by the

Dermatol Ther (Heidelb) (2018) 8:85–99 87

study team, which was then used throughoutthe analysis. Transcripts from adolescent andadult interviews were grouped and analyzedseparately to allow for identification of conceptsor themes occurring in only one group. Satura-tion, the point at which no new information isobtained from additional interviews [28], wasassessed using saturation tables; the study con-tinued until saturation was reached. The con-ceptual model was developed using theconcepts and themes identified in the analysis.The model was reviewed by a dermatologist andrevised until all authors were in agreement.

RESULTS

Sample Demographics

Fifty participants were recruited and inter-viewed; 34 adolescents and 16 adults withmoderate–severe acne from the UK (N = 20adolescents and N = 10 adults), Italy (N = 7adolescents and N = 3 adults), and Germany(N = 7 adolescents and N = 3 adults). Thedemographics of the sample are shown inTable 1. Over half of the adolescent sample wasfemale and three quarters identified themselvesas white, with an mean age of 15 years. Theadult sample had a mean age of 28 years; how-ever, the UK sample was older on average (meanage 32 years) than the Italian (mean age23 years) and German (mean age 19 years)samples. The adult sample had an equal numberof male and female participants. Most of thesample rated their acne as at least moderate atthe time of the interview and at least severewhen at its worst.

Qualitative Results

For most participants, acne had an impact onmany areas of their HRQL; however, one ado-lescent participant reported no impact on hisHRQL. The analysis identified seven main areasof HRQL that are affected by acne: emotionalfunctioning, social functioning, relationships,leisure activities, daily activities, and impact onsleep and school/work. The perception of acne

from others and their reaction to it was also acommon concept. Figure 1 shows the percent-age of adolescents and adults reporting animpact on each of the domains, demonstratingthat for almost all domains, a higher proportionof adult participants reported an impact com-pared with adolescents. Each of the domainsand their inter-relationships are described in thesections below, with example quotations pro-vided in Figs. 2 and 3.

Emotional Functioning

All except one adolescent reported that acnehad a detrimental impact on some aspect oftheir emotional well-being, particularly on theirself-confidence or self-esteem. For some partic-ipants, this was due to reaction from others.Having less confidence impacted other areas ofparticipants’ lives, such as participation inschool activities and socializing. Two-thirds ofadolescents reported that acne made them feeldown and almost half of participants felt lonelyor isolated. Half of adolescents also felt frus-trated by their acne because of having no con-trol over it or treatments not working.

Adult participants reported similar emo-tional impacts; almost all felt that acne loweredtheir self-confidence or self-esteem, made themfeel down or depressed, and self-conscious orembarrassed. Adults also reported feeling iso-lated or lonely because of their acne.

Social Functioning

Over two-thirds of adolescent and all adultparticipants reported that acne had an impacton their social activities. In particular, partici-pants mentioned that interacting with strangersis difficult; they felt that people focused on theiracne when speaking to them or judged thembecause of their acne. Participants did not wantto socialize when their acne flared up and someparticipants did not attend activities if it meantthat they would not be able to wear makeup.

Most participants reported that acne affectedtheir use of social media. This included notposting pictures of themselves if their acne wasvisible, editing photos before posting them,

88 Dermatol Ther (Heidelb) (2018) 8:85–99

Table1

Sampledemographics

UK

Italy

Germany

Total

Ado

lescents

(N5

20)

Adu

lts

(N5

10)

Ado

lescents

(N5

7)Adu

lts

(N5

3)Ado

lescents

(N5

7)Adu

lts

(N5

3)Ado

lescents

(N5

34)

Adu

lts

(N5

16)

Age Mean(SD)

15.2

(1.4)

32.1

(10.1)

13.9

(2.1)

23.3

(6.85)

16.1

(0.8)

18.7

(0.47)

15.1

(1.7)

27.9

(10.2)

Range

12–1

718–4

712–1

718–3

315–1

718–1

912–1

718–4

7

Gender

Femalen(%

)14

(70)

6(60)

3(43)

1(33)

6(86)

1(33)

23(68)

8(50)

Ethnicity

White

n(%

)14

(70)

7(70)

6(86)

3(100)

6(86)

2(66)

26(76)

12(75)

Location

Urban

n(%

)17

(85)

8(80)

7(100)

3(100)

6(86)

2(66)

30(88)

13(81)

Age

atdiagnosis

Mean(SD)

12.6

(1.7)

17.6

(5.7)

11.9

(1.1)

14.3

(1.2)

13.0

(1.3)

14.0

(1.63)

12.5

(1.6)

16.3

(5.2)

Typeof

spots(currently)

Blackheadsn(%

)10

(50)

9(90)

6(86)

3(100)

5(71)

1(33)

21(62)

13(81)

Whiteheadsn(%

)14

(70)

8(80)

7(100)

2(66)

3(43)

2(66)

24(71)

12(75)

Papulesn(%

)18

(90)

10(100)

6(86)

3(100)

6(86)

2(66)

30(88)

15(94)

Pustules

n(%

)17

(85)

7(70)

5(71)

3(100)

5(43)

3(100)

27(79)

13(81)

Nodules

n(%

)11

(55)

6(60)

0(0)

1(33)

4(57)

1(33)

15(44)

8(50)

Cystsn(%

)3(15)

6(60)

4(57)

1(33)

1(14)

–8(24)

7(44)

Current

severity

Noacne

n(%

)0(0)

–0(0)

–1(14)

–1(3)

–

Mild

n(%

)5(25)

2(20)

0(0)

–2(29)

1(33)

7(21)

3(19)

Moderaten(%

)9(45)

3(30)

4(57)

2(66)

4(57)

2(66)

17(50)

7(44)

Dermatol Ther (Heidelb) (2018) 8:85–99 89

asking people to remove photos of them,avoiding being in photos, or making sure theywere in the background of group pictures.

Relationships

Almost half of adolescents and several adultsreported that acne has an impact on them whentalking to unfamiliar people. For some this wasdue to a lack of confidence, while others wor-ried how new people would perceive their acne.Participants described feeling ‘‘discomfort’’,‘‘embarrassed’’, ‘‘anxious’’, or ‘‘intimidated’’when talking to new people. Some adolescentsreported that acne has an impact on formingrelationships with girlfriends/boyfriends, forthe same reasons. Two adult participants men-tioned that their acne had caused relationshipsto end. Some adolescents also discussed prob-lems acne caused with their friendships; thisincluded friends making fun of their acne orfriends not understanding when they complainabout their acne. Almost half of the adolescentsample had friends with acne, which meant thatthey found it easier to cope with their ownacne. In contrast, several adults did not haveany friends with acne and therefore felt they didnot have anyone to talk to who understood.

Leisure Activities

The leisure activities most commonly affectedby acne were swimming and sports/exercise.Participants did not like to go swimmingbecause other people would see more of theiracne; some felt that chlorine would aggravatetheir acne, others did not want to be seenwithout makeup, and some adults did not wanttheir acne scars to be visible. Taking part insport was also affected by acne for several rea-sons; some participants found that their acnewas made worse by sweat, while others did notwant to join teams with strangers as they feltthey would stare at their acne. Participants alsoreported feeling self-conscious about their acnewhen getting changed or when wearing anathletics vest. Four adolescents discussed acnehaving an impact on them taking part inactivities such as acting or public speaking

Table1

continued

UK

Italy

Germany

Total

Ado

lescents

(N5

20)

Adu

lts

(N5

10)

Ado

lescents

(N5

7)Adu

lts

(N5

3)Ado

lescents

(N5

7)Adu

lts

(N5

3)Ado

lescents

(N5

34)

Adu

lts

(N5

16)

Severe

n(%

)5(25)

4(40)

2(29)

1(33)

0(0)

–7(21)

5(31)

Verysevere

n(%

)1(5)

1(10)

1(14)

–0(0)

–2(6)

1(6)

Severity

atworst

Moderaten(%

)5(25)

–3(43)

–2(29)

1(33)

10(29)

1(6)

Severe

n(%

)10

(50)

6(60)

3(43)

1(33)

4(57)

1(33)

17(50)

7(44)

Verysevere

n(%

)5(25)

4(40)

1(14)

2(66)

1(14)

1(33)

7(21)

7(44)

90 Dermatol Ther (Heidelb) (2018) 8:85–99

because they did not have the confidence tostand up in front of others.

Daily Activities

Both adolescents and adults discussed the time-consuming aspect of acne, having to allow timefor their skin care and treatment routine eachday. All female participants discussed makeup; afew did not wear cosmetics as they felt it wouldmake their acne worse, others used makeup tocover up their acne and make it less noticeable.Some would not leave their house withoutmakeup on. Some participants did not wearcertain clothes because of their acne, as they didnot want their shoulders or chest to be visible orthey did not want new clothes to be bleached bytheir acne medication. Participants would feelanxious or embarrassed and feel like peoplewere staring at them; therefore, they avoidedgoing out when their acne was at its worst.

Impact on Sleep

Acne had an impact on sleep for a third ofadolescent and half of adult participants. For

several this was due to pain or soreness causedby their acne, which would make it difficult toget to sleep; for others itchiness made it difficultto sleep. Three participants sometimes found itdifficult to sleep because they worried abouttheir acne or felt depressed about it.

Impact on School or Work

All of the adolescent participants were at schoolor college; although most felt that their schoolwork was not affected by acne, some mentionedfeeling distracted by their acne when it was atits worst. Three participants contributed less toclass activities because of the impact of acne ontheir self-confidence. A few participants weresometimes bullied or picked on at school abouttheir acne. For two participants, acne affectedthem to the extent that they took days offschool when their acne was at its worst.

Acne also affected some adult participants’work. Two participants felt they were less likelyto get jobs because they would be judged ontheir acne, while another opted to work athome when his acne flared up under the pre-tense of having chickenpox. One participant

Fig. 1 Percentage of adolescent (n = 34) and adult(n = 16) participants reporting an impact of acne on eachhealth-related quality of life (HRQL) concept. Thisfigure was first presented at the 26th European Academy

of Dermatology and Venereology Congress, September13–17, 2017, Geneva, Switzerland

Dermatol Ther (Heidelb) (2018) 8:85–99 91

had lost her job because she would not go towork when her acne was bad, another partici-pant had resigned from her job because she feltpeople were laughing at her acne. A studentnurse felt patients thought he had an infectionwhen his acne flared up and therefore did notwant him to treat them.

Perception of Acne/Reaction of Others

Most participants had experienced people beingmean or insensitive to them about their acne.For adults this was more common when theywere younger and people were generally nowmore sympathetic. Many participants felt that

Fig. 2 Example quotes related to the impact of acne on emotional functioning, social activities, social media, andrelationships

92 Dermatol Ther (Heidelb) (2018) 8:85–99

people stared at them because of their acne; thismade them feel self-conscious or nervous andaffected their self-confidence. Some participants

felt that they are judged on the basis of theiracne and are viewed in a negative way becauseof it.

Fig. 3 Example quotes related to the impact of acne on leisure activities, daily activities, sleep, school/work, and reactionfrom others

Dermatol Ther (Heidelb) (2018) 8:85–99 93

Five adolescents and half of adults felt thatpeople thought their acne must be their fault insome way; either caused by a lack of hygieneand not looking after their skin properly, a baddiet, or drinking alcohol.

Participants were asked whether they felttheir acne is taken seriously by other people.Adolescents generally felt their acne is takenseriously, particularly by their family and theirdoctor. Over half of adults felt their acne is nottaken seriously by others, including their gen-eral practitioner (GP); some had to visit their GPseveral times before they were referred to adermatologist.

Conceptual Model

A conceptual model was developed from thequalitative data, which illustrates the impact ofacne on HRQL and the links between concepts(Fig. 4). Emotional functioning is central to theconceptual model, as this appeared to have asubsequent impact on all other areas of HRQL.

The arrows in the model are based on thequalitative data where participants indicatedthat concepts are linked and indicate thedirection of influence. The dotted arrows indi-cate a potential moderator that can have apositive or negative influence on the extent towhich HRQL is impacted. A concept that wascommon throughout adolescent and adultinterviews was the perception of acne fromothers and their reaction to it, which poten-tially had an impact on all areas of HRQL.

Attributes of Topical Acne Treatments

Participants were asked to rate how importantseveral different acne treatment attributes are tothem on a scale from ‘‘not important at all’’ to‘‘critical/essential’’. The same three attributeswere rated most highly by adolescents andadults: treatment works quickly, does not causeirritation, and does not bleach. Some examplequotations about the treatment attributes aredisplayed in Fig. 5. For adolescents it was

Fig. 4 Conceptual model of the impact of acne on health-related quality of life (HRQL). Arrows indicate directionof influence; dotted arrows indicate a potential moderatorthat can have a positive or negative influence on the extent

of impact on HRQL. This figure was first presented at the26th European Academy of Dermatology and VenereologyCongress, September 13–17, 2017, Geneva, Switzerland

94 Dermatol Ther (Heidelb) (2018) 8:85–99

important that an acne treatment does not con-tain alcohol; several felt that alcohol might stingor irritate their skin and cause a burning sensa-tion. This attribute was generally less importantfor adult participants who felt that the treatmentingredients were not important as long as thetreatment was effective. Some participants felt itwas very important for a treatment to onlyrequire application once a day; however, someparticipants would apply it as many times asnecessary if it was effective. For some participantsit was important that the treatment could beapplied with their fingers rather than an appli-cator or pad as they felt it would be more hygienicand convenient. Similarly, for convenience, someparticipants preferred a treatment that did notneed to be kept refrigerated.

DISCUSSION

This qualitative study explored the impact ofacne and its treatment on adolescents’ and

adults’ HRQL and found that HRQL was affectedby acne for all except one participant. Theconceptual model illustrates the impact onHRQL and demonstrates the importance of aneffective treatment for acne to reduce this.Although the effect of acne on adolescents andadults is similar, there are some important dif-ferences. For adolescents, acne is more commonamong people the same age; therefore, manyadolescents had friends with acne or otherpeople at school had acne and thus they hadsome support from others who understood howit felt. For adults, some commented that they donot know anyone else their age who has acneand therefore felt alone and suggested thatothers do not understand how it feels. Adultsalso commented that people view acne assomething that affects teenagers and thereforefelt that people believed it might be due tothem not looking after their skin, their diet, oranother skin condition.

Fig. 5 Example quotes about the attributes of topical acne treatments

Dermatol Ther (Heidelb) (2018) 8:85–99 95

One difference between male and femaleparticipants was evident in the use of makeup toconceal acne, which reinforces the use of adju-vant therapies to improve acne treatment out-comes [29, 30]. A small number of maleparticipants had tried to conceal their acne withcosmetics in the past; however, this topic waslargely discussed by female participants and forsome the ability to conceal their acne made iteasier to cope with.

This study also explored the importance ofdifferent attributes of topical acne treatments.For both adolescents and adults the mostimportant attributes were fast-acting treatmentsthat do not cause irritation and do not bleachclothing. Adolescents felt it was important for atreatment to not contain alcohol; however, thiswas less important for adults. Adults placedmore importance on a treatment that had nospecific storage requirements. Given the lowadherence to acne therapies [15] (and the linkbetween dissatisfaction with treatment andnon-adherence [16]), when prescribing treat-ments it is important to consider the attributesthat may lead to increased satisfaction withtreatment.

The results of this study support the manyother studies that demonstrate the negativeimpact of acne on HRQL [5–7]. A previous studyfound that for adults with acne, perceivedstigma is a significant predictor of acne-relatedHRQL, contributing more than factors such asseverity, gender, or age [31]. The findings of thecurrent study provide qualitative support tothis; although the term ‘‘stigma’’ was not usedby participants, the negative impact of feelingjudged by their acne or feeling as though peopleare staring at their acne was discussed by mostparticipants.

Participants in the current study reportedways in which acne affects their use of socialmedia. Although many participants had socialmedia accounts, they did not post pictures ofthemselves if their acne was visible and avoidedhaving pictures taken as they did not wantthem to be posted online by others. Previousstudies have explored social media in relation todermatology in terms of it being a source ofinformation or support [32, 33]; however, to our

knowledge, this is the first study to explore theimpact of acne on use of social media.

This study illustrates the impact of acnethrough the development of a conceptualmodel from qualitative data. Conceptual mod-els can be useful tools that provide a visualrepresentation of the impact of a condition,allowing the links between concepts to beidentified. In addition to highlighting the manyareas of HRQL that are affected by acne, themodel can be used to identify concepts ofinterest for future studies, to guide selection ofan appropriate instrument to measure theimpact on HRQL [23], or as the basis for thedevelopment of a new instrument to assessHRQL in acne. While existing acne-specificHRQL instruments assess several of the conceptsidentified in the conceptual model, there wereconcepts identified as important to participantsin the current study that are not assessed bysuch instruments. For example, most instru-ments do not capture the impact of acne onsleep, daily activities, or work/school; thereforeexisting instruments may not fully capture theimpact of acne on HRQL.

Participants discussed some ways in whichtheir relationships are affected by acne. Asreported in the results, some participants dis-cussed feeling anxious or embarrassed whentalking to new people or feeling like they werejudged on their acne, which caused problemswith forming relationships with girlfriends/boyfriends. Although some participants dis-cussed this, many did not report an impact onthis area of their HRQL. It may be that adoles-cents in particular did not feel comfort-able speaking about this or that a parent orfamily member was in the room during theinterview, which made participants reluctant todiscuss it. This is a possible limitation of thestudy, as qualitative telephone interviews maynot have obtained the depth of data on thistopic that might be expected. Items on rela-tionships are included in several acne-specificinstruments (Acne-QOL, AQOL, DLQI, Skindex-29) and it may be that using quantitativemethods is a more appropriate way to explorethis concept.

Some limitations should be considered wheninterpreting the findings of this study. The

96 Dermatol Ther (Heidelb) (2018) 8:85–99

extent to which the findings can be generalizedto all adolescents and adults with acne is limitedby the small sample size; however, data satura-tion was reached for both adolescent and adultsamples, suggesting that additional interviewsmay not have introduced new concepts. Therecruitment also relied on self-reported severityin order to identify people with moderate–sev-ere acne; however, all participants were cur-rently or recently prescribed topical treatmentand had facial papules and/or pustules at thetime of the interview. Although some partici-pants experienced acne on several areas of theirbody, the inclusion criteria only required par-ticipants to have facial acne; therefore, theresults can only be assumed to be relevant tofacial acne. In addition, it is possible thatexperiences of older adolescents and youngadults are similar and any differences notedbetween the adolescent and adult samples arereally due to the older adults in the sample. TheGerman adult sample consisted of teenagers;therefore, the experience of older adults inGermany may not be represented.

CONCLUSIONS

The results of this qualitative study demonstratethat moderate–severe acne has an extensiveimpact on adolescents’ and adults’ HRQL. Theconceptual model illustrates the many areas ofHRQL that are affected and draws attention tothe importance of effective treatments for acne.The study highlights the importance of mea-suring HRQL in future interventional studies ofacne treatments and identifies treatment attri-butes that are most important to patients.

ACKNOWLEDGEMENTS

Funding. This study and article processingcharges were funded by Meda, a Mylan com-pany. All authors had full access to all of thedata in this study and take complete responsi-bility for the integrity of the data and accuracyof the data analysis.

Authorship. All named authors meet theInternational Committee of Medical JournalEditors (ICMJE) criteria for authorship for thismanuscript and have given final approval of theversion to be published.

Medical Writing and/or Editorial Assis-tance. Medical writing assistance in the prepa-ration of this manuscript was provided by JaneMurphy (CircleScience, an Ashfield Company,part of UDG Healthcare plc) and funded byMeda, a Mylan company.

Thanking Patient Participants. Thank youto study participants for their involvement inthis study.

Disclosures. Gabriella Fabbrocini receivesresearch fees from Meda, a Mylan Company.Giuseppe Monfrecola receives research feesfrom Meda, a Mylan company. Sara Cacciapuotihas nothing to disclose.

Compliance with Ethics Guidelines. Theresearch was designed to comply with guideli-nes for conducting research with children andyoung people [24]. Ethical approval was pro-vided by Salus IRB, an independent reviewboard, and the study was conducted in accor-dance with the principles of the Declaration ofHelsinki. All adult participants providedinformed consent prior to participating in thestudy; parents or guardians of adolescent par-ticipants provided informed consent for theirchild to participate; adolescents also providedassent.

Data Availability. The datasets generatedand/or analyzed during the current study areavailable from the corresponding author onreasonable request.

Open Access. This article is distributedunder the terms of the Creative CommonsAttribution-NonCommercial 4.0 InternationalLicense (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommer-cial use, distribution, and reproduction in anymedium, provided you give appropriate creditto the original author(s) and the source, provide

Dermatol Ther (Heidelb) (2018) 8:85–99 97

a link to the Creative Commons license, andindicate if changes were made.

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