Condensation and validation of a 4-item index of the Acne-QoL

Patient-Reported Outcome Measures for Health-Related Quality of Life in Patients With Acne Vulgaris: A Systematic Review of Measure Development and Measurement Properties

Importance

Multiple patient-reported outcome measures (PROMs) for health-related quality of life (HRQoL) exist for patients with acne. However, little is known about the content validity and other measurement properties of these PROMs.

Objective

To systematically review PROMs for HRQoL in adults or adolescents with acne.

Data Sources

Eligible studies were extracted from PubMed and Embase (OVID).

Study Selection

Full-text articles published in English or Spanish on development, pilot, or validation studies for acne-specific, dermatology-specific, or generic HRQoL PROMs were included. Development studies included original development studies, even if not studied in acne patients per Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) recommendations. If a study included several diagnoses, the majority (ie, over 50%) of patients must have acne or acne-specific subgroup analyses must be available. Abstract and full-text screening was performed by 2 independent reviewers.

Data Extraction and Synthesis

Two independent reviewers assessed study quality applying the COSMIN checklist and extracted and analyzed the data. For each distinctive PROM, quality of evidence was graded by measurement property.

Main Outcomes and Measures

PROM properties (target population, domains, recall period, development language), PROM development and pilot studies, content validity (relevance, comprehensiveness, comprehensibility), and remaining measurement properties (structural validity, internal consistency, cross-cultural validity, reliability, measurement error, criterion validity, construct validity, and responsiveness). Quality of evidence was assigned for each measurement property of included PROMs. An overall recommendation level was assigned based on content validity and quality of the evidence of measurement properties.

Results

We identified 54 acne PROM development or validation studies for 10 acne-specific PROMs, 6 dermatology-specific PROMs, and 5 generic PROMs. Few PROMs had studies for responsiveness. The only acne-specific PROMs with sufficient evidence for content validity were the CompAQ and Acne-Q. Based on available evidence, the Acne-Q and CompAQ can be recommended for use in acne clinical studies.

Conclusions and Relevance

Two PROMs can currently be recommended for use in acne clinical studies: the Acne-Q and CompAQ. Evidence on content validity and other measurement properties were lacking for all PROMs; further research investigating the quality of remaining acne-specific, dermatology-specific, and generic HRQoL PROMs is required to recommend their use.

Quality of Life Assessed Using Skindex-16 Scores Among Patients With Acne Receiving Isotretinoin Treatment

Importance

Acne is a common dermatologic condition and significantly affects psychosocial health and quality of life. An international task force recommended routine use of quality-of-life measures for clinic visits associated with acne management, but this has yet to translate into clinical practice.

Objective

To assess mean Skindex-16 scores over time among patients with moderate to severe acne receiving isotretinoin treatment.

Design, Setting, and Participants

A longitudinal, retrospective case series study of Skindex-16 data collected at monthly visits from 57 consecutive patients with acne receiving isotretinoin; data were collected and evaluated between November 23, 2016, and January 22, 2019. Continuous variables were compared using quantile regression. Multivariable linear mixed models evaluated mean (95% CI) score trajectory over time.

Main Outcomes and Measure

Skindex-16 scores, including normalized scores for the emotional, symptomatic, and functional aspects of having skin disease as well as an overall score.

Results

Fifty-seven patients (31 [54.4 %] males, with median [interquartile range] age of 17.2 [15.9-18.1] years) in this case series study completed the Skindex-16 at baseline and at least once during follow-up. Baseline Skindex-16 scores were similar by sex but worse with increasing age. Emotional impact was more bothersome to patients with acne requiring isotretinoin treatment than either symptoms or functioning. Improvements of greater than 50% in overall and Emotional domain scores were seen by month 2 of receiving isotretinoin treatment (eg, overall scores decreased from 39.4 to 17.5 by month 2; a decrease of 22.0; P < .001). Qualitatively, Skindex-16 scores reached their nadir between months 3 and 5; at month 4, overall Skindex-16 scores showed a 4.4-fold improvement (from 39.4 at baseline to 8.9; P < .001) and Emotional domain scores showed a 4.8-fold improvement (from 57.7 at baseline to 11.9; P < .001).

Conclusions and Relevance

The findings of this case series suggest that patients receiving isotretinoin treatment achieve greater than a 50% improvement in quality of life by month 2 and can expect approximately 4-fold to 5-fold improvements from baseline with a full course of isotretinoin. This study shows the potential of routine administration of quality of life measures to assess patient care in dermatology.

Treatment challenges in adult female acne and future directions

Introduction: Acne is a chronic, inflammatory, and immune-mediated disease of the pilosebaceous unit, highly prevalent in adolescents. However, an increasing number of adults over 25 years old with facial acne, particularly women, have been observed. It is considered a different disease when compared to acne vulgaris. Face is the mainly involved area with inflammatory lesions and more sensitive skin, pointing out the need of a holistic approach.Areas covered: We performed a comprehensive literature search on PubMed database, up to January 2021, regarding adult female acne. We synthesized data about pathogenesis; differences compared to acne vulgaris; and treatment, with focus in the management challenges and perspectives.Expert opinion: It is essential to value the negative impact on quality of life of adult female acne, independently of severity. The disease has prolonged evolution, and patient might be resilient once the improvement, regardless of the treatment option, will just be noticeable after 3 months. Aggravating factors should be clearly discussed, such as the need of changing many habits, especially lesions manipulation. The therapeutic regimen includes make-up and tailored skin care (considering proneness to sensitivity), while anti-acne drugs should be chosen in accordance with desire to be pregnant, presence of pregnancy or breastfeeding.

Impact of acne on the daily life of adult patients: building a self-administered patient questionnaire

BACKGROUND

Acne is a long-lasting disease in adolescents and adults impacting the patient's daily life. Currently, there is no specific questionnaire that assesses its impact in adult patients.

AIM

To build a self-administered questionnaire assessing the impact of acne on the daily life in adult patients.

METHOD

A multidisciplinary working group was created, including 3 experts in healthcare questionnaires and dermatologists specialized in acne. A questionnaire using a standardized methodology for designing self-administered patient questionnaires according to conceptual, development and validation phases was developed. A cultural and linguistic validation into US English was conducted, based on the original French version.

RESULTS

A 14-item questionnaire demonstrating consistency, reproducibility and high reliability was build. The questionnaire significantly correlated with the SF-12 mental and SF-12 physical scores and CADI, indicating good external validity.

CONCLUSION

The present acne burden questionnaire AI-ADL allows the practioner to assess quickly and easily the burden of acne in patients during his daily clinical practice. Moreover, its short format allows patients to express easily and quickly their feelings and to initiate a conversation between the practioner and his patient. Thus, AI-ADL may help to better understand the multidimensional nature of acne, as well as the individual impact on the acne patient's daily life and moreover, it may play a key role in the decision-making process of treatment initiation and involvement of the patient in the management of his acne.

Correlation study between clinical classification and disability index in a holistic evaluation of acne severity and impact in Turkey

BACKGROUND

This study provides a comparison between disease severity observed by inspectors and the disease burden assessed by patients is scanty in acne study.

METHODS

In a multicenter prospective hospital-based study, modified Comprehensive Acne Severity Scale (mCASS) and Cardiff Acne Disability Index (CADI) were employed to grade disease severity and to determine the quality of life, respectively. The average of the mCASS and CADI scores, with range at 0-25, was termed as Acne Severity and Impact Grading System (ASIG).

RESULTS

In 1331 evaluated patients (mean: 21,51±4,93 years), including 306 men and 1025 women, an overall significant, positive correlation was found between ASIG and mCASS (r=0.862), or CADI (r=0.686), respectively (P=0.001 each). Adult women with back acne and adolescent with décolleté expressed greater concern (higher CADI) than the clinical severity (lower mCASS). The overall prevalence of acne in décolleté area, including neck, was 32.3%.

CONCLUSIONS

Discrepancies in the acne severity between self-perception and objective evaluation exist in certain subgroups of patients. Décolleté acne deserves special attention in clinical assessment.

Quality-of-Life Research in Acne Vulgaris: Current Status and Future Directions

Acne patients may have significant quality-of-life (QoL) impairment, therefore assessment of health-related QoL (HRQoL) in acne patients is recommended by several national and international guidelines as an integral part of acne management. The inclusion of QoL assessment in core outcome sets is now a popular idea. Several acne-specific QoL questionnaires are available but none cover all topics presented in other instruments. The impact of acne on different aspects of QoL may vary between patients from different age groups. The European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes has initiated a study on the relevance of the different QoL topics in acne patients. Detailed recommendations on treatment goals and changes of treatment approaches based on a validated banding system and a minimal clinically important difference in HRQoL questionnaires (such as the Dermatology Life Quality Index) may be an important and promising approach.

Development of a new patient-reported outcome measure to evaluate treatments for acne and acne scarring: the ACNE-Q

BACKGROUND

Psychosocial concerns represent important outcomes in studies of treatments for acne and acne scarring. Also important, but largely overlooked, is the concept of appearance.

OBJECTIVES

To design an acne-specific patient-reported outcome measure for acne and acne scarring.

METHODS

We used a mixed-methods approach. Phase I involved 21 patient interviews that were audio-recorded, transcribed and coded. Concepts were identified and developed into scales that were refined through 10 cognitive interviews and input from 16 clinical experts. Phase II involved data collection at hospital and community-based dermatology clinics in Canada and the U.S.A. Eligible participants were aged 12 years and older with acne and/or acne scars on the face, chest and/or back. Rasch Measurement Theory (RMT) analyses were performed to examine psychometric properties.

RESULTS

Phase I led to the development of seven scales that measure appearance of facial skin, acne (face, chest and back) and acne scars, acne-specific symptoms and appearance-related distress. In phase II, 256 patients completed the ACNE-Q. RMT analysis provided evidence that the items of each scale worked together conceptually and statistically. Most participants scored within the range of measurement for each scale (81·9-93·1%). Reliability was high, with person separation index values and Cronbach alpha values > 0·90 for the appearance scales, ≥ 0·87 for appearance-related distress and ≥ 0·75 for symptoms. Worse scores on appearance scales correlated with worse symptom scores and more appearance-related distress.

CONCLUSIONS

The ACNE-Q is a rigorously developed instrument that can be used to measure appearance and other patient-centred concerns. What's already known about this topic? Acne is a common dermatological condition that can have an important impact on psychosocial function. Current patient-reported outcome measures specific to acne focus mostly on measuring psychological and social impact. What does this study add? The ACNE-Q provides a set of independently functioning scales that measure appearance of facial, back and chest acne, acne scarring and facial skin. Additional scales measure appearance-related distress and acne symptoms. What are the clinical implications of this work? ACNE-Q provides the dermatology community with a rigorously developed patient-reported measure for acne that can be applied in clinical trials, research and patient care. The measurement of appearance by ACNE-Q scales is more comprehensive than in other instruments providing important information on appearance of their acne and/or acne scars from the patient perspective.

Content Validity of Patient-Reported Outcome Instruments used with Pediatric Patients with Facial Differences

Objective:

The aim of this systematic review was to identify patient-reported outcome (PRO) instruments used in research with children/youth with conditions associated with facial differences to identify the health concepts measured.

Design:

MEDLINE, EMBASE, CINAHL, and PsycINFO were searched from 2004 to 2016 to identify PRO instruments used in acne vulgaris, birthmarks, burns, ear anomalies, facial asymmetries, and facial paralysis patients. We performed a content analysis whereby the items were coded to identify concepts and categorized as positive or negative content or phrasing.

Results:

A total of 7,835 articles were screened; 6 generic and 11 condition-specific PRO instruments were used in 96 publications. Condition-specific instruments were for acne (four), oral health (two), dermatology (one), facial asymmetries (two), microtia (one), and burns (one). The PRO instruments provided 554 items (295 generic; 259 condition specific) that were sorted into 4 domains, 11 subdomains, and 91 health concepts. The most common domain was psychological (n = 224 items). Of the identified items, 76% had negative content or phrasing (e.g., “Because of the way my face looks I wish I had never been born”). Given the small number of items measuring facial appearance (n = 19) and function (n = 22), the PRO instruments reviewed lacked content validity for patients whose condition impacted facial function and/or appearance.

Conclusions:

Treatments can change facial appearance and function. This review draws attention to a problem with content validity in existing PRO instruments. Our team is now developing a new PRO instrument called FACE-Q Kids to address this problem.

Development of a Comprehensive Quality-of-Life Measure for Facial and Torso Acne

Background Acne is a chronic skin disorder which generally presents in adolescence but continues into adulthood, and negatively affects both physical and psychosocial well-being. Presently, there are no validated acne-specific quality-of-life (QoL) measures that include dimensions for both facial and torso acne.

OBJECTIVE

The objective of this study was to develop a QoL instrument for both facial and torso acne (CompAQ) in accordance with recommended standards.

METHODS

A literature review and Delphi survey of patients and clinicians were used to develop the conceptual framework for outcomes perceived important to acne patients. An initial version of the measure was developed, CompAQ-v1, and pilot tested with patients via cognitive interviews.

RESULTS

The Delphi survey generated 4 domains (physical, psychological, sociological, and treatment) and 54 items. These, along with a literature review and input from clinical experts, informed the development of the CompAQ-v1. Eleven cognitive interviews were conducted, resulting in the second version of the measure, CompAQ-v2. Psychometric validation resulted in the final 20-item CompAQ measure comprising 5 domains. An abbreviated 5-item measure was also developed (CompAQ-SF).

CONCLUSION

CompAQ and CompAQ-SF are instruments intended to evaluate QoL in patients with acne on their face or torso. The former is a 21-item QoL intended for research, while the latter is intended for clinical practice.

Quality of life measurement in acne. Position Paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa

Acne causes profound negative psychological and social effects on the quality of life (QoL) of patients. The European Dermatology Forum S3-Guideline for the Treatment of Acne recommended adopting a QoL measure as an integral part of acne management. Because of constantly growing interest in health-related QoL assessment in acne and because of the high impact of acne on patients' lives, the European Academy of Dermatology and Venereology Task Force on QoL and Patient Oriented Outcomes and the Task Force on Acne, Rosacea and Hidradenitis Suppurativa have documented the QoL instruments that have been used in acne patients, with information on validation, purposes of their usage, description of common limitations and mistakes in their usage and overall recommendations.

Development and Validation of a Comprehensive Acne Severity Scale

Background:

Although more than 25 acne grading systems exist, only 2 are inclusive of truncal acne. There is neither a gold standard nor a consistently used standardized system.

Purpose:

Our purpose was to develop and validate an acne grading system incorporating severity at the face, chest, and back.

Methods:

We developed a comprehensive acne severity scale (CASS) by modifying a preexisting facial acne scale, the Investigator Global Assessment, to include truncal acne. The validity and responsiveness of CASS grades were correlated with Leeds scores at baseline and after 6 months of standard acne treatment.

Results:

Spearman correlations were significant between Leeds and CASS grades for the face (0.823), chest (0.854), and back (0.872), respectively ( p < .001). After 6 months of therapy, changes in these scores were also significantly correlated ( p < .001) at all three sites.

Conclusion:

Concurrent validity of CASS is demonstrated by a very strong correlation with Leeds grading. CASS is simpler to use than the Leeds system and more appropriate for translation of research trial results to clinical practice.

Psychological impact of acne on 21st-century adolescents: decoding for better care

The psychological consequences of acne have been the subject of many studies. As a particularly visible skin disorder, acne complicates the daily lives of adolescents who are undergoing multiple transformations: physical, intellectual and emotional. While it is well established that acne can be responsible for depression and low self-esteem, it is likely that this impact is aggravated by the sociological evolution of adolescents in the 21st century. Understanding the codes of adolescents today (who can be characterized as being more concerned by their appearance than previous generations at the same age) allows us to optimize our medical approach to acne and facilitates treatment compliance and adherence.

Cultural Adaptation of the Cardiff Acne Disability Index to a Hindi Speaking Population: A Pilot Study

Background:

Acne vulgaris is known to impair many aspects of the quality of life (QoL) of its patients.

Aim:

To translate the Cardiff Acne Disability Index (CADI) from English into Hindi and to assess its validity and reliability in Hindi speaking patients with acne from India.

Methods:

Hindi version of CADI, translated and linguistically validated as per published international guidelines, along with a previously translated Hindi version of dermatology life quality index (DLQI) and a demographic questionnaire were administered to acne patients. The internal consistency reliability of the Hindi version of CADI and its concurrent validity were assessed by Cronbach's alpha co-efficient and Spearman's correlation co-efficient respectively. Construct validity was examined by factor analysis. Statistical analysis was carried out using the Statistical Package for the Social Sciences (SPSS) version 20 (SPSS Inc., Chicago, IL, USA) for Windows.

Results:

One hundred Hindi speaking patients with various grades of acne participated in the study. Hindi version of CADI showed high internal consistency reliability (Cronbach's alpha co-efficient = 0.722). Mean item-to-total correlation co-efficient ranged from 0.502 to 0.760. Concurrent validity of the scale was supported by a significant correlation with the Hindi DLQI. Factor analysis revealed the presence of two dimensions underlying the factor structure of the scale.

Conclusion:

Hindi CADI is equivalent to the original English version and constitutes a reliable and valid tool for clinical assessment of the impact of acne on QoL.

The Relationship Between Dermatologist- and Patient-Reported Acne Severity Measures and Treatment Recommendations

Background:

Acne treatment recommendations for individual patients may be derived from multiple factors including dermatologist- and patient-reported constructs.

Objectives:

To evaluate the effects of dermatologist- and patient-reported measures on acne treatment recommendations by dermatologists.

Methods:

An observational cross-sectional survey of acne patients was conducted with patient-reported quality of life and dermatologist-reported measures of primary and secondary (scar) acne severity using 3 assessment approaches: maximal regional grade, total grade, and facial grade.

Results:

The most highly associated factors with acne treatment recommendations were patient emotions, maximal regional acne severity, and total acne scar grade. Better acne-specific quality of life was negatively related to acne treatment recommendation intensity, while all 3 grading approaches were positively related to acne treatment recommendations.

Conclusions:

For dermatologists, overall acne severity is most highly associated with maximal regional acne grade, total scar grade, and patient’s emotional response to acne.

Acne smart club: an educational program for patients with acne

OBJECTIVE

To evaluate adherence to therapy in acne patients using mobile phones and Short Message Service (SMS) to communicate.

METHODS

160 patients were randomly assigned to two groups: the SMS group received 2 text messages twice a day for a period of 12 weeks; the control group did not receive any messages. Before and after 12 weeks, the following evaluations were performed in all patients: digital photographs, the Global Acne Grading System, the Dermatology Life Quality Index, the Cardiff Acne Disability Index, the doctor-patient relationship evaluated through the Patient-Doctor Depth-of-Relationship Scale, and the adherence to treatment evaluated by asking patients how many days a week they had followed the therapy. For statistical analysis we used Student's t test.

RESULTS

The SMS group had a better improvement of all parameters compared to the control group.

CONCLUSION

Adherence and compliance are higher for patients who are included in a strategy of control.

Quality of life measures for acne patients

Acne vulgaris affects most adolescents and two-thirds of adults and is associated with substantial psychosocial burden. Health-related quality of life (HRQOL) for patients with acne is an important factor of patient care, and several dermatologic and acne-specific measures have been created to assist in acne research, management, and care. This review describes several skin disease and acne-specific HRQOL measures and their applications in clinical care or research. The ideal HRQOL measure for the management of patients with acne is a concise questionnaire that places minimal burden on respondents and allows physicians to track improvement in HRQOL with successful treatment.

Development and Validation of a Scale for Acne Scar Severity (SCAR-S) of the Face and Trunk

Background:

Scarring is an important component of overall acne severity, but there are no global scales for its evaluation inclusive of the face and trunk.

Objective:

Our objective was to develop a global scale for acne scar severity inclusive of the trunk and the face.

Methods:

A six-category global severity scale (SCAR-S) was developed for assessment of acne scarring at each of the face, chest, and back. We evaluated SCAR-S against acne severity and patient-reported scar severity.

Results:

Of 973 subjects, 73% reported acne scarring. Self-assessment of scarring was associated with facial SCAR-S and overall SCAR-S scores ( p < .001, r = .31 and .30, respectively). Acne scarring was observed at the face in 87%, the back in 51%, and the chest in 38%. Clinically relevant scarring (mild or greater) at each of these regions was 55%, 24%, and 14%, respectively. Acne severity correlated with SCAR-S ( p < .001) for the back ( r = .612), the chest ( r = .548), and the face ( r = .514). Acne duration correlated with patient-reported severity of scarring ( r = .244) and overall SCAR-S scores ( r = .152). Clinically relevant scarring increased with acne duration.

Conclusion:

SCAR-S is a practical, validated, global system for acne scar evaluation and is clinically relevant in overall severity grading of acne.

Effect of Quality of Life Impact and Clinical Severity on Adherence to Topical Acne Treatment

Background:

Topical medications are the most commonly prescribed treatments for acne patients. However, adherence to these treatments and possible associations with clinical severity and quality of life (QoL) impact are unclear.

Purpose:

We evaluated the association between sociodemographic factors, clinical severity, and QoL impact and adherence to topical acne treatments.

Methods:

This was an observational study of acne patients referred for usual care to community-based dermatologists. Adherence was assessed with questionnaires after 2 months of acne therapy. The associations of adherence with factors of interest were evaluated by chi-square analysis and Spearman rank correlation.

Results:

In 152 acne patients treated with topical medications, low adherence was observed in 26%, medium in 49%, and high in 24%. Age, gender, duration of acne, education level, third-party drug plan coverage, smoking history, recreational drug use, ingestion of alcohol, and number of prescribed topical agents were not significantly associated with adherence. Adherence was significantly positively correlated with QoL impact ( r = .24, p = .003), with the role-emotional and self-perception domains having the highest correlations. In contrast, adherence was weakly negatively correlated with facial acne severity ( r = .16, p = .047).

Limitations:

This study focused on facial acne, and adherence was based on patient reporting.

Conclusions:

Adherence to topical acne therapy increases with impact on QoL but decreases with increasing acne severity.

Divergence of Demographic Factors Associated with Clinical Severity Compared with Quality of Life Impact in Acne

Background:

Previous smaller studies suggest that age, gender, and duration of acne may individually be associated with clinical acne severity and quality of life (QoL) impact.

Objective:

Our purpose was to concurrently evaluate the association of demographic factors with clinical acne severity and with QoL impact.

Methods:

Clinical acne severity was assessed using the Investigators Global Assessment, whereas QoL impact was evaluated by the patient-completed Acne-QoL. These outcomes were correlated with sociodemographic variables, including age, gender, and duration of acne.

Results:

In 862 acne patients, clinical severity was associated with younger age, male gender, and shorter acne duration (1–5 years). In contrast, greater impact on QoL was associated with older age, female gender, and longer acne duration (> 5 years).

Conclusions:

Clinical and QoL measures each differentiate between groups of patients most severely affected by acne. Our findings reinforce the imperative for clinicians to use both measures for comprehensive patient management.

Limitations:

Study limitations include referral population of acne patients and the restriction of outcome measures to facial acne.