The Social and Psychological Impact of Acne Treatment: A Cross-Sectional Study of Blood Donors

Abstract

Background

Acne in adolescence and adulthood is believed to have a long-term impact on socioeconomic status (SES) and health-related quality-of-life (HRQoL) in adults.

Objective

To estimate the cross-sectional prevalence of medically treated (MedTreAc) and untreated acne (UnTreAc) and to characterize its long-term impact in adults.

Methods

A nationwide cross-sectional study on 17 428 blood donors aged 18-35 was performed. Associations among acne and HRQoL, depressive symptoms, total income, and SES were investigated via linear/logistic/multinomial logistic regression analyses adjusted for relevant covariables. HRQoL was measured by the Short Form-12, and depressive symptoms by the Major Depression Inventory. The data were self-reported.

Results

Of the participants, 3591 (20.6%) and 1354 (7.8%) identified as the MedTreAc and UnTreAc phenotype, respectively. Neither phenotype was associated with a long-term impact on total income, but the MedTreAc group was associated with being an apprentice/student (OR = 1.26; 95% CI: 1.12, 1.42; P = 1.3×10^-4) or high skill-level employee (OR = 1.22, 95% CI: 1.07; 1.39, P = .0023), while self-employment was more common for those with UnTreAc (OR = 1.53; 95% CI: 1.12, 2.06, P = .0061). Additionally, the UnTreAc group was associated with a lower mental HRQoL (SF-12 mental component summary score −1.05, 95% CI: −1.56, −0.54; P = 1.4×10^-9) and increased odds ratio of depressive symptoms (OR = 1.44; 95% CI: 1.00, 2.02, P = .046).

Conclusion

In this population of blood donors, the cumulative prevalence of MedTreAc and UnTreAc were 20.6% and 7.8%, respectively. Untreated acne had a long-term impact on psychosocial well-being in adulthood. It was associated with lower mental HRQoL and higher occurrence of depressive symptoms. Acne was not associated with a lower salary or SES.

Keywords

acne vulgaris quality of life socioeconomic factors depression salaries income SF-12

Introduction

Acne vulgaris is a common multifactorial inflammatory skin disease affecting the pilosebaceous unit. Globally, acne affects 9.4% of the population, but predominantly adolescents and young adults. In female adults (>25 years), the prevalence of acne has been reported to range from 14% to 54%.^1

-4 Key pathogenic factors include seborrhea, abnormal follicular hyperkeratinization, microbial colonization, and pro-inflammatory activity of the cutaneous microbiome.^2,5,6 Conventional therapy includes topical therapy, hormonal agents, systemic antibiotics, and retinoids.^2,7,8

Unfortunately, both the medical and the layman community have, wrongfully, long viewed acne as a self-limiting teenage disease.⁹ This misconception may have led to a lack of awareness to the fact that acne is associated with serious psychosocial comorbidities (anxiety, depression, and reduced health-related quality of life^5,10

-13), and that severe acne potentially may lead to facial disfigurement if left untreated.¹⁴

Having a high Body Mass Index (BMI) has been associated with an increased risk of having acne, but not phenotype severity.^15,16 It has although been reported that the combination of hyperandrogenism and increased BMI may result in a more severe disease.¹⁷ The association between acne and smoking remains unclear, with some researchers claiming no association,¹⁸ while others categorize tobacco-smoking as protective.^3,19
-21

Acne treatment increases the financial strain of patients,^22,23 and the prevalence is therefore believed to be higher in groups with low socioeconomic status (SES).^22
-24

Many studies have focused on acne prevalence and the increased risk of psychosocial consequences. However, the difference in long-term sociopsychological impact between patients with medically treated acne and nonmedically treated acne in adolescence or adulthood remains unknown.

To explore this, we investigated the cross-sectional prevalence of both groups and compared their HRQoL, depressive symptoms and demographic factors in a large cohort of otherwise healthy adult blood donors.

Materials and Methods

Study Design and Population

This cross-sectional study is part of the Danish Blood Donor Study (DBDS), a multicenter, prospective public-health cohort and biobank (www.dbds.dk).^25

-28 More than 130 000 blood donors have consented to participate in the DBDS since March 2010, and fewer than 5% of the invited donors have declined participation. All active blood donors aged 18-67 years are eligible for inclusion. This study is based on the second version of the DBDS questionnaire circulated between July 2015 and May 2018. In this study, participants were restricted to those born between 1985 and 1998, capturing patients between 18-35.

Registries and Socioeconomic Status

All Danish inhabitants are assigned a unique ten-digit Civil Personal Register (CPR) number shortly after birth that makes easy record-linkage on a personal level possible.²⁹ Via encrypted CPR numbers, Statistics Denmark (DST) provides a multitude of information through various registries. For this study, data on salary, total income, SES as defined by job status, and all prescriptions written from January 1st, 1995, or later, were combined with the DBDS questionnaire data. SES is subdivided into a ranked and an unranked group. The ranked group consists of (1) executives (administrative/organizational leaders of companies/organizations), (2) high skill-level employee (chemist, architect, legal worker, etc.), (3) moderate skill-level employee (lab technician, optician, secretary, etc.), (4) basic skill-level employee (sales and customer service, etc.), (5) apprentices/students, (6) unemployed for at least 6 months in a year, and (7) publicly supported (cash benefits, educational support, sickness benefits, etc.). The unranked group consists of self-employed with 10+, 5-9, 1-4, or no employees; coworking spouse; retired; early retirement; and other employees (cleaning, delivery services, guard work etc.).

The Danish National Prescription Registry contains information on all drugs prescribed by a physician since January 1st, 1995. Prescriptions are indexed by CPR number, date of prescription, the Anatomical Therapeutic Chemical (ATC) code (https://www.whocc.no/atc/structure_and_principles/) of the drug and item number (to identify pack size).²⁹ For the list of medical acne treatment used to group the patients, see Supplmental Table 1.

Questionnaire and Acne Phenotypes

The second version of the DBDS questionnaire contains a question inquiring whether the participant in their lifetime had had acne severe enough to warrant treatment. Based on the answer to this question, and whether they had received treatment for acne (any treatment from Supplemental Table 1) they were grouped as the following: (1) those who reported severe acne warranting treatment and had received medical treatment (MedTreAc), (2) those who reported acne severe enough to warrant treatment, but were untreated (UnTreAc), and (3) healthy controls. Those in the treated group (MedTreAc) are those that between 1994 and 2016 had been treated with a systemic acne relevant treatment (Supplemental Material). All participants were at inclusion between 18 and 35, and it was therefore deemed that they could remember if they had had severe acne in their youth/adulthood. All treatment for acne were systemic and not topical.

Additional questions included lifestyle (BMI, smoking, and alcohol) and health-related items: the Major Depression Inventory (MDI) and The Short Form-12 (SF-12).²⁵ MDI is a validated Danish screening questionnaire for depression that covers diagnostic criteria for the International Classification of Diseases Version 10 (ICD-10), and can subsequently be used to assess severity.³⁰ Mild depression: 2 major + 2 minor criteria. Moderate depression: 2 major + 4 minor criteria. Severe depression: 3 major + 5 minor criteria. As the MDI does not investigate a possible organic reason for the symptoms, it is only indicative of depression.³⁰

The SF-12 is a shorter version of the original Short Form‐36 (SF‐36) that was designed to provide a single‐page HRQoL survey.³¹ SF‐12 provides a Physical Component Summary (PCS) and a Mental Component Summary (MCS). These scores explain more than 80% of the variance in the original 8 SF‐36 scores,³² with higher scores indicating better HRQoL.

Statistical Analysis

To isolate the association of MedTreAc and UnTreAc with outcomes, multiple linear regression analyses were performed for continuous outcomes (income, SF-12, and MDI), adjusting for age, sex, BMI, and smoking. The following were evaluated: linearity with scatter plots, multivariate normality with histograms and QQ plots, multicollinearity with a correlation matrix, and homoscedasticity with residuals against predicted values. Logistic regression analyses were performed to measure the association with depression rates and unranked SES, and a multinomial logistic regression analysis was performed to measure the association with the rank-ordered SES. These analyses were adjusted for the effects of age, sex, and BMI.

For descriptive statistics, medians and interquartile ranges were provided. Differences between groups were assessed with chi-square, t, or Mann–Whitney U tests depending on variable type and normality. All participants with missing information on BMI or smoking status were included in descriptive statistics but excluded from the multiple linear, logistic, and multinomial logistic regressions. Bonferroni correction for multiple testing was applied. The Bonferroni correction aims at adjusting the multiple P values due to the increased risk of type 1 error.

Statistics were performed in R-3.5.1 for Windows (GNU General Public license) applying relevant packages.³³

Results

Prevalence and Descriptive Statistics

Of the 17 428 participants, born 1985 and 1998, 20.6% (3591/17 428) had received medical treatment for acne, and an additional 7.8% (1354/17 428) were medically untreated but reported that they had treatment requiring acne. Consequently, 27.4% (1354/4945) of those reporting acne severe enough that they believed warranted treatment had never received a medical prescription.

Compared to the healthy controls, both the MedTreAc and the UnTreAc group had a higher ratio of females, a lower BMI, a lower ratio of current smokers, and reported a more frequent consumption of wine (Table 1; all P < .05).

Table 1

Descriptive Statistics of the 3 Groups.

Descriptive statistics		MedTreAc	UnTreAc	Healthy controls	P value	Difference between
Participants (% of all)		3591 (20.6)	1354 (7.8)	12 483 (71.6)
Treatment for acne (%)	- Local	3591 (100)
	- Systemic AB	830 (23.1)
	- Retinoid (systemic)	1102 (30.7)
Sex	- Female	2243 (62.5)	733 (54.1)	6425 (51.5)	<2.2 x 10^-16	Healthy and severe acne^a
Sex	- Male	1348 (37.5)	621 (45.9)	6058 (48.5)	<2.2 x 10^-16	Acne and severe acne^a
BMI, median (IQR)		23.5 (21.6; 25.7)	23.6 (21.9; 25.9)	24.2 (22.1; 26.9)	<2.2 x 10^-16	Healthy and acne^a
- NA (%)		7 (0.2)	2 (0.1)	39 (0.3)	<2.2 x 10^-16	Healthy and severe acne^a
Age, median (IQR)		25.3 (22.8; 28.0)	25.4 (22.8; 28.1)	25.3 (22.6; 28.2)	.53
Current smoker	- Yes (%)	528 (14.7)	186 (13.8)	2027 (16.3)	9.7 × 10^-3	Healthy and severe acne^b
	- No (%)	3058 (85.3)	1166 (86.2)	10 444 (83.7)		Healthy and acne^b
	- NA (%)	5 (0.1)	2 (0.1)	12 (0.1)
How frequently do you drink beer?	- At least once per week (%)	661 (18.4)	279 (20.6)	2446 (19.6)	.15
	- Less than once per week (%)	2925 (81.6)	1075 (79.4)	10 026 (80.4)
	- NA (%)	5 (0.1)	0 (0)	11 (0.1)
How frequently do you drink wine?	- At least once per week (%)	352 (9.8)	142 (10.5)	1090 (8.8)	.027	Healthy and severe acne^b
	- Less than once per week (%)	3234 (90.2)	1211 (89.5)	11 358 (91.2)		Healthy and acne^b
	- NA (%)	5 (0.1)	1 (0.1)	35 (0.3)
How frequently do you drink hard liquor?	- At least once per week (%)	138 (3.8)	56 (4.1)	467 (3.8)	.76
	- Less than once per week (%)	3447 (96.2)	1295 (95.9)	11 976 (96.2)
	- NA (%)	6 (0.2)	3 (0.2)	40 (0.3)

Abbreviations: BMI, body mass index; IQR, interquartile range; NA, missing data.

Table shows the descriptive statistics comparing MedTreAc, UnTreAc, and healthy controls groups.

^a P < .0001

^b P < .05

Psychological Comorbidities and HRQoL

According to the diagnostic ICD10 criteria for depression, 1.9% (67/3591) of the MedTreAc group and 2.7% (36/1354) of the UnTreAc group fulfilled the symptoms indicative for depression compared to 2.0% (249/12 483) of the healthy controls (Table 2). In a multivariable logistic regression analysis, this corresponded to an OR of 0.96 (95% CI: 0.72, 1.25; P = .75) for the MedTreAc group and 1.44 (95% CI: 1.00, 2.02; P = .046) for the UnTreAc group. While the increased rates of depression were not significant after the Bonferroni correction for multiple testing, the UnTreAc group had a significantly lower SF-12 MCS (−1.05, 95% CI: −1.56, −0.54; P = 1.4 × 10^-9). This was not so for the MedTreAc group and neither group showed a lower SF-12 PCS.

Table 2

Psychological and Income-Related Differences.

Questionnaire and registry data		MedTreAc	UnTreAc	Healthy controls	Crude P value	β-value when adjusted for age, sex, BMI, and smoking (95% CI)	Odds ratio when adjusted for age, sex, BMI, and smoking (95 % CI)^a	Adjusted P value
		N = 3591	N = 1354	N = 12 483
		N = 3591	N = 1354	N = 12 483					MDI, median (IQR)	6 (3; 9)	6 (3; 10)	6 (3; 9)	4.3 × 10-6^b	MedTreAc: 0.93 (0.56, 1.29)	5.9 × 10^-7
UnTreAc: 0.32 (0.09, 0.57)	7.9 × 10^-3d								MDI, median (IQR)	6 (3; 9)	6 (3; 10)	6 (3; 9)	4.3 × 10-6^b
	– NA (%)	34 (0.9)	18 (1.3)	164 (1.3)
MDI, classification	– Depression (%)	67 (1.9)	36 (2.7)	249 (2.0)	.19		MedTreAc: 0.96 (0.72, 1.25)	.75
	– Mild (%)						UnTreAc: 1.44 (1.00, 2.02)	.046
		20 (0.6)	10 (0.7)	90 (0.7)	.56		MedTreAc: 0.78 (0.47, 1.24)	.32
	– Moderate (%)						UnTreAc: 1.07 (0.52, 1.97)	.83
		30 (0.8)	19 (1.4)	119 (1.0)	.18		MedTreAc: 0.92 (0.61, 1.37)	.71
	– Severe (%)						UnTreAc: 1.64 (1.00, 2.61)	.049
		17 (0.5)	7 (0.5)	40 (0.3)	.26		MedTreAc: 1.42 (0.78, 2.48)	.23
SF-12 PCS, median (IQR)		55.9	55.9	55.8	.37	MedTreAc: −0.07 (-0.23, 0.09)		.38
SF-12 PCS, median (IQR)		(53.7; 57.5)	(53.7; 57.5)	(53.7; 57.4)	.37	UnTreAc: −0.09 (-0.32, 0.15)		.48
	– NA (%)	55 (1.5)	16 (1.2)	183 (1.5)
SF-12 MCS, median (IQR)		51.2	50.6	51.2	5.8 × 10^-4 ^c	MedTreAc: −0.19 (-0.52, 0.15)		.28
SF-12 MCS, median (IQR)		(44.8; 54.8)	(43.9; 54.6)	(45.6; 54.8)	5.8 × 10^-4 ^c	UnTreAc: −1.05 (-1.56, −0.54)		1.4 × 10^-9d ‡
	– NA (%)	55 (1.5)	16 (1.2)	183 (1.5)
Salary (DKK), median (IQR)		215 278 (72 212; 359 970)	235 663 (79 949; 376 111)	222 769 (74 257; 363 401)	.06	MedTreAc: −245 (−5772, 5281)		.93
Salary (DKK), median (IQR)		215 278 (72 212; 359 970)	235 663 (79 949; 376 111)	222 769 (74 257; 363 401)	.06	UnTreAc: 6786 (-1514, 15 086)		.11
Total income (DKK), median (IQR)		261 864 (150 091; 374 190)	271 981 (154 091; 388 355)	263 283 (149 146; 274 183)	.07	MedTreAc: 2656 (-2121, 7434)		.28
Total income (DKK), median (IQR)		261 864 (150 091; 374 190)	271 981 (154 091; 388 355)	263 283 (149 146; 274 183)	.07	UnTreAc: 5331 (-1842, 12 505)		.14

Abbreviations: CI, confidence interval ; DKK, Danish Kroner (April 2021: 10 000 DKK = €1345 = $1623, in accordance with Statistics Denmark the average yearly salary for a Danish worker aged 25-29 was in 2018, 257 139 DKK); HRQoL, Health-Related Quality of Life; IQR, interquartile range; MedTreAc, Received medical treatment for acne; N, number; NA, missing data; UnTreAc, Self-reported acne, but untreated.

Table shows the difference in depression rates, HRQoL, salary, and total income between the 3 groups: MedTreAc, UnTreAc, and healthy controls.

^aLogarithmic odds ratio and 95% CI have been exponentially transformed for easy assessment.

^bSelf-reported acne is significantly higher than both severe acne (P = .02) and healthy (P < .0001), and severe acne is significantly higher than healthy (P = .01).

^cSelf-reported acne is significantly lower than healthy (P = .0003).

^dStatistically significant after the Bonferroni correction for multiple testing.

Income and Socioeconomic Ranking

As seen in Table 2, after adjusting for the effects of covariables, there was no difference in annual salary or total income for either the MedTreAc group or the UnTreAc group.

The rank order of SES applied to 93.6%, 92.4%, and 91.6% of the UnTreAc group, the MedTreAc group, and the healthy controls, respectively. In the multinomial logistic regression analysis, the MedTreAc group was statistically significantly more likely to be a high skill-level employee (OR = 1.22; 95% CI: 1.07, 1.39; P = .0023) and apprentices/students (OR = 1.26; 95% CI: 1.12, 1.42; P = 1.3 x 10^-4). There were no differences between groups in regard to being either executives, moderate skill-level employees, unemployed, or publicly supported.

Additionally, for the un-ranked SES, there was no difference in levels of retirement, early retirement, coworking spouse, and other employees between the groups. While levels of self-employment were higher for the UnTreAc group (OR = 1.53; 95% CI: 1.12, 2.06; P = .006), this difference did not survive correction for multiple testing (Table 3).

Table 3

Socioeconomic Status Across the 3 Groups.

Socioeconomic status	Rank	MedTreAc	UnTreAc	Healthy controls	P value	Odds ratio and 95% CI from multinomial logistic/logistic regression of acne’s effect upon socioeconomic status^a	P value
		N = 3591	N = 1354	N = 12 483
		N = 3591	N = 1354	N = 12 483				Ranked socioeconomic status
Executive, N (%)	1	25 (0.7)	9 (0.7)	89 (0.7)	.98	MedTreAc: 1.24 (0.78, 1.96)	.36
Executive, N (%)	1	25 (0.7)	9 (0.7)	89 (0.7)	.98	UnTreAc: 0.95 (0.47, 1.92)	.89
High skill-level employee, N (%)	2	706 (19.7)	309 (22.8)	2289 (18.3)	1.6 × 10^-4 ^c	MedTreAc: 1.22 (1.07, 1.39)	.0023^b
High skill-level employee, N (%)	2	706 (19.7)	309 (22.8)	2289 (18.3)	1.6 × 10^-4 ^c	UnTreAc: 1.22 (1.02, 1.46)	.028
Moderate skill-level employee, N (%)	3	651 (18.1)	214 (15.8)	2138 (17.1)	.13	MedTreAc: 1.17 (1.02, 1.33)	.02
Moderate skill-level employee, N (%)	3	651 (18.1)	214 (15.8)	2138 (17.1)	.13	UnTreAc: 0,95 (0.78, 1.15)	.58
Basic skill-level employee, N (%)	4	584 (16.3)	258 (19.1)	2531 (20.3)	5.4 × 10^-7 ^d	Ref.
Apprentices/students, N (%)	5	1,244 (34.6)	446 (32.9)	3992 (32.0)	.01^e	MedTreAc: 1.26 (1.12, 1.42)	1.3 × 10^-4 ^b
Apprentices/students, N (%)	5	1,244 (34.6)	446 (32.9)	3992 (32.0)	.01^e	UnTreAc: 1.07 (0.90, 1.28)	.42
Unemployed, at least 6 months a year, N (%)	6	38 (1.1)	12 (0.9)	164 (1.3)	.23	MedTreAc: 1.01 (0.70, 1.46)	.96
Unemployed, at least 6 months a year, N (%)	6	38 (1.1)	12 (0.9)	164 (1.3)	.23	UnTreAc: 0.73 (0.40, 1.33)	.3
Publicly supported (sickness benefits educational support, etc.), N (%)	7	69 (1.9)	20 (1.5)	228 (1.8)	.58	MedTreAc: 1.15 (0.88, 1.57)	.26
	7	69 (1.9)	20 (1.5)	228 (1.8)	.58	UnTreAc: 0.85 (0.52, 1.36)	.49
Unranked socioeconomic levels
Self-employed, in total, N (%)	-	61 (1.70)	11 (0.81)	151 (1.21)	.02^f	MedTreAc: 0.67 (0.34, 1.18)	.2
Self-employed, in total, N (%)	-	61 (1.70)	11 (0.81)	151 (1.21)	.02^f	UnTreAc: 1.53 (1.12, 2.06)	.0061
Self-employed, no employees, N (%)	-	57 (1.59)	10 (0.74)	145 (1.16)	.03^g	MedTreAc: 0.62 (0.31, 1.14)	.16
Self-employed, no employees, N (%)	-	57 (1.59)	10 (0.74)	145 (1.16)	.03^g	UnTreAc: 1.47 (1.07, 2.00)	.02
Self-employed, 1-4, or more employees, N (%)	-	3 (0.09)	0 (0)	6 (0.05)	.49	MedTreAc: -	.99
Self-employed, 1-4, or more employees, N (%)	-	3 (0.09)	0 (0)	6 (0.05)	.49	UnTreAc: 2.30 (0.48, 8.83)	.24
Self-employed, 5-9 or more employees, N (%)	-	1 (0.03)	1 (0.7)	0 (0)	.03	MedTreAc: -
Self-employed, 5-9 or more employees, N (%)	-	1 (0.03)	1 (0.7)	0 (0)	.03	UnTreAc: -
Self-employed, 10 or more employees, N (%)	-	0 (0)	0 (0)	0 (0)	1	-
Coworking spouse, N (%)	-	0 (0)	0 (0)	1 (0.01)	.82	MedTreAc: -
Coworking spouse, N (%)	-	0 (0)	0 (0)	1 (0.01)	.82	UnTreAc: -
Early retirement, N (%)	-	1 (0.03)	1 (0.07)	7 (0.06)	.75	MedTreAc: 1.75 (0.09, 10.4)	.6
Early retirement, N (%)	-	1 (0.03)	1 (0.07)	7 (0.06)	.75	UnTreAc: 0.71 (0.04, 4.29)	.76
Retired, N (%)	-	0 (0)	0 (0)	0 (0)	1	-
Other employees, N (%)	-	174 (4.85)	58 (4.28)	691 (5.54)	.06	MedTreAc: 0.80 (0.60, 1.05)	.12
Other employees, N (%)	-	174 (4.85)	58 (4.28)	691 (5.54)	.06	UnTreAc: 0.95 (0.80, 1.13)	.58
Others, N (%)	-	38 (1.06)	16 (1.18)	202 (1.62)	.03^h	MedTreAc: 0.78 (0.45, 1.26)	.34
Others, N (%)	-	38 (1.06)	16 (1.18)	202 (1.62)	.03^h	UnTreAc: 0.70 (0.48, 0.98)	.045

Abbreviation: CI = confidence interval, MedTreAc = Received medical treatment for acne,N = number, SES = socioeconomic status, UnTreAc = Self-reported acne but was untreated.

Table shows the SES distribution of the 3 groups. The multinomial logistic regression (analysis for ranked SES) and logistic regression (analyses for unranked SES) are analyses of the association between SES and having severe or self-reported acne. The analyses are adjusted for the effect of sex, BMI, and age. In the multinomial logistic regression analysis, employee basic skill level was used as a reference.

^aCorrected for sex, BMI, and age and using employee basic skill levels as a reference category. For full table, see Table S1.

^bStatistically significant after the Bonferroni correction for multiple testing.

^cSelf-reported acne is significantly higher than both severe acne (P < .0001) and healthy (P < .0001).

^dSevere acne is significantly lower than healthy (P < .0001) and self-reported acne (P = .02).

^eSevere acne is significantly higher than healthy (P = .003).

^fSevere acne is significantly higher than self-reported acne (P = .03) and healthy controls (P = .03).

^gSevere acne is significantly higher than self-reported acne (P = .02) and healthy controls (P = .04).

^hSevere acne is significantly lower than healthy (P = .02).

Discussion

The prevalence of MedTreAc and UnTreAc was 20.6% and 7.8%, respectively, with 27.4% of those reporting acne severe enough to require treatment, never having received a prescription for acne treatment. This is an interesting finding as blood donors are typically healthy and altruistic individuals with a surplus of mental resources. This surplus perhaps translates into stronger self-care^34,35 and consequent pursuit of treatment for common diseases such as acne. Amongst students aged 10-19, it has been shown that 59% of those who report severe acne had not approached a health professional for treatment.³⁶ Reasons for this may vary, but an element of self-care and the usage of over-the-counter products may be prominent. Our results indicate that while more acne patients receive treatment in adult years, the need for treatment is nowhere near complete. This is disconcerting as treatment for acne initiated in the mid-twenties is associated with a failure rate between 30% and 80% depending on treatment modality,⁸ and that psychosocial sequalae are greater in those who go untreated. Previously, treatment of acne with isotretinoin has been met with resistance due to fear of psychiatric side effects.³⁷ This fear has now largely been put to rest, as acne patients treated with isotretinoin do not appear to have an increased risk of depression.^38,39 Our results confirm that patients with untreated acne have a numerical trend for increased risk of depression. The interpretation of these results is further dependent on the minimal clinically important difference (MCID). While the MCID of the SF-12 has not been calculated for acne, for some diseases , such as psoriasis and heart failure, it has been reported as low as 1 point.⁴⁰ These results confirm previous findings on reduced HRQoL for patients with acne,^10

-13 and add that long-term decreases in HRQoL are only seen for those whose acne goes untreated. Intuitively, these findings are sound, as acne impairs social functioning due to embarrassment and stigma, but does not hinder the physical capability of the individual.⁴¹ Long-term social and psychological impact is therefore most likely to present itself in people whose acne has remained untreated and continues to impact social interactions and life choices into adulthood. This may be further exemplified by the fact that the MedTreAc group was more likely to pursue higher education, whereas the UnTreAc group rather pursued self-employment, which can be a more socially isolated career. An alternate explanation may be that members of the UnTreAc group feel more stigmatized, which in turn could have kept them from both seeking treatment and caused them to have a lower HRQoL.⁴² A similar argument could be made due to feelings of hopelessness or simply their personality type. Each of these explanations however appears inadequate, as every participant had sufficient resources to commit to the purely altruistic act of blood donation.

Neither the MedTreAc nor the UnTreAc group had a lower salary or total income than the healthy controls. The MedTreAc group had a higher likelihood of being a high skill-level employee (level 2) or apprentices/students (level 5), and the UnTreAc were more likely to pursue self-employment. None of the groups had an increased risk of unemployment (level 6) or public support (level 7). Contrary to previous reports, we did not find either acne group to be correlated with a lower total income or SES. People with untreated acne may however prefer self-employed jobs that do not require the same social skills or exposure as basic skill-level jobs (eg, customer service and sales).⁴³ Preferring self-employment may however also indicate a higher level of determination and self-sufficiency, which might be the case for the UnTreAc group.

Few studies have investigated the association between acne and SES. Those that have, primarily focus on the added financial strain of acne on low-income/SES families, and how this may lead to reduced compliance and treatment-seeking behavior due to economic barriers.^22,23 Only 1 publication has reported on the association between acne and employment in adults.²⁴ This study, from 1986, states that among acne patients from Leeds aged 18-30 years, 15.4% were unemployed compared to the national average of 9.0%. The authors were unable to investigate SES, but their definition of unemployment matches the second-lowest SES level used in our study (unemployed for at least 6 months in a year). Unfortunately, their conclusion is based on only 625 patients, and analyses did not adjust for age or other variables that could affect employment status.

The strengths of this study are the unbiased reporting of acne treatment, salary, total income, and SES. These are accessible through the Danish registries and connected to the DBDS-reported lifestyle factors. Another strength is the large study sample.

With regard to limitations, the most apparent is that we had to restrict the participants to those born between 1985 and 1998. This was done to avoid recall bias of the acne phenotype in the questionnaire. While a physical examination coupled with a full medical history would have been the optimal choice, this was not feasible due to geographical and financial challenges of a study conducted on the national level. A more relevant bias is threshold bias, as the threshold needed for seeking treatment may be lower for high SES participants. Likewise, there could potentially be a sampling bias, as people with acne and low SES are less likely to become blood donors; however, this is true for everyone with low SES and not just those with acne. This bias is therefore not a systematic sampling bias. Lastly, despite adjustment for known and suspected confounders, we cannot rule out residual confounding.

There is a remaining unmet need for treatment, as 27.4% of those who report acne severe enough to require treatment never receive a prescription for medical treatment. The importance of this therapeutic shortcoming is augmented by the observations that untreated acne has a long-term impact on psychosocial well-being, specifically lower mental HRQoL and higher occurrence of depressive symptoms. In contrast to previous paradigms, neither treated nor untreated acne is associated with a lower salary or SES in our population. Yet, acne may influence the life-course of patients, as untreated acne may lead people to pursue careers of self-employment that have lower requirement for social interaction.

Supplemental Material

Table S1 - Supplemental material for The Social and Psychological Impact of Acne Treatment: A Cross-Sectional Study of Blood Donors

Supplemental material, Table S1, for The Social and Psychological Impact of Acne Treatment: A Cross-Sectional Study of Blood Donors by Rune Kjærsgaard Andersen, Dorra Bouazzi, Christian Erikstrup, Kaspar René Nielsen, Kristoffer Sølvsten Burgdorf, Mie Topholm Bruun, Henrik Hjalgrim, Susan Mikkelsen, Henrik Ullum, Ole Birger Pedersen and Gregor Borut Ernst Jemec in Journal of Cutaneous Medicine and Surgery

Footnotes

Acknowledgment

The authors would like to thank Karina Banasik who contributed with the general project design of DBDS and the cleaning of DBDS data.

Author Note

The author Henrik Hjalgrim is now affiliated with Department of Epidemiology Research, Statens Serum Institute. Department of Hematology, Copenhagen University Hospital, Rigshospitalet and Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RK Andersen, KR Nielsen, MT Bruun, KS Burgdorf, H Hjalgrim, S Mikkelsen, H Ullum, & OB Pedersen report no conflicts of interest. D Bouazzi: UCB Nordic has paid for EADV congress participation. GBE Jemec has received honoraria from AbbVie, Chemocentryx, Coloplast, Incyte, Inflarx, Novartis, Pierre Fabre, and UCB for participation on advisory boards; received grants from Abbvie, Astra-Zeneca, Inflarx, Janssen-Cilag, Leo Pharma, Novartis, Regeneron, and Sanofi, for participation as an investigator; and received speaker honoraria from AbbVie, Boehringer-Ingelheim, Galderma, and MSD. He has also received unrestricted departmental grants from Abbvie, Leo Pharma, and Novartis. C Erikstrup received an unrestricted research grant from Abbott.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This paper received funding from the Leo Foundation. Reference number LF 18002. The funding source was not involved in the planning, execution, or reporting of this study.

Availability of Data and Materials

Data from Danish registries are protected by the Danish Act on Processing of Personal Data and can only be accessed following application. Therefore, data sharing for this study is not possible.

Ethics Approval

This study has been approved by Danish Data Protection Agency, Copenhagen (2012-58-0004, RH-30-0444 / I-suite no.: 00922) and the Committee on Health Research Ethics in the Central Denmark Region (M-20090237).

**

The Department of Dermatology, Zealand University Hospital is a part of the European Reference Network on Rare and Undiagnosed Skin Disorders.

ORCID iDs

Dorra Bouazzi

Gregor Borut Ernst Jemec

Supplemental Material

Supplemental material for this article is available online.

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