Correspondence

“You [acne] have destroyed my self-confidence, created me physical and emotional pain, and have never once given me a break from you” 25-year-old woman, Canada (1)

Like facial acne, truncal acne (chest and/or back) presents with varying severity and distinctly impacts quality of life (QoL) (2, 3). Despite this, most QoL studies have focused on facial acne alone, resulting in a lack of understanding and limited dialogue on the impact of combined facial and truncal acne on people’s lives (2–5). Here, we explore the importance of the overall acne burden, in order to gain a complete profile of patients, and the need to develop QoL tools suitable for use in clinical practice to inform our treatment plans.

Due to time pressures, the trunk is not always discussed in acne consultations. Also, patients focus primarily on facial acne, since it is visible to others and difficult to hide. Evaluation of truncal acne has largely been neglected from an academic, clinical, and industry perspective. Although the Leeds photographic acne grading scale, which was developed in the 1970s to 1980s, includes the chest and back, truncal evaluation has not gained sufficient traction to enter the research paradigm. There has been an absence of regulatory authority guidance and paucity of guideline recommendations for truncal acne, as well as inadequate evaluation scales compared with facial acne. Similarly, the historical precedence of acne clinical trials has been the face, a circumscribed area that is relatively convenient to evaluate vs large areas of the trunk. As most topical treatments in the past have been developed and approved for facial acne, most QoL studies have also naturally focused on the face (2–5).

To gain insight into the extent to which the location of acne affects QoL, a large, international, cross-sectional survey was conducted recently (N = 1,309) using the validated QoL scales, dermatology-specific Dermatology Life Quality Index (DLQI and children’s DLQI), and acne-specific Comprehensive Quality-of-Life Measure for Facial and Torso Acne (CompAQ) (6). CompAQ is a 20-item questionnaire with 5 domains: psychological/emotional, social (judgement from others), social interactions, treatment concerns and physical symptoms. Among the several different acne-specific instruments available to assess QoL in people with acne, it is the only one that specifies the trunk (4, 7). CompAQ was developed in accordance with methodology from the US Food and Drug Administration (FDA) for patient-reported outcomes in clinical trials, and there is a recent drive for its wider use in clinical trials. In the past, we have typically relied on patient anecdotes, but this survey provided a comprehensive group analysis for the first time, accounting for the varied approaches and habits among dermatologists and patients from different cultures, and enabling robust and meaningful interpretations of the combined burden of facial and truncal acne.

The survey revealed that people with both facial and truncal acne are 1.5 times more likely to report a significantly greater impact on QoL than those with facial acne alone (DLQI odds ratio (OR): 1.61, p = 0.042; CDLQI: OR: 1.86, p = 0.028). Significantly more people with both facial and truncal acne experienced a detrimental impact on their daily life than those with facial acne alone, including feeling prohibited from going out in public and wearing clothes/participating in activities that reveal their acne, such as going to the beach, sauna or pool (6). The greater reduction in self-esteem observed with severe truncal acne, regardless of facial acne severity, suggests that the visibility of facial acne may not be the only factor in acne-related psychosocial distress. Facial and body features impact overall attractiveness for both sexes. For some, facial acne can contribute to reduced perception of attractiveness, whereas truncal acne may affect their perception of sexual appearance and negatively impact their intimate relationships (6). Notably, it has been reported that men prioritize bodily over facial attractiveness when evaluating a short-term vs long-term female partner, whereas women consistently prioritize facial attractiveness when choosing a partner (8).

Given these findings, it is important to conduct holistic evaluations and acne management for patients, where possible, taking into account previous treatments, diet, hobbies, and their relationship status. Approaching the subject of emotional burden and impact on daily life can be challenging and must be tailored for each patient with acne. The approach will differ among age groups and sex. In our experience, women typically experience a greater burden than men. Creating an inviting and safe environment for patients to discuss their concerns, and providing reassurance that there are treatments available, can help encourage dialogue.

Combining clinician-based and patient-reported outcomes is useful for comprehensive clinical evaluation and to inform treatment decisions. Ideally, patients should complete a QoL questionnaire before the consultation so they have time to reflect independently, as the presence of dermatologists or even parents can influence their answers. These questionnaires could serve as a basis for recognizing the overall burden of acne during consultations, but it may be important to establish a rapport with patients before initiating the conversation. Although adopting a QoL measure is recommended as a crucial part of acne management in several guidelines, such as European Dermatology Forum S3-Guideline (7), the validated QoL questionnaires used in clinical trials are typically too long for time-pressured consultations in clinical practice, highlighting the need for more practical tools for this purpose. In our experience, most dermatologists do not use lengthy questionnaires that disrupt their patient flow. Furthermore, if the questionnaires comprise multiple items, patients can lose interest and leave them incomplete.

As patients can be disheartened by the gradual effects of acne treatment, it is important to encourage treatment adherence in order to achieve the required goals. It is also important to appreciate that teenagers with facial and truncal acne may experience an additional burden due to their reliance on their parents to help with application of topical treatment, at a time in their lives when they are seeking independence and autonomy. Alongside physicians, nurses can have an important role in making patients feel comfortable and encouraging dialogue, while pharmacists can help educate patients about treatment adherence and adverse event management. In some cases in which patients are under severe psychosocial distress, specialists can provide the most appropriate support. Hypnotherapy, supportive psychotherapy and other interventions from mental health professionals can help to manage the burden. Online patient support groups may also provide a platform for patients to freely, yet anonymously, confide in their peers.

Typically, treatment decisions for acne are based on the worst clinical severity of acne lesions at each site or location (9). However, evaluating the combined burden of facial and truncal acne will provide further insight into the patient’s overall physical and psychological health status, and thus better inform treatment decisions. There is an unmet need for a practical tool to evaluate acne burden in time-pressured clinical practice, to enable a more comprehensive evaluation of patients. This tool should be easily adaptable to respect cultural differences and approaches across different regions and languages. Development of awareness programmes regarding the combined burden should also be actively encouraged, and treatments that address both facial and truncal acne should be included, as appropriate, in treatment plans. Ultimately, looking beyond the face and employing early and effective treatment will be important to reduce the psychosocial consequences and long-term burden of both facial and truncal acne.

Medical writing support was provided by Publicis Langland and funded by Galderma.

BD is an advisory board member for Galderma, Novartis, and Leo Pharma. JT is an advisor, consultant, investigator and/or speaker and received grants and honoraria from Almirall, Bausch, Botanix, Boots Walgreens, Cipher, Galderma, Novartis, Sol-Gel, Sun, and Vichy.