Anxiety and depression in patients with acne vulgaris at tertiary care hospital: A cross-sectional study

Satya Rayapureddy; Therissa Benerji; Madhavi Kodali; Roshini Pallekona; Harsha Enamurthy; MS Ravi Kumar

doi:10.4103/jdrntruhs.jdrntruhs_88_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 11 | Issue : 4 | Page : 351-355

Anxiety and depression in patients with acne vulgaris at tertiary care hospital: A cross-sectional study

Satya Rayapureddy¹, Therissa Benerji¹, Madhavi Kodali¹, Roshini Pallekona¹, Harsha Enamurthy², MS Ravi Kumar³
¹ Department of Psychiatry, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, Andhra Pradesh, India
² Dermatology Venereology and Leprosy, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, Andhra Pradesh, India
³ Department of Community Medicine, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, Andhra Pradesh, India

Date of Submission	26-Apr-2022
Date of Decision	28-Apr-2022
Date of Acceptance	30-Apr-2022
Date of Web Publication	17-Mar-2023

Correspondence Address:
Dr. Therissa Benerji
Department of Psychiatry, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada - 521 286, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdrntruhs.jdrntruhs_88_22

Abstract

Context: Acne vulgaris is a chronic inflammatory disease of the pilosebaceous follicles, characterized by comedones, papules, pustules, nodules, and often scars. Patients with acne feel self-conscious about the recurrence of skin lesions, especially their redness and scarring and often describe feelings of embarrassment, low confidence, depression, stress, and anxiety.
Aim:

To assess the levels of anxiety and depression in patients with acne vulgaris.
To assess the relationship between the severity of acne and anxiety and depression.

Setting and Design: Designed as a cross-sectional study conducted at a tertiary care hospital.
Methods and Material: This is a cross-sectional study involving 100 patients diagnosed with acne vulgaris in the dermatology venereology leprosy (DVL) outpatient department between 18 and 40 years of age. The Global Acne Grading System (GAGS) was applied to assess the severity of acne. The hospital Anxiety and Depression Scale (HADS) was used to assess the levels of anxiety and depression in patients with acne vulgaris.
Statistical Analysis Used: Statistical analysis was done using the statistical package for social science (SPSS) version 25.
Results: GAGS revealed 14 subjects to be having mild acne, 34 moderate, 40 severe, and 12 very severe acne. Symptoms of anxiety were observed in 74 subjects and depression in 48 subjects. A statistically significant association (P<.001) was found between the severity of acne and anxiety and depression.
Conclusion: High proportion of patients with acne had anxiety and depression, which were found to be significantly associated with the severity of acne.

Keywords: Acne vulgaris, anxiety, depression

How to cite this article:
Rayapureddy S, Benerji T, Kodali M, Pallekona R, Enamurthy H, Ravi Kumar M S. Anxiety and depression in patients with acne vulgaris at tertiary care hospital: A cross-sectional study. J NTR Univ Health Sci 2022;11:351-5

How to cite this URL:
Rayapureddy S, Benerji T, Kodali M, Pallekona R, Enamurthy H, Ravi Kumar M S. Anxiety and depression in patients with acne vulgaris at tertiary care hospital: A cross-sectional study. J NTR Univ Health Sci [serial online] 2022 [cited 2023 Mar 21];11:351-5. Available from: https://www.jdrntruhs.org/text.asp?2022/11/4/351/371765

Introduction

Acne vulgaris is a chronic inflammatory disease of the pilosebaceous follicles, characterized by comedones, papules, pustules, nodules, and often scars.^[1] It usually starts in adolescence and frequently resolves by the mid-twenties.^[2]

Patients with acne feel self-conscious about the recurrence of skin lesions, especially their redness and scarring and often describe feelings of embarrassment, low confidence, depression, stress, and anxiety, especially if they have tried many treatments.^[3]

According to the Global Burden of disease, acne vulgaris is the eighth most prevalent disease worldwide with a prevalence rate of 9.4%.^[4] The prevalence of acne vulgaris among the adolescent age group is 56%.^[2] It has a negative effect on persons' self-evaluation, interpersonal relationships, and daily performance. Patients with acne vulgaris have reported stress (50%), anxiety (44%), depression (18%), acute suicidal ideation (6%), body dysmorphic disorder (8%), impaired self-esteem, anger, and permanent effects on personality.^{[5],[6],[7],[8]}

In an Indian study by Bondade S et al.,^[9] psychiatry morbidity was found to be 40%, with depressive disorder in 34% and anxiety in 6% of the patients with acne vulgaris. A study on psychiatric morbidity in patients with acne vulgaris has reported clinically significant depression in 39.1% and anxiety in 4.35% of the patients.^[10]

It is estimated that 30%–60% of patients with skin disorders have psychiatric comorbidities. Skin conditions most commonly associated with psychiatry comorbidities are chronic disfiguring and those having visible skin signs and symptoms.^[11] Acne is associated with a greater psychological burden like depression, anxiety, and low self-esteem.^[12]

This study is taken up with the aim to assess the levels of anxiety and depression in patients with acne vulgaris and assessing the relationship between the severity of acne and anxiety and depression.

Methodology

The present study was a cross-sectional study conducted at a tertiary care hospital over a period of 2 years after obtaining approval from the Institutional Ethics Committee. Patients between 18 and 40 years of age diagnosed with acne vulgaris in dermatology venereology and leprosy outpatient department were approached. All those willing to give informed consent were included. Patients with a past history of psychiatric illness and usage of topical or systemic steroids, and those suffering from medical conditions such as polycystic ovarian syndrome (PCOS) and hypothyroidism were excluded. A total of 100 patients meeting the fixed criteria were included. Informed consent was obtained from all the participants after they were explained the nature and purpose of the study and verbally assured about their information confidentiality. Sociodemographic details were obtained, including age, gender, education, occupation, marital status, socioeconomic status, and family type using a semi-structured proforma developed in the department of psychiatry.

The Global Acne Grading System (GAGS) was done in the department of dermatology to assess the severity of acne. This was used to know the relationship between the severity of acne and anxiety and depression. In 1997, Doshi, Zaheer, and Stiller devised a global acne grading system (GAGS). This system divides the face, chest, and back into six areas (forehead, each cheek, nose, chin, and chest and back) and assigns a factor to each area on the basis of size. For the forehead, right cheek, and left cheek two factors are assigned, for the nose and chin one factor, and for the chest and upper back three factors are assigned. Each type of lesion is given a value depending on severity: no lesions = 0, comedones = 1, papules = 2, pustules = 3, and nodules = 4. The score for each area (Local score) is calculated using the formula: Local score = Factor × Grade (0–4). The global score is the sum of local scores, and acne severity is graded using the global score. A score of 1–18 is considered mild; 19–30, moderate; 31–38, severe; and >39, very severe.^[13]

The Hospital Anxiety and Depression Scale (HADS) was applied to assess the levels of anxiety and depression in patients with acne vulgaris. The HADS is a self-report questionnaire designed to assess the levels of anxiety and depression. It consists of two subscales with seven items each, one measuring anxiety, and another measuring depression. Each item is scored on a 4-point Likert scale (0–3), the possible scores range from 0 to 21 for each of the two subscales. The HADS manual indicates that a score between 0 to 7 is normal; 8–10, mild; 11–14, moderate; and 15–21, severe.^[14],[15]

Statistical analysis was done using the statistical package for social science (SPSS) 25 software. The levels of anxiety and depression were assessed using the Chi-square test. A probability value of less than 0.05 has been taken as statistically significant.

Results

A total of 100 patients between 18 and 40 years of age were evaluated [Table 1] with a mean age of the sample being 24.52 years with a standard deviation (SD) of 5.74. Most of them (n = 68; 68%) were females, belonging to middle socioeconomic status (n = 56; 56%), and acquired undergraduate education (n = 50; 50%). The majority were unmarried (n = 79; 79%), hailed from nuclear families (n = 76; 76%), and were students (n = 36; 36%).

Table 1: Socio-Demographic Characteristics

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GAGS revealed 14 subjects to be having mild acne, 34 moderate, 40 severe, and 12 very severe acne. Symptoms of anxiety were observed in 74 subjects, of which mild anxiety was found in 30%, moderate anxiety in 20%, and severe anxiety in 24%. Symptoms of depression were found in 48 subjects, of which mild depression was found in 30%, moderate depression in 15%, and severe depression in 3% [Table 2].

Table 2: Hads-Anxiety, Hads-Depression and Gags Scores

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In the present study, a statistically significant association (P <.001) was found between the severity of acne and anxiety with a Chi-square value of 96.42. A statistically significant association (P <.001) was also found between the severity of acne and depression with a Chi-square value of 69.73 [Table 3] and [Table 4].

Table 3: Correlation between Hads-Anxiety with Gags Score – Severity of Acne

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Table 4: Correlation between Hads-Depression with Gags Score – Severity of Acne

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Discussion

The present study is taken up with the aim to assess the levels of anxiety and depression in patients with acne vulgaris and to know the relationship between the severity of acne and anxiety and depression.

Studies have found low self-esteem, avoidance behaviors, hastiness, anxiety, depression, shame, suicidal thoughts and attempts, and difficulties in applying for a job in patients with acne vulgaris.^[16],[17] The participants' mean age was 24.52 years in the current study, which is similar to a study by Sarkar S et al.,^[18] where the mean age was 26. More number of females in our study reported symptoms of anxiety and depression (68%). A study on the prevalence of mental health problems in patients with acne vulgaris by Khan MZ et al.,^[19] has also found depression and social anxiety to be more common among female patients.

In our study, psychiatric morbidity was found to be more common in those who have attained undergraduate education (50%), which is similar to a study by Yolac Yarpuz A et al.^[20] A study by Abolfotouh MA et al.,^[21] has found that married patients experience less severe psychological impact due to skin diseases, which may be due to the fact that married patients are more secure and have a stable life. Analogous to the above study, psychiatric morbidity was more among unmarried patients (79%) in our study.

In the present study, the frequency of anxiety (74%) was higher than depression (48%) among patients with acne vulgaris which is similar to studies by Ahmed AE et al.,^[22] and Awad SM et al.,^[23] that reported a higher frequency of anxiety than depression among acne patients. In contrast to our study, a study by Bondade S et al.,^[9] found depression in 34% and anxiety in 6%, and Srivatsava S et al.,^[10] reported depression in 34% and anxiety disorder in 6% of the patients with acne vulgaris.

In the present study, a statistically significant association (P <.001) was found between the severity of acne and anxiety and depression, which is in line with the study by Erdemir AV et al.,^[24] and Saker AA et al.,^[25] which also showed a statistically positive correlation between the severity of acne and depression and anxiety.

Dermatologists should be trained to recognize early signs of anxiety and depression so that the patients can be referred to the specialist at the earliest, as untreated anxiety and depression can result in socio-occupational dysfunction. Apart from anxiety and depression, patients can also have severe adjustment problems secondary to acne. Early recognition and treatment of psychiatric problems associated with acne should be a part of holistic management.

There are a few limitations in the present study. The lack of a control group remained one limitation of this study. In addition, it was a hospital-based study with a relatively small study population.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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