Predictors of QOL for adults with acne: The Contribution of perceived stigma

Abstract

As dermatology patients complain that their psychological distress is extensive and often overlooked, it is concerning that there is a paucity of research investigating factors associated with acne-related QOL. This study, therefore, aimed to compile a preliminary list of risk factors for psychosocial distress as a result of having acne in adulthood, while specifically examining the role of an under investigated variable - perceived stigma – due to the high levels of stigmatization reported by these individuals. Adults with acne (=119, M/F: 38/81; mean age:= 26.37,=7.97), recruited from private dermatology offices in Athens were administered the Feelings of Stigmatization Questionnaire (FSQ; Ginsburg & Link, 1989) and Acne-Specific Quality of Life Questionnaire (Acne-QoL; Botek, Girman, Light, Lookingbill, Martin, & Thiboutot, 2001). Multiple regression analyses were conducted in order to assess the capacity of various psychosocial and demographic variables to predict acne-related QOL. While participants’ gender, age, history of acne and self-rated severity of acne emerged as significant predictors of acne-related QOL, perceived stigma made the largest contribution to the regression model. This research study provides preliminary evidence that adults who feel stigmatized are at risk for experiencing a poor quality of life as a result of having acne. Potential risk factors of secondary importance, which can aid the screening of psychological distress in these individuals, may also include one’s self-rated severity of acne, age, gender and previous history of acne.

Keywords: Quality of Life, Adult Acne, Perceived Stigma

1. Introduction

“I don’t feel equal to [others] because they are normal and I am not. Would you rather be an unblemished apple or an apple with lots of dents and bruises? Nobody likes damaged goods” (Murray & Rhodes, 2005, p18). This statement comes from a young male, Karl, who belongs to 1% of the adult population (Kent & Thompson, 2001) that bears the mark of a scar, blemish or disfigurement which constitutes a visible difference. As a type of visible difference, dermatological conditions are amongst the most common health problems worldwide associated with psychological, social and financial burden, yet they are usually characterized as non-threatening and minor nuisances which constitute more of a cosmetic rather than debilitating health issue (Basra & Shahruck, 2009). The present study will give credence to the gravity of having a dermatological condition, by investigating the factors which predict the quality of life among acne sufferers, in order to create a preliminary list of risk factors to help dermatologists screen for psychological distress in their adult patients.

The limited social psychological research investigating the nature of attitudes towards individuals with visible differences suggests that appearance based prejudice towards these individuals is a pervasive phenomenon (Borah & Rankin, 2003; Del Rosso, La Riche, Ritvo, & Stillman, 2011; Grandfield, Thompson, & Turpin, 2005). Experimental studies have also highlighted participants’ preferential attitude towards clear skin and aversion towards blemished ones (Del Rosso et al., 2011; Grandfield et al., 2005). Worryingly, negative attitudes towards blemished skin may translate to stigmatizing behavior and discriminatory practices, the most prevalent of which are negative attention - e.g. staring as well as rude comments - and avoidance - e.g. avoiding eye contact, conversation, physical closeness (Adams, Heading, Magin, Pond, & Smith, 2008).

Although the effects of prejudice and discrimination have been mainly studied for stigmatized individuals with contagious physical diseases, mental illnesses and minority groups, investigating dermatological stigma is important because of its documented association with psychological distress and disability in patients with psoriasis, eczema, vitiligo and atopic dermatitis (Griffiths, Main, Richards, & Wittowski, 2007). Indeed, it has been reported that dermatological conditions prevent an individual from being socially accepted, and the lack of inclusion results in lowered self-esteem (Amir, Besser, Biton, Buskila, Gesthalter, & Vardy, 2002), depression and loneliness (Papadopoulos & Walker, 2005). Gilbert and Miles (2002) further highlight that feelings of shame may result as a consequence of being devalued by others, and losing one’s social status. This may be especially true for patients whose dermatological conditions appear in adulthood, who not only have to cope with the loss of their former personal but also social identity (Amir et al., 2002).

The appearance of skim conditions has also been association with lowered quality of life, concerns about body image, interpersonal difficulties and psychological co-morbidities such as anxiety and depressive disorders (Harcourt & Rumsey, 2012). Despite the fact that quality of life measures have been introduced to dermatological research for over 20 years, they are not often used by dermatologists in clinical practice to guide treatment planning (Butler, Gupta, Huynh, Leon, Levin, & Koo, 2011). In fact, patients have reported that their dermatologists often fail to recognize the negative impact of their skin diseases on their lives (Butler et al., 2011). Yet,

research contradicts the widespread belief that acne is just a trivial problem, by demonstrating that patients with acne report similar levels of social and emotional problems compared to other chronic physical conditions such as asthma, arthritis, epilepsy and diabetes (Finlay, Klassen, Mallon, Newton, Ryan, & Stewart-Brown, 1999).

As the psychosocial impact of attaining a visible difference is extensive, researchers have attempted to identify both the factors which protect but also make these individuals more vulnerable to psychological distress (Harcourt & Rumsey, 2012; Papadopoulos & Walker, 2005). In particular, those with visible cutaneous pathologies are better adjusted than others with concealable blemishes; the latter have been found to behave more competently in social situations as they believe that others are not aware of their skin condition (Kent, 2002). In relation to age, even though research has indicated that teens suffer as a result of their acne, it has been reported that older adults become greatly distressed as well (Clark-Carter, Grogan, Hassan, Richards, & Yates 2009). As acne is usually associated with adolescence (Papadopoulos & Walker, 2005), it may comprise a more normative experience for teens who also observe that their peers also bear the marks of the skin condition. Women have also been found to cope less well with visible differences compared to men (Clark-Carter et al., 2009); these gender differences may relate to the social norms, and resulting cultural pressures, of women needing to look attractive and presentable (Harcourt & Rumsey, 2012). Lastly, individuals who rate their skin condition as more severe, have been found to more self-conscious and socially avoidant, while also have a lower self-esteem (Clark-Carter et al., 2009).

Although the existing literature is informative, it is limited in scope as (a) it outlines predictors of adjustment to visible differences in general and not specific to adult acne; (b) there is an omission of other potentially influential factors of psychological adjustment such as one’s level of perceived stigma, educational status, and whether one’s history of attaining a skin condition influences an individual’s adjustment when it re-emerges. Furthermore, a review of the extant literature revealed a scarcity of studies investigating the effects of perceived stigma among acne patients. The Feelings of Stigmatization Questionnaires (FSQ; Ginsburg & Link, 1989) which was originally constructed to measure feelings of stigmatization among individuals with psoriasis and eczema, and was later adapted by Kent (1999) for patients with vitiligo, has also yet to be modified for individuals with acne.

2.Problem Statement

As dermatology patients complain that their psychological distress is extensive and often overlooked (Basra & Shahruck, 2009; Bor, Legg, & Papadopoulos, 1999; Butler et al., 2011), it is concerning that there is a paucity of research investigating factors associated with acne-related quality of life (Chren & Larsek, 1998; Clark-Carter et al., 2009).

3.Research Questions

What is the predictive capacity of perceived stigma, self-rated severity, location and previous history of acne, gender, age, relationship status and education for the quality of life of adult dermatology patients?

4.Purpose of the Study

This study aimed to compile a preliminary list of risk factors for psychosocial distress as a

result of having acne in adulthood, while specifically examining the role of an under investigated

variable - perceived stigma – due to the high levels of stigmatization reported by individuals with visible differences (Borah & Rankin, 2003).

5.Research Methods

6.Findings

7.Conclusions

The present study contributes to and extends a growing body of literature which investigates the predictors of quality of life in individuals with cutaneous pathologies (Papadopoulos & Walker, 2005; Harcourt & Rumsey, 2012), by providing preliminary evidence that adults who feel stigmatized are at risk for developing psychological distress as a result of having acne. Making the largest contribution to the regression model, the results of the study specifically suggest that perceived stigma negatively impacts acne-related quality of life. That is, when participants’ scores of perceived stigma decreased (indicating higher perceived stigma levels), the self-perception, role social and role emotional scores decreased as well. Participants with higher levels of stigma were, therefore, more likely to indicate feeling unattractive and embarrassed about their acne; were more concerned about socializing and interacting with the opposite sex; while also felt upset for not looking presentable. In tandem with previous research which has highlighted that perceptions of stigmatization are common in individuals with visible differences (Borah & Rankin, 2003; Kent, 2005), participants in this study also reported feeling stigmatized as a result of having acne. The fact that, on average, the participants of this study reported lower (i.e. moderate) levels of perceived

stigma may be attributed to the nature of their visible difference. That is, other studies on visible differences have focused on more pronounced appearance altering conditions leading to severe facial disfigurements (Borah & Rankin, 2003); skin conditions, such as acne, may create minor changes in appearance which, in turn, may elicit less negative reactions from others and feelings of stigmatization.

The aforementioned association can be interpreted in the light of Kent’s (2002) cognitive - behavioural model, constructed to explain the effects of appearance altering medical condition on well-being. As he posits, afflicted individual utilize unhealthy coping strategies to deal with the activation of their anxiety schema which is triggered because of their anticipation or experience with stigma. That is, to deal with being stigmatized, participants in this study may have used avoidant coping strategies which are linked to poor adjustment, shame, social anxiety and other maladaptive cognitions and emotions. According to Papadopoulos and Walker (2005), avoidant coping strategies, such as the use of concealment, may be effective in the short-run but prevent an individual from facing the reality of their altered appearance. Bandura’s (2002) social cognitive theory of mass communication provides an equally plausible explanation for the negative impact of perceived stigma on participants’ QOL. As he states, the televised world contributes to a “symbolic modelling of stereotypes”, where misconceptions about individuals with visible differences may arise as they are mainly portrayed in a derogatory and negative, and therefore, stigmatizing light. As the public accepts media portrayals of people as “the authentic state of human affairs” (Bandura, 2002, p.281), they learn to view and treat people with visible differences in a prejudicial manner. The implication for this with individuals afflicted with skin conditions, such as the participants in this study, is that they receive the message that their altered appearance constitutes an undesirable and shameful difference.

Furthermore, the risk factors of secondary importance to the participants of this study were the self-rated severity of acne, gender, age and not having a previous history of acne. The results specifically indicated that as participants’ self-rated severity of acne increased (indicating that their skin was perceived to be worse), self-perception, role social and role emotional scores decreased. These results are consistent with previous findings (Clark-Carter et al., 2009; Harcourt & Rumsey, 2012), which demonstrated that the perceived severity of skin conditions is both highly associated with, while also predicts, poorer social outcomes and quality of life. Therefore, participants in this study who perceived their acne as worse may have been more self-conscious about their skin, developing many avoidant behaviours which could have affected their QOL.

Gender further emerged as a significant predictor of the first and third domains of acne-related quality of life. The results specifically indicated that female participants were more likely to have lower self-perception and role emotional scores than male participants. Therefore, female participants were more likely to feel unattractive, embarrassed and dissatisfied with their appearance due to their acne; they were also more likely to report feeling annoyed with having to spend time treating their face, while were more concerned with having medication and cover-up available at all time. These findings are consistent with previous literature which found that female participants are more self-conscious and embarrassed about their skin than males (Clark-Carter et al., 2009; Gawkrodger & Kellet, 1999). It has been suggested that these gender differences relate to the social and cultural pressures of women needing to look attractive and presentable (Clark-Carter et al.; 2009; Harcourt & Rumsey, 2012).

Participants’ age and history of acne also emerged as significant predictors of the first and second domains of acne-related quality of life respectively. Specifically, the results indicated that as the age of the participant increased, the self-perception score increased as well. Rating their selfperception more highly indicated that the older adults of the sample felt less unattractive, selfconscious and dissatisfied with their appearance as a result of having acne. This is inconsistent with the findings of Chren’s and Lasek’s (1998) study, who found that their older participants, aged 30 and above, were more bothered about the appearance of their acne compared to the younger

participants who were in their late teens. However, the finding that older participants in this study were less affected by their skin condition can be explained by recent research that has focused on age differences in appearance investment, where it has been found that “the importance attached to physical appearance tends to decrease with age” (Harcourt & Rumsey, 2012, p.146). By placing less emphasis on their looks, therefore, older participants of this study may have felt less threatened by their altered appearance as a result of having acne. Yet, the fact that participants’ age was a significant predictor of QOL suggests that the adults of this sample could be at risk of developing psychological distress due to their acne, a skin condition which is usually associated with and comprises a more normative experience for adolescents (Papadopoulos & Walker, 2005).

In addition, the results of this study indicated that participants without a previous history of acne attained lower role social scores than those with a previous history of acne. This means that participants without a previous history of acne were more likely to indicate a concern about going out in public, socializing and meeting new people as well as interacting with the opposite sex as a result of their newly experienced skin condition. Although no previous literature investigating history of acne as a predictor of QOL was found, the results of this study could be explained by the process of desensitization which typically occurs with individuals that have episodic skin conditions (Kent & Thompson, 2001; Papadopoulos & Walker, 2005). That is, participants with previous episodes of acne may have been given the opportunity to get accustomed and develop healthier coping strategies to deal with the alteration of their skin, resulting in their higher acnerelated quality of life levels. The fact that the majority of adult participants in this study did have a history of acne could also explain this study’s findings that older participants attained better QOL scores. That is, it could be hypothesized that the older participants had more previous episodes of acne which could be have contributed to their increased desensitisation of and better adjustment to their altered appearance. A future research study could collect more background information regarding the number and length of participants’ previous episodes of acne as to further investigate whether there is an interaction effect between age and history of acne in relation to levels of QOL.

In contrast, the variables of educational status, relationship status and location of acne did not appear to significantly contribute to participants’ Acne-QoL, which is inconsistent with previous findings in regards to the latter two variables (Bor et al., 1999; Harcourt & Rumsey, 2012). In terms of relationship status, perhaps having a satisfying and supportive social network was more important in buffering participants’ psychological distress, rather than merely being partnered. Also, being in a relationship does not necessarily guarantee an increase of support, as intimate relationship may also be a source of anxiety for individuals with skin conditions (Papadopoulos & Walker, 2005). It may have also been more meaningful to investigate whether participants’ acne was visible or not and if this affected their Acne-QoL levels, as it has been found that the visual salience of people’s acne, irrespective of its location on the body, increases their vulnerability to psychological distress (Finlay & Motley, 1989).

As an adjunct to this study, future researchers could also add other psychosocial variables to their regression model, such as self-esteem and coping styles, in order to attempt to explain the remaining variance of Acne-QoL. Also, following the footsteps of Hrehorow, Mutusiak, Reich, Salomon, & Szepietowski (2012) recent research, other studies could attempt to discern the most prominent aspects of the stigmatization experience in individuals with skin conditions, in order to gain a better understanding and create more appropriate interventions addressing the nature of their stigmatization. To this end, future researchers could assess which of the six factors of the FSQ (i.e., anticipation of rejection, feelings of being flawed, sensitivity to the opinions of others, guilt and shame, positive attitudes and secretiveness), best predict acne-related QOL. As the crosssectional design of this study also limits the findings to a certain point of time in participants’ lives, more longitudinal research is required to assess people’s adjustment to this episodic and

unpredictable skin condition which is thought to contribute to a “fluid identity” (Murray & Rhodes, 2005).

Although it is important to take into account the individual differences of adults with acne, the preliminary list of risk factors of psychological distress for afflicted individuals compiled in this study could be clinically useful in providing red flags for dermatologists treating adults with acne. That is, by being informed of the factors which place adults with acne more at risk of being handicapped by their skin condition, dermatologists can provide more holistic treatment by referring them to a mental health professional when needed. The introduction of QOL measures to dermatologists in this study was also helpful in increasing their awareness of the possible uses of such instruments in clinical practice.

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