439

From Private Practice Dermatology and Consulting Staff, Windsor

Regional Hospital, Ontario,
a
Queens University at Kingston,
b
and
The Department of Mathematics and Statistics, University of
Windsor.
c
Dr Tan serves on the Advisory Committee for Accutane, Roche
Canada.
Accepted for publication Aug 28, 2000.
Reprints not available from authors.
Copyright 2001 by the American Academy of Dermatology, Inc.
0190-9622/2001/$35.00 + 0 16/1/111340
doi:10.1067/mjd.2001.111340
A
cne vulgaris is an extremely common condi-
tion, affecting 91% of male and 79% of female
adolescents,
1
and 3% of male and 12% of
female adults.
2
Although there is a substantial litera-
ture on the basic science, clinical features, psy-
chosocial impact, and treatment of acne, there is a
paucity of information on the knowledge and
understanding of patients with acne about their
condition.
3-5
Such information can lead to develop-
ment of awareness and educational programs to
increase patient understanding of their condition, as
well as a patient-based cognitive model to enhance
patient adaptation, coping mechanisms, and com-
pliance with treatment.
6
The objective of this study
is to evaluate the knowledge, beliefs, and percep-
tions of patients with acne regarding their under-
standing of acne pathogenesis, sources of informa-
tion, treatment options, and expectations.
MATERIAL AND METHODS
A voluntary self-completed questionnaire (see
Appendix) was administered to all new patients with
acne referred to a community-based dermatologist
over a 10-week period between June and August 1999
during their initial office visit. Questionnaires were
designed for this study and pilot tested for compre-
hension in a group of 8 patients. The protocol was
approved by a local research and ethics review
committee. Questionnaires were administered before
interaction with medical or nursing personnel. Demo-
graphic and clinical data were obtained after ques-
tionnaire completion and before review of responses.
Acne grading was performed by a dermatologist (J. K.
L. T.) with a grading system based on that of Gollnick
and Orfanos
7
: grade 1 acne was facial acne with come-
dones and fewer than 10 inflammatory lesions, grade
2 was facial acne with comedones and 10 to 20 inflam-
matory lesions, grade 3 was inflammatory lesions at
trunk with or without facial involvement, and grade 4
was inflammatory lesions with nodules and presence
of scars at face or trunk.
Beliefs and perceptions of patients with acne
Jerry K. L. Tan, MD, FRCP,
a
Kirsten Vasey,
b
and Karen Y. Fung, PhD
c
Windsor, Ontario, Canada
Background: There is a paucity of information on the knowledge and understanding of patients with acne
about their condition.
Objective: The objective of this study is to evaluate the knowledge, beliefs, and perceptions of acne
patients regarding their understanding of acne pathogenesis, sources of information, treatment options,
and expectations.
Methods: Patients referred to a community-based dermatologist for management of acne vulgaris
completed a self-administered questionnaire. Responses were correlated with demographic and clinical
information.
Results: Seventy-four percent of patients waited more than 1 year before seeking medical attention for
acne. Nonprescription products used most frequently were cleansers, acne pads, and lotions. Acne was
most often believed to be caused by hormonal and genetic factors, although diet, poor skin hygiene, and
infection were also implicated. Information on acne was obtained primarily from family physicians, mass
media, friends, and family, but was largely believed to be inadequate. Acne was believed to be curable by
49% of patients with an anticipated treatment duration of less than 6 months. Male patients and those with
severe acne preferred systemic therapy compared with female patients and those with lesser grades of acne.
Conclusion: There is a need for accessible, accurate, community-based education on the natural history
of acne, pathogenesis, risk of sequelae, the effectiveness and expected duration of treatment, and the
importance of prompt medical attention. (J Am Acad Dermatol 2001;44:439-45.)
440 Tan, Vasey, and Fung J AM ACAD DERMATOL
MARCH 2001
lar in males (5.0 years) and females (5.6 years). Seventy-
four percent of patients had waited for more than 1
year before seeking medical attention for their acne;
12% waited 6 to 12 months, 6% waited 3 to 6 months,
and 7% waited less than 3 months (Fig 1). In both gen-
ders, parents were frequently implicated in the deci-
sion to seek medical attention (27%). Female patients
indicated that friends were more likely to influence this
decision (8%) compared with males (0%).
Beliefs on causes and aggravating factors
The factor most frequently implicated as a cause
of acne was hormones (64%). Other responses
included genetics (38%), diet (32%), poor skin
hygiene (29%), and infection (18%) (Table II).
Factors most often believed to aggravate acne were
stress (71%), dirt (62%), heat and humidity (54%),
cosmetics (46%), exercise and sweating (45%), and
diet (44%) (Table III). Female patients were more
likely than male patients to implicate hair products
and cosmetics as aggravating factors.
Sources of information
General information on acne was obtained most
frequently from family physicians (71%); other
sources included magazines (44%), television
(44%), parents (31%), and friends (28%). Female
patients were more likely to obtain information
from magazines, friends, and aestheticians. Male
patients were more likely to obtain information
from television and parents. Fifty-eight percent
believed that information on acne from these
sources was inadequate.
Statistical analysis
Statistical analysis was performed to evaluate
responses on the basis of gender and severity of
acne. Because of the relatively small number of
patients, severity grades I and II were grouped
together as were grades III and IV. Statistical analysis
was performed using the chi-square test with a 5%
significance level (P < .05).
RESULTS
Of 82 questionnaires administered, 78 were com-
pleted. The mean age of patients was 21.7 years
(range, 9 to 49 years); 29 were male and 49 female.
Respondents had the following acne severity distri-
bution: 8 patients had grade I, 31 patients had grade
II, 30 had grade III, and 9 had grade IV acne. Male
subjects tended to have a greater acne severity grade
than females (Table I).
Patients in this survey had acne for an average dura-
tion of 5.4 years. The mean duration of acne was simi-
Fig 1. How long did you have acne before seeking medical attention?
Table I. Acne severity and gender
Grade I (n = 8) Grade II (n = 31) Grade III (n = 30) Grade IV (n = 9)
Male patients (n = 29) 0 (0%) 8 (26%) 13 (43%) 8 (89%)
Female patients (n = 49) 8 (100%) 23 (74%) 17 (57%) 1 (11%)
Total (n = 78) 8 (100%) 31 (100%) 30 (100%) 9 (100%)
Table II. Factors believed by patients to cause acne
No. of % Responses/
Factor responses patients
Hormones 50 64%
Genetics 30 38%
Diet 25 32%
Poor skin hygiene 23 29%
Infection 14 18%
Other 1 1%
The most common sources of information on non-
prescription acne products were television (51%),
family physicians (37%), magazines (35%), and friends
(32%). Female patients were more likely than male
patients to obtain this information from magazines,
newspapers, aestheticians, and family physicians.
Male patients more frequently obtained information
from parents and pharmacists. The most common
sources of information on prescription acne products
were family physicians (64%), friends (35%), maga-
zines (32%), television (29%), and parents (19%).
Female patients were more likely than male patients
to have obtained information on these products from
friends, aestheticians, and pharmacists.
Impact of acne
Patients were asked to indicate the impact of acne
on self-image, interpersonal relationships with
friends and family, work, and school activities as
none, minimal, moderate, or severe (Appendix,
questions 13-17). The majority indicated that acne
had no impact on interpersonal relationships, work,
or school activities (Fig 2). These responses differed
from those on self-image in which the impact was
believed to be none in only 3 patients (4%); minimal
in 29 (39%), moderate in 32 (43%), and severe in 10
(14%)(Fig 3).
Beliefs about treatment
Forty-nine percent of patients believed that acne
was curable, 17% believed acne was incurable, and 37%
did not know. The treatment of acne was expected to
take less than 4 weeks by 31% of patients, less than 6
months by 45%, and longer than 6 months by 24%.
The most frequent acne treatments used by
patients before seeking medical attention were
cleansers (87%), acne pads (55%), acne lotions
(47%), acne cover-up products (27%), masks (27%),
and facials (22%). Female patients were more likely
than male patients to have used facials, acne camou-
flage or cover-up, and facial masks for treatment.
Prescription acne products most often recognized by
patients were isotretinoin (Accutane) (62%), antibi-
otic pills (62%), topical benzoyl peroxide (53%), top-
ical antibiotics (53%), and tretinoin or Retin-A (40%).
Although female patients were more likely to recog-
nize tretinoin and hormones as treatment options,
only 22% of female patients recognized that hor-
mones were used in acne treatment.
With respect to treatment preference (Appendix,
question 23), 26% preferred topical therapy, 21%
preferred systemic, and 53% had no preference.
Female patients preferred topical therapy compared
with male patients (37% vs 7%, respectively), where-
Tan, Vasey, and Fung 441 J AM ACAD DERMATOL
VOLUME 44, NUMBER 3
Fig 2. Impact of acne on relationships with friends, family, and occupational activities.
Table III. Factors believed by patients to aggravate
acne
No. of % Responses/
Factor responses patients
Stress 55 71%
Dirt 48 62%
Heat and humidity 42 54%
Cosmetics 36 46%
Exercise and sweating 35 45%
Diet 34 44%
Other 1 1%
exercise and sweating, and diet. Pearl et al
5
noted
similar responses in a community-based survey of
872 school-aged adolescents from New Zealand in
which factors believed to affect acne were hor-
mones, lack of cleanliness, heredity, diet, stress,
menses, and sweating. Rasmussen and Smith
3
found
that the most common beliefs regarding causality in
acne were stress/anxiety, diet, and poor skin hygiene.
The function of hormones and heredity were not
specifically addressed in their survey. The persis-
tence of misconceptions, particularly regarding the
involvement of diet and skin hygiene since the time
of the survey of Rasmussen and Smith and the pres-
ence of similar beliefs in surveys conducted in North
America and the Pacific islands, suggests that misin-
formation on acne is widespread and enduring.
In this survey of referred patients, it was antici-
pated that information on acne would most fre-
quently be obtained from family physicians. Other
frequently cited sources of information were televi-
sion and magazines, parents, and friends. The major-
ity of patients, however, believed that information
on acne from all sources was inadequate. In commu-
nity-based surveys, the most frequently cited sources
of acne information were television (74%), parents
(61%), friends (47%), and magazines (39%).
4,5
These
results reflect the primary function of the mass
media and lay public in provision of information on
acne and may also highlight the sources of both
accurate information and persisting misconceptions.
This information underscores the need for accurate,
as male patients preferred systemic therapy com-
pared with female patients (32% vs 14%, respective-
ly; P = .01). Patients with more severe grades of acne
significantly preferred systemic therapy compared
with those with milder grades (32% vs 10%, respec-
tively; P = .01) (Table IV).
DISCUSSION
There are few studies on the beliefs and percep-
tions of patients on the causes, aggravating factors,
management, and sources of information in a refer-
ral population of patients with acnea group of par-
ticular relevance to practicing dermatologists. The
most recent survey of these issues in such a popula-
tion was performed almost 2 decades ago by
Rasmussen and Smith
3
in a university clinic setting.
Our results are not directly comparable, however,
because of differences in questionnaire design, the
tertiary nature of their university setting, and geopo-
litical differences in health care systems.
The pathogenesis of acne is multifactorial, involv-
ing androgenic stimulation, sebaceous hypersecre-
tion, follicular obstruction, Propionibacterium
acnes, and inflammatory mediators.
8,9
Furthermore,
the tendency to severe acne may be inherited.
10,11
In
the present study, a large proportion of patients
accurately identified hormones and genetics as pri-
mary factors in acne pathogenesis. To a lesser extent,
diet, poor skin hygiene, and infection were also
implicated. Factors believed to aggravate acne were
stress and anxiety, dirt, heat and humidity, cosmetics,
442 Tan, Vasey, and Fung J AM ACAD DERMATOL
MARCH 2001
Fig 3. Impact of acne on self-image.
Table IV. Treatment preferences of patients with acne
Total Males* Females Acne grade Acne grade
(n = 78) (n = 29) (n = 49) I and II

(n = 39) III and IV (n = 39)

Topical 20 (26%) 2 (7%) 18 (37%) 15 (38%) 5 (13%)
Systemic 16 (21%) 9 (32%) 7 (14%) 4 (10%) 12 (32%)
No preference 41 (53%) 17 (61%) 24 (49%) 20 (51%) 21 (55%)
*Male patients preferred systemic therapy, female patients preferred topical therapy (P = .01).

Acne grade I and II patients preferred topical therapy; acne grades III and IV preferred systemic therapy (P = .01).
comprehensible information on acne that is readily
accessible.
Previous studies on the relationship of acne sever-
ity and psychosocial impact have yielded varying
results. In a survey of 180 patients, Layton, Seukeran,
and Cunliffe
12
observed a correlation between psy-
chosocial impact as measured by the Assessments of
Psychological and Social Effects of Acne (APSEA)
score and facial acne grade. In contrast, Krowchuk et
al,
13
who evaluated 39 teenagers with a self-concept
scale evaluating personal and social dissatisfaction,
found that a dermatologists rating of acne severity
did not correlate with dissatisfaction with appear-
ance. Lasek and Chren,
14
in a survey of 60 patients,
also found no association between distress with
facial appearance and severity of acne as determined
by a dermatologist. In view of the potential discor-
dance between objective morphologic severity of
acne and psychosocial impact, treatment strategies
should incorporate both patient-based subjective
scores and objective clinical grades independently
into a management paradigm. This can be facilitated
by the use of simple, validated questionnaires such
as the APSEA,
14
Skin Disease Specific Quality of Life
Index (SKINDEX),
13
or Acne Disability Index (ADI).
4
In this study, the effect of acne on self-image
appeared to be a more sensitive indicator of psy-
chosocial impact when compared with that of inter-
personal relationships, school, or occupational activ-
ities. Although the relatively small number of
patients was a limiting factor in this survey, it would
be of interest to validate this simple index against
larger psychosocial questionnaires.
In this study, half the respondents believed acne
was curable, with 76% anticipating treatment to last
less than 6 months, and 31% expecting therapy to
last less than 4 weeks. The latter finding is in agree-
ment with that of Rasmussen and Smith in which
35% of their patients expected substantial improve-
ment in less than 4 weeks of therapy. An unexpected
finding in this study was the delay in seeking medical
attention for acne. In Canada, medical care is acces-
sible and universally available to the populace with-
out direct cost to the patient. Despite the foregoing,
74% of acne patients waited more than 1 year before
seeking medical attention. Unfortunately, delay in
obtaining adequate treatment for acne has been
shown to increase the risk of scarring.
15
These find-
ings suggest the need for greater community aware-
ness of acne and its consequences, including the
importance of earlier intervention.
This survey recruited consecutive patients
referred for acne management and resulted in
almost twice as many female as male respondents.
The female predominance in acne surveys has been
Tan, Vasey, and Fung 443 J AM ACAD DERMATOL
VOLUME 44, NUMBER 3
previously noted and likely reflects the greater
prevalence of acne in preadolescent and adult
females
2-4,12,13
and the greater psychosocial impact
in females.
12
Male patients tend to have more severe
grades of acne in adolescence along with an increas-
ing prevalence to exceed that of female patients
between the ages of 13 and 18 years.
1,2
This dispari-
ty reverses in adulthood during which women are
more frequently and severely affected.
2
Despite the
increasing prevalence and severity of acne in adoles-
cent boys, they are underrepresented in this survey
population. Male patients and those with more
severe grades of acne preferred systemic therapy,
whereas female patients and those with milder acne
grades preferred topical therapy. These preferences
may reflect preconceived notions of effectiveness,
convenience, and familiarity.
There is a need for accessible, accurate, commu-
nity-based education on the natural history of acne,
pathogenesis, risk of sequelae, the effectiveness and
expected duration of treatment, and the importance
of prompt medical attention. The inadequacy of
information provided by current sources is evident
in ongoing misconceptions on causality and the per-
ceptions of respondents. Male patients, despite hav-
ing more severe acne, appear to be underrepresent-
ed in the present referral population; this suggests a
need for targeted education of this group.
Incorporating information on treatment preferences
on the basis of gender and severity may facilitate
patient input into therapeutic selection, enhance
understanding of treatment options, and improve
patient compliance.
REFERENCES
1. Lello J, Pearl A, Arroll B, Yallop J, Birchall NM. Prevalence of acne
vulgaris in Auckland senior high school students. N Z Med J
1995;108:287-9.
2. Goulden V, Stables GI, Cunliffe WJ. Prevalence of facial acne in
adults. J Am Acad Dermatol 1999;41:577-80.
3. Rasmussen JR, Smith SB. Patient concepts and misconceptions
about acne. Arch Dermatol 1983;119:570-2.
4. Kilkenny M, Merlin K, Plunkett A, Marks R. The prevalence of
common skin conditions in Australian school students: 3. Acne
vulgaris. Br J Dermatol 1998;139:840-5.
5. Pearl A, Arroll B, Lello J, Birchall NA. The impact of acne: a study
of adolescents attitudes, perception, and knowledge. N Z Med
J 1998;111:269-71.
6. Leventhal H, Diefenbach M, Leventhal EA. Illness cognition
using common sense to understand treatment adherence and
affect cognition interactions. Cogn Ther Res 1992;16:143-63.
7. Gollnick H, Orfanos CE. Clinical assessment of acne. In: Cunliffe
WJ, editor. Acne. Stuttgart: Hippokrates; 1993. p. 118.
8. Leyden JJ. Therapy for acne vulgaris. N Engl J Med 1997;336:
1156-62.
9. Webster G. Acne. Curr Probl Dermatol 1996;8:237-68.
10. Goulden V, McGeown CH, Cunliffe WJ. The familial risk of adult
acne: a comparison between first-degree relatives of affected
and unaffected individuals. Br J Dermatol 1999;141:297-300.
444 Tan, Vasey, and Fung J AM ACAD DERMATOL
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14. Lasek RJ, Chren MM. Acne vulgaris and the quality of life of
adult dermatology patients. Arch Dermatol 1998;134:454-8.
15. Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation of
acne scarring and its incidence. Clin Exp Dermatol 1994;19:303-
8.
11. Fitzsimmons JS, Guilbert PR. A family study of hidradenitis sup-
purativa. J Med Genet 1985;22:367-73.
12. Layton AM, Seukeran D, Cunliffe WJ. Scarred for life?
Dermatology 1997;195(Suppl 1):15-21.
13. Krowchuk DP, Stancin T, Keskinen R, Walker R, Bass J, Anglin TM.
The psychosocial effects of acne on adolescents. Pediatr
Dermatol 1991;8:332-8.
Appendix. Acne Perceptions Survey
1. How long did you have acne before seeking medical attention?
<3 mo 6-12 mo
3-6 mo >1 y
2. What influenced your decision to seek medical attention?
Parent Advertisements (please specify):______________
Friend Other:_______________
Self-made decision
3. What sources have provided you with information about acne?
Magazines School Aesthetician
TV Parents Pharmacist
Newspaper Relatives Doctor
Radio Friends Library
Internet Other:_________
4. Do you feel you have enough information about acne from the above sources?
Yes No
5. What products did you try for your acne before seeing a doctor?
Cleansers Facials Acne cover-up
Acne pads Masks Other:__________
Lotions Alternative therapy
6. Which of these was most useful?________________ least useful?________________
7. Where did you hear about these products?
TV School Aesthetician
Magazines Parents Pharmacist
Newspaper Relatives Doctor
Radio Friends Library
Internet Other:_________
8. Which of the following do you think affects acne?
Diet Moisturizers Stress
Dirt Heat/humidity Drugs/medications
Hair products Season of year Other:_________
Cosmetics Exercise/sweat
9. What do you think causes acne?
Poor skin hygiene Infection Genetics (inherited)
Diet Hormonal causes Other:__________
10. Do you think acne is a condition that can be cured (ie, permanently cleared)?
Yes No Dont know
11. How long do you expect acne treatment to take?
Days 2-4 wk <6 mo >6 mo
12. What percentage of people do you think have acne?
0%-25% 25%-50% 50%-75% 75%-100%
13. What impact has acne had on your self-image?
None Minimal Moderate Severe
Tan, Vasey, and Fung 445 J AM ACAD DERMATOL
VOLUME 44, NUMBER 3
Appendix. Contd
14. What impact has acne had on your relationships with your friends?
None Minimal Moderate Severe
15. What impact has acne had on your relationships with your family?
None Minimal Moderate Severe
16. What impact has acne had on your work activities?
None Minimal Moderate Severe
17. What impact has acne had on your performance at school?
None Minimal Moderate Severe
18. What bothers you the most about your acne?
__________________________________________________________________________________________________
19. Please complete the following chart about acne medications:
Have you heard about it? Do you think it could help you?
Yes No Yes No Dont know
Tretinoin lotion/Retin A
Benzoyl peroxide lotion
Antibiotic lotion
Antibiotic pills
Hormonal therapy/pills
Accutane
20. Where have you heard about these medications?
Magazines School Aesthetician
TV Parents Pharmacist
Newspaper Relatives Doctor
Radio Friends Library
Internet Other:________
21. Is there a medication you would like to try for your acne?
__________________________________________________________________________________________________
22. Is there a medication you would like to avoid? If so, why?
__________________________________________________________________________________________________
23. What form of medication would you prefer to use?
Topical (cream or lotion) Pill No preference