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Table 1.  Demographic Characteristics of the Study Participants
Demographic Characteristics of the Study Participants
Table 2.  Free-listing Response Breakdowna
Free-listing Response Breakdowna
Table 3.  Main Themes and Representative Quotes
Main Themes and Representative Quotes
Table 4.  Experiences With Common Acne Treatments
Experiences With Common Acne Treatments
1.
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Ip  A, Muller  I, Geraghty  AWA, McNiven  A, Little  P, Santer  M.  Young people’s perceptions of acne and acne treatments: secondary analysis of qualitative interview data.   Br J Dermatol. 2020;183(2):349-356. doi:10.1111/bjd.18684 PubMedGoogle ScholarCrossref
11.
Ip  A, Muller  I, Geraghty  AWA, Platt  D, Little  P, Santer  M.  Views and experiences of people with acne vulgaris and healthcare professionals about treatments: systematic review and thematic synthesis of qualitative research.   BMJ Open. 2021;11(2):e041794. doi:10.1136/bmjopen-2020-041794 PubMedGoogle Scholar
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Fabbrocini  G, Cacciapuoti  S, Monfrecola  G.  A qualitative investigation of the impact of acne on health-related quality of life (HRQL): development of a conceptual model.   Dermatol Ther (Heidelb). 2018;8(1):85-99. doi:10.1007/s13555-018-0224-7 PubMedGoogle ScholarCrossref
13.
Murray  CD, Rhodes  K.  ‘Nobody likes damaged goods’: the experience of adult visible acne.   Br J Health Psychol. 2005;10(Pt 2):183-202. doi:10.1348/135910705X26128 PubMedGoogle Scholar
14.
Pruthi  GK, Babu  N.  Physical and psychosocial impact of acne in adult females.   Indian J Dermatol. 2012;57(1):26-29. doi:10.4103/0019-5154.92672 PubMedGoogle ScholarCrossref
15.
Collier  CN, Harper  JC, Cafardi  JA,  et al.  The prevalence of acne in adults 20 years and older.   J Am Acad Dermatol. 2008;58(1):56-59. doi:10.1016/j.jaad.2007.06.045 PubMedGoogle ScholarCrossref
16.
O’Brien  BC, Harris  IB, Beckman  TJ, Reed  DA, Cook  DA.  Standards for reporting qualitative research: a synthesis of recommendations.   Acad Med. 2014;89(9):1245-1251. doi:10.1097/ACM.0000000000000388 PubMedGoogle ScholarCrossref
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Institute of Medicine roundtable on value & science-driven health care. Appendix C, comparative effectiveness research priorities: IOM recommendations (2009). In: Learning What Works: Infrastructure Required for Comparative Effectiveness Research: Workshop Summary. National Academies Press; 2011. Accessed June 15, 2021. https://www.ncbi.nlm.nih.gov/books/NBK64788
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19.
Smith  H, Layton  AM, Thiboutot  D,  et al.  Identifying the impacts of acne and the use of questionnaires to detect these impacts: a systematic literature review.   Am J Clin Dermatol. 2021;22(2):159-171. doi:10.1007/s40257-020-00564-6 PubMedGoogle ScholarCrossref
20.
Layton  AM, Whitehouse  H, Eady  EA, Cowdell  F, Warburton  KL, Fenton  M.  Prioritizing treatment outcomes: how people with acne vulgaris decide if their treatment is working.   J Evid Based Med. 2017;10(3):163-170. doi:10.1111/jebm.12249 PubMedGoogle ScholarCrossref
21.
Davern  J, O’Donnell  AT.  Stigma predicts health-related quality of life impairment, psychological distress, and somatic symptoms in acne sufferers.   PLoS One. 2018;13(9):e0205009. doi:10.1371/journal.pone.0205009 PubMedGoogle Scholar
22.
Taylor  MT, Barbieri  JS.  Depression screening at visits for acne in the United States, 2005-2016.   J Am Acad Dermatol. 2020;83(3):936-938. doi:10.1016/j.jaad.2019.12.076 PubMedGoogle ScholarCrossref
23.
Magin  P, Adams  J, Heading  G, Pond  D, Smith  W.  Psychological sequelae of acne vulgaris: results of a qualitative study.   Can Fam Physician. 2006;52:978-979.PubMedGoogle Scholar
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Harper  JC.  Acne vulgaris: what’s new in our 40th year.   J Am Acad Dermatol. 2020;82(2):526-527. doi:10.1016/j.jaad.2019.01.092 PubMedGoogle ScholarCrossref
25.
Cline  A, Winter  RP, Kourosh  S,  et al.  Multiethnic training in residency: a survey of dermatology residents.   Cutis. 2020;105(6):310-313. doi:10.12788/cutis.0012 PubMedGoogle ScholarCrossref
26.
Taylor  SC.  Meeting the unique dermatologic needs of black patients.   JAMA Dermatol. 2019;155(10):1109-1110. doi:10.1001/jamadermatol.2019.1963 PubMedGoogle ScholarCrossref
27.
Alhusayen  RO, Juurlink  DN, Mamdani  MM, Morrow  RL, Shear  NH, Dormuth  CR; Canadian Drug Safety and Effectiveness Research Network.  Isotretinoin use and the risk of inflammatory bowel disease: a population-based cohort study.   J Invest Dermatol. 2013;133(4):907-912. doi:10.1038/jid.2012.387 PubMedGoogle ScholarCrossref
28.
Barbieri  JS, Spaccarelli  N, Margolis  DJ, James  WD.  Approaches to limit systemic antibiotic use in acne: Systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments.   J Am Acad Dermatol. 2019;80(2):538-549. doi:10.1016/j.jaad.2018.09.055 PubMedGoogle ScholarCrossref
29.
Hansen  TJ, Lucking  S, Miller  JJ, Kirby  JS, Thiboutot  DM, Zaenglein  AL.  Standardized laboratory monitoring with use of isotretinoin in acne.   J Am Acad Dermatol. 2016;75(2):323-328. doi:10.1016/j.jaad.2016.03.019 PubMedGoogle ScholarCrossref
30.
Barbieri  JS, Shin  DB, Wang  S, Margolis  DJ, Takeshita  J.  The clinical utility of laboratory monitoring during isotretinoin therapy for acne and changes to monitoring practices over time.   J Am Acad Dermatol. 2020;82(1):72-79. doi:10.1016/j.jaad.2019.06.025PubMedGoogle ScholarCrossref
31.
Barbieri  JS, Frieden  IJ, Nagler  AR.  Isotretinoin, patient safety, and patient-centered care-time to reform iPLEDGE.   JAMA Dermatol. 2020;156(1):21-22. doi:10.1001/jamadermatol.2019.3270PubMedGoogle ScholarCrossref
32.
Barbieri  JS, James  WD, Margolis  DJ.  Trends in prescribing behavior of systemic agents used in the treatment of acne among dermatologists and nondermatologists: a retrospective analysis, 2004-2013.   J Am Acad Dermatol. 2017;77(3):456-463.e4. doi:10.1016/j.jaad.2017.04.016 PubMedGoogle ScholarCrossref
33.
Del Rosso  JQ, Rosen  T, Palceski  D, Rueda  MJ.  Patient awareness of antimicrobial resistance and antibiotic use in acne vulgaris.   J Clin Aesthet Dermatol. 2019;12(6):30-41.PubMedGoogle Scholar
34.
Barbieri  JS, Choi  JK, James  WD, Margolis  DJ.  Real-world drug usage survival of spironolactone versus oral antibiotics for the management of female patients with acne.   J Am Acad Dermatol. 2019;81(3):848-851. doi:10.1016/j.jaad.2019.03.036 PubMedGoogle ScholarCrossref
35.
Barbieri  JS, Choi  JK, Mitra  N, Margolis  DJ.  Frequency of treatment switching for spironolactone compared to oral tetracycline-class antibiotics for women with acne: a retrospective cohort study 2010-2016.   J Drugs Dermatol. 2018;17(6):632-638.PubMedGoogle Scholar
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Garg  V, Choi  JK, James  WD, Barbieri  JS.  Long-term use of spironolactone for acne in women: a case series of 403 patients.   J Am Acad Dermatol. 2021;84(5):1348-1355. doi:10.1016/j.jaad.2020.12.071 PubMedGoogle ScholarCrossref
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Guzman  AK, Barbieri  JS.  Comparative analysis of prescribing patterns of tetracycline class antibiotics and spironolactone between advanced practice providers and physicians in the treatment of acne vulgaris.   J Am Acad Dermatol. 2021;84(4):1119-1121. doi:10.1016/j.jaad.2020.06.044PubMedGoogle ScholarCrossref
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Han  JJ, Faletsky  A, Barbieri  JS, Mostaghimi  A.  New acne therapies and updates on use of spironolactone and isotretinoin: a narrative review.   Dermatol Ther (Heidelb). 2021;11(1):79-91. doi:10.1007/s13555-020-00481-w PubMedGoogle ScholarCrossref
39.
Barbieri  JS, Margolis  DJ.  Optimizing the trial design for a comparative effectiveness study of spironolactone versus oral antibiotics for women with acne: a Delphi Consensus Panel.   J Drugs Dermatol. 2020;19(12):1238-1239. doi:10.36849/JDD.2020.5145 PubMedGoogle ScholarCrossref
40.
Poli  F, Auffret  N, Leccia  M-T, Claudel  J-P, Dréno  B.  Truncal acne, what do we know?   J Eur Acad Dermatol Venereol. 2020;34(10):2241-2246. doi:10.1111/jdv.16634 PubMedGoogle ScholarCrossref
41.
Tan  JKL, Dirschka  T.  A new era for truncal acne: emerging from a legacy of neglect.   Dermatol Ther (Heidelb). 2021. doi:10.1007/s13555-021-00529-5 PubMedGoogle Scholar
Original Investigation
July 28, 2021

Patient Perspectives on the Lived Experience of Acne and Its Treatment Among Adult Women With Acne: A Qualitative Study

Author Affiliations
  • 1Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 2Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
  • 3Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 4Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 5Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
JAMA Dermatol. 2021;157(9):1040-1046. doi:10.1001/jamadermatol.2021.2185
Key Points

Question  What is the lived experience of acne among adult women?

Findings  In this qualitative study of 50 adult women with acne, participants described diverse lived experiences, including concerns about appearance, mental and emotional health consequences, and disruption to their personal and professional lives.

Meaning  These findings suggest that ensuring access to care and identifying optimal treatment approaches for women with acne are needed to improve outcomes in this population.

Abstract

Introduction  Acne often persists into adulthood in women. However, few studies have specifically explored the lived experience of acne in adult populations.

Objective  To examine the lived experience of acne and its treatment among a cohort of adult women.

Design, Setting, and Participants  A qualitative analysis was conducted from free listing and open-ended, semistructured interviews of patients at a large academic health care system (University of Pennsylvania Health System) and a private practice (Dermatologists of Southwest Ohio). Fifty women 18 to 40 years of age with moderate to severe acne participated in interviews conducted between August 30, 2019, and December 31, 2020.

Main Outcomes and Measures  Free-listing data from interviews were used to calculate the Smith S, a measure of saliency for each list item. Semistructured interviews were examined to detect themes about patient perspectives regarding their acne and its treatment.

Results  Fifty participants (mean [SD] age, 28 [5.38] years; 24 [48%] White) described acne-related concerns about their appearance that affected their social, professional, and personal lives, with many altering their behavior because of their acne. Depression, anxiety, and social isolation were commonly reported. Participants described successful treatment as having completely clear skin over time or a manageable number of blemishes. Many participants described frustration with finding a dermatologist with whom they were comfortable and with identifying effective treatments for their acne.

Conclusions and Relevance  The results of this qualitative study suggest that women with acne have strong concerns about appearance and experience mental and emotional health consequences and disruption of their personal and professional lives. In addition, many patients describe challenges finding effective treatments and accessing care. Future trials to understand the optimal treatment approaches for women with acne are needed to improve outcomes in this population.

Introduction

Acne is responsible for a greater global burden of disease than psoriasis, cellulitis, and melanoma.1-3 Not only can acne be associated with physical disfigurement, such as permanent scarring, but its emotional impact can lead to social isolation, depression, and suicidality. In fact, treatment of acne is associated with reduced symptoms of depression.4-6 Given the profound association of acne with quality of life, several qualitative studies7-11 have sought to understand the lived experience of acne among adolescents. These studies7-11 have highlighted that acne can have important effects on social and emotional functioning, relationships, school, and work.12

However, few studies have specifically explored the lived experience of acne in adult populations, and these studies13,14 have been limited by small sample sizes. Because acne often persists into adulthood in women, understanding their perspectives on acne and its treatment is important to guide clinical management in this population.15 The purpose of this study was to examine the lived experience of acne and its treatment among a large cohort of adult women.

Methods
Study Participants

Female patients 18 to 40 years of age with moderate to severe acne were recruited from clinics at the University of Pennsylvania Health System and Dermatologists of Southwest Ohio (a private practice in Cincinnati, Ohio). Patients were contacted by telephone and invited to participate in the interviews with the Mixed Methods Research Lab, a research service center at the University of Pennsylvania. Patients who did not speak English or were not reachable by telephone after 2 attempts were excluded. Participants were purposely sampled to recruit a diverse population with respect to age, race, and ethnicity. All patients provided verbal informed consent. This study was approved by institutional review board of the University of Pennsylvania. The study followed the Standards for Reporting Qualitative Research (SRQR) reporting guideline.16

Data Collection

Voluntary and confidential interviews were conducted by 2 research coordinators (R.N. and M.N.N.) by telephone, lasting a mean (SD) of 28 (8.11) minutes each, between August 30, 2019, and December 31, 2020. Interviews consisted of 2 methods of qualitative data collection: free listing and open-ended, semistructured interviews. During the free-listing phase, participants were asked to describe the first words that came to their mind regarding acne treatments, treatment success, and adverse effects. After the free-listing phase, semistructured interviews were conducted, using an interview guide designed to elicit participants’ perspectives on their experiences with and treatment for acne. Because the Institute of Medicine has prioritized a need for comparative effectiveness research on long-term treatments for acne, we additionally asked participants about their perspectives on participating in a theoretical comparative effectiveness trial to guide the design of a future trial.17 After the interview, participants were asked several questions about demographic characteristics, including race, ethnicity, age, and annual income, and to provide an overview of their medical and acne history.

Statistical Analysis

Free-listing data were edited by research coordinators (R.N. and M.N.N.) with an established judgment rule to collapse synonymous items, then imported into Anthropac (Analytic Technologies) to calculate the Smith S, a measure of saliency for each list item.18 The saliency index was calculated using the following formula: S = {[∑(L − Rj + 1)/L]/N}, where L is the length of each list, Rj is the rank of item J in the list, and N is the number of lists in the sample. Saliency describes the words that are most important for defining the domain of interest among members of a group. The salience index can range from 0 (items with low salience) to 1 (items with high salience).

Semistructured interviews were transcribed verbatim by Datagain Transcription Services and sent to the Mixed Methods Research Lab, where they were cleaned of identifying information. Transcripts were then uploaded to NVivo 12 Plus (QSR International), a software package used for qualitative data management. Two research coordinators (R.N. and M.N.N.) systematically reviewed 3 randomly selected transcripts to identify key themes and insights, defined these themes as analytic codes, and created a data dictionary known as a codebook. This codebook was then uploaded to NVivo 12 Plus and applied to each transcript according to the identified categories by 2 research coordinators (R.N. and M.N.N.). Consistency and agreement in the application of the codebook were assessed using the interrater reliability function in NVivo, and any discrepancies were resolved through discussion. This process was iterative, and several versions of the codebook were created until a final version was agreed on. After the codebook was finalized, thematic content analysis was performed to detect themes about patient perspectives regarding their acne and its treatment.

Results

Fifty women with acne (mean [SD] age, 28 [5.38] years; 24 [48%] White) participated in the study (Table 1). Many reported prior treatment with topical retinoids (29 of 37 [78%]), topical antibiotics (16 of 37 [43%]), combined oral contraceptives (16 of 37 [43%]), spironolactone (26 of 37 [70%]), oral antibiotics (23 of 37 [62%]), and isotretinoin (15 of 37 [41%]).

Free Listing

The most salient term with respect to treatment success, as assessed by the Smith S, was clear skin (salience index, 0.67) followed by no scarring (salience index, 0.09) and no acne (salience index, 0.09). The most salient term with respect to treatment adverse effects was dryness (salience index, 0.67) followed by redness (salience index, 0.21) and burning (salience index, 0.14) (Table 2).

Interview Results
Concerns About Appearance

When describing ways in which acne had affected their lives, participants consistently noted that their blemishes made them highly aware of their appearance. Participants noted struggling with intrusive thoughts about how they looked or how much attention others were paying to their acne. Concerns about appearance affected patients in their personal and professional lives. Several participants described feeling less confident at work because of their acne. Others shared that their acne made it difficult for them to feel confident while dating because they were worried about their acne and went out of their way to hide it from anyone they dated (Table 3).

Mental and Emotional Health

Participants often shared that their acne affected their mental health and well-being. Feelings of anxiety, depression, and low self-worth were common as a result of acne breakouts. Many participants stated that the mental health consequences of acne were magnified in adulthood because they had fewer peers with acne and thus felt more isolated. In particular, those who had had acne from a young age expressed feelings of fatigue with managing acne, having expected their acne to resolve in late adolescence.

Participants often noted that family members, friends, and colleagues would make unsolicited suggestions about how they should be managing their acne (eg, “try this product” or “see this physician”). This behavior often made them believe that those around them did not think that they could manage their acne on their own, which contributed to feelings of frustration because many of these individuals were already trying to address their acne.

Mental health and acne were closely tied in the minds of many participants. The idea that acne was only a cosmetic problem and not a significant medical issue was something with which many patients struggled because for many it had significantly affected their mental health (Table 3).

Everyday Life Consequences of Acne

Most participants thought acne affected their level of confidence in social situations and were concerned that their acne would change how they were perceived by others. Many participants thought their acne affected how they felt about themselves at school or work as well as how others perceived them in these settings. Concerns about how others view their acne continued for some participants into their professional lives, with some believing that having acne made them appear younger and less professional, trustworthy, or qualified in work-related interactions.

Choosing to cancel or postpone social interactions was a common experience among participants, particularly in the setting of acne flares. For many such interviewees, feeling the need to avoid socializing because of their acne had damaging mental health and self-esteem consequences. Participants also described that acne negatively affected their romantic relationships. Although most of these participants did not report that their romantic partners criticized their acne, they still felt high levels of self-consciousness and discomfort when revealing the extent of their acne to someone they were dating.

Some participants noted that they eventually developed a strong emotional resilience against their acne and reported that at a certain point they refused to allow their breakouts to affect how they felt about themselves or to prevent them from socializing. This resilience typically increased the longer that patients had dealt with their acne, and they often described a breaking point at which they began to let go of the stress around their breakouts (Table 3).

Successful Treatment

Participants described successful treatment as having completely clear skin over time or a manageable number of blemishes. Some patients focused on the reduction of the physical manifestation of acne on their faces, whereas others concentrated on the resolution of social and emotional repercussions of having acne, particularly in relationships outside their inner circle, such as professional acquaintances.

Interactions With the Health Care System

Participants described a wide range of experiences with their dermatologists, both positive and negative. Some participants described frustrating relationships with various dermatologists who continued prescribing acne treatments that the patients knew were not effective for their skin. Participants also expressed frustration when they felt pressured to use certain treatments, such as isotretinoin, that they thought were too strong for their acne.

Participants thought having a communicative, respectful relationship with their dermatologist was an important factor for successful treatment. Several mentioned spending years seeing different dermatologists before finally finding one who they thought listened to their concerns, was honest about treatments, and helped find a treatment regimen appropriate for their individual needs.

One participant shared that she thought her skin color was a factor in the kinds of acne treatments that were available to her. She shared that because she was Black, she experienced hyperpigmentation at a higher rate than others and had found that dermatologists often told her that nothing could be done about it (Table 3).

Treatments

Most participants were well versed with a variety of topical and oral medications for acne (Table 4). Participants who described their experience using topical retinoids generally thought it was effective for some types of acne but did not always work to address cystic acne breakouts. Some participants described barriers to use, such as dryness and peeling, as well as inconvenient lifestyle changes, such as limiting sun exposure while using topical retinoids.

Most participants did not think oral antibiotics were appropriate treatments for their acne, specifically because of limited long-term effectiveness. Other problems participants encountered with the use of oral antibiotics were gastrointestinal adverse effects and yeast infections. Several participants described seeing positive results when using oral antibiotics, but these results were temporary. Others thought that antibiotics had never had a substantive effect on their acne.

Participants who had experience taking spironolactone generally described this as the most successful treatment they had tried. Common problems with this treatment were the length of time it took to become effective and adverse effects, such as irregular menstrual cycles, increased need to urinate, lightheadedness, and headaches. The adverse effects caused some participants to stop their spironolactone treatment, whereas others thought that the benefits from the treatment outweighed any adverse effects.

Participants had strong feelings about the use of isotretinoin to treat acne. Those who had experience taking isotretinoin thought that it was highly effective but that it could be disruptive to their everyday lives because of the need for multiple forms of contraception, frequent laboratory appointments to assess blood work, and adverse effects, such as excessive dryness and peeling. Some participants described challenges in getting their physician to prescribe isotretinoin for their acne.

Many participants were concerned about the adverse effects of isotretinoin and described it as a last resort approach to acne. Participants expressed concerns about dryness, need for contraception, having to abstain from alcohol to avoid negative effects on the liver, and the potential for mental health consequences.

Participation in Comparative Effectiveness Research

Participants were generally open to the concept of participating in a comparative effectiveness clinical trial to understand the optimal treatment regimens for acne. Several participants added that they would specifically want to participate in such a study if they knew it would help themselves or others who had acne. Most participants were willing to be randomized and blinded to treatment allocation. Participants were amenable to being required to limit topical treatments, although a few participants shared that they relied heavily on topical treatments and would be hesitant to participate if required to discontinue their use. Those who were not interested in participating shared that it was because they already had a treatment that worked well for them and they did not want to change it or because they were generally wary of participating in trials.

Discussion

The results of this qualitative study highlight that acne has multifaceted quality-of-life consequences in women. Although acne is often viewed as a disease of adolescence, more than 50% of women experience acne in their 20s and more than 35% in their 30s.15 The study participants consistently described acne-related concerns about their appearance that affected their social, professional, and personal lives, with many altering their behavior because of their acne. The importance of appearance-related concerns among persons with acne was also highlighted by a systematic review19 of the impacts of acne and a survey20 on treatment outcomes conducted as part of a James Lind Alliance Acne Priority Setting Partnership.

Similar to smaller qualitative studies13,14 among adults with acne, themes of depression, anxiety, and social isolation were commonly reported in the study. These findings are also aligned with studies7-9,11,12,21 of adolescent acne in which many patients noted significant negative mental and emotional health issues. Given the high frequency of comorbid mental health disorders among patients with acne, identifying and addressing these comorbid mental health conditions is important in this population.22,23 In addition, it is important for payers to recognize the impact of acne in adult women and to provide coverage for treatments in this population.24

Many patients described frustration with finding a dermatologist with whom they were comfortable and with identifying effective treatments for their acne. In contrast, those who thought their dermatologist listened to their concerns and individualized their treatment plan reported higher levels of satisfaction. Issues identifying patient-centered and effective treatments have also been described among adolescents being treated for acne.10 In addition, 1 patient with skin of color expressed frustration with her dermatologists’ understanding of managing acne in patients with darker skin tones. Ensuring multiethnic training in residency is crucial to prepare dermatologists to care for patients of diverse backgrounds with acne.25,26

Although isotretinoin was effective for many patients, concerns about adverse effects and challenges with access were common limitations. Additional patient education about isotretinoin adverse effects and treatment plans could be helpful.5,27,28 Furthermore, as the literature to support reducing the frequency of laboratory monitoring increases, the elimination of excess blood draws may improve the experience of patients taking isotretinoin.29,30 There is also a need to reduce the burden of iPLEDGE (a computer-based risk management program designed to further the public health goal to eliminate fetal exposure to isotretinoin).31

Although oral antibiotics are the most commonly prescribed systemic treatment for acne, with a previous study32 finding that they are used 3 to 7 times more often than alternatives such as spironolactone for women with acne, many patients described hesitancy regarding adverse effects and long-term effectiveness. These results are aligned with a survey that found that more than 75% of patients would prefer an antibiotic-free treatment option if possible.33 In contrast, patients often described positive experiences with spironolactone, which may represent an effective alternative to oral antibiotics for women with acne.28,34-38 The Institute of Medicine designates long-term treatments for acne as 1 of the top priorities for comparative effectiveness research, and patients in the current study were generally willing to participate in such research, which could provide important evidence to guide practice.17,39

Limitations

This study has limitations. It should be interpreted in the context of its qualitative design. Although patients from both academic and private practice settings were enrolled, patients in this study had relatively severe acne as related to their prior treatments, and the study findings may not generalize to other patient populations. As a result, some themes may be amplified or underrepresented because of the severity of acne present in this population. In addition, it was not possible to assess for differences between patients with truncal-only, facial-only acne vs truncal and facial acne.40,41 Finally, complete demographic information for all participants could not be captured.

Conclusions

The women in this qualitative study described various lived experiences related to their acne, including concerns about appearance, mental and emotional health consequences, and disruption to their personal and professional lives. In addition, many patients described challenges finding effective treatments. Future trials to understand the optimal treatment approaches for women with acne are needed to improve outcomes in this population.

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Article Information

Accepted for Publication: May 21, 2021.

Published Online: July 28, 2021. doi:10.1001/jamadermatol.2021.2185

Corresponding Author: John S. Barbieri, MD, MBA, Department of Dermatology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, South Tower, Seventh Floor, Philadelphia, PA 19104 (john.barbieri@pennmedicine.upenn.edu).

Author Contributions: Mss Neergaard and Nelson had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Barbieri, Barg, Margolis.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Barbieri, Neergaard, Nelson, Margolis.

Critical revision of the manuscript for important intellectual content: Barbieri, Fulton, Neergaard, Barg, Margolis.

Statistical analysis: Neergaard.

Obtained funding: Margolis.

Administrative, technical, or material support: Barbieri, Fulton, Neergaard, Nelson, Barg.

Supervision: Nelson, Barg, Margolis.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by grant R34-AR074733-01A1 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr Barbieri receives partial salary support through a Pfizer Fellowship in Dermatology Patient Oriented Research grant to the Trustees of the University of Pennsylvania.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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