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| Journal of the New Zealand Medical Association,
20-August-2004, Vol 117 No 1200
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Acne prevalence in secondary school students and their
perceived difficulty in accessing acne treatment
Diana Purvis, Elizabeth Robinson, Peter Watson
Acne vulgaris is a disease caused by inflammation of the
pilosebaceous follicles. Signs of acne include increased sebum production,
comedones, papules, pustules, and deeper inflamed nodules. It may result in
scarring. Acne occurs most frequently on the face, back, and chest. Typically,
it begins in adolescence and resolves in early adulthood, although lesions may
persist through adult life.
Acne is associated with puberty and so usually has an
earlier onset in females, who enter puberty at a younger mean age than males.
Females usually self-report acne at a higher rate than males, but population
studies using clinical examination report severe acne to be more prevalent in
males, particularly aged 15–18
years.1–4 The estimated prevalence of
acne in the adolescent population varies between 23 and
100%.1–8 The wide range in prevalence is
likely to be in part due to studies using different systems to diagnose and
grade severity of acne, and sampling from significantly different populations.
It has been suggested that the prevalence and severity of
acne, and the need for dermatologist consultation in the school-age population,
have fallen over the last 20 years—perhaps because of improved over the
counter treatments.3 There have been few
studies of acne in New Zealand adolescents and no nationwide population-based
studies to date.
Treatment of acne has improved in recent decades, both in
the range of topical treatments available and with the development of
isotretinoin for use in moderate-severe acne.9
However many New Zealand students demonstrate a poor understanding of the causes
of acne and are not aware of available effective treatments. Most rely on
information gained from parents and friends rather than seeking help from health
professionals.10 Little is known about the
ability of young people to access medical treatment for acne, or whether they
face barriers to care.
This study reports on the epidemiology of self-reported acne
in New Zealand high school students and their perceived ability to access to
treatment.
MethodsThis is a secondary analysis of
data collected in 2001 from a national secondary school youth health and
wellbeing survey—‘Youth2000’. The methodology and early
findings have been reported in detail
elsewhere.11,12
In brief, a questionnaire was developed after
consultation with health and community groups. This was transformed into a
multimedia computer-assisted self-interviewing (M-CASI) survey tool, which was
piloted and found to be acceptable to students. The final questionnaire had 523
items that were administered via laptop computer. With regards to acne, students
were asked ‘Have acne or pimples been a problem for you?’ to which
they had a choice of responses: ‘it hasn’t been a problem for
me’, ‘not too bad’, ‘really bad’,
‘terrible’. Those replying that acne had been ‘really
bad’ or ‘terrible’ were classified as having ‘problem
acne’ for the purposes of further analysis.
Regarding access to treatment, students were asked
‘Have you ever wanted to get treatment from a doctor or specialist for
acne or pimples but been unable to or couldn’t afford to?’ to which
they could reply: ‘yes’, ‘no’, or ‘does not apply
to me’.
In total, 12,934 year 9 to 13 (ages 12 to 18 years)
students were randomly selected and invited to participate from 133 randomly
selected secondary schools. Students were excluded if they were not New Zealand
residents, had insufficient English language skills (less than Year 6), or had a
disability preventing them from using a standard laptop computer.
Ethics approval was gained from the University of
Auckland Human Subjects Ethics Committee. Written informed consent was obtained
from all participating schools and students.
Students were recruited using a clustered sample design
with unequal probabilities of selection. In all analyses, the data have been
weighted and the variance of estimates adjusted to allow for correlated data
from the same school. Chi-squared tests were used to test for differences in
proportions between males and females. Prevalences and their 95% confidence
intervals (95%CI) are presented adjusted for the sampling design.
Socioeconomic status was calculated by combining
variables of school decile, overcrowding, being in a two parent family, family
owning a car and telephone, and whether someone in the home was in paid
employment. All analyses have been conducted using either SAS version 8.2, or
SUDAAN version 7.5.
ResultsSample
characteristics—The school response rate to the survey was 85.7%
and the student response rate 75.0%—resulting in an overall response rate
of 64.3%. The surveyed sample represents 4.0% of the total number of students on
the New Zealand secondary school roll in 2001. Details of the demographics have
been reported previously.11
Prevalence
and associations with ‘problem acne’—A total of 9398
(98.2%) students answered the question regarding presence of acne, with 32.7%
(31.5-33.8) reporting that acne had ‘not been a problem’, 53.2%
(51.7-54.6) stating that acne had been ‘not too bad’ a problem,
10.0% (9.4-10.6) stating that acne had been ‘really bad’, and 4.1%
(3.6-4.7) stating it was ‘terrible’. The frequency of self-reported
‘problem acne’ was 14.1% (13.3-14.9).
Table 1. Frequency of self-reported ‘problem
acne’
*Adjusted for age, sex and
ethnicity; †Adjusted for selected age, sex, ethnicity, and selected
socioeconomic variables; ‡From model II.
Table 1 shows the frequency of ‘problem acne’.
‘Problem acne’ was more likely to be reported by female than male
students (odds ratio [OR] 1.29; 1.15–1.45). Reports of ‘problem
acne’ increased during the teenage years to peak at the age of 16 years
for both genders. Pacific students were more likely to report ‘problem
acne’ than New Zealand European students (OR 1.53; 1.27-1.89).
Age (p<0.001), gender (p=0.0002), and ethnicity (p=0.003)
all showed an independent association with ‘problem acne’ when
included as explanatory variables in a logistic regression analysis.
Accordingly, the highest frequency of self-reported ‘problem acne’
was among female Pacific students (24.4%; 19.9–29.0). The frequency among
Pacific male students (14.3%; 9.3–19.4) was similar to those of males from
other ethnic groups.
Logistic regression analyses were performed adjusting for
age, gender, and ethnicity. The second model also included adjustment for
selected socioeconomic variables with little effect on the odds ratios; although
there was slightly less evidence for an association with ethnicity (p=0.08).
However, Pacific students still remained at higher risk of reporting
‘problem acne’ than their New Zealand European peers.
Prevalence and associations
with difficulty accessing acne treatment—Only students reporting
some acne (ie, responding that acne was a ‘not too bad’,
‘really bad’, or ‘terrible’ problem) were included in
the analysis of access to acne treatment (n=6299). Those students who reported
that acne had ‘not been a problem’ were excluded (n=3054), as were
45 who said they had acne but did not answer the question on
treatment.
Table 2. Self-reported difficulty in accessing
treatment for acne
*Adjusted for age, sex,
ethnicity and acne severity; †Adjusted for age, sex, ethnicity, acne
severity and selected socioeconomic variables; ‡From model
II.
Overall 20.2% (18.6–21.7) of students with acne
reported that they wanted treatment but were unable to access (or afford)
treatment from a doctor or specialist. A further 73.7% (71.9–75.4)
reported no problem with access, and 6.2% (5.5–6.8) responded that the
question did not apply to them. These two groups were combined to form a group
of students with acne who did not have a problem accessing treatment.
Table 2 shows the frequency of reported difficulty in
accessing acne treatment. Difficulty accessing treatment was more commonly
reported by female than male students (OR 1.58, 1.39–1.79). The frequency
of difficulty in accessing acne treatment increased during the teenage years to
peak at age 16 years. Students belonging to Maori or Pacific ethnic groups
reported difficulty accessing treatment more frequently than New Zealand
Europeans (Maori OR 1.65, 1.42–1.91; Pacific OR 3.15,
2.55–3.89).
Those students with ‘problem acne’ were
significantly more likely to report difficulty in accessing treatment than those
whose acne was ‘not too bad’ a problem (OR 5.55; 4.84–6.36).
Logistic regression analysis adjusting for age, gender,
ethnicity, and acne severity confirmed the findings above and is shown in Table
2. The variables of gender (p<0.0001), age (p=0.01), ethnicity (p<0.0001),
and acne severity (p<0.0001) were all independently associated with
difficulty accessing treatment. After including selected socioeconomic variables
in the second logistic regression model, female and 16-year-old students
remained more likely to report difficulty in accessing treatment for acne.
The effect of ethnicity and acne severity was reduced, but
(as they reported) access to acne treatment remained a significant problem for
Maori and Pacific students, and for those with ‘problem
acne’.
DiscussionThis data comes from the largest
randomly selected group of secondary school students studied in New Zealand, and
offers contemporary data on the national population of adolescents. Acne is
common—and females, Pacific, and older students report ‘problem
acne’ more frequently than other groups. Reported difficulty in accessing
treatment is associated with more severe self-reported acne, female gender,
older age, and Maori or Pacific ethnicity. Nearly half of all students with
‘problem acne’ report difficulty in accessing treatment from a
doctor or specialist.
In this study, the presence of ‘problem acne’
was assessed subjectively by participating students. This may result in
variability due to individuals’ differences in their perceptions of
severity of acne. Studies have found that subjects may under-report or
over-report the severity of acne when compared with clinical assessment by a
trained examiner.1,3,13,14
A comparison of self-report of the presence of acne with
clinical examination in Australian school students found self-report had a
sensitivity of 70% and a specificity of 94%.7
Self-report studies have generally found higher rates of acne in females,
whereas studies using clinical examination usually rate acne as more severe in
males. This may be due to females being more sensitive to (and hence likely to
self-report) the presence of acne, particularly in its milder forms.
An accurate measure of the prevalence of acne from this
study is limited, as the survey question asked about whether acne is a problem
rather than the presence of acne. However it may be argued that acne (that
results in a problem for the young person) is more clinically relevant, as it
may result in psychosocial morbidity and the desire for medical intervention.
The degree of embarrassment and social disability associated with acne has been
found to be associated with patient rating of severity, but not with
dermatologist rating.14
A computer-assisted survey of Australian adolescents found
that 81% of students had some acne in the past 12 months, and that female
students reported acne more frequently than
males.1 Older students reported acne more
frequently and there was a significant linear trend of acne associated with
advancing pubertal development. These results are consistent with our findings.
In comparison, a study by Lello et al of 847 16–19
year-old Auckland high school students (using objective assessment by trained
investigators) found acne to be present in 91% of males and 79% of
females.2 Severe acne was present in 6.9% of
male and 1.1% of female students. No association was found between
moderate-severe acne versus parental occupational group or ethnicity. The higher
rates of acne in Lello’s study may reflect the diagnosis being made by
clinical rather than subjective assessment as discussed above, and the older age
of their study population in whom the prevalence of acne is higher.
In this study, Pacific students (particularly Pacific
females) reported acne with greater frequency than students from other ethnic
groups. The reasons for this are not clear. It may be that acne is more common
among Polynesian peoples, although this was not found by Lello et al using
clinical examination.2 Differences due to
cultural definitions and perceptions of the importance of acne may be
significant.
Genetic and biological factors may explain different rates
of acne. For example, there is a potential role for obesity and polycystic
ovarian syndrome in the incidence of acne among female students, which this
study was not designed to address. Indeed, with a high incidence of obesity
noted in New Zealand young people (especially of Pacific ethnicity) one could
postulate that a corresponding increase in polycystic ovarian syndrome and acne
may occur.15
Those students with ‘problem acne’ were
significantly more likely to report difficulties in accessing treatment from a
doctor or specialist than those whose acne was ‘not too bad’. Young
people tend to rely on family and friends for advice regarding treatment, rather
than seeking help from a doctor or
pharmacist.7,10 It may be that part of the
cause of poor access of medical treatment for acne lies with a lack of public
awareness of the availability of therapies. Many of these students could
probably have been successfully treated in primary care. However those with
moderate-to-severe acne vulgaris are more likely to require treatment with
isotretinoin—the use of which is restricted to dermatologists.
The proportion of students reporting ‘problem
acne’ that would be eligible for treatment with isotretinoin could not be
assessed in this study. It is possible that many of those with ‘problem
acne’ would have benefited from specialist dermatologist care, and
reported difficulties in accessing treatment may reflect limited access to
specialist services.
This study confirms that acne is a common problem for New
Zealand adolescents. Perceived barriers to medical treatment were more
frequently found among females, and Pacific and Maori students. It is concerning
to note that nearly half of students with ‘problem acne’ also
reported difficulty in accessing treatment. This has important implications when
we consider the way acne treatment services to this age group are planned and
delivered.
Reducing disparities in health status and access to health
services are critical issues for Maori and Pacific young people. More research
is required to gain a deeper understanding of the barriers young people face in
accessing medical treatment for acne—and access to both primary and
secondary medical services for young people needs to be improved. It is likely
that there will continue to be limited availability of some acne treatments to
this population, due to the ongoing cost of drug treatments (through primary or
private care, and current pressures on publicly funded dermatology services).
Of increasing concern is the recognition of the link between
acne and adverse psychological effects, such as embarrassment, impaired
socialisation, anxiety, and depression.13,14
Indeed, with effective treatment for acne being available but not necessarily
accessible, there may be significant downstream health and social costs to bear
if the New Zealand public health system does not urgently respond to this
important youth health issue.
Author information:
Diana Purvis, Chief Resident, Starship Children’s Hospital, Auckland;
Elizabeth Robinson, Biostatistician, School of Population Health, Faculty of
Medical and Health Sciences, The University of Auckland ; Peter D Watson,
Principal Investigator, Adolescent Health Research Group, Faculty of Medical and
Health Sciences, The University of Auckland, Auckland
Acknowledgements:
This research was supported by grant 00/208 from the Health Research Council of
New Zealand. Portables Plus Ltd and the Starship Foundation provided support
with laptop computers. We also thank the participating school students (and
schools), the project workers, project advisory groups, and the Adolescent
Health Research Group.
Correspondence: Dr
Peter Watson, The Centre for Youth Health, P O Box 23-562, Hunters Corner,
Auckland. Fax: (09) 2795111; email: pwatson@middlemore.co.nz
References:
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