Content uploaded by Neirita Hazarika
Author content
All content in this area was uploaded by Neirita Hazarika on May 09, 2017
Content may be subject to copyright.
© 2016 Indian Journal of Dermatology | Published by Wolters Kluwer - Medknow 515
Abstract
Background: Acne vulgaris causes erythematous papulopustular lesions in active stage and
often leave behind residual scarring and pigmentation. Its onset in adolescence may add to the
emotional and psychological challenges experienced during this period. Aims: To assess the
impact of acne on the various psychosocial domains of daily life. Materials and Methods: This
was a prospective, cross-sectional study done in the dermatology out-patient department of a
tertiary care hospital from January to March 2015. A total of 100 consecutive, newly diagnosed
patients of acne vulgaris, aged 15 years and above were included in this study. The relationship
between acne vulgaris and its sequelae was analyzed with ten different domains of daily
life by using dermatology life quality index (DLQI) questionnaire. Results: Females (56%),
15–20 year olds (61%), facial lesions (60%), and Grade II acne (70%) were most common.
Acne scars were noted in 75% patients, whereas 79% cases had post-acne hyperpigmentation.
Thirty-seven percent patients had DLQI scores of (6–10) interpreted as moderate effect on
patient’s life. Statistically significant correlation (P < 0.05) found were as follows: Physical
symptoms with grade of acne; embarrassment with site and grade of acne; daily activities with
grade of acne and post-acne pigmentation; choice of clothes with site of acne; social activities
with gender, site and grade of acne; effect on work/study with grade of acne; interpersonal
problems with site and post-acne pigmentation; sexual difficulties with grade of acne.
Limitation: It was a hospital-based study with small sample size. Conclusion: Significant
impact of acne and its sequelae was noted on emotions, daily activities, social activities,
study/work, and interpersonal relationships. Assurance and counseling along with early
treatment of acne vulgaris is important to reduce disease-related psychosocial sequelae and
increase the efficacy of treatment.
Key Words: Acne, dermatology life quality index, psychosocial impact, quality of life
The Psychosocial Impact of Acne Vulgaris
Neirita Hazarika, Archana M
Access this article online
Quick Response Code:
Website: www.e‑ijd.org
DOI: 10.4103/0019‑5154.190102
Introduction
Acne vulgaris is a common skin disease with prevalence
reaching up to 80% during adolescence.[1] Major
complications of acne are scarring and psychosocial
distress which persists long after the active lesions
have disappeared.[2] Its onset in adolescence may
add to the emotional and psychological challenges
experienced during this period,[3] and it can lead to the
developmental issues of body image, socialization, and
sexuality.[4] Psychological issues such as dissatisfaction
with appearance, embarrassment, self-consciousness,
lack of self-confidence, and social dysfunction such as
reduced/avoidance of social interactions with peers and
opposite gender, reduced employment opportunities have
been documented.[4-6] Acne can negatively influence the
intension to participate in sports.[7] Moreover, anxiety
and depression are found to be more prevalent among
acne patients than controls.[8-10] Even suicidal ideation
was found in 6–7% of acne patients.[11]
Although acne was earlier considered to be merely a
cosmetic affliction, the psychosocial effects of the disease
have now been scientifically proven. Studies have shown
these effects to improve when acne is treated.[12] Thus, it
is imperative that quality of life (QoL) issues of acne are
taken into consideration for a wholesome management
From the Department of
Dermatology, Venereology and
STD, Tagore Medical College and
Hospital, Chennai, Tamil Nadu,
India
Address for correspondence:
Dr. Neirita Hazarika,
Department of Dermatology,
Venereology and STD,
Tagore Medical College and
Hospital, Rathinamangalam,
Chennai - 600 127,
Tamil Nadu, India.
E-mail: neiritahazarika@yahoo.
com
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Hazarika N, Archana M. The psychosocial impact
of acne vulgaris. Indian J Dermatol 2016;61:515‑20.
Received: February, 2016. Accepted: June, 2016.
ORIGINAL ARTICLE
What was known?
Acne vulgaris commonly causes visible, erythematous, papulopustular lesions in the active stage, often leaving behind residual scarring and pigmentation. This may lead to
psychosocial issues. There is a scarcity of studies on the psychosocial effects of acne among Indian patients.
[Downloaded free from http://www.e-ijd.org on Tuesday, May 9, 2017, IP: 59.97.82.233]
Hazarika and Archana: Psychosocial impact of acne vulgaris
516Indian Journal of Dermatology 2016; 61(5)
of the patients. The use of QoL questionnaires can
help us to adequately understand how acne affects the
patient on a day-to-day basis and can aid in assessing
the efficacy of therapy. In this study, the dermatology
life quality index (DLQI) questionnaire,[13] a general
health-related QoL questionnaire, was used as it enquires
into ten different domains of daily life activities. There
is a paucity of studies on the psychosocial impact of
acne vulgaris in the Indian scenario. The aim of this
study was to assess the impact of acne on the various
psychosocial domains of daily life.
Materials and Methods
It was a hospital-based, prospective, cross-sectional
study done in the dermatology and STD out-patient
department of a tertiary care teaching hospital, for a
period of 3 months (January to March 2015). Approval
from the Institutional Research and Ethics Committees
was obtained, and patients were recruited after informed
written consent (Tamil/English).
Inclusion criteria
A total of 100 consecutive patients, newly diagnosed as
acne vulgaris, of age 15 years and above, were included
in the study.
Exclusion criteria
Acne patients with known history of mental disorder,
concurrent physical illnesses and disabilities that can
affect their mental state, patients who used topical
and systemic drugs known to predispose to acne were
excluded from the study.
The parameters collected were divided
into – (1) Clinicodemographic data: Age, sex, duration, site,
grade of acne, post-acne hyperpigmentation, and acne scars.
Acne was graded into four grades (I–IV),[14] whereas acne
scars (all types included) were graded[2] as mild, moderate,
and severe. (2) DLQI questionnaire (Tamil or English) filled
up by the patients without assistance. English version
of the DLQI was translated into Tamil by two bilinguals.
Forward and backward translation was done by different
translators and validated by two other members.
The DLQI questionnaire[13] (used after formal written
permission) grades QoL by assessing the following
domains: (a) Physical symptoms and feelings
(Q1, Q2), (b) daily activities (Q3, Q4), (c) leisure
(Q5, Q6), (d) work/school (Q7), (e) personal relationships
(Q8, Q9), and (f) treatment (Q10). Each question is
scored as four-point Likert scale (score 3-0), keeping in
mind the problems faced the previous week due to the
disease. Final DLQI score is the sum of all scores (range
0–30). DLQI score interpretation is done as follows:
Score (0–1) no effect on patient’s life, (2–5) small effect
(6–10) moderate effect, (11–20) very large effect, and
score (21–30) extremely large effect on patient’s life.
Statistical analysis
The data collected were subjected to Chi-square test and
analysis of variance using IBM SPSS statistics software
version 20 (IBM Corporation, Armonk, New York, USA).
The level of significance was set at P < 0.05.
Results
Among a study population of 100 patients, females
predominated with 56% cases. Sixty-one percent were
in the age group of 15–20 years, whereas 39% patients
had recent onset of acne (0–6 months duration).
Facial acne as single site involvement was the most
common (60%) type encountered, whereas multiple
site involvement (face, chest, and back together) was
seen in 37% cases. Grade II acne with 70% patients
was the most common clinical type found. Seventy-five
percent of cases had varying degree of acne scars,
whereas post-acne hyperpigmentation was seen in 79%
cases. Table 1 shows the clinicodemographic profile of
study population. Thirty-seven percent patients had
a DLQI score in the range of (6–10) interpreted as
moderate effect on patients life, whereas 29% patients
scored (11–20) interpreted as very large impairment of
QoL [Table 2].
Table 3 shows the significance of correlation
between the ten different domains of the DLQI
questionnaire (Q: 1–10) with the each of the following
clinicodemographic factors: Gender, age, site of lesions,
grade of acne, acne scars, and post-acne pigmentation.
Statistically significant correlation (P < 0.05) was seen
between Q1: Physical symptoms and grade of acne. The
domain, Q2: Embarrassment/self-consciousness showed
statistical significant correlation to site and grade
of acne while Q3: Effect on daily activities showed
significant statistical association to the grade of acne
and post-acne pigmentation. Statistically significant
correlation was seen between Q4: Choice of clothes
and site of acne. The domain, Q5: Effect on social
activities showed statistically significant correlation to
gender, site, and grade of acne. Statistically significant
correlation was seen between Q7: Effect on work/study
and grade of acne while the domain, Q8: Problems with
partner/close friends/relatives showed statistically
significant correlation to the site of acne and post-acne
pigmentation. The domain, Q9: Sexual difficulties
showed statistically significant correlation to the
grade of acne. The domains, Q6: Effect on sports and
Q10: Treatment taking up time/making skin messy did
not show statistically significant correlation to any of
the clinicodemographic factors studied (P > 0.05).
Discussion
The present research aimed to study the QoL issues
among acne patients in India. The influence of factors
[Downloaded free from http://www.e-ijd.org on Tuesday, May 9, 2017, IP: 59.97.82.233]
Hazarika and Archana: Psychosocial impact of acne vulgaris
517 Indian Journal of Dermatology 2016; 61(5)
such as age, gender, site of lesions, grade of acne, acne
scars, and post-acne pigmentation on ten psychosocial
domains of daily life was analyzed.
Q1: Physical symptoms of itch, soreness,
pain, stinging
Physical symptoms were reported by 78% patients in the
present study. Tasoula et al.[15] reported 25% of cases
of facial acne and 33% cases of acne in the back to be
having itch as a physical symptom while Reich et al.
reported 50% of acne cases to have itch.[16] Enquiry
into the exact nature of physical symptom was however
outside the purview of this study; however, many
patients complained of discomfort/pain in the acne
lesions. In this study, physical symptoms were found to
show statistically significant correlation to the grade of
acne (P < 0.001).
Q2: Embarrassment/self‑consciousness
In this study, 88% cases reported embarrassment/
self-consciousness due to acne which was consistent
to previous studies.[15,17] In the study by Ogedegbe
and Henshaw,[18] 64.4% patients were psychologically
perturbed by the appearance of their skin. Magin et al.[5]
in their qualitative study on the psychological sequelae
of acne stated that acne negatively affected self-image
in all patients, at least to some degree. Embarrassment
and self-consciousness were directly linked to low
self-image and self-esteem; this finally led to decrease
in self-confidence. In the present study, the degree of
embarrassment/self-consciousness showed statistically
significant correlation to the severity of acne (P < 0.001),
which was similar to the findings by Tasoula et al.[15] and
van der Meeren.[19] Moreover, the association between
site of acne and embarrassment/self-consciousness was
found to be statistically significant (P < 0.05) in this
study. Patients with facial acne reported feeling highly
self-consciousness about their acne and this was the
main reason they sought treatment.
Q3: Eect on daily activities‑shopping,
looking after home, garden
In this study, problems in daily activities were
complained by 69% patients. The degree of difficulty
in daily activities showed statistically significant
association (P < 0.05) to the grade of acne and post-acne
hyperpigmentation. Magin et al. established a linear
relationship of appearance to self-image and self-esteem;
unattractive appearance lead to embarrassment and
finally to avoidance of social contact. Moreover, they
could demonstrate a temporal association between
anger, frustrations, and acne.[5] Thus, problems in daily
activities due to acne may be attributed to avoidance
behavior, anger, and frustration.
Q4: Influence on choice of clothes
Appearance is often appraised through dressing[20] and
thus clothes form an important component of social
acceptance. While 25–29% patients in previous studies
reported difficulty in dressing attributable to acne,[15,21] it
was 37% in this study. Site of acne showed statistically
significant correlation (P < 0.05) to choice of clothes
Table 1: Clinicodemographic characteristics of the
study population
n=100 (%)
Gender
Male 44
Female 56
Age (years)
15-20 61
21-25 31
>25 8
Duration of acne (months)
0-6 39
7-12 23
13-24 20
25-36 5
>36 13
Site
Face 60
Chest 0
Back 2
Face and chest 11
Face and back 17
Chest and back 1
Face, chest and back 9
Grade of acne
I 11
II 70
III 17
IV 2
Postinflammatory hyperpigmentation
Present 79
Absent 21
Acne scar
Mild 23
Moderate 25
Severe 27
Absent 25
Table 2: Interpretation of dermatology life quality index scores
Total
patients n
No effect
score (0-1)
Mild effect
score (2-5)
Moderate effect
score (6-10)
Very large effect
score (11-20)
Extreme large
effect score (21-30)
100 (100) 0 34 (34%) 37 (37%) 29 (29%) 0
[Downloaded free from http://www.e-ijd.org on Tuesday, May 9, 2017, IP: 59.97.82.233]
Hazarika and Archana: Psychosocial impact of acne vulgaris
518Indian Journal of Dermatology 2016; 61(5)
in this study. Patients with truncal acne consciously
avoided wearing clothes that revealed their acne affected
skin. In the study by Ogedegbe and Henshaw,[18] 14.4%
adolescent avoided wearing costumes that exposed
extrafacial areas affected by acne.
Q5: Eect on social/leisure activities
In this study, 68% patients reported acne affected their
social activities. Negative influence on social/leisure
activities showed statistically significant correlation
(P < 0.05) to gender, site of lesions, and grade of acne.
Patients responded that they especially avoided social
gatherings during an episode of acute acne flare as they
felt other people stared at their acne and this made them
uncomfortable. This was more so in females. A higher
degree of social anxiety, social avoidance/withdrawal
due to acne was also reported by Yolaç et al.[22] and
Fried and Wechsler.[23] Magin et al.[5] stated that many
subjects reported avoidance behavior in response to their
acne and some went on to develop permanent effect on
personality such as avoidant personality trait.
Q6: Diculty in sports
A study among Scottish students found that 10% of acne
sufferers avoided swimming and other sport because of
embarrassment.[24] While Tasoula et al.[15] reported 14.4%
of acne patients having difficulty in sports attributed
to acne, it was 25% in this study. No statistically
significant correlation could be demonstrated between
the clinicodemographic factors and sports in this study.
This could be because the study population was mainly
suburban, where sports may not be an important part of
day-to-day life.
Q7: Eect on work/study
In the present study, 57% patients reported negative
effect of acne on work/study. Twenty-one percent of
pupils felt that acne affected their schoolwork and
personal activities.[15] Similar findings were also reported
by Walker et al.[24] In this study, negative effect on
work/study showed statistically significant correlation
to the grade of acne (P < 0.05). Patients stated that
they were constantly bothered by their acne and facial
appearance, and this affected their ability to concentrate
on study/work.
Q8: Problems with partner/close friends/
relatives
In the present study, 75% patients reported interpersonal
problems. Problems with partner/close friends/relatives
showed statistically significant correlation (P < 0.05) to
the site of acne and post-acne pigmentation. Patients
reported being constantly enquired about their acne,
even teased by peers and relatives. Female patients felt
that acne reduced their prospect in getting alliances for
arranged marriage. Psychosocial research have shown
that physically attractive strangers attribute more
Table 3: Significance of correlation (P) between the clinicodemographic factors and ten domains of dermatology life quality index questionnaire
Clinicodemographic
factors
Domains of DLQI
Q1: Physical
symptoms
Q2: Embarrassment Q3: Daily
activities
Q4: Choice
of clothes
Q5: Social or
leisure activities
Q6: Sports Q7: Work
or study
Q8: Inter-
personal problems
Q9: Sexual
difficulty
Q10: Treatment
difficulties
Gender 0.091 0.595 0.231 0.063 0.050* 0.546 0.143 0.300 0.507 0.997
Age of patient 0.149 0.296 0.118 0.083 0.277 0.475 0.193 0.261 0.463 0.319
Site of lesions 0.469 0.048* 0.614 0.005* 0.005* 0.712 0.458 0.019* 0.794 0.310
Grade of acne <0.001** <0.001** 0.003* 0.921 0.046* 0.782 0.003* 0.851 0.050* 0.082
Acne scars 0.144 0.090 0.405 0.364 0.128 0.629 0.726 0.441 0.511 0.140
Post-acne
pigmentation
0.226 0.329 0.050* 0.441 0.073 0.402 0.230 0.028* 0.859 0.724
*P<0.05, **P<0.001. DLQI: Dermatology life quality index
[Downloaded free from http://www.e-ijd.org on Tuesday, May 9, 2017, IP: 59.97.82.233]
Hazarika and Archana: Psychosocial impact of acne vulgaris
519 Indian Journal of Dermatology 2016; 61(5)
positive qualities such as friendliness, intelligence, and
higher social skill levels to each other, compared with
physically unattractive strangers.[25] Adult females with
acne agreed to the advantage of physical attractiveness
in getting jobs and life partners.[26] Magin et al.
stated that primary concern of patients with acne was
appearance which might be, in part, a media generated
ideal of perfect skin. Subjects were acutely aware that
they failed to live up to the ideal of perfect, flawless
skin portrayed in advertising and television. This led
to a self-perceived reduction in sexual attractiveness.
Subjects also had a perception of being judged by others
because of acne while many feared being thought of as
unhealthy or unhygienic.[5]
Q9: Sexual diculties
Only 5% patients in this study reported sexual difficulties
due to acne. Statistically significant association was
observed between sexual difficulties and grade of acne
(P < 0.05). However, enquiry into the exact cause
of sexual difficulty was outside the purview of this
study. Sexual difficulties reported could be secondary
to self-perceived reduction in sexual attractiveness;
disinterest secondary to acne associated anxiety; or
unwillingness to divulge personal information. Kulthanan
et al.[2] reported similar findings and opined that it is a
feature of Asian culture that people became embarrassed
or avoided questions about personal relationships.
Q10: Treatment of acne making home messy/
taking up time
Treatment of acne is probably more time consuming than
generally thought, causing discomfort and annoyance to
many patients.[27] Twenty-five percent of pupils under
the treatment for acne reported that treatment was
unpleasant.[15] In the present study, 45% reported that
treatment/home remedies of acne were taking up time or
making life messy. No statistically significant correlation
could be demonstrated between the clinicodemographic
factors and treatment difficulties in this study. Patients
admitted that their daily routine to hide acne, took a
lot of their grooming time. Adolescents with acne feel
uncomfortable, avoid eye contact, grow their hair long
to cover their faces and girls used makeup to camouflage
their acne.[28] Women found camouflaging their acne with
makeup was effective in decreasing embarrassment and
self-consciousness.[5] More than half of the untreated
pupils with acne brought over the counter products
without prior consulting a dermatologist.[15] Patients
in this study confessed to trying self-remedies in the
form of using creams/medications for acne as suggested
by peers or using turmeric powder paste, which is a
common skin care routine in South India.
Limitations
One limitation of this study was the possibility of
referral bias and overestimation of psychometric
morbidity with hospital-based data. Furthermore, the
sample size was small. There is a need to replicate this
study in community setting to extrapolate the findings
to all acne patients.
Conclusion
The present study showed significant impact of acne
and its sequelae on physical symptoms, emotions, daily
and social activities, study/work, and also interpersonal
relationships. Thus, it is safe to conclude that severity of
acne should not be assessed solely on the physical grade
of acne alone but should include its effect on QoL. The
need of inclusion of QoL questionnaires in evaluating
patients of acne vulgaris at baseline, during, and
after treatment is of utmost importance. Education of
dermatologists and general practitioners alike, about the
psychosocial impairments of acne can help in identifying
cases with QoL issues. There is a need for integration
of psychological intervention in the management of acne
vulgaris, for improvement in the QoL in such patients.
Setting up supportive groups could also be of immense
help for these patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
What is new?
Acne vulgaris and its sequele commonly affects emotions, daily & social activities,
quality of study/work and interpersonal relationships. Identifying acne patients
with QoL issues is important so as to be able to provide a wholesome management
leading to clinical and QoL improvement.
References
1. Rzany B, Kahl C. Epidemiology of acne vulgaris. J Dtsch
Dermatol Ges 2006;4:8-9.
2. Kulthanan K, Jiamton S, Kittisarapong R. Dermatology
life quality index in Thai patients with acne. Siriraj Med J
2007;59:3-7.
3. Misery L. Consequences of psychological distress in adolescents
with acne. J Invest Dermatol 2011;131:290-2.
4. Tan JK. Psychosocial impact of acne vulgaris: Evaluating the
evidence. Skin Therapy Lett 2004;9:1-3, 9.
5. Magin P, Adams J, Heading G, Pond D, Smith W. Psychological
sequelae of acne vulgaris: Results of a qualitative study. Can
Fam Physician 2006;52:978-9.
6. Purvis D, Robinson E, Merry S, Watson P. Acne, anxiety,
depression and suicide in teenagers: A cross-sectional survey
of New Zealand secondary school students. J Paediatr Child
Health 2006;42:793-6.
7. Loney T, Standage M, Lewis S. Not just ‘skin deep’:
Psychosocial effects of dermatological-related social anxiety in
a sample of acne patients. J Health Psychol 2008;13:47-54.
8. Yazici K, Baz K, Yazici AE, Köktürk A, Tot S, Demirseren D,
et al. Disease-specific quality of life is associated with anxiety
and depression in patients with acne. J Eur Acad Dermatol
Venereol 2004;18:435-9.
9. Sayar K, Ugurad I, Kural Y, Acar B. The psychometric
[Downloaded free from http://www.e-ijd.org on Tuesday, May 9, 2017, IP: 59.97.82.233]
Hazarika and Archana: Psychosocial impact of acne vulgaris
520Indian Journal of Dermatology 2016; 61(5)
assessment of acne vulgaris patients. Dermatol Psychosom
2001;1:62-5.
10. Khan MZ, Naeem A, Mufti KA. Prevalence of mental health
problems in acne patients. J Ayub Med Coll Abbottabad
2001;13:7-8.
11. Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of
suicidal ideation among patients with skin disease. J Am Acad
Dermatol 2006;54:420-6.
12. Fakour Y, Noormohammadpour P, Ameri H, Ehsani AH,
Mokhtari L, Khosrovanmehr N, et al. The effect of
isotretinoin (roaccutane) therapy on depression and quality
of life of patients with severe acne. Iran J Psychiatry
2014;9:237-40.
13. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) – A
simple practical measure for routine clinical use. Clin Exp
Dermatol 1994;19:210-6.
14. Adityan B, Kumari R, Thappa DM. Scoring systems in acne
vulgaris. Indian J Dermatol Venereol Leprol 2009;75:323-6.
15. Tasoula E, Gregoriou S, Chalikias J, Lazarou D, Danopoulou I,
Katsambas A, et al. The impact of acne vulgaris on quality of
life and psychic health in young adolescents in Greece. Results
of a population survey. An Bras Dermatol 2012;87:862-9.
16. Reich A, Trybucka K, Tracinska A, Samotij D, Jasiuk B,
Srama M, et al. Acne itch: Do acne patients suffer from
itching? Acta Derm Venereol 2008;88:38-42.
17. Wu SF, Kinder BN, Trunnell TN, Fulton JE. Role of anxiety and
anger in acne patients: A relationship with the severity of the
disorder. J Am Acad Dermatol 1988;18(2 Pt 1):325-33.
18. Ogedegbe EE, Henshaw EB. Severity and impact of acne
vulgaris on the quality of life of adolescents in Nigeria. Clin
Cosmet Investig Dermatol 2014;7:329-34.
19. van der Meeren HL, van der Schaar WW, van den Hurk CM.
The psychological impact of severe acne. Cutis 1985;36:84-6.
20. Feingold A. Good-looking people are not what we think.
Psychol Bull 1992;111:304-41.
21. Motley RJ, Finlay AY. How much disability is caused by acne?
Clin Exp Dermatol 1989;14:194-8.
22. Yolaç Yarpuz A, Demirci Saadet E, Erdi Sanli H,
Devrimci Ozgüven H. Social anxiety level in acne vulgaris
patients and its relationship to clinical variables. Turk
Psikiyatri Derg 2008;19:29-37.
23. Fried RG, Wechsler A. Psychological problems in the acne
patient. Dermatol Ther 2006;19:237-40.
24. Walker N, Lewis-Jones MS. Quality of life and acne in Scottish
adolescent schoolchildren: Use of the Children’s Dermatology
Life Quality Index (CDLQI) and the Cardiff Acne Disability
Index (CADI). J Eur Acad Dermatol Venereol 2006;20:45-50.
25. Layton AM. Disorders of sebaceous glands. In: Burns T,
Breathnach S, Cox N, Griffiths C, editors. Rook’s Textbook
of Dermatology. 8th ed., Vol. 42. Oxford: Wiley-Blackwell
Publication; 2010. p. 1-89.
26. Pruthi GK, Babu N. Physical and psychosocial impact of acne
in adult females. Indian J Dermatol 2012;57:26-9.
27. Rubinow DR, Peck GL, Squillace KM, Gantt GG. Reduced
anxiety and depression in cystic acne patients after successful
treatment with oral isotretinoin. J Am Acad Dermatol
1987;17:25-32.
28. Tedeschi A, Dall’Oglio F, Micali G, Schwartz RA,
Janniger CK. Corrective camoufl age in paediatric dermatology.
Cutis 2007;79:110-2.
[Downloaded free from http://www.e-ijd.org on Tuesday, May 9, 2017, IP: 59.97.82.233]