Perceptions of Acne and Its Treatments Among Chinese College Students: A Cross-Sectional Survey

Li-Ping Liu＊, Yu-Mei Li Si-Meng Gu, Wei Wu, Mei Fang, Hang Zhou

1 Department of Dermatology, Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang, Jiangsu 212001, China;2 Institute of Regenerative Medicine, Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang, Jiangsu 212001, China;3 Department of Psychology, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu 212013, China.

Abstract Objective: This cross-sectional survey aimed to explore Chinese college students’ perceptions regarding acne and its topical medications, and to evaluate whether these perceptions affect their motivation to seek and adhere to treatments.Methods: A cross section survey was performed using a 14-item questionnaire was administered via WeChat.among Chinese college students at Jiangsu University aged 18–24 years.Results: One thousand and four hundred and fifteen responses were received. The prevalence of selfdiagnosed acne was 34.1%. The factors associated with a greater likelihood of seeking treatment were being female, having acne for a longer duration, and having severe acne. Nearly two-thirds of the respondents had discontinued topical medication use within 1 month, with only 4.8% continuing for over 6 months. The main reason for discontinuation was slow onset of action. Patients who considered acne a long-term condition were more likely to seek treatment and use medication for longer periods than those who considered it a short-term condition. Lack of knowledge about medication features, proper usage, and prevention of adverse effects may lead to early discontinuation. Furthermore, 93.8% of the respondents hoped to obtain the above information from doctors.Conclusion: Detailed explanations of acne and medication guidance are necessary to help patients understand the necessity of continuous treatment and the expected efficacy.

Keywords: acne, adherence, perception, topical medication

Introduction

Acne vulgaris is a chronic inflammatory skin disease and it is especially common in the youth population, with a prevalence of up to 37.3% in Chinese population aged 15–24 years.1Acne not only causes cosmetic issues, but is also associated with significant psychological and social problems. People with acne often have lower self-esteem and satisfaction with their bodies, which greatly affects their quality of life2and increases the risks of depression, anxiety, and suicide.3–5Effective treatments can significantly improve skin appearance, quality of life, and self-esteem.6However, patient adherence to acne treatment is often poor,7which undoubtedly hampers their therapeutic effect. Understanding the associated factors and determining appropriate solutions may be as important for treatment outcomes as choosing the right medication.8

Adherence to acne treatment is affected by various factors,9-10including patients’ perceptions of the disease and its medications.10However, as many previous studies on adherence have been carried out in other countries, there is a paucity of data relevant to the Chinese population. Considering regional and cultural differences,7the present study aimed to explore the perception of acne and its topical treatment among Chinese college students, and to evaluate whether these perceptions affect their motivation to seek and adhere to acne treatments. In addition, patients’ concerns during physician-patient communication were explored.

Material and Methods

Study Design and Procedure

This cross-sectional observational study was approved by the Ethics Committee of Biomedical Research in the Affiliated Hospital of Jiangsu University(SWYXLL20200429–6). The survey was conductedviaWeChat and the participants’ identities were kept anonymous. Prior to the investigation, participants were informed of the purpose of this survey and that their participation was voluntary.

To eliminate the interference of age and culture-related differences with perceptions, Chinese college students at Jiangsu University aged 18–24 years were surveyed.

The questionnaire contained 14 questions that mainly covered the following three aspects: (1) participant characteristics, such as gender, college major, self-reported severity of acne, length of time since acne onset, history of seeking treatment, and medication use; (2) perceptions of acne and its topical medications; (3) concerns during physician–patient communication. The severity of acne11was self-evaluated by participants in accordance with the text descriptions (Mild: comedones, a few papulopustular lesions, or both; Moderate: comedones, more papulopustular lesions, or both; Severe: widespread nodules,cyst or scarring) and picture references included in the questionnaire.

Statistical Analysis

Data were collected and recordedviaWenjuanxing, an online platform in China. Descriptive statistics were calculated as numbers and percentages. Significant differences were analyzed using the rank sum test for grade data (categorical variables that can be graded) and Pearson Chisquared test for classification data (categorical variables that cannot be graded) with SPSS version 23 (IBM Corp.,Armonk, NY, USA). The level of significance was set atP＜ 0.05.

Results

Participant Characteristics

Between April and June 2020, 1,415 valid questionnaires were collected, giving a response rate of 21.5%(1,415/6,581). Participants’ demographic characteristics are shown in Table 1. The prevalence of self-diagnosed acne was 34.1% (483/1,415), with 56.5% (273/483)reporting that they had had acne for over 36 months. Of those with acne, 70.0% (338/483) had mild acne, while 24.2% (117/483) had moderate acne, and 5.8% (28/483)had severe acne.

Treatment Seeking

Among the participants with acne, 75.8% (366/483)had tried topical applications. However, only 45.6%of them (167/366) had visited doctors for acne-relatedtreatment in the previous 12 months. The percentage of participants who had visited doctors significantly differed between those with mild, moderate, and severe acne, with prevalence of 28.4% (96/338), 47.0%(55/117), and 57.1% (16/28), respectively, (Table 2,P＜ 0.001). The length of time since acne onset was classified as less than12 months, 12–36 months, and over 36 months. Respondents who were female and had experienced acne for a longer duration were the most likely to use topical applications and seek medical treatment (Table 2). Among the participants with acne, 24.2% (117/483) had never used topical reagents. The main self-reported reason was the lack of severity of the acne condition (75/117; 64.1%),which was consistent with the results of the self-assessment of acne as mild in 70.0% of cases; other reasons included the view that leaving acne untreated does not have adverse consequences (41/117; 35.0%),concerns about the adverse effects of medication(25/117; 21.4%), and the belief that acne resolves on its own (24/117; 20.5%).

Table 1 Demographic characteristics of participants.

Medications

When asked “What is the shortest duration for which you have continuously used prescribed topical medication?,” 62.9% (105/167) of the respondents reported a period of less than 1 month; only 4.8% (8/167) had used prescribed topical medication for over 6 months(Fig. 1A). The main self-reported reasons for treatment discontinuation were that medications take too long to take effect (44.1%; 71/161) and that medications have no effect (18.0%; 29/161) (Fig. 1B). Moreover,23.6% (38/161) either forgot or were too busy to use their medication. Based on the duration of use of prescribed medications, participants were divided into two groups–no long-term use (continuous use for less than 1 month) and long-term use (continuous use for more than 1 month)–for the analysis of the associations of acne treatment with gender, academic major, acne duration, and severity (Table 2). Patients with severe acne used medication for longer periods than those with mild acne.

Table 2 Association of participants’ characteristics with their behavior.

Perceptions of Acne

When asked “Do you think acne is a long-term chronic skin condition or a short-term disease that will resolve on its own?,” 76.5% (1,082/1,415) of the total sample indicated that they considered acne a long-term condition. A similar proportion of people with self-reported acne reported this perception (365/483; 75.6%),while the prevalences of this perception among participants with acne for over 36 months, 12-36 months,and less than 12 months were 83.5% (228/273), 68.3%(69/101), and 62.4% (68/109), respectively (P＜ 0.001).This suggests that patients who had experienced acne for a longer duration were more aware of its chronic nature. A similar proportion of patients with acne who considered acne a long-term chronic skin condition had tried topical applications (77.3%; 282/365) as those who considered it a short-term skin condition (71.2%;84/118) (Fig. 2A). Among those who considered acne a long-term condition, 39.5% (144/365) had visited doctors over the previous 12 months, compared with 19.5% (23/118) of those who considered it a short-term condition (Fig. 2B,P＜ 0.001). These results suggest that patients who considered acne a long-term condition were more likely to seek medical treatment. Although there was no significant difference in the duration of continuous medication use between the two groups(Fig. 2C), people who considered acne a long-term condition seemed more likely to use medication for longer periods.

Knowledge About Acne Treatments

Figure 1. Features of acne treatment discontinuation. (A) Proportion of patients with the shortest Percentation of topical medication use. (B)Reasons for discontinuation. w: week; m: month.

Figure 2. Perceptions of acne and its association with (A) topical treatments, (B) doctor visits, and (C) adherence to medication use. (D, E)Association of knowledge about the difference between cosmetic and pharmaceutical products with doctor visits and medication adherence.(F, G) Associations of knowledge about topical medication features and method of use with medication adherence. N.S.: not significant.

The degree of knowledge about acne medications was classified into four levels: 0 (no knowledge), 1 (limited knowledge and overall lack of clarity), 2 (basic knowledge, but lack of clarity about some aspects), and 3 (high knowledge).For the question “Do you know whether the topical applications you use are cosmetic or pharmaceutical?,” 12.8%(47/366) of patients who had tried topical applications stated that they could differentiate them quite well (level 3). Of the respondents, 41.0% (150/366) reported that they only had little knowledge (level 1), while 9.3% (34/366)had a complete lack of knowledge about the differences between cosmetic and pharmaceutical products (level 0).When grouped in accordance with these levels of knowledge(0–3), 29.4% (10/34), 36.7% (55/150), 51.1% (69/135),and 70.2% (33/47) of participants, respectively, had visited doctors during the previous 12 months. This indicated that possessing the knowledge necessaryto differentiate between cosmetic and pharmaceutical products was associated with a higher likelihood of seeking medical treatment (Fig. 2D,P＜ 0.001). Among participants in the level 0 group, 90.0%(9/10) had used medication for less than 1 month, while this proportion was only 54.5% (18/33) among participants in the level 3 group (Fig. 2E,P＜0.05). The proportions of participants in the level 0, 1, 2, and 3 groups who responded affirmatively to the question “Do you know the name, components, and efficacy of this drug?” were 5.0% (8/161), 55.3% (89/161), 32.3% (52/161), and 7.5%(12/161), respectively. The proportion of respondents who discontinued medication within 1 month was 87.5% (7/8)in the level 0 group, compared with only 41.7% (5/12) in the level 3 group (Fig. 2F,P＜ 0.05). The proportions of participants in the level 0, 1, 2, and 3 groups who responded affirmatively to the questions “Do you know how to use these topical medications properly, such as the frequency,dosage, or site? Do you know how to avoid side effects?”were 11.2% (18/161), 45.3% (73/161), 40.4% (65/161),and 3.1% (5/161), respectively. Medication had been used for less than 1 month by all participants in the level 0 group(5/5), compared with only 44.4% (8/18) of the level 3 group(P＜ 0.05, Fig. 2G). This suggests that difficulty in differentiating between cosmetic and pharmaceutical products and a lack of knowledge about the features of topical medications, proper use, and avoidance of adverse effects may lead to early discontinuation of treatment.

Patient Concerns During Physician-Patient Communication

When asked “What information would you like doctors to provide or explain to you during your communication?,”93.8% (151/161) of respondents stated that they would like to receive information about proper medication usage, efficacy, and potential adverse effects. In addition, they hoped to obtain information regarding alternative treatment options(102/161; 63.4%), reliable sources of information about acne, such as WeChat Public, (63/161; 39.1%) treatment costs (59/161; 36.7%), and follow-up (56/161; 34.8%).

Discussion

There is a common perception that acne is an adolescent problem that resolves without treatment.12A survey of the Chinese population showed that 79.7% consider acne a natural occurrence, while only 17.2% consider it a disease.1The perception of acne as a short-term condition affects patients’ expectations of treatment effectiveness,self-management, and adherence to seek treatment. In this study, we found that participants who considered acne a short-term condition were less likely to seek treatment and adhere to medication than those who considered acne a long-term condition, indicating that these views affect behaviors.

In addition, we found that 366 participants had tried topical applications to treat their acne, while only 167 had visited doctors for treatments. This gap indicates that a large number of young people are likely to purchase topical applications over the counter or from Internet pharmacies rather than from hospitals; this may be attributed to their confusion regarding the difference between cosmetic and pharmaceutical products. In addition, 70.2% of those with full knowledge of the difference between cosmetic and pharmaceutical products tended to seek treatments from doctors, while this proportion was only 29.4% in the population without any related knowledge. Thus, this confusion may result in alternative treatments serving as the first option.10A recent study found that 58.7% of college students do not know the name of their prescribed acne medication.13Similarly, 60.2% of those in the level 0 and 1 groups of the present study did not know the name, components, or efficacy of the acne medication they used and 43.5% of participants in the level 0 and 1 group did not know how to use their topical medication properly. Topical medications for acne treatment often take weeks or even months of continuous use to produce a significant effect. Thus, patients who are not adequately familiar with the features of the medication feel that such drugs are ineffective, leading to frustration and poor adherence.14In addition, the improper use of topical drugs, especially retinoic acid drugs, causes erythema, desquamation, itching, and even a burning sensation. These adverse effects often lead to discontinuation of treatment. The data analysis in our study is consistent with the previous study.10

Physician-level factors play an important role in patient adherence to treatment9; when physicians display a lack of patience or do not provide adequate explanations,the result is poor treatment adherence. According to our results, it is necessary for physicians to take the time to adequately explain acne treatment to patients.8

Acne treatment adherence is assessed using several methods, such as questionnaire,7detection of drug concentrations, drug counts or weights,15and inter-views.10However, there is currently no gold standard,16and different assessment methods produce varying results.7,10,15In the present qualitative exploratory survey, the likelihood of poor adherence was assessed by the discontinuation of topical medication use. Quantitative indicators for treatment adherence and specific medications are necessary in future studies. In addition, as this was a cross-sectional study, no inferences can be made regarding causality. The study has the following limitations: as the focus was only on topical medication, questions regarding oral drugs were not included in the questionnaire; thus, future studies should investigate perceptions and adherence in the context of oral drugs.

Treatment adherence evaluation can contribute to the development of strategies to help patients achieve better efficacy. It is crucial to provide information to patients with acne regarding its chronic features, onset of action of treatments, methods of use, and prevention of adverse effects. In addition, as indicated by the present results, it may be helpful to provide specific alternative strategies,specify medication costs, and offer guidance on how to obtain evidence-based information.

Source of funding

This work was supported by the Natural Science Foundation of Jiangsu Province (No. BK20180281).