A Response to: Assessment of Anxiety and Depression in Patients with Acne Vulgaris in Medina: A Case-Control Study [Letter]

Dear editor

We read with great interest the article by Molla et al¹ exploring the assessment of anxiety and depression in patients with Acne Vulgaris in Medina. As medical students with interests in psychodermatology, particularly the impact chronic skin conditions such as Acne have on mental health outcomes, we appreciate what this article delineates and would like to suggest some changes for consideration, particularly to the study methodology, which may offer more rigorous conclusions about this topic.

Molla et al conducted a case-control study, however the overall aim was never clearly defined within the study. The reader has to infer that the aim was to establish differences in rates of anxiety and depression between those who suffered from Acne Vulgaris to those who did not. It is a triumph that the study manages to include a large age distribution (12y-60y) which ensures that results are representative and have a broad applicability.²

However, the exclusion criteria includes the “use of drugs that can exacerbate acne”, which is vague and poorly defined - and risks being subjective in nature. Zohra et al’s paper evaluating severity of Acne Vulgaris in patients included a range of useful and explicit drug measures such as oral contraceptive pills and iron intake.³ Furthermore, other crucial factors such as whether a patient was suffering from active malignancy, or a cosmetic related/induced acne were excluded.³ Such criteria will have been more useful in effectively eliminating unsuitable candidates for the study.

Within the study, a single dermatologist has the role of examining participants for acne grading. This runs the risk of measurement error. This can be reduced by ensuring that the dermatologist is trained to ensure they are obtaining the data in a standardised fashion.⁴

The use of the Global Acne Grading Score (GAGS) could also be re-considered. Whilst it is a simple and quick method, it is largely subjective and less accurate and for that reason a Lesion Counting Method is often used in the context of a clinical trial.⁵

Interestingly, the study found that the prevalence of Acne was highest amongst the patients that were single, however, the discussion failed to examine why this was. Hazarika et al’s paper explored the psychosocial impact of Acne Vulgaris which persists long after active lesions have disappeared. This can have devastating impacts on development, body perception, socialisation, and sexuality, and further, psychological issues such as lack of self-confidence, social dysfunction and an avoidance of social interactions with the opposite gender - which may be impairing this group of individuals from forming relationships and thus getting married.⁶

We believe these changes to the study would provide more vigorous conclusions about the relationship between anxiety and depression in patients with Acne Vulgaris in Medina and begin to form conclusions that could be modelled both nationally and internationally. Despite this, the authors are to be commended for their effort in exploring such a vital topic that is often neglected in the world of Dermatology.