Patient Expectations, Safety Concerns, and Adherence to Topical Acne Medications: Findings from a Web-Based Survey

Introduction

Acne vulgaris (AV) is a highly prevalent skin disease that predominantly affects adolescents and young adults.^1,2 In China, the prevalence of acne among adolescents has been reported to range from 39.2% to 53.5%,^2–4 and the burden has continued to rise over the past three decades.⁵ Although not life-threatening, AV has significant psychological and social impacts on patients.^6,7 AV requires long-term management due to its chronic and relapsing nature, with topical medications serving as the mainstay of the treatment.^8–10 However, patients frequently report suboptimal treatment outcomes,^11–13 highlighting a critical disconnect between clinical guidelines and real-world practice.^14,15 An accurate understanding of AV and the appropriate use of topical medications are therefore crucial to therapeutic success.^12,16,17 Investigating how patients actually use these topical agents is essential to address this gap.

Insufficient knowledge about acne and its treatment remains widespread among patients.^17,18 Previous studies across various countries have consistently shown that patients hold misconceptions regarding the etiology and management of AV and often exhibit suboptimal treatment behaviors.^19–21

In the current era of rapid information exchange and fast-paced lifestyles, patients increasingly rely on online channels for purchasing products and accessing health information.^22–24 Dietary habits (eg, high‑glycemic‑index foods and dairy products), together with lifestyle factors such as stress and sleep deprivation, have been implicated in AV exacerbation.²⁵ These factors are increasingly prevalent in modern Chinese society and may contribute to the growing burden of AV among young adults.³ This trend underscores the urgent need to accurately assess the current landscape of patient knowledge and practices related to AV and its topical treatments, particularly given the disease’s wide prevalence and substantial impact. To date, a comprehensive nationwide investigation into patients’ understanding of AV and their use of topical medications has been lacking in China.

This study aims to bridge this gap by using a web-based survey to investigate the perceptions of AV and the detailed usage patterns of topical medications among young AV patients in China. The findings are expected to offer evidence-based insights to inform clinical practice and patient education initiatives.

The results will be vital for improving support for this substantial patient population and will provide crucial insights to guide both clinical management and educational strategies. Notably, the findings underscore the necessity for dermatologists, even in the midst of demanding schedules, to engage in patient education actively. This study offers the specific, practical guidance needed for clinicians to provide more precise and effective patient support.

Methods

This cross-sectional study was conducted utilizing a specifically designed web-based questionnaire between December 2023 and January 2024. The survey targeted young individuals diagnosed with AV, aged 16 to 29 years, in China. All patients completed the questionnaire anonymously and voluntarily. None of them, nor their families, work in advertising agencies, public relations firms, media outlets, market sectors, pharmaceutical sales, healthcare venues, or medical research institutions.

Data collection covered demographics, skin characteristics, disease perception, psychosocial impact, information sources, and detailed topical medication usage, knowledge, and adherence patterns. No other personally identifiable information (such as name, ID number, telephone number, or residential address) was sought or recorded. All participants were required to provide informed consent electronically before starting the survey. The survey consisted primarily of closed-ended questions, incorporating both single-choice and multiple-choice formats to capture participant responses systematically. Descriptive statistics were presented as means ± standard deviations (SD) for continuous variables and as numbers and percentages (n, %) for categorical variables. Categorical variables were compared between genders using the Chi-square test. A two-sided p-value of less than 0.05 was considered statistically significant. All analyses were performed using SPSS Statistics (version 27; IBM Corp., Armonk, NY, USA).

Results

A total of 501 valid questionnaires were collected from 238 male (47.50%) and 263 female (52.50%) patients. Most patients were categorized as having oily or mixed skin with sensitive symptoms (Table 1).

Table 1 Demographic and Skin Characteristics of Patients

Patients obtained information about AV from various sources (Figure 1A), among which they trusted dermatologists in hospitals or clinics the most. There is no difference in the choice of information sources between different genders. It is worth noting that the majority of patients choose online platforms, including Internet hospitals, online pharmacies, and social media. Although a large majority (82.83%) of respondents correctly identified AV as a chronic relapsing disease necessitating long-term therapy, a substantial minority misperceived it as a temporary condition. The correct rate of females’ awareness of AV was significantly higher than that of males (86.69% vs 78.57%, p < 0.01). Most patients believed that the primary etiology of AV is an endocrine disorder (29.54%), personal lifestyle and habits (21.56%), and skin oiliness and pore clogging (21.16%) (Figure 1B). In this regard, there is no difference in the understanding between females and males. The distress caused by AV for patients includes restricted behavior, impacts on social interactions, and negative emotions such as feelings of inferiority (Table 2). Compared with males, females were significantly more restricted in terms of makeup (39.54% vs 2.94%, P < 0.001).

Table 2 Distress Caused by Acne Vulgaris

Figure 1 Information sources of acne vulgaris among patients (A). Patients’ perceived causes of acne vulgaris (B).

The topical medications used by patients mainly included retinoids, benzoyl peroxide, topical antibiotics, azelaic acid, and traditional Chinese medicine (Figure 2A). The most frequently used topical medications were adapalene (40.92%), tretinoin (32.93%), benzoyl peroxide (24.75%), and clindamycin (20.96%). As this was a multiple-choice question, the percentages sum to more than 100%. Only 3.39% of young individuals reported use of hydroquinone, dexamethasone, or betamethasone. No significant gender‑related differences were observed in the use of topical anti‑acne agents. Before applying topical drugs, most young patients consulted dermatologists or obtained prescriptions, while some received recommendations from the internet or non-specialists (Figure 2B). A majority of young patients were not well-informed about the ingredients, mechanisms of action, applicable situations, onset time, and age indications. A sizable portion had limited knowledge about how to use the medications, their specific effects, and side effects. Only around 30.00% of patients fully or relatively understood this information (Figure 2C). There was no difference in knowledge levels between different genders. Additionally, the information most desired by patients includes side effects and precautions, onset time, and usage instructions (Figure 2D).

Figure 2 Topical medications that patients used (A). The way of confirmation before the administration of topical medicine (B). Patients’ knowledge level regarding information on topical medications (C). The information that patients were most interested in (D). Abbreviation: TCM, Traditional Chinese Medicine.

The method of applying topical drugs did not differ by type of medicine. 78.11% of the patients applied topical medications in a spot-on manner, while the rest spread them over a larger area. 20.00% of patients were unaware that retinoids require a gradual build-up of tolerance, and 63.00% did not know how to build tolerance correctly.

A significant majority of patients (83.17%) expected topical medications to take effect within 1 week, with 10.89% even anticipating improvement within one day (Figure 3A). However, actual usage patterns revealed notably short treatment durations. The majority of patients used topical medications for less than four weeks. Specifically, over half of retinoid users (50.00% in total, comprising the “less than 1 week” and “1–2 weeks” groups) discontinued treatment within two weeks. In contrast, a notable proportion of patients (23.53%) used topical antibiotics for over eight weeks (Figure 3B). The main reasons patients gave for discontinuing topical medications were slow onset or poor efficacy (44.00%), and concerns about or inability to tolerate side effects (40.00%). Furthermore, 44.59% of patients experienced relapse in three months after withdrawal.

Figure 3 The expected onset time of topical medicines (A). The actual duration of topical medication usage (B).

Discussion

This web-based survey of 501 young patients with AV confirms the substantial psychosocial burden associated with the condition and underscores the central role of topical therapies in its management.^6,10 However, our findings reveal a critical disconnect between clinical importance and patient practice: a widespread lack of knowledge about AV and its treatment,^12,17 coupled with suboptimal and underutilized application of topical medications.^14,16

Advancing patient knowledge about AV remains a critical need. A notable proportion of patients in this study still perceived AV as a temporary condition or believed it did not require formal treatment—misconceptions that are likely to influence their medication adherence and usage patterns negatively.^12,25,26 Furthermore, comparative analyses revealed a significant gender disparity in disease awareness, with female patients demonstrating a higher level of understanding than their male counterparts (86.69% vs 78.57%, p<0.01).²² This finding highlights the importance of implementing targeted educational interventions, particularly for male patients, to improve their knowledge.²⁷ Conversely, the data also indicated that female patients bear a disproportionate psychosocial burden from AV, experiencing greater psychological distress and more pronounced impacts on quality of life.^27,28 These observations underscore the need to integrate gender-specific support into clinical practice.²⁹ Providing structured psychological support and emotional reassurance for female patients, in addition to knowledge-focused education for males, should be considered within comprehensive dermatological care.

The intervention of non-professional opinions may affect the correctness of topical medicine use. Most patients received prescriptions or recommendations from dermatologists before treatment, indicating that specialists still play a leading role in patients’ initial decisions regarding medication use.³⁰ The predominant rational selection of topical medications among patients reflects standardized prescribing practices among Chinese dermatologists and the measurable impact of public health education initiatives, particularly through nationwide guideline dissemination campaigns and the Healthy China policy framework. However, a small number of patients obtained advice by searching the Internet or by following recommendations from friends or family members, similar to previous studies.^20,31 This exposure to information of varying quality and accuracy poses a substantial risk of improper medication use.²³ For instance, the reported use of glucocorticoids or hydroquinone cream, which are not mainstream acne treatments, may reflect attempts to alleviate inflammatory symptoms or post-acne hyperpigmentation based on such informal guidance. As patients increasingly turn to digital and social media for health information,^30,32 these channels also represent a critical opportunity for dermatologists to deliver accurate, accessible education and counteract the spread of misinformation.³³

In practice, patients showed poor adherence to both the duration of medication use and the proper application methods. They used topical medication for a shorter period than recommended, possibly because they expected quick results.¹² Most patients believed that topical medicine would work within a very short time, even within 24 hours, showing their urgent desire for improvement.^12,34 However, the actual onset time of different drugs can vary depending on factors like drug type and individual differences.¹⁶ The gap between these unrealistic expectations and reality may further reduce patients’ adherence to treatment.¹² Additionally, patients mainly worried about the side effects of topical medications. These concerns may lead to non-adherence to prescribed topical regimens.³⁵ Therefore, it is essential to provide detailed patient education about how medications work and realistic timelines for improvements to set proper expectations. At the same time, addressing therapeutic hesitancy requires fully informing patients about possible side effects and using evidence-based preventative strategies.

Suboptimal adherence, characterized by an irregular method of use and insufficient treatment duration, is likely associated with the relatively high recurrence rate observed after drug withdrawal. International guidelines recommend retinoids as a fundamental treatment for most acne cases. However, their efficacy depends on proper and sustained use, which includes an initial period of several weeks to achieve effectiveness and a subsequent maintenance phase typically lasting 3 to 12 months.^8,9 While most patients in this study used guideline-recommended agents, indicating a general awareness of appropriate drug selection, notable deficiencies were observed in the practical application details. Common issues included a predominant use of spot application rather than larger-area application, a lack of knowledge of tolerance-building techniques for retinoids, and prolonged use of topical antibiotics beyond recommended durations, which may promote bacterial resistance.³ These specific gaps in the “how” and “how long” of treatment, rather than the “which”, represent a critical target for future patient education efforts by dermatologists.

This study has several limitations. The sample size, although informative, remains relatively small. Furthermore, the questionnaire specifically focused on topical medications and used closed-ended questions, which may not have fully captured the variety of patient experiences and behaviors. Additionally, the self-reported nature of the data is vulnerable to recall bias and social desirability bias. Future studies would benefit from a larger sample, the use of mixed-method approaches, and more open-ended questions to better understand real-world clinical practices. Despite these limitations, this investigation provides valuable foundational insights and serves as an important reference for designing future large-scale cohort studies on acne vulgaris.

Conclusion

Despite the wide availability of health information, young AV patients in this study demonstrated limited understanding of the disease and its underlying causes. Dermatologists were identified as the most trusted and primary source of reliable information on topical treatments. Nevertheless, patients demonstrated limited knowledge of topical medication use, particularly regarding application techniques, treatment duration, and onset of action, and often held unrealistic expectations for rapid results. Enhanced education regarding AV perception and detailed instructions on topical medication use are crucial for improving patient awareness and treatment compliance.