Acne scars impact on the quality of life and the willingness to pay for treatments among adults in Riyadh, Saudi Arabia: A cross-sectional study

INTRODUCTION

Acne vulgaris is a long-lasting inflammatory condition of the pilosebaceous unit of the skin brought on by androgen-induced increased sebum production, altered keratinization, inflammation, and Cutibacterium acnes bacterial colonization, and characterized by open and closed comedones. Furthermore, papules, pustules, and nodules can be present. The face, neck, chest, and back are the most commonly affected areas.^1,2

Acne vulgaris is considered the eighth most frequent condition globally and is one of the most prevalent skin disorders.³ Adolescents typically experience peak incidence between 14 and 19.⁴ The prevalence of acne vulgaris in Saudi Arabia is high, sitting at a percentage of 78% of adolescents between 15 and 30 years old.⁵

Although not life-threatening, acne has psychological effects. Even though active acne might only last several years, acne scars can last a lifetime, predisposing patients to depression, and anxiety.^6,7

According to research done in the US, the yearly direct and indirect cost of management is more than $3 billion.⁸

Scars are skin lesions formed after healed traumas or inflammation, such as a sequela of acne.^9,10 Depending on whether there is a net loss or growth of collagen, there are two fundamental types of scars (atrophic and hypertrophic scars, respectively). The scars can also be post-inflammatory macules, erythematous, hyperpigmented, or hypopigmented.^9,10

Prevention is the best way to avoid post-acne scars; however, numerous effective procedures can be used to treat atrophic scars, most notably chemical peels, laser therapy, radiofrequency microneedling, subcision, filler injections, and microneedling.^10,11

Although there are compelling and well-documented treatments for acne scars, our literature review could not appreciate Saudi patients’ knowledge, perception, and willingness to pay (WTP) for acne scar treatments. The objective of this study is to reflect acne scarring patients’ awareness of treatment options and their WTP for treatments also to evaluate the WTP’s association with patients’ sociodemographics, scar severity, and effect on the quality of life (QoL).

MATERIAL AND METHODS

RESULTS

Sociodemographic characteristics

In the present study, we received a total of 633 responses. However, excluded were records of 79 respondents who had no acne lesions and 153 responses from those with active current acne lesions without scars [Figure 1]. Therefore, a total of 401 adult participants were included in the study. The majority of the participants were female (64.3%), and most were in the age range of 18–29 years (73.6%). Regarding nationality, the majority were Saudi (85.3%). The highest educational level attained by most participants was university or postgraduate studies (75.3%). In terms of occupation, the largest proportion of participants were students (43.6%), followed by office workers (15.7%). Concerning household income, the most common category was “20,000 Saudi Riyals (SAR) or more,” accounting for 37.9% of the participants [Table 1].

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Figure 1:

Proportions of acne lesions among all the participants of the study.

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Description of the SCARS and FASQoL results and their association with the sociodemographic characteristics

Out of the included participants, mild, moderate, and severe SCARS categories were prevalent among 32.4%, 31.7%, and 23.4%, respectively, whereas mild, moderate, and severe FASQoL categories were reported among 61.1%, 18.0%, and 20.9% of them, respectively [Figure 2]. Based on the inferential analyses, significant differences in the severity of scars are based on marital status (P < 0.001), occupation (P = 0.015), and household income (P = 0.022). In addition, there were significant differences in the FASQoL categories in terms of participants’ gender (P = 0.009), marital status (P < 0.001), and household income (P < 0.001). Furthermore, the categories of severity on the SCARS questionnaire differed significantly according to the QoL of participants (P < 0.0001, [Table 1]).

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Figure 2:

Proportions of Each Self-Assessment of Clinical Acne-Related Scars (SCARS) and Facial Acne Scar Quality of Life (FASQoL) Category among study participants.

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Awareness regarding the modalities used for acne scar treatment

Based on participants’ responses, the most commonly identified modalities for acne scar management were laser resurfacing (66.3%) and chemical peels (64.1%), whereas the least perceived modalities were collagen/fat filler injections (23.9%) and radiofrequency microneedling (27.7%, [Figure 3]).

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Figure 3:

Proportions of awareness regarding acne scar treatment modalities among the included participants of the study.

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DISCUSSION

Acne vulgaris is one of the most common skin conditions.³ It frequently leaves the affected individuals with scarring that predisposes them to numerous psychological conditions.^16,17 Due to the significant impact on the QoL, the results highlight acne scar prevalence, severity, QoL impact, awareness of treatment options, and WTP. In the present study, the prevalence of acne scarring was found to be 63.4% [Figure 1], which was broadly in line with a past study,¹⁸ in which 73% of the participants complained of acne scarring. However, our findings differed significantly from other studies conducted in Brazil, USA, Morocco, and Japan, where acne scars occurred in 22%,¹⁹ 43%,²⁰ 84%,²¹ and 91%²² respectively. This could be due to ethnicity-specific scarring response variation, with some more likely than others.²³

The present study describes the results of sociodemographics and SCAR severity and their associations with QoL, indicating that severe acne scars and female gender are independent factors for decreased psychosocial well-being, which concurs with earlier research.^14,24 The severe SCARS category was associated with an increased score of FASQoL. Yet, 9.8% of the participants with a moderate and lower SCARS score displayed severe effects on FASQoL, highlighting the negative impact on self-image even with minor scarring.

The majority of the participants had good awareness regarding acne scar treatment; nevertheless, 43.4% never underwent any treatment for their scars, and 30.9% were not willing to undergo any treatment. Reluctance to undergo treatment may stem from the lack of awareness, belief scars are untreatable, fear of side effects, and cost. When compared with participants from a study set in Nigeria, only 14% were not willing to pay for acne scars.¹⁵ Furthermore, of the 69.1% who were willing to pay for acne scar therapy in the present study, almost half were not willing to pay the amount for a good result, which is below 1000 SAR. The price to get satisfying results depends on the type of scar, its severity, and the procedure performed. This finding was also seen previously in the antecedent study, where the majority of the participants were willing to pay, but it was low compared to the cost of pleasing treatment.¹⁵ However, another study conducted in China showed that participants were more willing to pay for treatment.²⁵ We speculate that this is due to cultural differences in skincare and economic differences.

The participants showed considerable awareness of some treatment modalities but not all. The awareness varied from only 23.9% being aware of collagen/fat filler injection to 66.3% being aware of laser resurfacing, as shown in Figure 3. This is significantly higher than that of the aforesaid Nigerian study.¹⁵ This could be because Saudi Arabia has a more established dermatology and cosmetics infrastructure. This speculation is supported by Alsharif et al.²⁶ who concluded in his study that the Saudi population displayed good knowledge of skin care.

The findings reveal a significant correlation between a higher FASQoL score and subjectively increased WTP, whereas no significant link was observed between an elevated SCARS score and WTP. This suggests that individuals may subjectively express a greater WTP for psychological benefits compared to physical attractiveness, providing insight into this particular observation. Similarly, Reckers-Droog et al.²⁷ reported in their study that participants are more willing to pay for higher QoL gains.

Awareness of acne scar modalities was associated with increased WTP, which is consistent with the previous literature.¹⁵ Participants who were aware of chemical peels, laser resurfacing, microneedling, and radiofrequency microneedling were more willing to pay. On the other hand, participants who were aware of collagen/fat filler injections and subcision were less willing to pay; this could be attributed to the invasiveness of these techniques and their fear of them. Furthermore, the regression analysis showed that being aware of chemical peels made participants 1.82 times more likely to pay, whereas awareness of other modalities did not affect WTP. This finding is similar to Xiao et al.’s,²⁵ in which they described that desirable treatment effectiveness was strongly correlated with WTP for chemical peels. This finding can also be explained by the fact that the population is more familiar with the older chemical peels and, therefore, has more trust in them. A 2017 systematic review²⁸ found that post-acne scarring improves by 10–100% following subcision, 31–62% improvement with microneedling and dermal fillers showing positive results. Trichloroacetic acid chemical reconstruction of skin scars showed 70% improvement in 73.3% of patients, while 20% glycolic acid had no effect in 25%. Each technique has its benefits and risks, and specific therapies should be used accordingly. Even though chemical peels are known, participants need to be familiar with the new techniques.

Multivariate regression analysis with confounding variables controlled demonstrated that Saudi locals were 3.41 times more likely to pay than non-Saudis. These results support prior studies and show a strong relationship between non-local income and WTP for healthcare services.²⁹ Furthermore, locals could have better familiarity with the medical system and higher faith in the standard of care.

An additional income-related finding revealed that in the multivariate linear regression model as well as the univariate analysis, higher income substantially predicted WTP. Consistent with earlier research,^25,30 multivariate analysis revealed that participants whose monthly family income was above 20,000 SAR (5331 USD) were 2.69 times more likely to make a payment. This finding is well proven in literature, in which the WTP and adjusted QoL both rise with subject wealth, as has been previously demonstrated.^31,32

A noteworthy finding revealed that participants with moderate impact on FASQoL were 2.17 times more likely to pay, while those with mild and severe impairments showed no increase in WTP. We surmise that with a powerful impact on the QoL, this leads to an increase in psychological consequences that may discourage individuals from seeking treatment, hence explaining the above-mentioned result. For comparison, a study conducted in Iraq³³ found that the more severe the lesion, the greater the impact it had on QoL, leading to an increase in psychological severity.

There were a few limitations encountered during our study. First, there was limited data in the literature regarding the QoL of patients suffering from acne scars and its relation to their WTP for acne scar treatment, which proved challenging when discussing our data with current available studies. Furthermore, the study may also be subject to selection and recall biases.

Although the present study offers insightful data about acne scars and their effects in the region, there is still room for development. Henceforth, we recommend future studies include a larger sample size, an in-depth exploration to assess how the degree of the participant’s knowledge of different acne scar treatment modalities will affect their WTP and each socioeconomic group to be associated with the percentage of participants willing to pay to get their acne scars adjusted for the effect on their QoL. This will help clinicians provide more cost-effective methods for patients struggling with the psychological consequences of acne scarring.

In addition, future research should carefully examine the causes behind treatment reluctance, taking into account elements such as cost, side effect concerns, perceptions of scar treatability, and awareness, to fill in the gaps in the existing literature and offer a more objective understanding.

CONCLUSION

Participants demonstrated good awareness of different acne scar treatment modalities, with laser resurfacing and chemical peels being the most recognized modalities. However, even with good knowledge regarding the modalities, a significant percentage of patients are reluctant to undergo any treatment. Furthermore, WTP for acne scar treatment was more influenced by psychological effects than physical severity. Moreover, other factors that influence WTP include income levels, awareness of treatment modalities, and being a resident. Ultimately, these findings could influence dermatologists to start awareness campaigns to shed light on acne scar treatment modalities and their efficacy in improving QoL.