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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 9  |  Page : 1289-1294

Internalized stigma in acne vulgaris and its relationship with quality of life, general health, body perception, and depression


1 Akdeniz University School of Medicine, Antalya, Turkey
2 Biostatistics and Medical Informatics, Akdeniz University School of Medicine, Antalya, Turkey
3 Department of Dermatology and Venereology, Akdeniz University School of Medicine, Antalya, Turkey

Date of Submission21-Feb-2020
Date of Acceptance28-May-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Prof. E Alpsoy
Department of Dermatology and Venereology, Akdeniz University School of Medicine, 07059 - Antalya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_86_20

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   Abstract 


Backround: Internalized stigma, adoption of negative attitudes, and societal stereotypes regarding acne vulgaris (AV) have not been previously studied. Objective: To investigate the internalized stigma state in AV and determine its association with quality of life, perceived health, body image, and depression Methods: A total of 77 AV patients (43 female, 34 male; aged 19.7 ± 2.3 years) were enrolled in this cross-sectional study. The scales used in the study were Acne Internalized Stigma Scale (AISS), Acne Quality of Life scale (AQOL), FDA Global score, Perceived Health Status (PHS), Body Image Scale (BIS), and Beck Depression Inventory (BDI). Results: Mean AISS scores (53.68 ± 13.6) were significantly higher in males than in females (57.41 ± 14.37, 50.39 ± 12.25, P = 0.042). There was a significant positive correlation between mean values of AISS and AQOL (r = 0.816, P < 0.001), FDA Global grade (r = 0.391, P = 0.002) and BDI (r = 0.440, P < 0.001). Lower PHS (P = 0.027) was another determinant of high AISS scores. The mean AISS score of patients with a family history was significantly lower than those without a family history (P = 0.007). VAS was also found to be correlated with mean values of AISS and AQOL. Linear regression analysis revealed that the most important determinant of internalized stigma was AQOL (β = 0,632; P < 0.001), followed by gender (β = -0,229; P = 0.001), FDA Global score (β = 0,193; P = 0.007), and BDI (β = 0,177; P = 0.024). Discussion: Significant and independent predictive factors for high internalized stigma state were the negative quality of life, male gender, the severity of the illness, and depression. Therefore, internalized stigma may be one of the major factors responsible for the psychosocial burden of AV.

Keywords: Acne vulgaris, depression, psychodermatology, quality of life, stigmatization


How to cite this article:
Kotekoglu D, Parlakdag A, Koramaz F S, Varol G, Aslankoc V, Bozkurt S, Memis C, Karakas A A, Alpsoy E. Internalized stigma in acne vulgaris and its relationship with quality of life, general health, body perception, and depression. Niger J Clin Pract 2020;23:1289-94

How to cite this URL:
Kotekoglu D, Parlakdag A, Koramaz F S, Varol G, Aslankoc V, Bozkurt S, Memis C, Karakas A A, Alpsoy E. Internalized stigma in acne vulgaris and its relationship with quality of life, general health, body perception, and depression. Niger J Clin Pract [serial online] 2020 [cited 2020 Sep 27];23:1289-94. Available from: http://www.njcponline.com/text.asp?2020/23/9/1289/294693




   Introductıon Top


Acne vulgaris (AV) is one of the main diseases that have important psychosocial effects on the individual when the face localization and the affected age group are considered. Comedones, papules, pustules, nodules, cysts, postinflammatory changes, and scars can be seen during the course of AV that may cause negative body image, decrease in self-esteem, social withdrawal, shyness, loneliness, shame, fear, and stress. Regardless of the severity of AV, even in the mildest severity, depression, and suicidal ideation were found more frequently than in the normal population.[1],[2],[3],[4] Because of the visible nature of its lesions, AV can be recognized from the outside. Therefore, it may distinguish the individual from others, in other words, it stigmatizes the patient. Another dimension of the stigmatization is the internalized stigma; the individual accepts negative stereotypes about the illness created by society and withdraws himself/herself from society with emotions such as worthlessness and shame. The patient presumes that other people have a reaction towards his/her illness and eventually withdraws him/herself from social life, ending up with decreased self-esteem and life-satisfaction, increased depression and suicidality, and difficulty in coping with the illness.[5] The internalized stigma that may negatively affect both the quality of life of the individual and his/her response to treatment has not been previously studied in AV.

The primary aim of this study was to investigate the level of internalized stigma in AV and to determine its association with quality of life, perceived health, body image, and depression. Identification of the influence of sociodemographic and clinical characteristics on the internalized stigma was the secondary aim of the study.


   Materıals and Methods Top


77 AV patients with no previous psychiatric illnesses, taken from the Akdeniz University School of Medicine student body, were enrolled in the study. Informed consent was obtained from all participants, and the study was conducted according to the Declaration of Helsinki Principles. The study was approved by the Ethics Committee of Akdeniz University School of Medicine (70904504/76).

Socio-demographic characteristics of the patients (age, gender, disease duration, family history, previous treatments, etc.), and the distribution of acne lesions were recorded. The severity of the disease was assessed using both subjective and objective measurements. For the subjective measurement, all patients were asked to rate the severity of their disease from 0 to 10 by visual analog scale (VAS). For the objective measurement, FDA Global grade was used to assess the disease severity.[6] FDA Global grade was calculated with the help of a dermatologist (CM).

Data collection scales

Internalized stigma scale (ISS)

; was developed by Ritscher et al.[7] for mental illnesses, and has been adapted for many diseases other than psychological disorders. ISS is a Likert-type scale composed of 29 items measuring the internalization of stigma experienced by the patients. It has five dimensions; alienation (6 items), stereotype endorsements (7 items), perceived discrimination (5 items), social withdrawal (6 items), and stigma resistance (5 items). ISS values range between 4 and 91. High ISS scores mean more severe internalized stigma. Its validity and reliability of mental illnesses have been studied in Turkey by Ersoy et al.[8] ISS in dermatological diseases was first studied by Alpsoy et al.[9] In this recent study, psoriasis ISS was shown to be a valid and reliable scale in identifying internalized stigma (Cronbach's alpha = 0.89).

Acne Quality of Life scale (AQOL), developed by Gupta et al.,[10] is a Likert-type scale consisting of 9 questions. These questions are related to feelings of restlessness in the presence of others, decrease socialization, relationship problems, problems with close friends and family, feeling of isolation, being ridiculed, romantic reluctance, and rejection by friends. The total score ranges from 9 to 36 and the high score means the low quality of life. The Turkish validity and reliability study was carried out by Demirçay et al.[11]

Body Image Scale (BIS) was developed by Secord and Jurard.[12] It is a five-point Likert-type scale, which evaluates the satisfaction of the 40 separate body parts or functions. The total score of the scale ranges from 40 to 200. Hovardaoglu[13] has shown its validity and reliability in our country. High scores indicate that the level of satisfaction of the person's body parts or function is low.

Beck Depression Inventory (BDI), developed by Beck et al.[14] and adapted to Turkish by Hisli,[15] is a Likert-type scale composed of 21 items. The total score varies between 0 and 63. The scores ≥10 were defined as mild depression, ≥19 as moderate depression, and ≥30 severe depression.

Perceived Health Status (PHS) is a five-point Likert-type scale measuring general health with a single question. In the analysis, Likert scorings are classified as 1, 2, 3: “worse than good” and 4 and 5: “good”.

Statistics

Cronbach's alpha was used to estimate reliability for all multi-item scales. The Shapiro–Wilk test was used to verify the normality of the distribution of continuous variables. Statistical analysis of clinical data between two groups consisted of Student t-tests for parametric data and Mann Whitney U test for nonparametric data, whereas the Chi-square/Fisher's exact tests were used for categorical variables. Linear regression analysis was used to analyze the risk predictors of Acne ISS (AISS). The analyses were performed using IBM SPSS Statistics for Windows, Version 22.0 software and a two-tailed P value less than 0.05 was considered statistically significant.


   Results Top


The mean age of the patients was 19.7 ± 2.3 years, the mean age at onset of the disease was 15.2 ± 2.7 years, and the mean disease duration was 4.49 ± 3.4 years. 55.8% of the patients were female. While 35.06% of the patients had a family history of AV, 66.23% of them had never used any treatment for AV. FDA Global I (37.7%) was the most common AV severity score. There was no difference in acne severity among the genders. No significant difference was also observed between male and female patients in terms of frequency of treatment use (53.8% and 46.2%, respectively). 80.2% of the patients defined their PHS as good or very good. Sociodemographic and clinical characteristics of the study patients are summarized in [Table 1].
Table 1: Sociodemographic characteristics of acne vulgaris patients

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The mean AISS was calculated as 53.68 ± 13.6. AISS reliability was interpreted by calculating internal consistency coefficients for subscales and for the scale as a whole. The internal consistency coefficient for the whole scale was 0.917. The reliability coefficients of subscales together with Cronbach alpha values are shown in [Table 2]. The scores of the subscales ranged from 0.58 to 0.88. Among the five subscales, the lowest value belonged to the stigma resistance and the highest value belonged to the alienation. The mean values of other scales were 14.04 ± 5.9 for AQOL, 11.48 ± 9.6 for BDI, and 146.4 ± 25.2 for BIS. Cronbach alpha values were found to be 0.913 for AQOL, 0.894 for BDI, and 0.952 for BIS.
Table 2: Reliability coefficients for acne internalized stigma subscales (Cronbach alpha)

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There was a significant difference in the mean values of AISS between males and females (57.41 ± 14.4 vs 50.39 ± 12.2, P = 0.042). Similarly, the mean BIS scores were significantly higher in males than in females (154.38 ± 24.3 vs 140.09 ± 24.3, P = 0.013). The mean BDI scores were higher in females, but the difference was not statistically significant (13.05 ± 10.3 vs 9.5 ± 8.2, P = 0.1). The mean AQOL scores did not show significant differences between males and females (14.09 ± 5.6 vs 14.00 ± 6.1, P = 0.948).

There was a strong positive correlation between the mean values of AISS and AQOL (r = 0.816, P < 0.001). A statistically significant positive correlation was also found between the mean values of AISS and the FDA Global grade (r = 0.391, P = 0.002). When the relationships between the mean values of AISS and BDI and BIS were examined, a statistically significant correlation was found between the mean values of AISS and BDI (r = 0.440, P < 0.001) while no correlation was found between AISS and BIS values (r = -0.210, P = 0.101) [Table 3].
Table 3: Correlation between acne internalized stigma subscales and FDA Global score, Acne Quality of Life scale (AQOL), Beck Depression Inventory (BDI) and Body Image Scale (BIS)

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The mean AISS scores of those patients with a perceived health score of “worse than good” were significantly higher than that of those with a perceived health score of “good” (61.8 ± 17.6 vs 51.8 ± 12.2, P = 0.027). The VAS values were also found to be correlated with mean values of AISS (r = 0.347, P = 0.006).

There was no statistically significant correlation between AISS mean values and the disease duration (r = 208, P = 0.108). The mean AISS score of patients with a family history was significantly lower than those without a family history (P = 0.007). AISS subscales, alienation (P = 0.008), perceived discrimination (P = 0.048), and social withdrawal (P = 0.011) were found to be statistically significantly lower in those with a family history of AV.

The mean AISS values of patients with the trunk, shoulder, and/or arm involvement in addition to the face, were higher than those with only face involvement, but the difference was not statistically significant (54.5 ± 13.8 vs 50.6 ± 12.4, P = 0.301). There was no significant AISS difference between the patients who were treated during the study and the patients who did not use any treatment.

Multivariate analysis was adjusted for all statistically significant variables on the AISS at univariate analyses. Linear regression results showed that AQOL, BDI, gender, and FDA Global grade are the main determinants of internalized stigma. On the contrary, there was no significant difference between the AISS and perceived health or family history [Table 4]. Factors contributing to the change in the AISS were examined with standardized Beta coefficients. Linear regression analysis revealed that the most important determinant of internalized stigma was AQOL (β = 0,632; P < 0.001), followed by gender (β = -0,229; P = 0.001), FDA Global score (β = 0,193; P = 0.007), and BDI (β = 0,177; P = 0.024).
Table 4: Linear regression analysis for acne internalized stigma scale (AISS)

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   Discussion Top


In our study, when statistically significant variables on high AISS scores in univariate analysis were examined in a multivariate analysis, negative quality of life, male gender, AV severity, and depression were found to be significant and independent factors for internalized stigma. The lowest value among the five subscales belonged to the stigma resistance and the highest value belonged to alienation. We could not compare our results with other studies because internalized stigma has not been previously studied in AV. However, similar results were also observed when the reliability coefficients regarding the subscales of ISS were compared with Cronbach alpha values obtained from original reliability validity study,[7] from the reliability validity study conducted for psoriasis in Turkey[9] and from the multicenter study evaluating internalized stigma in 1485 psoriasis patients[5] [Table 2]. In those studies, all values other than stigma resistance were 0.70 or over. In contrast to the other four subscales, stigma resistance assesses the individual's ability to cope with illness and resistance to stigmatization. In our study, all AISS domains except stigma resistance showed a positive correlation with AQOL and BDI [Table 3]. Internalized stigma in AV may cause a vicious cycle, which may reduce patients' resistance to stigmatization. Therefore, the inclusion of approaches to enhance resistance to stigmatization in existing treatment protocols may also reduce the level of internalized stigma.

The mean AISS for AV was comparable with those obtained from psychiatric and dermatologic patient populations. Our results indicate that acne patients internalize the negative stereotype judgments of the society. The level of internalized stigma is more pronounced in male patients. The average age of the study participants was 19. Early adulthood is an important period of identity formation and sexual maturation in human life. AV has a significant effect on physical appearance due to the localization of the visible parts of the body. In our previous study,[5] the involvement of visible parts of the body in psoriasis patients was also related to significantly higher internalized stigma scores. The appearance of acne lesions in male patients may have adversely affected the perception that the opposite sex does not find them attractive enough. The male patients may also have thought that face involvement is a negative factor in competing with other men for women, and may increase the likelihood of romantic rejection. Additionally, women can easily camouflage the negative image of acne with makeup. This may lead to a decrease in internalized stigma in women. In our study, the average BIS scores were also more prominent in male patients. This result also supports that AV affects physical appearance and body sensation in men more significantly compared with women.

We observed a strong positive correlation between the mean values of AISS and AQOL. Moreover, linear regression results showed that the strongest predictor of internalized stigma was AQOL. This result indicates that the significance of internalized stigma and negative life quality are parallel to each other. The high AISS values established in our study for AV do another proof that patients internalize the stigma that exist in society. AQOL is a valid and reliable scale for AV patients. The strong correlation of AQOL with AISS is also important for showing the high validity of AISS in AV. We also found a positive correlation between the high levels of internalized stigma and the severity of the disease. In psychiatric disorders, internalized stigma has been shown to negatively affect seeking and complying with treatment, and as a result, negatively effect the severity of the disease.[16],[17] For this reason, it can be claimed that internalized stigma may also have an effect on increasing disease severity.

The mean BDI score of 11.48 ± 9.58 points out mild depressive symptoms of acne patients. A significant positive correlation between the mean AISS and the BDI values indicates that depression is parallel to that of the internalized stigma in AV patients. Our results suggest that because of the visible nature of its lesions, AV increases psychiatric morbidity. Likewise, in the perceived health questionnaire that assessed general health with a single question, the mean AISS values of those patients with a perceived health score of “worse than good” was significantly higher than that of those with a perceived health score of “good”. All these results indicate that internalized stigma, general health, and mental illnesses show parallel trends, and this is in compliance with the results in mental diseases.[18]

Our study also had some limitations. Because of the cross-sectional study design, causality cannot be determined exactly. Additionally, only students attending Akdeniz University Medical School were enrolled in this study; this sould be taken into account when generalizing results of this study to the entire population.

In conclusion, acne patients internalize the negative stereotype judgments of society, and this is more prominent in men. There is also a strong relationship between high levels of internalized stigma and negative quality of life, the severity of the disease and depression. When these findings are taken together, strategies to ameliorate the internalized stigma may be effective in improving the quality of life in acne patients. In fact, studies conducted for psychiatric disorders support that such initiatives can positively affect treatment outcomes and quality of life.[17] The high levels of internalized stigma show a parallel course with a reduction in patient's self-efficacy and self-esteem, which negatively affects the patient's adherence to treatment. The inclusion of educational approaches in treatment plans as well as psychotherapy in selected patients that address the internalized stigma can provide better compliance and effective use of healthcare.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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