Mental health outcomes are similar in skin of color and white acne patients: a population-based study

To the Editor: Acne is a common dermatologic disease characterized by papules, pustules, comedones, nodules, and cysts. Patients with acne who are from different racial and ethnic backgrounds differ with respect to clinical presentation; complications, including postinflammatory hyperpigmentation and hypertrophic scarring; and treatment regimens.1Davis E.C. Callender V.D. A review of acne in ethnic skin: pathogenesis, clinical manifestations, and management strategies.J Clin Aesthet Dermatol. 2010; 3: 24-38Google Scholar Despite these well-studied differences, there is limited research on how acne impacts mental health outcomes among different races and ethnicities. While the overall relationship between acne and mental health comorbidities such as depression and anxiety has been characterized,2Samuels D.V. Rosenthal R. Lin R. Chaudhari S. Natsuaki M.N. Acne vulgaris and risk of depression and anxiety: a meta-analytic review.J Am Acad Dermatol. 2020; 83: 532-541Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar determining the relationship between acne and race, ethnicity, and mental health are crucial to providing the best care for patients of all backgrounds. This study aimed to evaluate the differential impact of acne on mental health in patients from different racial and ethnic backgrounds. We performed a nationwide, cross-sectional study comparing the mental health outcomes of White patients with those of patients with skin of color (SOC) using the 2004-2017 Medical Expenditure Panel Survey. We defined the SOC study population as patients who self-identified as Black, American Indian/Alaskan Native, Asian, Native Hawaiian/Pacific Islander, or multiple races.3Kaymak Y. Taner E. Taner Y. Comparison of depression, anxiety and life quality in acne vulgaris patients who were treated with either isotretinoin or topical agents.Int J Dermatol. 2009; 48: 41-46Crossref PubMed Scopus (94) Google Scholar A weighted total of 8,537,264 patients in the United States in the Medical Expenditure Panel Survey database (6,952,001 White and 1,585,263 SOC patients) with acne who reported mental health outcomes during 2004-2017 were included. The socio-demographic/clinical characteristics and mental health outcome scores of White and SOC patients are summarized in Table I. A multivariable linear regression analysis adjusted for ethnicity, age, gender, insurance status, cognitive/social limitations, poverty level, and comorbidities is presented in Supplemental Table I (available via Mendeley at https://data.mendeley.com/datasets/vp9g7xy22k/1).Table ISocio-demographic and clinical characteristics of White patients and patients with skin of color with acne from the MEPSCharacteristicWhite patientsPatients with skin of colorP value(weighted n = 6,952,001)(weighted n = 1,585,263)Age, mean (SEM) years32.85 (0.66)35.35 (1.76).616∗2-tailed t-tests of the differences between U.S. adult White patients and patients with skin of color with acne.Gender, female n (%)4,713,904 (68)1,104,737 (70).678†χ2 of the differences between U.S. adult White patients and patients with skin of color with acne.Insurance status, n (%) Private5,929,387 (85)1,302,551 (82).013†χ2 of the differences between U.S. adult White patients and patients with skin of color with acne. Public523,520 (8)243,623 (15) Uninsured499,094 (7)39,089 (2)Cognitive limitations, n (%)221,746 (3)37,074 (2).464†χ2 of the differences between U.S. adult White patients and patients with skin of color with acne.Social limitations, n (%)220,683 (3)44,944 (3).785†χ2 of the differences between U.S. adult White patients and patients with skin of color with acne.Poverty level category, n‡Poverty level category was measured as percent of federal poverty level (FPL).(%) Poor378,183 (5)101,935 (6).434†χ2 of the differences between U.S. adult White patients and patients with skin of color with acne. Near poor113,783 (2)46,596 (3) Low income581,706 (8)92,015 (6) Middle income2,127,533 (31)428,293 (27) High income3,750,797 (54)916,425 (58)CCI, mean (95% CI)1.18 (1.14-1.22)1.19 (1.12-1.27).688∗2-tailed t-tests of the differences between U.S. adult White patients and patients with skin of color with acne.Mean mental health scores Psychological distress3.64 (95% CI, 3.28-4.01)3.19 (95% CI, 2.5-3.87).226∗2-tailed t-tests of the differences between U.S. adult White patients and patients with skin of color with acne. Depression0.685 (95% CI, 0.579-0.448)0.632 (95% CI, 0.448- 0.817).65∗2-tailed t-tests of the differences between U.S. adult White patients and patients with skin of color with acne. Overall mental health50.11 (95% CI, 49.25-50.97)50.74 (95% CI, 49.2-52.27).474∗2-tailed t-tests of the differences between U.S. adult White patients and patients with skin of color with acne. Perceived mental health state1.91 (95% CI, 1.83-2)1.83 (95% CI, 1.68-1.99).365∗2-tailed t-tests of the differences between U.S. adult White patients and patients with skin of color with acne.MEPS, Medical expenditures panel survey; SOC, patients with skin of color; SEM, standard error of the mean; CCI, Charlson comorbidity index; CI, confidence interval; K6, Kessler 6-item psychological distress scale; PHQ2, patient health questionnaire 2; MCS, mental component summary score; MNHTLH, perceived mental health status.∗ 2-tailed t-tests of the differences between U.S. adult White patients and patients with skin of color with acne.† χ2 of the differences between U.S. adult White patients and patients with skin of color with acne.‡ Poverty level category was measured as percent of federal poverty level (FPL). Open table in a new tab MEPS, Medical expenditures panel survey; SOC, patients with skin of color; SEM, standard error of the mean; CCI, Charlson comorbidity index; CI, confidence interval; K6, Kessler 6-item psychological distress scale; PHQ2, patient health questionnaire 2; MCS, mental component summary score; MNHTLH, perceived mental health status. No significant differences in mental health outcomes were observed between White and SOC patients (Fig 1, Table I). Results were consistent across 2 additional sensitivity analyses that classified race and ethnicity differently (Supplemental Tables II-VII available via Mendeley at https://data.mendeley.com/datasets/vp9g7xy22k/1). Overall, our results indicate that acne patients of all races and ethnicities appear to suffer similarly from mental health conditions (Table I, Supplemental Tables IV and VII available via Mendeley at https://data.mendeley.com/datasets/vp9g7xy22k/1). As multiple studies have suggested that acne patients are at an increased risk for anxiety and depression,2Samuels D.V. Rosenthal R. Lin R. Chaudhari S. Natsuaki M.N. Acne vulgaris and risk of depression and anxiety: a meta-analytic review.J Am Acad Dermatol. 2020; 83: 532-541Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar it is important to treat acne in patients of all races and ethnicities adequately to decrease the impact of mental health comorbidities.4Rogers A.T. Semenov Y.R. Kwatra S.G. Okoye G.A. Racial disparities in the management of acne: evidence from the National Ambulatory Medical Care Survey, 2005-2014.J Dermatolog Treat. 2018; 29: 287-289Crossref PubMed Scopus (8) Google Scholar Although our study did not uncover differences in mental health outcomes among different races and ethnicities, it is important for clinicians to recognize disparities in access to acne treatment between these groups. Studies have shown that patients with SOC are less likely than White patients to be seen by a dermatologist for acne or be prescribed systemic agents for acne.5Kelly A.P. Taylor S.C. Lim H.W. Serrano A.M.A. Taylor and Kelly's Dermatology for Skin of Color, 2e. McGraw-Hill, 2016https://accessmedicine.mhmedical.com/book.aspx?bookID=2585Date accessed: June 11, 2021Google Scholar To mitigate health care disparities, clinicians must advocate for improved access to acne treatment for patients of all racial, ethnic, and socioeconomic backgrounds. A limitation of this study is that Medical Expenditure Panel Survey does not contain information on acne severity or complications (including postinflammatory hyperpigmentation, scarring, and keloids), which may affect mental health outcomes. A future research direction can focus on understanding the potential impact of acne complications on mental health comorbidities in patients of different races and ethnicities. Dr Armstrong has no financial conflict of interest relevant to this publication. Dr Armstrong is a research investigator and/or scientific advisor to AbbVie, Bristol Meyers Squibb, Incyte, Leo, Union Chimique Belge, Janssen, Lilly, Novartis, Ortho Dermatologics, Sun, Dermavant, Dermira, Sanofi, Regeneron, Pfizer, and Modmed. Authors Kohn, Pourali, Rajkumar, and Hekmatjah have no conflicts of interest to report.