Undertreatment of acne vulgaris in Dutch adolescents: A complex interplay of socioeconomic, sex and ethnic-related differences

Acne vulgaris is a prevalent disease¹ with a high burden.² Despite the availability of effective treatment options,² undertreatment remains an issue.^{3, 4} A possible explanation is access to care for minorities with less insurance coverage.⁵ This study aims to describe acne prevalence and self-reported treatment exposures in adolescents and to assess whether socioeconomic status (SES) is associated with healthcare utilisation for acne.

This cross-sectional study from the population-based prospective study ‘Generation R’⁶ consisted of adolescents around the age of 13 years and their parents in Rotterdam, the Netherlands. Parents received questionnaires with questions on acne in their child. When they reported a positive history of acne, they were subsequently asked about prior treatment. The outcome ‘treatment exposure’ was created by classifying these answers into three ordinal categories ranging from least to most healthcare utilisation: (1) ‘No’, (2) ‘Yes, bought over the counter’ or (3) ‘Yes, physician prescribed treatment’. The associations between SES-determinants ‘household income’ and ‘maternal education’⁶ and the outcome were explored simultaneously while adjusting for potential relevant confounders (sex, ethnicity,⁶ perceived skin colour and physician-graded acne severity⁷) using complete cases in ordinal logistic regression analyses. These resulted in adjusted odds ratios (AORs) with 95% confidence intervals (CIs) displaying the log-likelihood of utilising a higher level of healthcare for the treatment of acne.

Parents of 4698 adolescents responded to the acne-related questions (response rate 75.6%) (Table 1). While 45.8% of the parents indicated their children ever had acne, just 17.6% of them had ever used treatment (only 33% in the physician-graded moderate/severe acne group). More severe acne was positively associated with care (AOR 8.69 [95% CI 5.42–14.46] for moderate/severe versus. [almost] clear acne) (Table 2). SES-determinants were not associated with more healthcare utilisation (AORs: 1.47 [95% CI 0.71–2.86] low vs. intermediate maternal education and 0.98 [95% CI 0.63–1.51] low versus middle income levels). However, sex-stratified analyses showed that only boys from a low versus middle income used less care (AOR 0.30 [0.11–0.75]). Finally, Non-European ethnicity was associated with a higher level of care (AOR 1.96 [95% CI 1.23–3.12]), but sex-stratification showed this association merely in girls (AOR 2.43 [1.34–4.44]).

Our study confirms the gap between acne prevalence and treatment^3-5 among young adolescents—even in the most severe acne group—and shows that healthcare utilisation for acne in a country with a social healthcare system is a result of an interplay of SES and sex-related differences. More specifically, sex modifies the relationship between SES and healthcare utilisation. Our study showed different treatment seeking behaviour between the sexes within the same SES category, possibly due to a different perception to acne severity³ or beauty standards.

We found that non-European girls were more likely to seek treatment compared to Europeans. It is unlikely that a higher prevalence of acne sequelae (scarring or post-inflammatory hyperpigmentation) is an underlying cause because the analyses were adjusted for skin colour and acne severity. Different beliefs and attitudes towards acne in women of different ethnicities^{8, 9} could be a motive.

However, this study population is relatively well-educated and see relevance in joining a health research programme. They may have more interest in health and be better informed about treatment options resulting in overestimation of the treatment exposure. Other limitations include the young age of participants so results may not extrapolate to older populations and the cross-sectional nature of the study which hinders researching causality. Strengths of this study are the large and multiethnic sample size. Finally, there is still a large gap between acne prevalence and treatment which needs further research focused on sex and socio-cultural related differences to improve quality of life in all individuals.

Willemijn Witkam, Luba Pardo and Tamar Nijsten designed the study. Willemijn Witkam and Paul Buckers analysed the data and drafted the manuscript. All authors revised the manuscript and approved the final version.

S. E. Dal Belo is an employee of L'OREAL. Other authors declare no conflict of interest.

L'OREAL Research and Innovation (unrestricted research grant).

The general design, all research aims and the specific measurements in the Generation R study have been approved by the Medical Ethical Committee of Erasmus MC, University Medical Center Rotterdam. Registration number: MEC 2015-749 NL55105.078.15. All patients in this manuscript have given written informed consent for participation in the study and the use of their de-identified, anonymized, aggregated data and their case details for publication.