Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(1):4854 1 Attention Deficit Hyperactivity Disorder and Treatment Adherence in Adolescent Acne Patients: Investigating the Relationship for Better Care Strategies Huriye Aybüke Koç1, Cansu Altınöz Güney2, Bedia Sultan Önal3 1 Department of Dermatology, Prof. Dr. A. Ilhan Ozdemir State Hospital, Giresun, Turkey 2 Department of Dermatology, Dinar State Hospital, Afyonkarahisar, Türkiye 3 Department of Child and Adolescent Mental Health and Diseases, Giresun University Faculty of Medicine, Giresun, Türkiye Key words: Acne Vulgaris, Adolescent, Attention Deficit Hyperactivity Disorder, Medication Adherence Citation: Koç HA, Altınöz Güney C, Önal BS. Attention Deficit Hyperactivity Disorder and Treatment Adherence in Adolescent Acne Patients: Investigating the Relationship for Better Care Strategies. Dermatol Pract Concept. 2025;15(1):4854. DOI: https://doi.org/10.5826/ dpc.1501a4854 Accepted: September 21, 2024; Published: January 2025 Copyright: ©2024 Koç et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Ethics Approval Statement: The study protocol was reviewed and approved by the Giresun Training and Research Hospital Clinical Research Ethics Committee (approval number: 19.06.2023/17). Corresponding Author: Huriye Aybüke Koç, Department of Dermatology, Prof. Dr. A. Ilhan Ozdemir State Hospital, Giresun, Turkey. Phone: +905320697391; E-mail: aybukecibelik@gmail.com Introduction: Accompanying comorbidities in acne vulgaris (AV) patients affect treatment adherence. Objectives: The purpose of this study was to investigate the relationship between treatment compli- ance and attention deficit hyperactivity disorder (ADHD) in adolescents with AV. Methods: This study included 140 patients with AV. At the beginning of the treatment, each patient acne severity was assessed, and the Conners-Wells Adolescent Self-Report Scale-Long Form (CASS-L) was administered. The Morisky Medication Adherence Scale (MMAS-8) was used to assess treatment adherence. The treatment response was assessed using a six-point scale. Results: Significant differences were found in the scores on the 10 subscales of the CASS-L among the 3 groups. The Global Acne Grading System (GAGS) scores showed a positive correlation with the scores of the subscales of the CASS-L, with 3 of them at a moderate level and 7 at a weak level. Five MMAS subscales had a weak correlation and 5 had a moderate correlation with the CASS-L subscale scores. The 9 subscales and the treatment response showed a slight negative correlation. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(1):4854 Introduction Acne vulgaris (AV) is a chronic inflammatory condition that is commonly observed in adolescents and adults. Its etio- pathogenesis involves abnormal follicular hyperkeratiniza- tion, hyperseborrhea, colonization by Cutibacterium acnes, and inflammation. Furthermore, it is commonly known that androgens play a role in the occurrence of acne [1,2]. Androgens increase sebum secretion and keratinocyte pro- liferation, leading to increased bacterial colonization and inflammation [1]. The neurodevelopmental disorder known as Attention Deficit Hyperactivity Disorder (ADHD) is defined by impul- sivity, hyperactivity, and inattention. While the exact cause of it is unknown, a number of variables, including stress, hormones, and heredity, are thought to be involved. There is a correlation between ADHD and higher incidence of other psychiatric comorbidities [3]. Research on individuals with acne vulgaris suggests increased prevalence of diverse psychi- atric disorders [4]. Objectives To our knowledge, psychiatric comorbidities accompany- ing acne reduce patients treatment adherence [5]. Moreover, ADHD can trigger the emergence of various psychiatric co- morbidities in patients with acne [6]. Clinical studies have investigated psychiatric comorbidities and treatment adher- ence in patients with acne vulgaris [5,7–10]. Still, no clini- cal study that we are aware of has looked into how ADHD affects treatment response and adherence for acne. Our goal was to look into these associations in teenage AV patients who also exhibit symptoms of ADHD. Methods Study Design Between October 25, 2023, and April 25, 2024, 140 vol- unteer acne vulgaris patients aged 12-17 who visited the dermatology outpatient clinic were included in the study. Since the patients were under 18 years old, informed con- sents were obtained from their parents. Individuals aged >18 years with neurological/systemic diseases or chronic medication use were excluded from this study. The patients who participated in the study applied to the outpatient clinic with their parents before treatment and at each follow-up visit. Information about the drugs prescribed for treatment and the use of these drugs was explained to both the patient and his/her parents. Especially in younger patients, it was ensured that the treatment was carried out under parental control. During the initial examination, sociodemographic data were collected. Global Acne Grading System (GAGS) and type of treatment decided after the examination (topi- cal medication, topical and oral medication, or oral isotreti- noin) were recorded. Each patient was then administered the Conners-Wells Adolescent Self-Report Scale-Long Form (CASS-L). At the 12-week follow-up, a 6-point scale for treatment response and the Morisky Medication Adherence Scale (MMAS) for treatment adherence were applied. Patients were categorized into 3 groups according to MMAS: high, moderate, and low adherence. The CASS-L scores and treat- ment methods were compared between the groups. The cor- relations between CASS-L scores and acne severity (GAGS), treatment adherence (MMAS), and treatment response were examined. The Giresun Training and Research Hospital Clinical Research Ethics Committee (19.06.2023/17) granted ethical approval for this study. Global Acne Grading System In 1997, the Global Acne Grading System (GAGS) was first created. Using a scale of 0 to 4, the severity in each region of the face, chest, and back is assessed (0 indicating no lesions, 1 for comedones, 2 for papules, 3 for pustules, and 4 for nodules). Each anatomical region factor was established by taking into account the density, distribution, and surface area of the pilosebaceous units. After computing the overall score for every six areas, the severity of the acne was divided into four categories: mild (1–18), moderate (19–30), severe (31–38), and very severe (>39) [11]. Conners-Wells Adolescent Self-Report Scale-Long Form (CASS-L) Adolescent psychopathology, specifically ADHD, is mea- sured in adolescents between the ages of 12 and 17 using Conclusions: ADHD is one of the many psychiatric comorbidities that frequently coexist with acne vulgaris. Its treatment is long-term and achieving a good treatment response relies heavily on patient adherence. Our study, which showed a decrease in acne treatment adherence and response as ADHD symptoms increased, will raise awareness among dermatologists to be more vigilant in their approach to this patient group. Original Article | Dermatol Pract Concept. 2025;15(1):4854 3 the Conners-Wells Adolescent Self-Report Scale (CASS-L). It relies on adolescents reflections on their experiences in the past month. The CASS-L consists of 87 items and in- cludes 10 subscales: family problems, emotional problems, conduct problems, cognitive problems/attentiveness, anger control problems, hyperactivity, ADHD index, and the Di- agnostic and Statistical Manual of Mental Disorders (DSM) Symptom Scales (DSM-IV-Inattentive, DSM-IV-Hyperactive- Impulsive, and DSM-IV-Total). The higher the score on the scale, the more the adolescent has a problem defined by the scale. The validity and reliability of the CASS-L has been es- tablished for Turkish patients, demonstrating the suitability of its psychometric properties for research purposes [12]. In this study, this scale was used to determine the severity of ADHD symptoms. Scale of Acne Severity Based on Percentage of Reduction (SASBR) Christiansen et al created a scale in 1977 that uses the per- centage of reduction to determine how severe acne is. This scale categorizes treatment effectiveness into the following six levels: A score of 4 indicated a 100% reduction in acne lesions, indicating excellent results. A score of 3 indicates a 75%–99% reduction, which is considered good. A score of 2 signifies a 50%–74% reduction, classified as moderate. A score of 1 represents a 1%–49% reduction, which is deemed insufficient. A score of 0 indicates no change in acne severity, while a score of -1 signifies a worsening condition. This scale provides a clear and objective way to evaluate the success of acne treatment and guide adjustments in treat- ment plans, as needed [13]. Morisky Medication Adherence Scale In 1986, Morisky et al created the MMAS-8 to measure medication adherence in people with long-term conditions. Originally composed of four questions, the scale was later revised to include eight. The MMAS-8 consists of seven di- chotomous (yes/no) questions and a five-point Likert scale. A “no” response receives one point for questions 1-4, 6, 7, and a “yes” response receives one point for question 5. The eighth question, a Likert-type question, was scored with 1 point for “never/rarely” and 0 points for all other responses. A total score of 8 indicated high adherence, 6-7 indicates me- dium adherence, and a score of less than 6 indicated low ad- herence. The scale has undergone validity and reliability tests [14]. As an example, a pre- and post-treatment photograph of a patient with high adherence to treatment is presented in Figure 1 . Statistical Analysis Data were analyzed using the statistical program SPSS version 25.0. For categorical data, descriptive statistics are displayed as numbers and percentages; for numerical data, they are displayed as mean, standard deviation, minimum, and maximum. The categorical variables were compared based on treatment adherence using the chi-square test. Once the Kolmogorov-Smirnov test had determined whether the numerical variables were normally distributed, the Kruskal-Wallis test was employed to compare the data in terms of treatment adherence. The significance level was set at P < 0.05, and 95% confidence intervals (CI) were calculated. Results The study comprised 140 AV patients who were monitored for 3 months in total. Treatment adherence of the patients was assessed using the MMAS-8, and based on this, they were categorized into 3 groups: high adherence, medium ad- herence, and low adherence. Among the group with low ad- herence, 26.7% had mild, 51.1% had moderate, and 22.2% had severe acne. In the medium adherence group, 62.5% had mild acne and 37.5% had moderate acne. In the high adher- ence group, 63.8% had mild acne and 36.2% had moderate acne. The groups did not differ statistically significantly with regard to age, sex, or length of acne. Only the topical treat- ment showed a significant difference (P = 0.008). Comparing the medium- and high-adherence groups to the low- adherence group, the rates of topical treatment use were higher. How- ever, no significant difference was observed between the groups in terms of specific topical treatment agents ( Table 1 ). The CASS-L subscale scores of patients with low, me- dium, and high adherence to acne vulgaris treatment were Figure 1 . Pre-treatment (GAGS:25) and 3-month follow up pho- tograph (SASBR:4, MMAS:8) of the 16 years old patient receiving oral isotretinoin. 4 Original Article | Dermatol Pract Concept. 2025;15(1):4854 Table 2. Comparison of CASS-L Subscale Scores Across Groups Based on Treatment Adherence CASS-L Subscales Low Adherence N = 45 (mean) Medium Adherence N = 48 (mean) High Adherence N = 47 (mean) χ2 df P Value CASS-L– Family Problems 86.46 68.07 57.70 11.864 2 0.003 CASS-L– Emotional Problems 92.01 66.83 53.65 21.242 2 0.000 CASS-L– Conduct Problems 82.81 74.24 54.89 11.812 2 0.003 CASS-L– Cognitive Problems/Inattentive 90.56 69.79 52.02 20.876 2 0.000 CASS-L– Anger Control Problems 87.23 73.46 51.46 18.345 2 0.000 CASS-L– Hyperactivity 87.14 71.00 54.05 15.416 2 0.000 CASS-L– ADHD Index 92.84 65.88 53.83 22.305 2 0.000 CASS-L– DSM-IV-Inattentive 94.73 68.67 49.17 29.337 2 0.000 CASS-L– DSM-IV-Hyperactive/Impulsive 92.18 69.51 47.40 24.338 2 0.000 CASS-L– DSM-IV-Total 95.68 69.51 47.40 32.688 2 0.000 CASS-L = Conners-Wells Adolescent Self-Report Scale-Long Form; DSM = Diagnostic and Statistical Manual of Mental Disorders. Table 1. Distribution of Study Variables Across Groups Based on Treatment Adherence Characteristics Low Adherence N = 45 (%) Medium Adherence N = 48 (%) High Adherence N = 47 (%) P Value Age (years) mean ± SD 15.11 ± 1.66 15.35 ± 1.,45 15.47 ± 1.38 0.740 Sex Male Female 14 (31.1%) 31 (68.9%) 18 (37.5%) 30 (62.5%) 18 (38.3%) 29 (61.7%) 0.734 Acne duration (month) 21.24 ± 16.88 21.50 ± 14.,0 22.11 ± 16.11 0.332 Topical medication 9 (20%) 23 (47.9%) 22 (46.8%) 0.008 Topical retinoids 4 10 8 0.273 Benzoyl peroxide and antibiotic combination 5 13 14 0.071 Topical medication and oral antibiotic 19 (42.2%) 13 (27.1%) 14 (29.8%) 0.257 Oral isotretinoin 17 (37.8%) 12 (25%) 11 (23.4%) 0.249 SD = standard deviation. compared. Significant differences were observed for all ten subscales (P < 0.05). As the CASS-L subscale scores in- creased, indicating an increase in ADHD symptoms, treat- ment adherence also decreased (Table 2). Correlations between CASS-L subscale scores and acne severity, treatment adherence, and treatment response scores were analyzed. The results of the Spearman rho correlation test, as detailed in Table 3, revealed significant relationships between various CASS-L subscale scores and measures of GAGS, MMAS-8, and treatment response. Specifically, there is a positive correlation with GAGS and negative correla- tions with MMAS-8 and treatment response. Original Article | Dermatol Pract Concept. 2025;15(1):4854 5 obtain and start treatment) or secondary (not following the treatment procedure or discontinuing the treatment). While the acceptable rate of treatment adherence is 80%-95%, it is typically approximately 50% for most chronic diseases. Non-adherence to treatment remains a significant issue, es- pecially in chronic diseases, such as acne vulgaris [17,18]. Many previous studies have investigated treatment ad- herence in patients with AV [10,16,17,19]. The adherence rates in these studies varied widely, from 7% to 96% [10]. We believe that this wide range was due to the different methodological approaches used to assess treatment adher- ence. In our study, we used the validated MMAS-8 to mea- sure it. Three groups were created based on the MMAS-8. The distribution of patients receiving only topical treatment showed a significant difference, despite the fact that there were no statistically important differences between groups in regarding age, gender, or length of acne. In the medium- and high-adherence groups, the proportion of patients receiv- ing only topical treatment was higher than that in the other treatment options (P = 0.008). Conclusions Treatments for AV can have a variety of negative effects from topical to systemic. Topical treatment can cause peel- ing, burning sensation, dryness, erythema, scaling, and pain. Among systemic treatments, antibiotics, such as doxycycline, can cause gastrointestinal side effects, such as phototoxicity, nausea, vomiting, and esophagitis. Another systemic treat- ment option, isotretinoin, can lead to mucocutaneous, mus- culoskeletal, and ophthalmic disorders as well as changes in liver function tests and blood lipid profiles. These side ef- fects often limit their use. Additionally, some patients may be prescribed combinations of topical and systemic treatments, complicating medication regimens and disrupting adherence. However, to observe the effects of AV medications, they should be used regularly for an average of 12 weeks [15]. Therefore, treatment adherence is crucial for success [16]. The degree to which a patient adheres to the recom- mended course of treatment is referred to as treatment adher- ence. Non-adherence can be classified as primary (failing to Table 3. Correlations Between CASS-L Subscale Scores and Acne Severity, Treatment Adherence, and Treatment Response Scores CASS-L Subscales GAGSa MMAS-8a Treatment Response CASS-L– Family Problems r : 0.386 P = 0.000 r : -0.323 P = 0.000 r : -0.312 P = 0.000 CASS-L– Emotional Problems r: 0.413 P = 0.000 r : -0.416 P = 0.000 r : -0.249 P = 0.003 CASS-L– Conduct Problems r: 0.328 P = 0.000 r : -0.314 P = 0.000 r : -0.317 P = 0.000 CASS-L– Cognitive Problems/Inattentive r: 0.365 P = 0.000 r : -0.383 P = 0.000 r : -0.112 P = 0.187 CASS-L– Anger Control Problems r: 0.317 P = 0.000 r : -0.394 P = 0.000 r : -0.314 P = 0.000 CASS-L– Hyperactivity r: 0.366 P = 0.000 r : -0.365 P = 0.000 r : -0.238 P = 0.005 CASS-L– ADHD Index r: 0.436 P = 0.000 r : -0.400 P = 0.000 r : -0.279 P = 0.001 CASS-L– DSM-IV-Inattentive r: 0.391 P = 0.000 r : -0.468 P = 0.000 r : -0.237 P = 0.005 CASS-L– DSM-IV-Hyperactive/Impulsive r: 0.361 P = 0.000 r : -0.430 P = 0.000 r : -0.242 P = 0.004 CASS-L– DSM-IV-Total r: 0.411 P = 0.000 r : -0.494 P = 0.000 r : -0.278 P = 0.001 a Spearman rho correlation test. Note: ‘r’ represents the strength and direction of the association between two variables. An ‘r’ value between 0.00-0.19 indicates a very weak correlation, 0.20-0.39 indicates a weak correlation, 0.40-0.69 indicates a moderate correlation, 0.70-0.89 indicates a strong correlation, and 0.90-1.00 indicates a very strong correlation.CASS-L = Conners-Wells Adolescent Self-Report Scale-Long Form; DSM = Diagnostic and Statistical Manual of Mental Disorders;GAGS = Global Acne Grading System; MMAS-8 = Morisky Medication Adherence Scale. 6 Original Article | Dermatol Pract Concept. 2025;15(1):4854 with dermatological conditions, including those who had AV. Patients with psychiatric comorbidities such as anxiety and depressive disorders were found to have low treatment adherence. Psychiatric comorbidities were identified as the most important reason for treatment non-adherence [24]. In 204 patients with AV, Alghofaili et al looked into the ef- fect of depression on treatment compliance and discovered a negative correlation between treatment satisfaction and depression. Their results demonstrated that when satisfac- tion got higher, so did treatment adherence. Consequently, it was indicated that depression might coexist in patients with acne and that treating depression could enhance adherence to acne treatment [9]. Various research studies have examined children and teenagers compliance with ADHD medication; results have varied from 21%-74% [25–27]. Wehmeier et al noted that comorbidities, such as anxiety disorders, in children with ADHD also reduced treatment adherence [26]. All studies indicated that patient adherence decreased as the treatment duration increased. In adolescents, belief in the effectiveness of the drug increased their willingness to use it. The most important factors affecting medication adherence were effec- tiveness, tolerability, ease of use, simplified dosing regimen, cost, comorbid conditions, and frequency of doctor visits [25,27,28]. Our study was planned based on studies in the literature showing that treatment adherence in patients with AV or ADHD can decrease due to complex treatment regi- mens, low tolerance to adverse side effects, and prolonged treatment duration [27–29]. Consistent with this informa- tion, we found that patients with acne in the low treatment adherence group had more ADHD symptoms. Moreover, the correlation evaluation showed that as CASS-L scores increased, indicating the prevalence of ADHD symptoms, treatment adherence decreased. Limitations Our study has a few limitations. First, the number of pa- tients available for research was limited, which may affect how broadly the results can be applied. Second, the tools we use, such as the MMAS and CASS-L, rely on patients own as- sessments of their behavior and symptoms. These limitations highlight the need for further research to verify our findings. A patient quality of life is greatly impacted by the chronic condition acne vulgaris. It is often associated with various psychiatric comorbidities, including ADHD. The side effects of medications used in AV treatment, need for prolonged therapy, and concurrent comorbidities can reduce treatment adherence. Enhancing adherence to treatment can result in better treatment outcomes, a higher standard of living, and lower expenses. Therefore, early detection and appropriate Diverse outcomes have been reported in prior research examining the adherence of patients receiving topical treat- ment for acne vulgaris. Some studies have reported increased adherence to topical treatment, which is consistent with our findings. For instance, Dreno et al found higher adherence among those receiving only topical treatment compared to those receiving both topical and systemic treatments, or isotretinoin, noting that adherence increased if the topical treatment was applied once daily, had fewer side effects, and had a rapid onset of action [20]. Similarly, in a study includ- ing 428 patients, Miyachi et al observed higher adherence among patients with acne receiving topical treatment, high- lighting that adherence was influenced by treatment satis- faction and side effects [21]. Conversely, while some studies have found lower adherence rates among patients receiving topical treatment, others have indicated that adherence does not decrease with topical treatment [10 19]. Kouotou et al found higher adherence in patients receiving oral treatment than in those receiving topical treatment. Conducted in Africa, this study suggested that patient higher sociocultural beliefs in systemic treatments could lead to greater treat- ment satisfaction, and thus, higher adherence [19]. Similarly, Hayran et al observed that patients using both topical med- ication and oral antibiotics had higher treatment adherence than those using only topical treatments. Despite the known decrease in adherence to complex treatment regimens, it was suggested that increased patient satisfaction might have im- proved adherence [10]. It has been shown that patients with AV have higher rates of various psychiatric comorbidities such as depres- sion, anxiety, stress, and increased suicide risk than healthy controls [4]. ADHD can also trigger various psychiatric morbidities in these patients [6]. In studies evaluating pa- tients with AV, the factors that reduce treatment adherence include lack of information, difficulties in using medications, poor doctor-patient relationships, side effects, cost, and psy- chiatric comorbidities [22,23]. Psychiatric diseases can lead to a decrease in patients beliefs about the effectiveness and success of treatment, resulting in dissatisfaction, inadequate treatment, or refusal of treatment [4]. Research has indicated that psychiatric disorders reduce treatment adherence in patients with acne [9,19,24]. The MMAS, which we also utilized in our study, was utilized by Kouotou et al to assess acne patients compliance to treat- ment. They observed that over 50% of the patients had low treatment adherence, and psychiatric comorbidities were identified as contributing factors. They thought that those with psychiatric disorders might not fully understand their illnesses and treatments and could forget to take their medi- cations [19]. 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