Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(4):6108 1 Risk Factors and Epidemiology of Acne Severity and Acne Scar Development: A Comprehensive Clinical Study Fatma Etgu1, Gul Sekerlisoy Tatar2,3 1 Ordu University, School of Medicine, Department of Dermatology, Ordu, Türkiye 2 Department of Dermatology, Liv Hospital, Samsun, Türkiye 3 Istinye University, Department of Dermatology, Istanbul, Türkiye Key words: Acne, Acne scarring, Acne severity, Acne scar severity, Risk factors Citation: Etgu F, Sekerlisoy Tatar G. Risk Factors and Epidemiology of Acne Severity and Acne Scar Development: A Comprehensive Clinical Study. Dermatol Pract Concept. 2025;15(4):6108. DOI: https://doi.org/10.5826/dpc.1504a6108 Accepted: August 28, 2025; Published: October 2025 Copyright: ©2025 Etgu 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. Corresponding Author: Fatma Etgu, Ordu University, School of Medicine, Department of Dermatology, Nefsi Bucak Street, No: 94/1, 52200; Altınordu/Ordu. ORCID ID: 0000-0003-1214-3327. E-mail: fatmaetgu@gmail.com Introduction: Acne vulgaris, affecting around 9.4% of the global population, is a common disorder of the pilosebaceous unit. Approximately 95% of affected individuals develop some degree of scarring, which, along with active acne, contributes significantly to psychosocial morbidity. Objectives: This study aimed to evaluate the factors influencing acne severity, the development of acne scars, and the severity of scarring in patients with acne vulgaris. Methods: A cross-sectional study was conducted between May and November 2024 at the dermatol- ogy outpatient clinic of Ordu University, Turkey. Demographic data, characteristics of acne lesions, treatment history, and various potential risk factors for acne and scarring were recorded. Acne severity and scar severity were evaluated using standardized grading systems. Results: A total of 269 patients (175 females, 94 males) were included, with acne scars observed in 71.3%. Younger age, earlier, and adolescent-onset acne were significantly associated with greater acne severity and scarring. Male sex and severe acne further increased the risk and severity of scars. Patients with scarring reported higher emotional stress. Post-lesional hyperpigmentation and erythema predict- ed more severe scarring. Prior use of topical agents and systemic antibiotics was linked to increased scar risk, while systemic isotretinoin had a protective effect. Conclusions: Early identification of risk factors and timely intervention may help reduce the burden of acne scarring and improve patients’ quality of life. Recognizing predictors of acne severity and scar- ring can guide clinicians in implementing preventive strategies and optimizing long-term outcomes. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(4):6108 Introduction Acne vulgaris is a chronic inflammatory disorder of the pilosebaceous unit characterized by the presence of come- dones, papules, pustules, and cysts. Its lifetime prevalence approaches 100%, and it affects individuals globally [1,3]. With a reported prevalence of 9.4%, acne ranks as the eighth most prevalent disease worldwide [2]. It affects approxi- mately 85% of adolescents and often persists into adult- hood, particularly in females over the age of 25 [1,2]. Several factors have been implicated in acne severity, in- cluding female sex, older adolescent age, parental education, positive family history, oily skin type, and higher body mass index (BMI) [4]. The relationship between acne and dietary factors or smoking remains less clearly defined. Further stud- ies are necessary to elucidate these associations [4]. Acne scarring occurs in up to 95% of patients with acne [5,7], although the prevalence in the general population ranges from 1% to 11% [7]. Even mild-to-moderate acne can result in clinically significant scarring [5]. Given that acne lesions commonly occur on visible areas, scarring can lead to con- siderable psychosocial burden. Currently, there is no univer- sal consensus on optimal treatment modalities for acne scars [6,7], and many patients present with multiple scar types, complicating management strategies [6]. Consequently, early identification of high-risk patients is essential to implementing timely and effective interventions to prevent scarring [5]. This study aimed to evaluate the risk factors associated with acne severity, acne scar development, and acne scar se- verity in individuals with acne vulgaris. Materials and Methods Study Population, Setting, and Ethics This cross-sectional study was conducted between May 2024 and November 2024 in the dermatology outpatient clinic of Ordu University, Ordu, Türkiye. Ethical approval was ob- tained from the university’s Ethics Committee (Approval No: 2024/34). Sample size calculations indicated a minimum of 104 participants for a 95% confidence interval. Partic- ipants aged 18–65 years with a diagnosis of acne vulgaris who consented to participate were included. Patients with other dermatological conditions affecting acne-prone areas were excluded. Informed consent was obtained from all par- ticipants. The study adhered to the Declaration of Helsinki and the Guidelines for Good Clinical Practice. This study was reported in accordance with the STROBE guidelines (see Table S1). Study Design Two senior dermatologists evaluated each participant for diagnosis, classification, and severity assessment of both acne and acne scarring. Demographic and clinical data, in- cluding age, marital status, employment, disease duration, age at onset, history of adolescent acne, skin type, family history, lesion location and type, post-lesional hyperpigmen- tation and erythema, and scar morphology, were recorded. Scar types included icepick, rolling, and boxcar scars. Addi- tional data included prior acne treatments, smoking/alcohol use, cosmetic usage, use of potential triggering medications, emotional stress level (0–10 Likert scale), seasonal acne vari- ation, and dietary habits, including dairy consumption. In female patients, menstrual irregularities and clinical signs of hyperandrogenism were also documented. Acne Severity: Global Acne Grading System (GAGS) The Global Acne Grading System (GAGS), developed by Doshi et al. in 1997, evaluates acne severity across six ana- tomical regions with assigned multipliers. Lesions are graded from 0 (none) to 4 (nodules), and the region score is calcu- lated by multiplying the lesion grade by the region multiplier. The final score classifies acne as: 1–18 (mild), 19–30 (moder- ate), 31–38 (severe), and >39 (very severe) [8]. Acne Scar Classification According to Jennings et al., acne scars are categorized as atrophic, hypertrophic, keloidal, or papular. Atrophic scars are further divided into icepick, rolling, and boxcar sub- types [6]. Acne Scar Severity A 4-point scale was used to assess scar severity: Grade 1 (macular changes), Grade 2 (mild), Grade 3 (moderate), and Grade 4 (severe) [9]. Clinical grading of acne scars was performed using the Goodman and Baron qualitative scar grading scale, a widely accepted and validated method. Two senior dermatologists calibrated their scoring before the study to ensure consistency. Blinding was not feasible as dermatologists performed direct patient examinations and collected clinical data, including acne type and lesion charac- teristics. The calibration and standardized assessment proce- dures aimed to minimize inter-rater variability and improve scoring reliability. Assessment of Clinical Signs of Hyperandrogenism Hyperandrogenism is a clinical condition caused by excess androgen production from the ovaries and adrenal glands or increased peripheral conversion. Its manifestations include seborrhea, acne, infertility, hirsutism, and virilization [10]. In this study, only clinical signs relevant to dermatology, such as adult female acne, hirsutism, and female pattern hair loss, were assessed, without biochemical evaluation. Original Article | Dermatol Pract Concept. 2025;15(4):6108 3 Statistical Analysis MedCalc version 20.009 (Ostend, Belgium) was used for statistical analyses. Normality of continuous variables was assessed using the Kolmogorov-Smirnov test and Q-Q plots. Mean, standard deviation (SD), median, and interquartile ranges (IQR), are reported for continuous variables; categor- ical data are summarized using frequency and percentage. Independent t-tests and Mann-Whitney U tests were used for group comparisons. Logistic regression analysis was per- formed to identify risk factors associated with acne severity and scarring. Univariable odds ratios (uORs), multivariable odds ratios (mORs), and their 95% confidence intervals (CIs) are reported. To evaluate factors associated with the presence and severity of acne scarring, a multivariable lo- gistic regression model was applied. A p-value of <0.05 was considered statistically significant. Power Analysis The power (1-β) of the study was calculated using G*Power version 3.1.2 software. The test family was specified as z tests, and the statistical test used was logistic regression. The type of power analysis was set to ‘‘Post hoc; Compute achieved power—given α, sample size, and effect size.’’ Based on previous studies, a two-tailed test was applied, with α = 0.05, H0 = 0.59, X distribution = Binomial, and a sample size of N=269. The calculated power (1-β) value was 0.87, indicating that the study had sufficient power to detect the observed effect size. Results The study included 269 patients, of whom 75 (65.1%) were females and 94 (34.9%) were males. The mean age of the par- ticipants was 25 ± 6.6 years, with an average acne onset age of 19.5 ± 6.2 years. The average duration of acne was 5.7 ± 5.6 years. Stress levels were measured with a mean score of 6.2 ± 2.7, and the mean GAGS score was 23.4 ± 7.9. Based on the GAGS score, acne severity was classified as mild in 26.4%, moderate in 59.1%, severe in 12.3%, and very severe in 2.2% of participants. Acne scarring was pres- ent in 71.3% of patients, with severity graded as Grade 1 in 23.8%, Grade 2 in 36.8%, Grade 3 in 22.8%, and Grade 4 in 16.6%. Detailed demographic information is shown in Table 1. Risk Factors Associated with Acne Severity Patients with severe acne were significantly younger (mean age 23 ± 5.5 vs. 25 ± 9; P=0.000) and had an earlier onset of acne (16.5 ± 6 vs. 19 ± 10; P=0.001). A history of adolescent acne increased the likelihood of severe acne, with patients having a 1.87 times higher odds of developing severe acne Table 1. Demographic Characteristics of the Study Group. Variables N % Adolescent acne No 153 56.9 Yes 116 43.1 Skin type Dry 122 45.4 Oily 147 54.6 Family history of acne No 126 46.8 Yes 143 53.2 Family history for acne scar No 198 73.6 Yes 71 26.4 Forehead No 54 20.1 Yes 215 79.9 Cheek No 19 7.1 Yes 250 92.9 Nose No 205 76.2 Yes 64 23.8 Chin No 93 34.6 Yes 176 65.4 Submandibular area No 175 65.1 Yes 94 34.9 Back No 148 55.0 Yes 121 45.0 Chest No 198 73.6 Yes 71 26.4 Postlesional hyperpigmentation No 106 39.4 Yes 163 60.4 Erythema No 65 24.2 Yes 204 75.8 Previous treatment No 100 37.2 Topical 120 44.6 Antibiotic (Oral) 40 14.9 İsotretinoin(Oral) 9 3.3 Smoking No 221 82.2 Yes 48 17.8 Alcohol No 258 95.9 Yes 11 4.1 Regular use of cosmetics No 96 35.7 Yes 173 64.3 Triggering medication No 226 84.0 Yes 43 16.0 Dairy consumption No 164 61.0 Yes 105 39.0 Menstruation history Regular 142 52.8 Irregular 32 12.3 Not applicable 94 34.9 Hyperandrogenism No 154 57.2 Yes 21 7.8 İNot applicable 94 34.9 4 Original Article | Dermatol Pract Concept. 2025;15(4):6108 (OR = 1.453; P < 0.0001) and global acne severity (OR = 1.079; P = 0.033) were significant risk factors for scarring. Topical treatments (OR = 3.158; P = 0.007) and oral anti- biotics (OR = 4.263; P = 0.026) increased the odds of scar- ring, while oral isotretinoin was protective (OR = 0.088; P = 0.037). Postlesional hyperpigmentation (OR = 2.436; P = 0.031) was also significantly associated with scarring, but erythema did not show a significant impact (P = 0.365). Other factors such as age, sex, acne onset, and family history did not sig- nificantly affect scarring risk. Risk Factors for Acne Scar Severity: Multivariable Analysis A multivariable logistic regression analysis identified key factors associated with the severity of acne scarring. Higher global acne severity (OR = 1.195; P = 0.000) and postle- sional hyperpigmentation (OR = 4.751; P = 0.001) were sig- nificantly linked to more severe scarring. Regular cosmetic use had a protective effect (OR = 0.413; P = 0.041). Scar- ring on the nose was less severe compared to other regions (OR = 0.302; P = 0.028). Other factors, such as stress, acne du- ration, and prior treatments, were not significantly associated Table 4 summarizes the factors contributing to acne se- verity, the development of acne scarring, and the severity of acne scars. The factors associated with acne severity are de- rived from the univariable analysis, while those related to acne scarring and acne scar severity are based on the multi- variaable analysis results. Discussion This study assessed the factors influencing acne severity, scar formation, and scar severity. Younger age, adolescent acne history, and earlier onset were significantly associated with more severe acne and scarring. Male sex and high acne sever- ity emerged as risk factors for scar development and severity. It is well established that patients with acne vulgaris ex- perience a reduced quality of life, diminished psychological well-being, lower satisfaction with their appearance, greater social impairment, and a higher tendency toward depressive temperament. Therefore, identifying and effectively manag- ing the factors associated with acne is crucial for the appro- priate treatment of this prevalent chronic dermatological condition [11]. Several studies have examined factors affecting acne fre- quency and severity. A systematic review of 35 articles found that older adolescents are more frequently affected than were younger adolescents and adults [4]. Similarly, our study showed greater severity in those with adolescent-onset acne. While acne is generally more common in females— consistent with our findings—it has been reported as more severe in (odds ratio (OR)=1.87; 95% CI: 1.14–3.08; P=0.013). Acne lesions located on the forehead (OR=0.0001) were signifi- cantly linked with higher acne severity. Table 2 presents a detailed univariable analysis of the factors associated with acne severity. These findings emphasize the multifactorial na- ture of acne severity and highlight the importance of lesion localization in predicting severity. Risk Factors Associated with Acne Scarring Previous treatments played a significant role; patients who received topical treatments had an increased risk of scarring (OR2.02; 95% CI: 1.12–3.65; P=0.019), and those treated with oral antibiotics had an even higher risk (OR=4.11; 95% CI: 1.48–11.4; P=0.006). Conversely, oral isotretinoin was associated with a significantly reduced risk of acne scarring (OR=0.16; 95% CI: 0.03–0.85; P=.031), suggesting a pro- tective effect. These findings underline the importance of appropriate treatment choices and their potential to prevent scarring. Table 3 provides a detailed univariable analysis of the clinical and demographic factors associated with the de- velopment of acne scars. Risk Factors for Acne Scar Severity Several factors were identified as significant predictors of acne scar severity. Patients with a history of adolescent acne had a significantly higher likelihood of severe scarring (OR2.66; 95% CI: 1.41–5.01; P=0.002). Additionally, involvement of specific anatomical areas such as the forehead (OR=4.46; 95% CI: 1.64–12.2; P=0.003), cheek (OR=7.00; 95% CI: 0.87–55.9; P=0.034), and back (=2.32; 95% CI: 1.28–4.18; P=0.005) were all strongly related to more severe scarring. Post-inflammatory changes such as hyperpigmentation (OR = 1.88; 95% CI: 1.01–3.51; P = 0.045) and erythema (OR = 2.22; 95% CI: 1.04–4.74; P = 0.038) also contributed to increased scar severity. Nasal involvement did not signifi- cantly impact scar severity (OR = 0.302; 95% CI: 0.1–0.88; P = 0.028). Table 2 provides a detailed univariable analysis of the clinical and demographic factors associated with the severity of acne scarring. Post-inflammatory changes such as hyperpigmentation (OR=1.88; 95% CI: 1.01–3.51; P=0.045) and erythema (OR=2.22; 95% CI: 1.04–4.74; P=0.038) also contributed to increased scar severity. Nasal involvement did not signifi- cantly impact scar severity (OR=0.302; 95% CI: 0.1–0.88; P=0.028). Table 2 provides a detailed univariable analysis of the clinical and demographic factors associated with the severity of acne scarring. Risk Factors for Acne Scarring: Multivariable Analysis A multivariable logistic regression analysis was performed to identify factors associated with acne scarring. Stress levels Original Article | Dermatol Pract Concept. 2025;15(4):6108 5 T ab le 2 . U ni va ri ab le A na ly si s of F ac to rs A ss oc ia te d w it h A cn e Se ve ri ty a nd A cn e Sc ar S ev er it y (N =2 69 ). G A G S (≤ 25 ) (n = 1 53 ) G A G S> 25 (n = 1 16 ) A cn e Se ve ri ty A cn e sc ar ri ng (G ra de 1 -2 ) (n = 1 17 ) A cn e sc ar ri ng (G ra de 3 -4 ) (n = 7 6) A cn e Sc ar S ev er it y N % N % uO R 95 % C I p- va lu e N % N % uO R 95 % C I p- va lu e Se x Fe m al e 10 1 66 .0 74 63 .8 1. 00 R ef er en ce 75 64 .1 40 52 .6 1. 00 R ef er en ce M al e 52 34 .0 42 36 .2 1. 10 0. 66 -1 .8 2 0. 70 5 42 35 .9 36 47 .4 1. 60 0. 89 -2 .8 9 0. 11 3 A do le sc en t ac ne N o 76 49 .7 40 34 .5 1. 00 R ef er en ce 55 47 .0 19 25 .0 1. 00 R ef er en ce Y es 77 50 .3 76 65 .5 1. 87 1. 14 -3 .0 8 0. 01 3* 62 53 .0 57 75 .0 2. 66 1. 41 -5 .0 1 0. 00 2* Sk in t yp e D ry 68 44 .4 54 46 .6 1. 00 R ef er en ce 52 44 .4 34 44 .7 1. 00 R ef er en ce O ily 85 55 .6 62 53 .4 0. 91 0. 56 -1 .4 9 0. 73 1 65 55 .6 42 55 .3 0. 98 0. 55 -1 .7 6 0. 96 8 Fa m ily h is to ry of a cn e N o 71 46 .4 55 47 .5 1. 00 R ef er en ce 52 44 .4 36 47 .4 1. 00 R ef er en ce Y es 82 53 .6 61 52 .6 0. 96 0. 59 -1 .5 5 0. 86 9 65 55 .6 40 52 .6 0. 88 0. 49 -1 .5 8 0. 69 0 Fa m ily h is to ry o f N o 11 2 73 .2 86 74 .1 1. 00 R ef er en ce 85 72 .6 56 73 .7 1. 00 R ef er en ce Y es 41 26 .8 30 25 .9 0. 95 0. 55 -1 .6 5 0. 86 3 32 27 .4 20 26 .3 0. 94 0. 49 -1 .8 2 0. 87 4 Fo re he ad N o 50 32 .7 4 3. 4 1. 00 R ef er en ce 28 23 .9 5 6. 6 1. 00 R ef er en ce Y es 10 3 67 .3 11 2 96 .6 13 .5 0 4. 74 -3 8. 95 <0 .0 00 1* 89 76 .1 71 93 .4 4. 46 1. 64 -1 2. 2 0. 00 3* C he ek N o 18 11 .8 1 0. 9 1. 00 R ef er en ce 10 8. 5 1 1. 3 1. 00 R ef er en ce Y es 13 5 88 .2 11 5 99 .1 15 .3 3 2. 01 -1 16 .6 0. 00 0* 10 7 91 .5 75 98 .7 7. 00 0. 87 -5 5. 9 0. 03 4* N os e N o 12 3 80 .4 82 70 .7 1. 00 R ef er en ce 91 77 .8 58 76 .3 1. 00 R ef er en ce Y es 30 19 .6 34 29 .3 1. 70 0. 96 -2 .9 9 0. 06 5 26 22 .2 18 23 .7 1. 08 0. 54 -2 .1 5 0. 81 3 C hi n N o 70 45 .8 23 19 .8 1. 00 R ef er en ce 39 33 .3 15 19 .7 1. 00 R ef er en ce Y es 83 54 .2 93 80 .2 3. 41 1. 95 -5 .9 4 <0 .0 00 1* 78 66 .7 61 80 .3 2. 03 1. 02 -4 .0 2 0. 04 1* Su bm an di bu la r ar ea N o 10 9 71 .2 66 56 .9 1. 00 R ef er en ce 81 69 .2 40 52 .6 1. 00 R ef er en ce Y es 44 28 .8 50 43 .1 1. 87 1. 13 -3 .1 1 0. 01 4* 36 30 .8 36 47 .4 2. 02 1. 11 -3 .6 8 0. 02 0* B ac k N o 11 3 73 .9 35 30 .2 1. 00 R ef er en ce 72 61 .5 31 40 .8 1. 00 R ef er en ce Y es 40 26 .1 81 69 .8 6. 53 3. 82 -1 1. 17 <0 .0 00 1* 45 38 .5 45 59 .2 2. 32 1. 28 -4 .1 8 0. 00 5* C he st N o 13 3 86 .9 65 56 .0 1. 00 R ef er en ce 92 78 .6 46 60 .5 1. 00 R ef er en ce Y es 20 13 .1 51 44 .0 5. 21 2. 87 -9 .4 7 <0 .0 00 1* 25 21 .4 30 39 .5 2. 40 1. 26 -4 .5 4 0. 00 7* Po st le si on al hy pe rp ig m en ta tio n N o 64 41 .8 42 36 .2 1. 00 R ef er en ce 49 41 .9 21 27 .6 1. 00 R ef er en ce Y es 89 58 .2 74 63 .8 1. 26 0. 77 -2 .0 8 0. 35 0 68 58 .1 55 72 .4 1. 88 1. 01 -3 .5 1 0. 04 5* T ab le 2 c on ti nu es 6 Original Article | Dermatol Pract Concept. 2025;15(4):6108 G A G S (≤ 25 ) (n = 1 53 ) G A G S> 25 (n = 1 16 ) A cn e Se ve ri ty A cn e sc ar ri ng (G ra de 1 -2 ) (n = 1 17 ) A cn e sc ar ri ng (G ra de 3 -4 ) (n = 7 6) A cn e Sc ar S ev er it y N % N % uO R 95 % C I p- va lu e N % N % uO R 95 % C I p- va lu e E ry th em a N o 41 26 .8 24 20 .7 1. 00 R ef er en ce 32 27 .4 11 14 .5 1. 00 R ef er en ce Y es 11 2 73 .2 92 79 .3 1. 40 0. 79 -2 .4 9 0. 24 7 85 72 .6 65 85 .5 2. 22 1. 04 -4 .7 4 0. 03 8* Sm ok in g N o 12 2 79 .7 99 85 .3 1. 00 R ef er en ce 92 78 .6 63 82 .9 1. 00 R ef er en ce Y es 31 20 .3 17 14 .7 0. 67 0. 35 -1 .2 9 0. 23 5 25 21 .4 13 17 .1 0. 75 0. 36 -1 .5 9 0. 46 7 A lc oh ol N o 14 8 96 .7 11 0 94 .8 1. 00 R ef er en ce 11 2 95 .7 74 97 .4 1. 00 R ef er en ce Y es 5 3. 3 6 5. 2 1. 61 0. 48 -5 .4 2 0. 43 5 5 4. 3 2 2. 6 0. 60 0. 11 -3 .2 0 0. 55 4 R eg ul ar u se of c os m et ic s N o 58 37 .9 38 32 .8 1. 00 R ef er en ce 40 34 .2 33 43 .4 1. 00 R ef er en ce Y es 95 62 .1 78 67 .2 1. 25 0. 75 -2 .0 8 0. 38 3 77 65 .8 43 56 .6 0. 67 0. 37 -1 .2 2 0. 19 7 T ri gg er in g m ed ic at io n N o 13 2 86 .3 94 81 .0 1. 00 R ef er en ce 10 0 85 .5 64 84 .2 1. 00 R ef er en ce Y es 21 13 .7 22 19 .0 1. 47 0. 76 -2 .8 2 0. 24 7 17 14 .5 12 15 .8 1. 10 0. 49 -2 .4 6 0. 81 0 D ai ry N o 95 62 .1 69 59 .5 1. 00 R ef er en ce 73 62 .4 46 60 .5 1. 00 R ef er en ce Y es 58 37 .9 47 40 .5 1. 11 0. 68 -1 .8 2 0. 66 4 44 37 .6 30 39 .5 1. 08 0. 59 -1 .9 5 0. 79 4 *S ig ni fi ca nt d if fe re nc e at < 0. 05 le ve l a cc or di ng t o lo gi st ic r eg re ss io n. u O R : u ni va ri ab le o dd s ra ti o. C I: c on fi de nc e in te rv al . T ab le 2 . U ni va ri ab le A na ly si s of F ac to rs A ss oc ia te d w it h A cn e Se ve ri ty a nd A cn e Sc ar S ev er it y (N =2 69 ). ( co nt in ue d) Original Article | Dermatol Pract Concept. 2025;15(4):6108 7 Table 3. Clinical Characteristics and Univariable Analysis of Factors Associated with Acne Scar. Variables acne scarring (+) (N=193) acne scar (-) (N=76) p-value N % N % OR 95% CI p-Value Gender Female 115 59.6 60 78.9 1.00 Reference Male 78 40.4 16 21.1 2.54 1.36-4.73 0.003** Adolescent acne No 74 38.3 42 55.3 1.00 Reference   Yes 119 61.7 34 44.7 1.98 1.16-3.39 0.012** Skin type Dry 86 44.6 36 47.4 1.00 Reference   Oily 107 55.4 40 52.6 1.12 0.65-1.90 0.677 Family history of acne No 88 45.6 38 50.0 1.00 Reference   Yes 105 54.4 38 50.0 1.19 0.70-2.03 0.515 Family history of acne scar No 141 73.1 57 75.0 1.00 Reference   Yes 52 26.9 19 25.0 1.10 0.60-2.03 0.745 Forehead No 33 17.1 21 27.6 1.00 Reference   Yes 160 82.9 55 72.4 1.85 0.98-3.46 0.054 Cheek No 11 5.7 8 10.5 1.00 Reference   Yes 182 94.3 68 89.5 1.94 0.75-5.04 0.170 Nose No 149 77.2 56 73.7 1.00 Reference   Yes 44 22.8 20 26.3 0.82 0.44-1.52 0.542 Chin No 54 28.0 39 51.3 1.00 Reference   Yes 139 72.0 37 48.7 2.71 1.56-4.69 0.000** Submandibular area No 121 62.7 54 71.1 1.00 Reference   Yes 72 37.3 22 28.9 1.46 0.82-2.59 0.196 Back No 103 53.4 45 59.2 1.00 Reference   Yes 90 46.6 31 40.8 1.26 0.74-2.17 0.386 Chest No 138 71.5 60 78.9 1.00 Reference   Yes 55 28.5 16 21.1 1.49 0.79-2.81 0.214 Postlesional hyperpigmentation No 70 36.3 36 47.4 1.00 Reference Yes 123 63.7 40 52.6 1.58 0.92-2.71 0.094 Erythema No 43 22.3 22 28.9 1.00 Reference Yes 150 77.7 54 71.1 1.42 0.78-2.59 0.251 Previous treatment No 63 32.6 37 48.7 1.00 Reference Topical 93 48.2 27 35.5 2.02 1.12-3.65 0.019** Antibiotic (Oral) 35 18.1 5 6.6 4.11 1.48-11.4 0.006** İsotretinoin (Oral) 2 1.0 7 9.2 0.16 0.03-0.85 0.031** Smoking No 155 80.3 66 86.8 1.00 Reference   Yes 38 19.7 10 13.2 1.61 0.76-3.43 0.210 Alcohol No 186 96.4 72 94.7 1.00 Reference   Yes 7 3.6 4 5.3 0.67 0.19-2.38 0.544 Regular use of cosmetics No 73 37.8 23 30.3 1.00 Reference Yes 120 62.2 53 69.7 0.71 0.40-1.26 0.245 Triggering medication No 164 85.0 62 81.6 1.00 Reference Yes 29 15.0 14 18.4 0.78 0.38-1.57 0.494 Dairy consumption No 119 61.7 45 59.2 1.00 Reference Yes 74 38.3 31 40.8 0.90 0.52-1.55 0.711 *Significant difference at <0.05 level according to logistic regression. uOR: Univariable dds ratio. CI: confidence interval. 8 Original Article | Dermatol Pract Concept. 2025;15(4):6108 Table 4. Summary of Factors Affecting Acne Severity, Scarring, and Scar Severity. Factor Associated with Effect uOr/ mOR p-value Comment Younger age Acne severity ↑ Acne Scar ↑ Increased risk — 0.000/ 0.001 Severe acne is more common in younger individuals Earlier acne onset Acne severity ↑ Acne Scar Increased risk — 0.001/ 0.003 Early onset is linked to higher severity History of adolescent acne Acne Severity ↑ Acne Scar ↑ Increased risk 1.87 / 1.98 0.013 / 0.012 Increases both severity and scarring risk Stress levels Acne Scar ↑ Increased risk 1.453 < 0.0001 Strong predictor of scarring Global acne severity (GAGS) Acne Scar ↑ / Scar severity ↑ Increased risk 1.079 / 1.195 0.033 / 0.000 Both scar presence and severity increase with acne severity Postlesional hyperpigmentation Acne Scar ↑ / Scar severity ↑ Increased risk 2.436 / 4.751 0.031 / 0.001 Strongest marker for scar risk and severity Topical treatment Acne Scar ↑ Increased risk 3.158 0.007 May indicate insufficient control in moderate/severe cases Oral antibiotic Acne Scar ↑ Increased risk 4.263 0.026 Linked to delayed or inadequate treatment Oral isotretinoin Acne Scar ↓ Protective 0.088 0.037 Strongly protective against scarring Regular cosmetic use Scar severity ↓ Protective 0.413 0.041 May reduce scar severity Nasal acne Scar severity ↓ Less severe 0.302 0.028 Scars on the nose tend to be milder Significant difference at <0.05 level according to logistic regression., Unadjusted odds ratios (uOR) are reported for acne severity, while adjusted odds ratios (mOR) are reported for acne scarring and acne scarring risk males [4, 11]; however, we found no sex-based difference in severity. Although a positive family history has been linked to both acne risk and severity in some studies [12–15], others reported no such association [4]. In our study, family history was not related to acne severity or scarring. Previous studies have associated oily and mixed skin types with increased acne severity [4]; however, in our study, skin type was not linked to acne severity or scarring. Although hormonal factors are known to influence acne in females, Heng et al. reported in a systematic review no association between menstrual history and severe acne [4]. Similarly, we found no relationship between acne severity, scarring, and menstrual irregularity or hyperandrogenism. Dietary factors, particularly milk consumption, remain a debated topic. While milk has been frequently implicated in acne pathogenesis due to its hormonal and IGF-1 con- tent [10,14,15], some studies have reported protective effects [4,11] A systematic review found this association primarily in Western populations [3], and some studies have linked milk intake to the presence of acne and the severity of acne scars [12,13]. In contrast, our study did not identify any as- sociation between milk consumption and acne severity or scarring. Studies on smoking and alcohol have shown inconsistent results regarding their effects on acne and scarring. While some linked living with a smoker or alcohol use to greater acne severity, others found no association [4,12,13]. In line with Yan et al. [16], our study found no relationship between smoking or alcohol intake and acne severity or scarring. In our study, 71.3% of patients had acne scarring, consis- tent with Yan et al.’s finding of 61.3%, and most of the scars were mild, similar to previous reports [5,13,14,16]. Studies have identified male sex, younger age, family or sibling his- tory, and behaviors like squeezing as risk factors for scarring [13,14,16]. While milk consumption appeared protective, butter intake was linked to more severe scars, and smoking showed no clear association [13,14]. In our study, acne scars were more severe in males and in those with earlier acne onset and younger age, consistent with previous findings [5,13–15]. Unlike some reports [13,14,16], we found no link Original Article | Dermatol Pract Concept. 2025;15(4):6108 9 more likely to experience severe acne and scarring. Topical treatments and oral antibiotics increased scarring risk, while oral isotretinoin had a protective effect. Post-inflammatory hyperpigmentation was a key factor in scar severity. These findings underline the importance of early, appropriate treat- ment and highlight the role of both physical and psycholog- ical factors in acne management. References 1. Chilicka K, Rusztowicz M, Szyguła R, Nowicka D. Methods for the Improvement of Acne Scars Used in Dermatology and Cos- metology: A Review. J Clin Med. 2022;11(10):2744. Published 2022 May 12. DOI:10.3390/jcm11102744. PMID: 35628870; PMCID: PMC9147527. 2. Vasam M, Korutla S, Bohara RA. Acne vulgaris: A review of the pathophysiology, treatment, and recent nanotechnology based advances. Biochem Biophys Rep. 2023;36:101578. Published 2023 Nov 23. DOI:10.1016/j.bbrep.2023.101578. PMID: 38076662; PMCID: PMC10709101. 3. Meixiong J, Ricco C, Vasavda C, Ho BK. Diet and acne: A systematic review. JAAD Int. 2022;7:95-112. Published 2022 Mar 29. DOI:10.1016/j.jdin.2022.02.012. PMID: 35373155; PMCID: PMC8971946. 4. Heng AHS, Chew FT. Systematic review of the epidemiology of acne vulgaris. Sci Rep. 2020;10(1):5754. Published 2020 Apr 1. DOI:10.1038/s41598-020-62715-3. PMID: 32238884; PMCID: PMC7113252. 5. Tan J, Kang S, Leyden J. Prevalence and Risk Factors of Acne Scarring Among Patients Consulting Dermatologists in the USA. J Drugs Dermatol. 2017;16(2):97-102. PMID: 28300850. 6. Jennings T, Duffy R, McLarney M, et al. Acne scarring- pathophysiology, diagnosis, prevention and education: Part I. J Am Acad Dermatol. 2024;90(6):1123-1134. DOI:10.1016 /j.jaad.2022.04.021. PMID: 35792196. 7. Fife D. Evaluation of Acne Scars: How to Assess Them and What to Tell the Patient. Dermatol Clin. 2016;34(2):207-213. DOI:10.1016/j.det.2015.11.009. PMID: 27015781. 8. Doshi A, Zaheer A, Stiller MJ. A comparison of current acne grading systems and proposal of a novel system. Int J Dermatol. 1997;36(6):416-418. DOI:10.1046/j.1365-4362.1997.00099.x. PMID: 9248884. 9. Goodman GJ, Baron JA. Postacne scarring--a quantitative global scarring grading system. J Cosmet Dermatol. 2006; 5(1):48-52. DOI:10.1111/j.1473-2165.2006.00222.x. PMID: 17173571. 10. Sharma A, Welt CK. Practical Approach to Hyperandrogenism in Women. Med Clin North Am. 2021;105(6):1099-1116. DOI:10.1016/j.mcna.2021.06.008. PMID: 34688417; PMCID: PMC8548673. 11. Ryguła I, Pikiewicz W, Kaminiów K. Impact of Diet and Nutri- tion in Patients with Acne Vulgaris. Nutrients. 2024;16(10):1476. Published 2024 May 14. DOI:10.3390/nu16101476. PMID: 38794714; PMCID: PMC11124289. 12. Say YH, Heng AHS, Reginald K, et al. Modifiable and non-modifiable epidemiological risk factors for acne, acne sever- ity and acne scarring among Malaysian Chinese: a cross-sectional study. BMC Public Health. 2021;21(1):601. Published 2021 between family history and scar severity. Scar severity cor- related with acne severity [5,15], but showed no association with cosmetic use, medications, acne duration, or stress. In our study, topical and systemic antibiotic treatments were associated with an increased risk of acne scarring, con- sistent with Yan et al. [15], while systemic isotretinoin re- duced this risk. Previous research supports early low-dose oral isotretinoin as effective for managing and preventing acne scars [17,18]. We also identified postlesional hyper- pigmentation and erythema as risk factors for scar sever- ity. Acne scars can significantly impact mental well-being, increasing risks of depression, suicide, and reduced quality of life [6]. Emotional stress was more prevalent among pa- tients with acne scars, underscoring the psychosocial burden of this condition. These findings reinforce the importance of early, aggressive acne management. Limitations of the Study This study has several limitations that should be acknowl- edged. First, the cross-sectional design precludes the estab- lishment of causal relationships. Additionally, there is a potential for recall bias, as participants may not have accu- rately remembered or reported relevant information, includ- ing family history of acne or scarring, cosmetic use, dairy consumption, and the use of acne-triggering medications. Specifically, the consumption of milk and dairy products was assessed through self-reported frequency-based mea- sures, which may introduce reporting bias and represent a limitation of the study. This limitation may have influenced the strength or direction of the associations observed and should be taken into account when interpreting the results. Furthermore, as the study was conducted in a tertiary care setting, the findings may not be generalizable to the broader population. This setting also introduces the possibility of se- lection bias, as patients with more severe acne and scarring may have been overrepresented. While the sample size was adequate for the study’s aims, future research with larger and more diverse populations would help strengthen the general- izability of the findings. A notable strength of this study is that all participants were evaluated in person by experienced dermatologists, rather than participants’ providing self-reported data, thereby enhancing the accuracy and reliability of clinical assessments. Conclusion This study demonstrates that acne severity and scarring are influenced by multiple factors, including age, age at onset, stress levels, lesion location, and treatment history. Younger patients with earlier acne onset and higher stress levels were 10 Original Article | Dermatol Pract Concept. 2025;15(4):6108 16. Yan C, Phinyo P, Yogya Y, Chuamanochan M, Wanitphakdee- decha R. Risk Factors Associated with Facial Acne Scarring in Thai Patients with Acne: A Cross-Sectional Study. J Cosmet Der- matol. 2025;24(1):e16695. DOI:10.1111/jocd.16695. PMID: 39601200; PMCID: PMC11704995. 17. Xue H, Ye D, Huang S, et al. 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DOI:10.1111/bjd.12149. PMID: 23210645. 15. Karadağ AS, Balta İ, Saricaoğlu H, et al. The effect of personal, familial, and environmental characteristics on acne vulgaris: a prospective, multicenter, case-controlled study. G Ital Derma- tol Venereol. 2019;154(2):177-185. DOI:10.23736/S0392 -0488.17.05532-8. PMID: 28704984.