Acne vulgaris is a prevalent problem in the adolescent community, with the literature citing prevalence between 35 to 90% at some stage and some studies showing the prevalence of comedonal acne approaching 100%. Mean age of onset of acne in girls is 11 years and in boys is 12 years. We know that being afflicted with acne places a significant burden on the life of a teenager, and studies have shown diminished quality of life and increased presence of depressive symptoms in teens with acne. Dalgard et al looked at effects of moderate and severe acne on self-esteem and body satisfaction in adolescents. In their study, girls with acne reported significantly higher levels of depressive symptoms, greater feelings of uselessness, and lower self-attitude, sense of pride, self-worth, and body satisfaction compared to girls without acne; a similar tendency was observed in boys. Halvorsen et al performed a cross-sectional questionnaire-based study to evaluate psychological effects of acne in adolescents aged 18-19 years old. They found that in the 14% of participants who had substantial acne- defined as self reported a lot or very much acne, suicidal ideation was twice as frequently reported in girls and three times more frequently reported in boys compared to subjects of either gender with no or a little acne per patient self report. Suicidal ideation was significantly associated with substantial acne with an odds ratio of 1.80. To our knowledge, there has been no research that evaluates parent perception of their teenager's acne in comparison to clinical data points such as investigator global assessment or patient-reported quality of life. Nor have there been data comparing investigator global assessment of acne with patient-reported Likert scale of acne severity. Magin et al looked at 108 patients, of whom 41 had acne and assessed difference in clinician evaluation of acne severity (using the Leeds method as an indicator of severity) compared to patient assessment of acne. They found a moderately poor agreement between objective clinician assessment and patient self-assessment of acne severity (weighted kappa 0.35, with 95% CI 0.1981 - 0.5084). There have been studies as well showing that patients with acne often underestimate the severity of their acne. Smithard A et al studied 317 students aged 14-16 and found that students tended to underestimate their acne severity, with only 66% of patients with mild acne via Leeds scoring self-determining that they had acne. Demircay et al looked at physician's assessment of acne severity, by means of Global Acne Grading System (GAGS) scoring of 0 as none, 1-18 as mild, 19-30 as moderate and \> 31 as severe acne. Patient's assessment of acne severity used a 10-point Likert-type scale. Patients were asked how severe their acne was, and 0 denoted "no acne" and 9 denoted "most severe acne that can be imagined". Results of the Likert-type scale were analyzed in four groups: 0 = none, 1-3 = mild, 4-6 = moderate, 7-9 = severe. No correlation was found between physician GAGS scores and any of the patients' own assessments. Smidt et al developed and validated a quality of life index for adolescents with skin disease, using the adult-oriented Skindex and Skindex-16 instruments as models. Skindex-Teen is a 21-item questionnaire, self-administered by the patient and generally is able to be completed in 5 to 10 minutes. The instrument inquires about the patient's perceptions of his/her primary skin condition during the previous 4 weeks. Standardized responses consist of 4-category choices relating to frequency with 0 being never and 4 being all the time. Analysis demonstrated that the refined Skindex-Teen was a valid and effective way of measuring the effects of skin disease in adolescents. A Likert scale is a type of psychometric scale frequently used in psychology questionnaires. On a questionnaire, a Likert scale asks subjects to circle, check or mark the number that most closely correlates to their feelings on a scale.

We speculate that parents of teenagers underestimate how much acne vulgaris affects their teenager's skin disease-related quality of life. By having both the teenage patient and his/her parent independently complete the Skindex-Teen questionnaire at the same time point, we will be able to assess potential differences in how teenagers perceive their acne and how their parents perceive the impact of the teen's acne on quality of life and correlate this with clinical acne severity.