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Understanding how young people perceive acne and acne treatments

decrements in quality of life. In their linked article, Meulendijks et al. have used a novel qualitative approach to explore potential risk factors for developing a first episode of VLU from the patient’s perspective. This is intrinsically interesting, and may also inform further quantitative research. Studies of VLU risk factors have been heavily influenced by including recurrent VLU (with the dominant predictor of incident VLU being previous VLU). However, there is a dearth of longitudinal evidence for risk factors for first VLU. This is understandable given that much chronic venous disease does not progress to a VLU and the time course to first VLU is prolonged. Cross-sectional and case–control studies have provided limited evidence for overall VLU risk factors. Preventive strategies for first VLU, predicated on a close understanding of specific risk factors, would be attractive given the chronic and recurrent nature of established VLU, and given suggestions from case–control studies of modifiable lifestyle risk factors for VLU (obesity and physical activity levels). As Meulendijks et al. suggest, greater understanding of risk factors could inform medicaland patient-level preventive activities analogous to those established in diabetic foot ulceration. In their study, Meulendijks et al. recruited Dutch patients with active VLU to participate in semi-structured interviews, using a narrative approach whereby participants were able to relate their stories and reflect on the progression of events, and on any cause-and-effect they perceived in the progression to first VLU. The researchers then organized the individual narratives into chronological order and applied thematic analysis to the narratives. Themes that may be of relevance in understanding VLU risk factors were found in participants’ perceptions. The theme of Mobility (with limited physical activity and changes in walking biomechanics) is consistent with known pathophysiology of venous hypertension and with evidence from cross-sectional and case–control studies of associations of (mainly recurrent) VLU. 9 The theme of Comorbidity is also of interest. Participants mentioned comorbidities including recurrent erysipelas infections, stress, peripheral vascular disease, diabetes and musculoskeletal injury. A wide range of comorbidities (especially vascular comorbidities) have been proposed to be associated with VLU. A prominent perception among participants was that comorbidities influenced VLU via their effect on mobility. The theme of Work and Lifestyle in the participants’ narratives often entailed distant events reflecting factors known to have an effect on circulation. Work and Lifestyle also linked to Mobility. As well as these findings potentially informing future quantitative research, there may be implications for current practice. The generally poor participant understanding of the role of venous hypertension in VLU aetiology (theme, Acknowledgment of Chronic Venous Disease) is important. Despite our imperfect understanding of VLU risk factors, the role of venous hypertension in VLU pathophysiology is accepted and preventive measures to address venous hypertension seem reasonable. Meulendijks et al.’s findings suggest patient education is needed here. Acknowledgments: thanks to Dr Linda Klein (University of Newcastle, Australia; University of Sydney, Australia) for comments on this manuscript.