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Background: Acne-induced scarring is associated with a similar burden as acne, i.e. diminished quality of life, and may be avoided if patients receive appropriate and timely acne treatment. In 2017, a four item-Acne-Scar Risk Assessment Tool (4-ASRAT) was designed by Tan et al. to categorise patients with acne into lower-risk or higher-risk for acne scarring. Its applicability outside the initial study population (France, Brazil and United States) remains to be determined.  Methods: A study protocol was developed to create a systematic approach for validating and adapting 4-ASRAT to different populations, Ecuador in this case. The protocol was reviewed by 11 local and international dermatologists and pilot-tested in an Ecuadorian population using a sample of 10 participants who currently had or had had acne. Feedback from the pilot study was used to improve the study protocol. The results of the pilot study are included here, and the final study protocol is available as extended data.  Results: The protocol proved to be applicable. Images taken of participants were a valuable resource for dermatological evaluation about the presence or absence of acne scars. Tangential light is necessary for this evaluation. Although dermatological assessments varied, we concluded that assessment by three local dermatologists for each participant was adequate for reaching a consensus on the presence or absence of acne scars.   Conclusions: Considering the morbidity related to acne and acne scars, tools designed as prevention that alert patients about risk of developing scarring are necessary. The proposed protocol shows a feasible way of validating and adapting 4-ASRAT to different populations.

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Background: Acne is a common disease that causes a large global disease burden. The Global Burden of Skin Disease reported that in 188 countries the burden from acne as measured by disability-adjusted life years (DALYs), years lived with disability and years of life lost is greatest in Western Europe, high-income North America and Southern Latin America. This paper aims to identify risk factors for acne scarring specific to the Ecuadorian population in order to adapt the 4-ASRAT tool accordingly. Methods: This was an observational prospective study. Participants were recruited to complete a survey that was developed based on the potential risk factors for acne scarring and had facial photographs taken. To determine risk factors and their respective weighting, a logistic regression was performed. Results: The study included 404 participants. Results from univariate analyses indicated that male sex (OR=2.76 95%CI [1.72; 4.43]), severe or very severe acne scarring (OR=4.28 95%CI [1.24; 14.79]), acne duration over 1 year (OR=1.71 95%CI [1.12; 2.60]), oily skin (OR=2.02 95%CI [1.27; 3.22]) and the presence of acne on the neck (OR=2.26 95%CI [1.30; 3.92]), were all significantly associated with the presence of acne scarring. Male sex (2.56 95%CI [1.58;4.17]), oily skin (1.96 95%CI [1.20;3.20]) and severe or very severe acne (3.75 95%CI [1.05;13.37]) remained significant risk factors for acne scarring in the multivariate analysis. Conclusion: By identifying acne scarring risk factors and applying the tool in everyday dermatology visits, we can reduce the physical and psychological burden that acne scarring causes in the adolescent and adult population. Further research should be performed to reassess potential risk factors and complete the adaptation of the tool for the Ecuadorian population, with a larger and more representative study population.