Assessing the Psychosocial Impact of Acne Scars on Individuals With Pigmented Skin: A Multicenter Observational Study

Acne scars negatively impact psychosocial and emotional wellbeing. However, data on the impact of acne scarring on anxiety and depression as well as quality of life are limited. This study assessed the effects of facial acne scars on quality of life, anxiety, and depression, and identifies risk factors associated with scar severity. We conducted an observational cross-sectional study between February 2023 and January 2024 at dermatology clinics in two public hospitals. A total of 175 patients with facial acne scars were recruited. Data collection included patient demographics, acne severity, scar severity (SCAR-S) and questionnaires such as Dermatology Life Quality Index (DLQI) and Hospital Anxiety and Depression Scale (HADS). The association between scar severity, quality of life, anxiety, and depression was analyzed using Chi-square tests and ordinal logistic regression. The median age of participants was 26.9 years and 56% were female. Most patients had mild (37.7%) to moderate (28.6%) acne scars. Among patients with severe/very severe scars, 69.2% reported a significant impact on quality of life (DLQI>10). A significant association was observed between scar severity and anxiety (p=0.009) as well as depression (p<0.001). There was a positive correlation between HADS and DLQI scores (r=0.602, p<0.001). Delayed or absent treatment after acne onset was a significant risk factor for acne scar severity. Facial acne scars are associated with impairment in quality of life and increased anxiety and depression. Timely and effective acne treatment is essential to reduce the severity of scarring and its psychosocial burden.

Acne vulgaris is a common disease involving adolescents predominantly, which can lead to scar formation. This study aimed to compare the efficacy of fractional CO2 laser therapy, alone or combined with topical Timolol or insulin, for acne scar treatment, which has not been yet rigorously investigated. In this Randomized Controlled Trial (RCT) conducted in 2024, we enrolled 30 subjects and randomly assigned them to groups A and B. Both groups received bilateral fractional CO2 laser therapy; one group received unilateral topical 0.5% Timolol Maleate, while the other received unilateral topical regular insulin. Scar severity was assessed using the Scale for Acne Scar Severity (SCAR-S), Acne Scar Assessment Scale (ASAS), and Goodman and Baron Quantitative Global Scarring Grading System (GBAQGS) before and after the therapy. Additionally, patients' quality of life was evaluated using the Dermatologic Life Quality Index (DLQI) questionnaire at the designated time points. Statistical analyses were conducted using the IBM ™ SPSS Statistics application (version 26.0). The subjects consisted of 20 females and 10 males of Persian ethnicity, with a mean age of 32.20 years. Despite significant improvements in acne scar severity, and quality of life observed following fractional CO2 laser therapy alone and in combination with topical Timolol or insulin application, no significant differences existed between these treatment approaches. No adverse effect was seen during the study. Fractional CO2 laser alone or its combination with topical Timolol or insulin mitigated acne scar severity and enhanced patients' quality of life, despite the absence of significant differences.

BackgroundAcne affects more than 80% of adolescents and young adults, who most often develop acne scars. Supporting data on the effect of acne scars on patient’s health-related quality of life (HRQOL) are limited.ObjectiveThe aim was to determine how the severity of acne scars impacts the HRQOL of afflicted individuals.MethodsIn this population-based cross-sectional study, 723 adults with facial acne scars but without active acne lesions self-completed the Self-assessment of Clinical Acne-Related Scars (SCARS) questionnaire formulated to investigate degree of acne scarring. The Facial Acne Scar Quality of Life (FASQoL), Dermatology Life Quality Index (DLQI), and Dysmorphic Concern Questionnaire (DCQ) were completed to assess the attitude of these patients toward their scars and the impact of scarring on their HRQOL.ResultsThe mean (standard error) DLQI score for facial acne scars was 6.26 (0.22). Acne scars were considered a ‘very large’ or ‘extremely large’ concern by 19.3% of participants with mild scars as compared to 20.1% and 34.0% of participants with moderate and severe/very severe scars, respectively (P = 0.003). Higher FASQoL scores were associated with increased severity of scarring (P = 0.001). In total, 16.9% of participants had clinical features of dysmorphia (i.e., DCQ > 13). DCQ scores were significantly higher among participants with more severe scarring (mean DCQ score of 8.04 [0.28], 8.40 [0.18], and 10.13 [0.08] among participants with mild, moderate, and severe/very severe acne scars, respectively; P = 0.001). Most commonly reported signs of emotional distress were self-consciousness (68.0%) and worry about scars not going away (74.8%).ConclusionsThis study highlights the significant psychosocial impact of atrophic acne scars in the form of embarrassment and self-consciousness. Individuals with mild scars also expressed significant impact on quality of life that increased with aggravation of scar severity. Patient-reported outcomes provide an insight into the physical, functional, and psychological impact of acne scarring from the patient’s perspective.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40257-021-00628-1.

Acne vulgaris is a chronic inflammatory skin condition that primarily affects the face, affecting a person's physical appearance. Anxiety, depression, and body dysmorphic disorder (BDD) are the three primary psychological conditions seen in dermatological patients. This study aimed to assess how prevalent anxiety, depression, and BDD in acne patients and the negative effect of acne on quality of life and self-esteem in dermatology patients. This cross-sectional study was done at the dermatology clinic in East Jeddah Hospital, Jeddah, Saudi Arabia. Data was collected using two pre-designed questionnaires. Part 1 contained demographic information and part 2 included four sets of questionnaires including the dermatology life quality index (DLQI), Rosenberg Self-Esteem Scale (RSES), Hospital Anxiety and Depression Scale (HADS), and Body Dysmorphic Disorder Questionnaire (BDDQ). Post-acne hyperpigmentation index (PAHPI), globalscale for acne scar severity (SCAR-S), and LEEDS were used by the dermatologist to assess the patients' acne severity, post-acne scars, and pigmentation conditions. Data were analyzed using the IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States). The majority of the participants were females (76%), Saudi Arabians (95%), students (58%), single (82%), and attended university (66%). The mean acne duration was 5.75 ± 4.58 years and 44% of the participants used social media for more than five hours per day. The participants scored high on the RSES (27.54 ± 3.05), indicating normal self-esteem. The HADS-A score was 11.14 ± 2.74, whereas the HADS-D score was 11.46 ± 1.78, indicating anxiety and depression symptoms. Their mean SCAR-S score is 4.38 ± 2.89. DLQI scores (6.04 ± 6.05) indicate that acne had a moderate effect on patients' quality of life. The percentage of positive BDD patients is significantly higher than those with negative BDD (p = 0.022). Furthermore, a significant association between PAHPI total score and SCAR-S (r = 0.48, p ≤ 0.001) and HADS-D (r = 0.39, p = 0.005) total scores. The study focuses on how acne vulgaris affects patients' quality of life. The findings suggest that acne-related quality of life is positively associated with anxiety and depressive symptoms. This study provides clinicians with practical advice for implementing a more thorough management strategy for acne vulgaris.

There have been very few studies on the prevalence and severity of acne scars in Japanese patients. The aim of the present study was to investigate the prevalence of acne scars and their impact on the quality of life (QOL) in Japanese acne patients. Acne scars were classified as mini-scars (atrophic scars of ≥0.5 and <2mm in diameter) atrophic scars (≥2 mm in diameter), and hypertrophic scars. The severity of acne and acne scars were evaluated. The background of patients and their QOL in relation to acne were assessed. Of 240 subjects, 218 (90.8%) had scars. All patients with scars had mini-scars; 61.2% and 14.2% of 240 had atrophic scars and hypertrophic scars, respectively. Severe scarring was found in patients who had experienced severe acne symptoms, although 15.0% of patients with scars had experienced only mild acne symptoms. The total Dermatology Life Quality Index score was significantly higher in patients with scars than in patients without scars (5.9±4.4 vs 4.2±4.1). Almost all the patients had small atrophic scars with a diameter of 0.5 or more and less than 2mm, which we have termed "mini-scars". Acne scars had a negative impact on patient QOL. Early initiation of treatment is recommended to avoid acne scars.

Background:Scarring is one of the most dreadful complications of acne for which patients seek surgical treatment.Objective:The aim of this research was to study the morphological features of acne scarring and the relationship between severity of acne and its treatment with type and severity of acne scars.Materials and Methods:This was a hospital-based, noninterventional, cross-sectional study carried out over a period of 1 month on 100 patients with post-acne scarring. A morphological evaluation of the types, sites, and severity of acne scars was done, and details of the severity and treatment of acne were recorded.Results:Of 100 patients included in the study, 61 were male and 39 were females. Females had an earlier onset of acne (15.8 years) as compared to males (16.5 years). The mean duration of active acne was longer in males (99.3 months) than that in females (74.4 months). Male patients had more severe acne vulgaris as compared to females (P = 0.0001). Of 100 patients, 52 started treatment 1 year after the onset of acne, and 18 patients had never taken any anti-acne medication. Morphologically, majority of post-acne scars were ice pick scars in 94% patients, followed by rolling scars in 86%, boxcar scars in 54%, and keloidal scars in 10% patients. Male patients had more severe acne scarring than females (P < 0.05). Of 54 patients with severe acne, 22 progressed to moderate grade and 32 patients progressed to severe grade of acne scarring. Significant reduction in the severity of acne scarring was observed in patients who received isotretinoin as compared to that in patients who received oral antibiotics.Conclusion:Majority of patients with active acne delay treatment, which leads to increased acne scarring. Ice pick scars are the most common type of acne scars, and keloidal scars are more common in males. Males have a longer duration of acne, they delay treatment, and have more severe acne scarring. Early introduction of oral isotretinoin may help to reduce the severity of acne scarring. Public education is essential to urge patients to seek early and appropriate treatment of acne that can reduce the incidence and severity of acne scarring and its psychosocial consequences.

BACKGROUND Acne vulgaris is a common disease mostly affecting the adolescents. The lesions can be distributed over the sebaceous rich areas of the body like face, chest, back and upper arm. The commonest location is face. Face is psychologically the most important part of the body. So, the presence of lesions on the face can have significant effects on the quality of life of the patients. The purpose of this study was to assess the effect on the quality of life (QOL) of the patients who have acne vulgaris on their face. Along with that this study was planned to assess as to whether the effect on QOL is related to two demographic factors - age &amp; gender and two clinical factors - duration of disease and grade of acne vulgaris. METHODS 81 patients having acne vulgaris on their face who attended the Dermatology OPD were assessed using the Dermatology Life Quality Index (DLQI) questionnaire. RESULTS Acne vulgaris of the face had significant adverse effect on the QOL of the affected patients. DLQI score was found to be more with increase in age of the patients. There was no significant association between DLQI score &amp; gender. The clinical factors, duration of disease and the grade of acne vulgaris had statistically significant positive correlation with DLQI score. CONCLUSIONS Acne vulgaris had an adverse effect on the QOL of the patients. QOL was more affected with increase in age of the patients. Duration of the lesions and grade of acne vulgaris had a positive correlation with the effect on the QOL of the patients. The lesions can be controlled with treatment. Proper counselling is also very important. KEYWORDS Acne Vulgaris, Quality of Life (QOL), Dermatology Life Quality Index (DLQI)

Anxiety symptoms and depressive symptoms are observed in approximately 20%-50% and 30% of patients with psoriasis, respectively.1,2 To date, however, evidence for the association of these symptoms with patients' direct perception of their disease (called patient-reported outcomes [PROs]) remains limited. We assessed the association of anxiety symptoms and depressive symptoms with the severity of psoriasis, psoriatic symptoms, health-related quality of life (HRQoL), and satisfaction levels in Japanese patients with psoriasis using baseline data of participants from a single-arm, open-label, multicenter, prospective cohort study-ProLOGUE (Japan Registry of Clinical Trials identifier: jRCTs031180037).3 Patients (aged ≥18 years) who had plaque psoriasis without peripheral arthritis symptoms and were eligible for self-administration of brodalumab were enrolled at 15 facilities across Japan (study period, October 2017-March 2020).3.

Rosacea is a chronic inflammatory skin condition primarily affecting the face, which greatly influences patients' quality of life and mental well-being. This research aimed to examine environmental and dietary factors, systemic comorbidities, and their effects on the quality of life and psychological impact of rosacea in Chinese patients. The study was an observational case-control design involving 200 individuals with rosacea and 200 healthy participants. Participants completed a questionnaire addressing skin color, specific habits, dietary and environmental factors, comorbidities, and assessments of quality of life and depression levels using the Dermatology Life Quality Index (DLQI) and the Patient Health Questionnaire-9 (PHQ-9), respectively. The chi-square test was employed to compare the distribution of general characteristics. Univariate analysis was conducted using Pearson's chi-square test. DLQI is a continuous scale analyzed via independent t-test and PHQ-9 is an ordinal scale analyzed via Mann-Whitney U test. Spearman's rank correlation coefficient was used for nonparametric correlation between two ranked variables. A p value < 0.05 was considered statistically significant. Chi-square results with OR and 95% CI indicated significant associations between rosacea and factors such as female gender, age, smoking, alcohol consumption, environmental influences (sun exposure, use of cosmetics/hair products, exercise, exposure to hot weather, hot baths), dietary factors (dairy products, hot coffee consumption), and comorbidities (diabetes mellitus). No significant links were found with skin colors, dietary factors (fatty food, hot and spicy food, hot tea, sweet food), or other comorbidities (hypertension, high cholesterol, Helicobacter pylori, cancer, Crohn's/ulcerative colitis, dry eye syndrome, chronic kidney disease, and migraine). The rosacea group showed notably higher DLQI scores with moderate effect (9.0%), large effect (40.5%), and extremely large effect (45.5%), along with elevated PHQ-9 scores for depression compared to controls, highlighting a significant impact on their quality of life and mental health. Spearman's rank correlation coefficient demonstrated a significantly positive correlation between DLQI and PHQ-9 scores among participants (rho = 0.423, p < 0.001), indicating that greater quality of life impairment is linked to increased depression levels. These results underscore the complex nature of rosacea and its significant psychosocial burden. Addressing modifiable risk factors (e.g., smoking cessation, avoid alcohol, hot coffee and dairy products intake, sun protection, cessation of cosmetic products) and incorporating (DLQI/PHQ-9 screening) mental health screening and psychological support into treatment could enhance patient outcomes. Further research is necessary to clarify causal mechanisms and improve management strategies, which will aid in preventing and improving rosacea conditions and treatment approaches in the future.

Introduction: Psoriasis is a chronic inflammatory disease that negatively impacts patients' quality of life (QoL) and mental health. Itch and pain are prevalent symptoms of psoriasis and contribute to the psychosocial burden of this disease. This study aimed to evaluate the impact of skin pain on the prevalence and severity of symptoms of anxiety and depression and on the QoL in psoriasis patients. Methods: The studied population comprised 106 adults with psoriasis (34% female; mean age 42.1 ± 13.0 years). Disease severity was measured with the Psoriasis Area and Severity Index (PASI). The intensity of skin pain was assessed with the NRS and the Short Form McGill Pain Questionnaire (SF-MPQ). The Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) questionnaires were used to estimate the severity of depression and anxiety, respectively, as was the Hospital Anxiety and Depression Scale (HADS). Quality of life (QoL) was studied using the Dermatology Life Quality Index (DLQI). Results: Regarding anxiety assessment, females reported significantly higher scores with the HADS-A (8.42 ± 4.85 points vs. 5.14 ± 3.9 points; p < 0.001) and the GAD-7 compared to men (7.50 ± 5.58 points vs. 5.24 ± 4.79 points; p = 0.036). Similarly, the severity of depression was significantly higher in women, as measured with the PHQ-9 (7.50 ± 5.58 points vs. 5.24 ± 4.79 points, p = 0.021). Psoriasis patients with skin pain scored significantly higher in HADS Total score (p = 0.043), HADS-A (p = 0.022), PHQ-9 (p = 0.035), and DLQI (p < 0.001) than the rest of the studied group. The intensity of skin pain measured with the SF-MPQ correlated significantly with HADS Total score (p = 0.021), HADS-A (p < 0.001), HADS-D (p = 0.038), and PHQ-9 (p < 0.001). Additionally, there was a significant correlation between the intensity of cutaneous pain assessed using the VAS and the PHQ-9 (p = 0.022). Conclusions: Skin pain significantly influences the well-being of patients with psoriasis as well as the symptoms of anxiety and depression. In particular, women with psoriasis are at increased risk of developing anxiety and depression. Our findings underline the necessity for a multidisciplinary approach to the management of this dermatosis.

The aim of this study was to assess the association between acne and the quality of life among children and adolescents. A cross-sectional study was conducted on 1277 schoolchildren aged 7-19 years in three schools of Kaunas city, Lithuania. The diagnosis of acne was confirmed by a specially trained dermatologist when there were any acne lesions on the face, back or chest. The severity of acne was measured according to the Leeds revised acne grading scale. After clinical examination, the participants were asked to fill out the Children’s Dermatology Life Quality Index (CDLQI). The overall prevalence of acne (82.9%) was strongly age-dependent with highest rates among adolescents. Acne had no impact on the quality of life for more than one-half (63.6%) of schoolchildren with acne. Respectively, for 29.5%, 5.0%, and 1.8% of schoolchildren acne had slight, medium, and strong impact on their quality of life. The impairment of the quality of life was associated with puberty and the duration of acne. The association of acne with the quality of life was stronger among schoolchildren with moderate or severe acne compared to schoolchildren with mild acne (OR 4.9; 95% confidence interval: 1.4–17.3). The quality of life was only weakly associated with the prevalence of acne among schoolchildren in Lithuanian schools. However, in more severe forms of acne, longer acne duration, and after puberty, the impact of this skin disease on their quality of life became more substantial.

It is unknown how the quality of life (QOL) is affected in patients with pityriasis rosea (PR), and whether it is related to rash severity. We constructed a valid and reliable Cantonese version of the Dermatology Life Quality Index (DLQI). We recruited patients with PR, with atopic dermatitis and with acne vulgaris, and controls of the same sex and comparable age. We applied the DLQI and the Pityriasis Rosea Severity Score (PRSS) to the patients with PR, the DLQI and the SCORing Atopic Dermatitis Index (SCORAD) to the controls with atopic dermatitis, and the DLQI and the Leeds Acne Grading System (LAGS) to the controls with acne vulgaris. Total DLQI scores of the 22 patients with PR (mean: 6.36, SD: 5.79) were significantly lower than those of the 22 controls with atopic dermatitis (mean: 12.00, SD: 5.38) (P = 0.021), but were insignificantly different from those of the 22 controls with acne vulgaris (mean: 6.86, SD: 4.53) (P = 0.57). Correlation between the total DLQI and PRSS scores was weak (gamma(s) = +0.19) and insignificant (P = 0.40). All six DLQI parameters were insignificantly correlated with the PRSS scores. In contrast, the total DLQI scores and most of the DLQI parameters were strongly correlated with the rash severity scores for the control subjects. Significantly more patients with PR have concerns regarding disease etiology and infectivity. The QOL of the patients with PR was significantly less affected than that for the patients with atopic dermatitis, but was insignificantly different from the patients with acne vulgaris. Unlike atopic dermatitis and acne vulgaris, the effects on the QOL in PR are insignificantly correlated with rash severity. These results bear important implications on clinical management.

The association between dermatology and psychiatry has been well known from mid-nineteenth century and is evolving since then as a consequence of overwhelming psychiatric morbidities among the persons with certain dermatoses. This study is intended to unveil such relationship and to establish gamut of opportunities directed to enhance the quality of life of such individuals. 1) To assess the socio-demographic profile of patients diagnosed with Acne Vulgaris (AV) and Psoriasis. 2) To grade the severity of disease using Pillsbury scale for AV and Psoriasis Area and Severity Index (PASI) for Psoriasis. 3) To assess the psychological burden of the disease by using Dermatological Life Quality Index (DLQI). 4) To determine the effect of dermatological treatment if any and to assess its impact on DLQI score. This study enrolled 116 patients diagnosed with AV and Psoriasis attending the Department of Dermatology, Venereology and Leprosy Vinayaka Mission Medical College &amp; Hospital, Salem and questions regarding socio-demographic profile, disease severity (PASI and Pillsbury scale), quality of life (DLQI) were measured and compared before and after intervention. Data were entered in Microsoft Excel [2007] and analyzed using Statistical Package for Social Sciences [SPSS] version 21.0 Chicago, USA This study was dominated by females (twice) and the subjects averaged 27.6 ± 12.9 years of age. The patients with moderate and severe forms of AV were the maximum (96.3%). Similarly the patients with moderate and severe psoriasis comprised two-third. Both the sub-groups has averaged larger effect of the respective disease condition downgrading their quality of life (DLQI score 20.1± 3.2 for AV and 23.4 ± 2.4 for psoriasis) although post-treatment scores declined by significant margins (DLQI score 7.9± 2.1 for AV and 9.1 ± 2.3 for psoriasis) As there exist positive correlations between earlier treatment onset and advancing quality of life, expediting the implementation of psychological assessment for the potential dermato-psychiatric illnesses has to be scaled up in all dispensaries.

Acne vulgaris is an inflammatory skin disease that shows chronic effects in adolescents and young adults. Its impact on quality of life (QoL) often extends beyond the physical symptoms, influencing social interactions and reducing self-confidence. Although these impacts are widely acknowledged, they are seldom given sufficient attention or assessed in depth with standardized measures like the Dermatology Life Quality Index (DLQI). This study aimed to evaluate the extent to which acne interferes with QoL in young adults using DLQI scores and its associations with demographic and clinical factors. This hospital-based, cross-sectional study was conducted between October 2023 and December 2023 at Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Visakhapatnam, India. The study population comprised 200 participants aged 16-28 diagnosed with acne. Data collected included demographic factors (age, sex), clinical features (acne grade, duration, site, scars, hyperpigmentation, and skin type), and DLQI scores. Acne severity was classified from grade I to IV, and the relationships between DLQI scores and clinical/demographic variables were analyzed using chi-squared tests, with statistical significance set at p<0.05. Data analysis was performed using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). The mean age of participants was 19.6 years, with women comprising 68.5% of the study population. Acne grade II was the most common, and the average DLQI score was 11.14, indicating a noticeable impact on QoL. Nearly half of the participants (48%) reported a "very large" effect on QoL. Highly significant associations were found between duration of acne, post-acne hyperpigmentation, and grade of acne with DLQI scores (all p<0.001), showing that longer duration, hyperpigmentation, and higher grades of acne significantly worsened QoL. Significant associations were also observed for site of acne and acne scars (both p<0.05), with multiple acne sites and severe scarring linked to greater negative impacts on DLQI scores. Grade III-IV acne were especially tied to bigger hits on QoL. Additionally, site of acne and acne scars were highly associated with acne grade (p<0.001). Factors such as having acne for over two years, oily skin, acne across multiple sites (face, chest, and back), and post-acne hyperpigmentation contributed to higher DLQI scores. Acne vulgaris has a marked impact on QoL in young adults, especially those with severe, persistent, and extensive cases. Focusing on both the physical and mental aspects of acne in treatment could make a difference. Further multi-center studies with larger samples are recommended to generalize these findings and help create targeted interventions.

Background : Fractional CO2 laser resurfacing in the treatment of acne scars, attempts to reduce the adverse effect of laser resurfacing by creating microscopic injury zones to the dermis with skipped interval areas. Aim of the study : The purpose of this study is to compare the safety and efficacy of high pulse energy (70 mJ) and low pulse energy (45 mJ) of fractional CO2 laser resurfacing in the treatment of facial acne scars. Patients and Methods : Twenty patients with moderate to severe atrophic acne scars were treated with three sessions of fractional CO2 laser resurfacing at four-week intervals with high and low energy levels applied to each side of the face separately. The severity of acne scars at baseline and after treatment was assessed using Goodman and Baron’s qualitative scar grading system. Patient satisfaction score was obtained using a quartile grading scale. Results : The severity of acne scars on both sides was comparable to each other before the treatment (p = 0.643). At the final assessment, both sides with high and low energy levels demonstrated an excellent response (p = 0.000). However, the difference between the mean final scores of both sides was not significant (p = 0.731). The most frequently reported side effects were crustation and erythema. Crustation lasted longer on the right side (mean = 6.75 days) whereas for the left side (mean = 5.45 days). Erythema was transient and only in four cases persisted beyond a week (right side mean = 10.5 days while left side mean = 8.75 days) Conclusions : Both high energy (70 mJ/pulse) and low energy (45 mJ/pulse) CO2 fractional laser resurfacing of acne scar results in satisfactory outcomes with no statistically significant differences. While the duration of side effects (crustation and erythema) was increased slightly with higher fluence.