Medical knowledge | Dermatology » Epidemiology of Acne Vulgaris, Prevalence, Severity and its Impact among School Teenagers in Makkah, Saudi Arabia

68 Epidemiology of Acne Vulgaris: Prevalence, Severity and its Impact among School Teenagers in Makkah, Saudi Arabia Enas H. Alfalogy1, Nahla H Hariri 2, Ibtihal T Yamani 3, Wedyan H Al-Mosa 3, Rawabi D Majrashi 3 1 Family Medicine Department, Faculty of Medicine, Suez Canal University, Ismalia, Egypt. 2 Community Department, College of Medicine, Umm Al-Qura University, Makkah,, Saudi Arabia. 3 Medical student, College of Medicine, Umm Al-Qura University, Makkah,, Saudi Arabia. Abstract: Background: Acne vulgaris is one of the most prevalent chronic inflammatory dermatological problems among teenagers worldwide. It has a significant emotional and psychosocial impact on patients quality of life. Acne vulgaris influence is found to be much higher in developing countries once compared to developed countries. Aim: to estimate the prevalence of acne vulgaris, severity, types and its influence on quality of life among Teenagers. Subjects and Methods: A cross sectional study was conducted

on 196 female teenagers aged between 13-19 years who were selected randomly. They were surveyed using a self- administered questionnaire followed by a physical examination by global acne grading (GAG) system. Cardiff Acne Disability Index (CADI) was employed to evaluate effect of acne on quality of life. Results: The prevalence of acne vulgaris was (457%) The majority of teenagers had acne with moderate severity (38.9%) followed by mild acne (30%), severe acne (266%) and very severe acne (4.5%) The mean (CADI) score was (4 ± 23) More than half (567%) have mild disability on their quality of life, 30% have moderate disability while 13.3% have severe disability. About 40% of the teenagers reported a major concern about their skin appearance and 33.4% consider their acne a bad problem Predictors of disability were use of cosmetic, family history, menstrual disturbance and dietary factors.Conclusions: Acne is a very common skin problem among teenagers with the majority having moderate

severity with mild to moderate disability. Keywords: Acne, adolescents, disability, quality of life Introduction: Acne vulgaris is one of the Burden of Disease (GBD).(2) most common chronic inflammatory Approximately 14% of dermatological diseases among adolescents. dermatologists’ consultations are related to It is characterized by obstruction and/or Acne problems.(3) inflammation of the pilosebaceous unit. described by a wide range of skin lesions Acne can classified as noninflammatory such as comedones, papules, pustules and, lesions (comedones), inflammatory lesions, may or a combination of both, affecting the face Previous frequently however, may affect the chest different prevalence rates ranging from and the back.(1) The burden of Acne 28.9% to 913% across countries(5-7) In exhibits worldwide. It is considered one of United States, the life time prevalence of the major causes of disability adjusted life Acne vulgaris was 80% predominantly in years

(DALYs) in the late adolescent period males.(8) (15–19 year olds) in developed and have demonstrated a higher prevalence developing countries according to Global rates of acne among adolescents. One study * Corresponding Author: Enas hamdy2007@yahoo.com reach Clinically, Acne is nodules studies have and scarring.(4) reported Recently, most very studies 68 conducted in Lithuania among adolescents anxiety was 37.4% among acne patients(16) revealed that the occurrence of acne was To our knowledge, 82.9%, and was predicted by age with examined the prevalence rate of acne highest rates in the teenagers (13-19 vulgaris among adolescents in Makkah city. years).(9) This study is aimed to examine the no studies have Another study was conducted in prevalence of acne vulgaris, its pattern and Malaysia, and revealed that the prevalence impact among Teenagers in Makkah city, of students who had facial acne was Saudi Arabia. 67.5%(10) Similarly, The

prevalence rate Methods: A cross-sectional study was of Acne vulgaris among adolescents is high conducted among 196 teenager females in Saudi Arabia 68.2 % and 535% in who were selected using stratified random Riyadh city and Northern region of Saudi sampling Arabia consequently.(11, 12) secondary and high schools from 1st Genetic technique from preparatory, 2016 to 31st May 2017 in predisposition is considered the chief November primary cause of acne vulgaris. In addition, Makah, Kingdom of Saudi Arabia. An other triggering factors are documented informed consent was obtain from to the such as androgen excess, stress, hormonal selected students and their parents. Students disturbances and frequent use of Cosmetic were interviewed by using a semi structured agents.(13) questionnaire Remarkably, adolescents who suffer to assess the socio- demographic from Acne vulgaris are susceptible to data psychosocial problems such as social menarche), avoidance,

and duration, degree, site and its pattern) and Overall, possible risk factors for acne (stress, eating anxiety depressive disorders problems.(14) these studies highlighted that acne has (age, education presence and of onset acne of (onset, a habits, caffeine intake, chocolate intake, use negative effect on adolescents quality of of cosmetics, family history, menstrual life. in Makah city one study reported that irregularities and frequent face washing). 40.8% of acne patients had depression in Diagnosis of acne was based on physical particular female patients.(15) Similar study examination findings by researchers. The was conducted in Addis Ababa, Ethiopia to examination included the face, chest and estimate the prevalence and associated upper back regions. The acne severity was factors of anxiety in patients with acne assessed using Global Acne Grading which revealed that the prevalence of Egyptian Family Medicine Journal (EFMJ) Vol .2(1),May

2018 www.efmj-egorg 66 (GAG) System [(mild (1-18), moderate (19- linear regression analysis was performed to 30), severe (31-38) and very severe >39].(17) conclude which of the influences were Students who have acne were asked independently associated with higher CADI to fill a self-reported Cardiff Acne score in teenagers with acne vulgaris as it Disability Index (CADI) questionnaire, was normally distributed without skewness. Arabic version to assess the resulted P value less than 0.05 was considered disability from acne.(16) The Cardiff Acne significant. Disability Index is planned for use in Ethical considerations: Ethical approval adolescents, and even young adults with was gained from the research and ethics acne. CADI questionnaire includes five committee of the faculty of Medicine at statements with a Likert scale, four grades Umm Al-Qura University, Makkah, Saudi (0–3). The total score ranges from 0–15 Arabia. An informed consent was

obtain The five statements are aggressive feeling from to the selected students and their or frustration, social life disturbance, public parents. avoidance, concern about facial appearance Results: A total of 196 teenagers were and an indication of how bad the acne was. assessed aged between 13-19 years (mean The CADI score was calculated by ±SD 17.2 ±1) The overall prevalence of summing the score of every statement acne was 45.7% (Figure 1) The majority of resulting in a possible highest score of 15 female teenagers had moderate acne in and least score of 0. CADI scores were severity (38.9%) followed by mild acne classified as low (0–4), medium (5–9) and (30%), severe acne (26.6%) and very severe high (10–15). The lesser the CADI score, acne (4.5%) (Figure 2) The mean of CADI the minimal disability experienced by the score was 4 ± 2.3, more than half of teenager or adolescent while a greater score subjects (56.7%) have mild disability, indicated a

major disability. (30%) have moderate disability while Outcomes variables: Severity and disability (13.3%) have severe disability (Figure 3) from acne were assessed as outcome About (40%) of the teenagers reported a variables. major concern about their skin appearance Statistical analysis: Data was investigated and (33.4%) consider their acne a bad using IBM advanced SPSS statistical problem (Figure 4). package version 23. Chi-square test was The risk factors of acne vulgaris used to test the relation between categorical among teenagers are shown in Table 1. variables of precipitating factors. Multiple There was a significant relation between Egyptian Family Medicine Journal (EFMJ) Vol .2(1),May 2018 www.efmj-egorg 68 acne and family history of acne (55.6 %), Riyadh city, the capital city, the prevalence menstrual stress, rate of Acne vulgaris among adolescents is (82.2%), dietary factors (544%), use of much higher that was 68.2% and the mean cosmetics

(70%) and frequent face washing. age of onset was 15.5 years (11) Table 2 presents Predictors of disability However, the low prevalence in our study resulted from acne; they were the use of may be due to the fact that our study was cosmetic, family history of acne, menstrual conducted on female participants only disturbance and dietary factors. whereas this acne is more common in disturbance (80%), males. Furthermore the difference in Discussion: Acne is a chronic skin disease prevalence rates between these studies was caused by an inflammation that increases affected by different diagnostic criteria. sebum production of the pilosebaceous unit. In the current study, it was observed that In the current study, the age group of the the symptoms of acne ranging from open participants ranged from 13 to 19 years old. and closed comedones to nodules. We also The prevalence of facial acne in this study used the global acne grading system for was found to be 45.7%

among teenaged assessment acne severity. The majority of females in Makkah, Saudi Arabia. Similar female teenagers had acne with moderate results were reported in an Australian study severity (38.9%) followed by mild acne which found that overall prevalence of acne (30%), severe acne (26.6%) and very severe among male and female participants was acne (4.5%) [5] in addition, another study was Comparatively, the study conducted in conducted in the Northern region of Saudi Muar, Malaysia showed that 87.7% of the Arabia, which reported the prevalence of students had mild acne, 8.4 % 36.1% Acne vulgaris was 53.5% (12) had . There is moderate acne, and 3.7 % had severe consistency in the rates reported in recent acne.(10) Similarly, in a study conducted studies the among adolescents in Sao Paulo showed assessment tools used.Different results were that majority of the participants reported to reported in a cross-sectional study which have comedones acne (61.1 %)

followed by was conducted in Turkey and found that the mild acne (30.6%) and lastly moderate acne prevalence of acne among high school (7.6%)(18) The difference in distribution of students both male and female was 23.1% severity in these studies may be due to the which is difference in lifestyle and risk factors of despite diminished. the variation of comparatively different (17)] and On the other hand, In Egyptian Family Medicine Journal (EFMJ) acne. Vol .2(1),May 2018 www.efmj-egorg 89 In addition, the assessment of the effect of Furthermore, the mean of CADI score was acne on the quality of life was done using 4.0 which is low Overall this result the Cardiff Acne Disability Index. The indicates that the teenagers were mildly index assessed the quality of life in affected by acne in their lives. The high teenagers suffering from acne and studied prevalence of mild acne and low prevalence its relationship to aggressive feeling or of severe acne

demonstrated that the impact frustration, social life disturbance, public of acne on the quality of life increased with avoidance, concern about facial appearance the increase in severity of facial acne. This and an indication of how bad the acne was. result is concurrent with previous studies The study compared these factors over the which have shown a association between previous month. In addition, an indication facial acne severity and the Cardiff Acne was made to how bad the acne was doing Disability Index. (7) presently. The mean of Cardiff Acne Disability Index was 4 ± 2.3 and 567% of Conclusions: Acne vulgaris is a very subjects have mild disability, 30% have common skin problem among teenagers moderate disability while 13.3% have with severe disability. Likewise, the study severity.it has mild to moderate impact on conducted in Muar, Malaysia reported the quality of life. Predictors of disability (1.8%) with score 13 in Cardiff Acne were frequent use

of cosmetic, family Disability Index history, menstrual disturbance and dietary impairment. which meant severe (10) the majority having moderate factors. The current study revealed that about 40% Limitations of the study: Limitations of of the teenagers reported a major concern the study were that the study was conducted about their skin appearance and 33.4% among females only. Short time devoted consider their acne a bad problem. In from school administrative bodies to fulfill agreement that the questionnaires and do the assessment. conducted among teenaged Scottish school Refusal of some parents to examine their children as 50% of subjects had negative students. with another study influence on emotions resulted from their acne. 20% of subjects had disturbances in Financial support and sponsorship: Nil. their personal and social lives due to their acne. (19) Egyptian Family Medicine Journal (EFMJ) Vol .2(1),May 2018 www.efmj-egorg 89 Conflicts

of interest: The authors confirm different age-groups]. that they have no conflicts of interest to brasileiros declare. 2009;84(4):349-54. 4. Simpson de Anais dermatologia. NB, Cunliffe WJ. Acknowledgements: The authors express Disorders of sebaceous glands. In: their thanks to Abrar Ghazi Najjar, Afnan Burns T, Breathnach S, Cox N, Abdullah Basallom, Asalah Fahad Alhazmi, Griffiths Bashayer Abdulrahman Althaqafi, Bashair Textbook of Dermatology, 7th ed., Waleed Melibari, Bushra Waleed Melibari , Oxford: Blackwell publishing; 2004. Bayan Muhammad Fatani, Bayan Nasser p. 431 - 4375 C, editors. Rook.s Bugis, Bayan Saud Algethami , Haneen 5. Stathakis V, Kilkenny M, Marks R Mohammad Banjar, Lamis Hisham Bosy, Descriptive epidemiology of acne Maumounah Faisal Al-Najjar, Muruj Salah vulgaris in the community. The Filfilan, Rawan Osama Mirza, Raghda Australasian journal of dermatology. Talal Alsharif, Ranin Mohammed Masarit, 1997;38(3):115-23. Salwa Obed

Alomeri, And Shatha Awadh 6. Galobardes B, Davey Smith G, Althobaiti for their help in different steps Jefferys M, McCarron P. Has acne of the research such as data collection and increased? data entry. history among university students References: between 1. Dawson AL, Dellavalle RP Acne vulgaris. BMJ. 2013 May 8. 346:f2634. Prevalence 1948 and of 1968. acne The Glasgow Alumni Cohort Study. The British journal of dermatology. 2005;152(4):824-5. 2. Haagsma JA, Graetz N, Bolliger I, 7. Goulden V, Stables GI, Cunliffe Naghavi M, Higashi H, Mullany WJ. Prevalence of facial acne in EC, et al. The global burden of adults. Journal of the American injury: Academy incidence, mortality, disability-adjusted life years and of Dermatology. 1999;41(4):577-80. time trends from the Global Burden 8. Collier CN, Harper JC, Cafardi JA, of Disease study 2013. Injury Cantrell WC, Wang W, Foster KW, Prevention. 2016;22(1):3-1 et al. The prevalence of acne in

3. Schmitt JV, Masuda PY, Miot HA adults 20 years and older. J Am [Acne in women: clinical patterns in Egyptian Family Medicine Journal (EFMJ) Vol .2(1),May 2018 www.efmj-egorg 89 Acad Dermatol. 2008 Jan 58(1):56- Arabia. International Journal of 9. Medical Science and Public Health. 9. Karciauskiene J, Valiukeviciene S, Gollnick H, Stang A. 2014;3(9):1150-6. The 14. Demircay Z, Seckin D, Senol A, prevalence and risk factors of Demir F.Patient’s perspective: an adolescent among important issue not to be overlooked schoolchildren in Lithuania: a cross- in assessing acne severity.Eur J sectional study. Journal of the Dermatol. 2008;18:181-4 acne European Academy of Dermatology 15. Abebe G AG, Andargie G, and Venereology. 2014;28(6):733- Getachew M, Tesfaw G. Prevalence 40. and 10. Hanisah A, Omar K, Shah SA Factors Anxiety Associated among with Patientswith Prevalence of acne and its impact on Common Skin Disease on follow up the quality

of life in school-aged at Alert Referral Hospital, Addis adolescents in Malaysia. Journal of Ababa, primary health care. 2009;1(1):20-5 2016;19.)763( 11. AboEl-Fetoh Ethiopia. J Psychiatry. R, 16. Motley RJ, Finlay AY Practical use Albarqi W, Asiri S, Alruwaili N. of a disability index in the routine Epidemiology Of Acne Vulgaris In management of acne. Clinical and Adolescent And Young Females In Experimental Riyadh City, Kingdom Of Saudi 1992;17(1):1-3. N, Alghamdi 17. - Gürel MS, Yanık M, 1imßek Z, Arabia. 2016; 589-98 12. M Abo El-Fetoh N, G Alenezi N, G Alshamari N, G Dermatology. Alenezi Kati M, Karaman A. Quality of life O. instrument for Turkish people with Epidemiology of acne vulgaris in skin diseases. Int J Dermatol 2005; adolescent male students in Arar, 44: 933–938. Kingdom of Saudi Arabia2016. 1449 p 18. Bagatin E, Timpano DL, Guadanhim LRdS, Nogueira VMA, 13. Al-Huzali SA-M, K; Al-Nikhali, S Terzian LR, Steiner D ,et al. Acne

& Al-Matrafi, K. Prevalence of vulgaris: prevalence and clinical depression among acne patients in forms in adolescents from São King Faisal Hospital and King Paulo, Brazil(). Anais brasileiros de Abulaziz Hospital in Makkah, Saudi dermatologia. 2014;89(3):428-35 Egyptian Family Medicine Journal (EFMJ) Vol .2(1),May 2018 www.efmj-egorg 89 19. Walker N, Lewis-Jones MS Quality of life and acne in Scottish Cardiff Acne Disability (CADI). Journal of the European adolescent schoolchildren: use of Academy the Childrens Dermatology Life Venereology Quality Index (CDLQI) and the 2006;20(1):45-50. Egyptian Family Medicine Journal (EFMJ) Index Vol .2(1),May 2018 of Dermatology : and JEADV. www.efmj-egorg 68 45.7% Having acne vulgaris No acne vulgaris 54.3% Figure (1):Prevalence of acne vulgaris among teenagers 40% 38.9% Percent of participants 35% 30% 30% 26.6% 25% 20% 15% 10% 5% 4.5% 0% mild mild moderate moderate severe severe

very severe very severe Figure (2): Severity of acne vulgaris based on GAG system. Egyptian Family Medicine Journal (EFMJ) Vol .2(1),May 2018 www.efmj-egorg 66 Cardiff Acne Disability Index (CADI) 13.3% 30.0% Mean 4 ± 2.3 Mild 56.7% moderate severe Figure (3) : Cardiff acne disability index 70 60 50 Nil 40 mild moderate severe 30 20 10 0 Frustration Social affection Public avoidance Feeling of skin Indicating acne appearance as a problem Figure (4): Domains of CADI score Egyptian Family Medicine Journal (EFMJ) Vol .2(1),May 2018 www.efmj-egorg 68 Risk factors No Acne vulgaris Total 50 (55.6 %) 72 (80 %) 9 (8.4%) 13(12.1%) 59(29.9%) 85 (43.1%) 51.787 91.741 <0.001 <0.001 74 (82.2 %) 49(54.4 %) 63 (70 %) 28 (31.1 %) 39 (36.4 %) 9 (8.4 %) 15 (14 %) 6 (5.7 %) 113 (57.4%) 58 (29.4%) 78 (39.6%) 34(17.3 %) 41.876 49.865 64.053 21.989 <0.001 <0.001 <0.001 <0.001 Yes       Family history Menstrual disturbance

Stress Dietary factors Use of cosmetics Frequent face washing X2 P -value Table (1): Risk factors of acne vulgaris among teenagers Table (2): Multiple linear regression model for CADI for teenagers with acne vulgaris Unstandardized Coefficients B t Sig. 95% Confidence Interval for B Lower Upper 2.448 3.991 Use of -1.606 0.258 -0.347 6.218 <0001 -2.115 cosmetics  Family -1.492 0.260 -0.303 5.743 <0001 -2.005 history  Menstrual 1.423 0.231 0.311 6.172 <0001 0968 disturbance  Dietary -0.836 0.277 -0.167 3.014 <0001 -1.384 factors Variables excluded from model: frequent face washing and stress -1.096  Constant 3.219 Std. Error 0.391 Standa rdized Coeffic ients 8.230 <0.001  Egyptian Family Medicine Journal (EFMJ) Vol .2(1),May 2018 -0.980 1.878 -0.289 www.efmj-egorg ‫‪‬‬ ‫‪89‬‬ ‫الملخص العربى‬ ‫وبائٌة حب الشباب‪ :‬مدي انتشاره وشدته وتأثٌره لدي

المراهقٌن فً مكة المكرمة ‪ -‬المملكة العربٌة السعودٌة‬ ‫ايناس محدي الفالوجي‪ -‬هنلو احلريري‪ -‬ابتهال مياين – وداين ادلوسا‪ -‬روايب اجملراشي‬ ‫اخللفية‪ :‬يعد حب الشباب الشائع واحد من أكثر األمراض اجللدية ادلزمنة انتشاراً بني ادلراىقني يف مجيع أحناء العامل‪ ,‬ويؤثر سلبيا على الناحية العاطفية‬ ‫والنفسيةاإلجتماعية مما ينعكس على جودة احلياة لدى ادلريض‪ .‬وقد ُوجد أن حب الشباب الشائع ذا أتثري أعلى بكثري يف البلدان النامية مقارنة ابلبلدان‬ ‫ادلتقدمة‪ .‬اهلدف‪ :‬هتدف الدراسة إىل حساب مدى انتشار حب الشباب الشائع ‪ ،‬أنواعو ‪

،‬وأثره على جودة احلياة بني ادلراىقني‪ ‬املنهجية وطرق‬ ‫البحث ‪ :‬أجريت دراسة مقطعية مستعرضة على ‪ 691‬مراىقة ترتاوح أعمارىن بني ‪ 61‬و ‪ 69‬سنة مت اختيارىن عشوائياً‪ .‬مت مسحهن ابستخدام‬ ‫استبيان ذايت مث الفحص ‪ .‬مت استخدام مؤشر كارديف حلب الشباب لتقييم أتثري حب الشباب على جودة احلياة‪ ‬النتائج‪ :‬كان انتشار حب الشباب‬ ‫(‪ . )٪ 74‬معظم ادلراىقات لديهن حب الشباب متوسط الشدة (‪ )٪ 139‬يليو حب الشباب اخلفيف (‪ ، )٪ 13‬وكان حب الشباب الشديد‬ ‫يشكل (‪ )٪ 61.1‬وحب الشباب الشديد جدا (‪ )٪ 7‬كان ادلتوسط احلسايب مؤشر كارديف حلب الشباب (‪ )61

±7‬أكثر من النصف‬ ‫(‪ )٪.14‬يعانون من عجز خفيف على نوعية وجودة احلياة‪ )٪13(,‬لديهم عجز متوسط ‪ ,‬يف حني أن ( ‪ )٪ 611‬لديهن عجز شديد‪ ‬ويف‬ ‫حوايل (‪ )٪ 73‬من ادلراىقات ُسجل وجود قلق كبري حول مظهر اجللد ‪ ,‬وكانت وجهة نظر (‪ )٪ 11.7‬أن حب الشباب مشكلة سيئة‪ ‬التنبؤ ابلعجز‬ ‫والتأثري على جودة احلياة كان من خالل ما إذا مت استخدام مستحضرات التجميل التجميلية ‪ ،‬اتريخ العائلة ‪ ،‬اضطراابت الطمث والعوامل‬ ‫الغذائية‪.‬اخلالصة‪ : :‬حب الشباب ىو مشكلة جلدية شائعة بني ادلراىقني‪ ,‬و الغالبية متوسط الشدة‪ ,‬مع أتثريخفيف إىل متوسط على نوعية

وجودة‬ ‫احلياة‪ .‬الكلمات املفتاحية‪ :‬حب الشباب ‪ ،‬ادلراىقني ‪ ،‬العجز ‪ ،‬جودة احلياة‪‬‬ ‫‪www.efmj-egorg‬‬ ‫‪Vol .2(1),May 2018‬‬ ‫)‪Egyptian Family Medicine Journal (EFMJ‬‬