Journal of Cosmetics, Dermatological Sciences and Applications, 2017, 7, 67-76

http://www.scirp.org/journal/jcdsa
ISSN Online: 2161-4512
ISSN Print: 2161-4105

Acne Vulgaris in Jeddah Medical Students:

Prevalence, Severity, Self-Report, and
Treatment Practices

Shadi Zari1,2, Asraa Turkistani3

1
Department of Dermatology, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
2
Division of Dermatology, Faculty of Medicine, McGill University, Montreal, Canada
3
Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

How to cite this paper: Zari, S. and Tur- Abstract

kistani, A. (2017) Acne Vulgaris in Jeddah
Medical Students: Prevalence, Severity, Self- Acne is a common skin disorder of teenagers and continues into adulthood.
Report, and Treatment Practices. Journal of Research has been limited regarding acne prevalence, perception and health
Cosmetics, Dermatological Sciences and
care utilization in Saudi Arabia. The objective of this study was to assess acne
Applications, 7, 67-76.
https://doi.org/10.4236/jcdsa.2017.71007 prevalence in final year female medical students in Jeddah, Saudi Arabia using
the global acne grading system (GAGS) compared with student’s self-report of
Received: January 23, 2017 their acne. This is a cross-sectional study conducted among 151 students dur-
Accepted: March 10, 2017
Published: March 13, 2017
ing 2016, in which students were interviewed subjectively and examined ob-
jectively by a trained physician. This study showed that acne was reported
Copyright © 2017 by authors and subjectively by 83.4% of female students compared to 98% of students as-
Scientific Research Publishing Inc.
sessed objectively by the global acne grading system. 14.6% of students claimed
This work is licensed under the Creative
Commons Attribution International having no acne while it was objectively present, which was statistically signifi-
License (CC BY 4.0). cant (Χ2 = 15.4, P < 0.001). 41% visited a dermatologist and 28.5% waited 1
http://creativecommons.org/licenses/by/4.0/ year until seeking a dermatologist. However, 35.8% of students got an over-
Open Access the-counter drug for their acne. Surprisingly, treatment duration expectation
was <1 week in 9.9% compared to >2 months in 39.1% of students. Acne was
present in 41.1% of the students parents compared to 83.4% in their siblings.
A total of 41.7% of student had trunk acne. 60.9% of students had scarring
and 72.8% of them had pigmentation. Moderate to severe acne students had
higher siblings acne history of 95.2% (Χ2 = 5.85, P < 0.05), higher scaring of
73.8% (Χ2 = 4.05, P < 0.05), and higher pigmentation of 85.7% (Χ2 = 4.87, P <
0.05) which was statistically significant. Our study confirms that acne is very
common in female medical students in Jeddah, Saudi Arabia with a preva-
lence rate of 98%. Knowledge regarding acne treatment was inadequate de-
monstrating the need for educational and awareness programs about early
treatment that will prevent suffering from acne scarring or pigmentation.

DOI: 10.4236/jcdsa.2017.71007 March 13, 2017

S. Zari, A. Turkistani

Keywords
Acne, Acne Vulgaris, Acne Prevalence, Acne Treatment,
Acne Self-Report

1. Introduction
Acne is one of the most common inflammatory chronic skin diseases that affect
teenagers and continues into adulthood. Women are most commonly affected
with a mean age for presentation of 24 years [1]. In the US, the prevalence rate
of acne is 85% in those aged 12 to 24 years [2]. Only a small percentage of acne
patients are treated by a dermatologist or prescribed medications [3]. While
there is no associated mortality with acne, suffering mainly is due to permanent
scarring, post inflammatory hyperpigmentation and poor self-image [4]. Various
studies on acne prevalence showed that patients have a greater degree of acne
severity if there is first-degree relative’s acne history [5] [6]. There are many stu-
dies on twins and families that proved that a first-degree relative acne history
has a strong influence on age of onset, severity and treatment [7]. There is ab-
undance in the availability of over the counter (OTC) skin care products in
pharmacies and centers promoted to the public. Without seeing a dermatologist,
patients will choose OTC treatments that may not control their acne [8]. In-
flammatory acne lesions can result in permanent scars, the severity of which
may be affected by delay in treatment and by the degree of acne severity [9] [10].
Also, there is relatively few information in the medical literature on the pre-
valence, clinical severity and self-report of acne among medical students in Saudi
Arabia. This study reports the prevalence and clinical severity of acne in com-
parison with the self-report of acne in final year female medical students in King
Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia. The secondary
outcome measures of the percentage of students who visited a dermatologist,
how long they waited before seeking treatment, percentage of students who got
an OTC drug, treatment duration expectation, family history of acne in parents
and siblings, most common areas affected by acne, and the percentage of scar-
ring and pigmentation resulting from their acne were recorded in a question-
naire.

2. Methods
A questionnaire-based cross-sectional study was conducted among 151 final year
female medical students attending the medical faculty at King Abdulaziz Uni-
versity during 2016 followed by an objective evaluation of their acne (see Ap-
pendix). The study was approved by the Ethics Committee at KAUH and the
Research Committee at the University of Jeddah Faculty of Medicine.
Final year female medical students were interviewed using a confidential, ano-
nymous interviewing questionnaire to collect personal data, knowledge, percep-

68
 S. Zari, A. Turkistani

tion and practice regarding their acne. After students oral consent, they were
given a questionnaire to complete. All the students completed the questionnaire
that was distributed to them. Upon completion of the questionnaire by students,
an intern who was trained earlier by the consultant dermatologist examined the
students for the presence of acne lesions. The trained intern then graded the
acne severity and was blinded to the study outcome.
Clinical classification of acne severity was done using the Global Acne Grad-
ing System (GAGS). Each type of lesion was given a value depending on severity:
no lesions = 0, comedones = 1, papules = 2, pustules = 3 and nodules = 4. The
score for each area (Local score) is calculated using the formula: Local score =
Factor x Grade (0 - 4). The global score is the sum of local scores, and acne se-
verity was graded using the global score. A score of 1 - 18 is considered mild; 19
- 30, moderate; 31 - 38, severe; and >39, very severe [11].

3. Statistical Methods
According to the GAGS, students were classified into four groups: None, mild,
moderate, and severe acne. Individuals with moderate and severe acne were in-
cluded in one group for some evaluations. The primary outcomes of the study
were the prevalence and clinical severity of acne in comparison with the self-
report of acne in final year female medical students in Jeddah, Saudi Arabia.
The association between clinical acne grade as the dependent variable and
other factors as explanatory variables were analyzed by chi-squared test. Analysis
of data was done using SPSS Version 13 (SPSS, Inc., Chicago, IL, USA). Data
were presented by OR and 95% CI. P values of <0.05 were considered statisti-
cally significant.

4. Results
4.1. Acne Severity
Using the GAGS to examine the students, acne was present in 148/151 (98%) of
female medical students involved in the study. 106/151 (70.2%) had mild acne,
and 36/151 (23.8%) moderate, and 6/151 (4%) had severe acne present (Table
1).

4.2. Acne Self-Rating by Students

According to the Acne self-rating question in the questionnaire, 126 out of 151
(83.4%) medical students have acne. As 91/151 (60.3%), 30/151 (19.9%) and
5/151 (3.3%) rated their acne as mild, moderate and severe respectively (Table
2).
Comparing between patient self-assessment and objectively assessing patient
acne by the global acne grading system, it was found in our study that 14.6% (22
students) claimed to have no acne while they were having acne objectively which
was statistically significant (Χ2 = 15.426, P < 0.001), OR = 6.727 (95% CI 4.575 -
9.892) (Table 3).

69
S. Zari, A. Turkistani

Table 1. Grade of acne severity.

Frequency Percent Cumulative Percent

None 3 2.0 2.0

Mild 106 70.2 72.2

Moderate 36 23.8 96.0

Severe 6 4.0 100.0

Total 151 100.0

Table 2. How would you rate your current acne?

Frequency Percent Cumulative Percent

None 25 16.6 16.6

Mild 91 60.3 76.8

Moderate 30 19.9 96.7

Severe 5 3.3 100.0

Total 151 100.0

Table 3. Objective assessment vs. self assessment cross tabulation.

Self assessment
Total
None Acne

Count 3 0 3
None
% within objective assessment 100.0% 0.0% 100.0%
Objective
assessment
Count 22 126 148
Acne
% within objective Assessment 14.9% 85.1% 100.0%

Count 25 126 151

Total
% within objective Assessment 16.6% 83.4% 100.0%

4.3. Acne Location

Our study conduct showed a total of 63 (41.7%) students with truncal acne
(chest and back). 54 students have more acne on their back compared to 33 stu-
dents who had more acne on their chest area (Table 4), as some students had
acne both on their chest and back areas. 85 out of 151 (56.3%) have acne present
in more than one area on the face. For acne localized in one area only, it was
most commonly present on the forehead 21/151 (13.9%) (Table 5).

4.4. Acne Treatment Practices

Only 62 out of 151 (41%) students visited a dermatologist regarding their acne
(Table 4). 43/151 (28.5%) of students waited 1 year before seeing a dermatolo-

70
 S. Zari, A. Turkistani

gist (Table 6). 54 out of 151 (35.8%) students got an acne treatment without a
prescription (Table 4).

4.5. Acne Treatment Duration Expectation

The treatment duration expectation was less than 1 week in 15/151 (9.9%) of
students compared to more than 2 months in 59/151 (39.1%) (Table 7).

4.6. Acne Family History

Acne was present in 62/151 (41.1%) of the students parents compared to 126/151
(83.4%) in their siblings (Table 4). For student with moderate to severe acne, the
higher percentage of siblings history of 95.2% (40/42) was statistically significant
(Χ2 = 5.859, P = 0.016), OR = 0.187 (95% CI 0.042 - 0.832) (Table 8).

Table 4. Response of students to questionnaire.

Questionnaire Number (QN) Variable Yes No Total P value Χ2 test

2 Presence of acne on the back 54 97 151 <0.001

3 Presence of acne on the chest 33 118 151 <0.001

5 Visiting a dermatologist regarding acne 62 89 151 0.028

6 Getting acne treatment without a prescription 54 97 151 <0.001

9 Acne presence in parents 62 89 151 0.028

10 Acne presence in siblings 126 25 151 <0.001

11 Presence of scars 92 59 151 0.007

12 Presence of post inflammatory hyperpigmentation 110 41 151 <0.001

Table 5. Response of students to acne location on the face.

QN Variable None Forehead Right cheek Left cheek Nose Chin More than one side Total P value Χ2 test

Acne location
4 14 21 5 10 3 13 85 151 <0.001
on the face

Table 6. Response of students to duration until seeking a dermatologist.

Less than 3 to 6 6 to 12 More than P value

QN Variable None Total
3 months months months one year Χ2 test

Waiting before
7 47 15 28 18 43 151 <0.001
seeing a doctor

Table 7. Response of students regarding treatment duration expectation.

Less than 1 week to 1-2 More than P value

QN Variable None Total
1 week 1 month months 2 months Χ2 test

Acne treatment
8 24 15 27 26 59 151 <0.001
duration expectation

71
S. Zari, A. Turkistani

4.7. Presence of Scarring and Post-Inflammatory

Hyperpigmentation
Scars were present in 92/151 (60.9%) of students (Table 4). Post inflammatory
hyperpigmentation (PIH) was present in 110/151 (72.8%) of students (Table 4).
In moderate to severe acne students, 73.8% (31/42) had scaring and 85.7%
(36/42) had PIH which was statistically significant (Χ2 = 4.056, P = 0.044), OR =
0.451 (95% CI 0.206 - 0.989) (Table 9) and (Χ2 = 4.87, P = 0.027), OR = 0.352
(95% CI 0.136 - 0.914) (Table 10) respectively.

Table 8. Modified acne grading vs. brothers and sisters acne.

Risk Estimate

95% Confidence Interval

Value
Upper Lower

Odds ratio for modified grading

0.187 0.042 0.832
(none & mild vs. moderate & severe)

For cohort brothers and sisters acne (none & mild) 0.828 0.736 0.932

For cohort brothers and sisters acne (moderate & severe) 4.431 1.092 17.976

Number of valid cases 151

Table 9. Modified acne grading vs. scars.

Risk Estimate

95% Confidence Interval

Value
Upper Lower

Odds ratio for modified grading

0.451 0.206 0.989
(none & mild vs. moderate & severe)

For cohort scars (none & mild) 0.758 0.593 0.969

For cohort scars (moderate & severe) 1.681 0.970 2.914

Number of valid cases 151

Table 10. Modified acne grading vs. pigmentation.

Risk Estimate

95% Confidence Interval

Value
Upper Lower

Odds ratio for modified grading

0.352 0.136 0.914
(none & mild vs. moderate & severe)

For cohort pigmentation (none & mild) 0.792 0.662 0.947

For cohort pigmentation (moderate & severe) 2.248 1.021 4.950

Number of valid cases 151

72
 S. Zari, A. Turkistani

5. Discussion
Acne prevalence was reported to be 85% in the population age of 12 to 24 years
[2] [12] [13]. On the acne self-assessment questionnaire, acne was reported by
83.4% of students compared to 98% by the physician’s examination. Menon
showed acne prevalence determined by the trained observer to be 0.55 (95% CI
0.49 - 0.61), while Self-reported acne prevalence was 0.43 (95% CI 0.37 - 0.49).
Not many studies in the literature have analyzed the validity of self-reported
acne in comparison with the trained observer diagnosis of acne. The few studies
that looked at this problem concluded that there is lack of agreement between
self-report and the trained observer acne evaluation, which is similar to our
study [14].
Our study showed that 41.7% of students had truncal acne (chest and back).
This goes with a previous study that showed that 41% of women have truncal
acne [15]. Our study also showed that acne is present more on the back than on
the chest area. This shows the importance of always examining the back of an
acne patient by the treating physician, to prevent unnecessary scarring from a
delay in treating back lesions.
Moderate and severe acne students in our study had a higher percentage in
seeking a dermatologist regarding their acne. 28.5% of students in our study
waited more than 1 year to see a dermatologist. Although there is an abundant
availability of acne treatments, there is underutilization of them. According to
one study, treatment of acne is used in only 18% of adolescents suffering from
acne [16]. Our study showed that 35.8% of students got an acne treatment with-
out a prescription; which are most probably over the counter drugs. This is
comparable to the general estimation that 30% of affected acne patients are likely
to use OTC treatments [14]. Surprisingly the treatment duration expectation was
less than one week in 9.9% of students and more than 2 months in 39.1% of stu-
dents only. Based on these numbers, there should be more education regarding
the time required to see a full response to medications, which is usually 2 to 3
months [17].
Our study is compatible with another study that showed undergraduate stu-
dents to have acne by 78% heritability in first-degree relative’s [18]. Previous
studies showed that moderate to severe acne were strongly associated with first-
degree relative’s acne history [5] [19]. Students in our study with moderate to
severe acne had a higher percentage of sibling’s history of 95.2%.
Our study showed that scaring was present in 60.9% of our student’s popula-
tion, in which we postulate that not seeking a dermatologist for treatment is the
main reason. A large percentage of students had post inflammatory hyperpig-
mentation (72.8%); which is likely due to the Middle Eastern ethnic group; who
are mostly Fitzpatrick skin types 3 and 4. Also, using over the counter treat-
ments such as exfoliating products or strong toners can contribute to PIH by
causing skin irritation [20]. This is why designing a treatment regimen individu-
alized for every patient will help reducing PIH and increasing the patient satis-
faction. Our students with moderate to severe acne revealed that 85.7% of them

73
S. Zari, A. Turkistani

had PIH. A study done by the Asian acne board showed that 58.2% of patients in
their study had PIH [21]. The higher percentage of PIH in our study may be ex-
plained again because of darker Fitzpatrick skin types in Arabian skin compared
to Asian skin.
One of the limitations of our study is that all the students are females with no
male participants. We believe that the results from our female study sample are
representative of females in Saudi Arabia of a similar age group. The high acne
prevalence in our study compared to other studies may be due to the fact that it
was done in a classroom setting and was not clinic based, which allowed us to
include many students with mild acne who would not usually seek medical ad-
vice. Acne is usually considered a disorder of adolescence. However, there are
not many data on the prevalence of acne in the adult population [22]. Although
acne is best assessed by a dermatological examination, standardized diagnostic
criteria are not available [23].

6. Conclusion
Our study confirms that acne is very common in female medical students in
Jeddah, Saudi Arabia with a prevalence rate of 98%. This is the first study in
Saudi Arabia to compare acne prevalence and severity using an objective as-
sessment by the GAGS compared to the students self-report of acne. Our study
showed a discrepancy between the self-assessment of acne and objective assess-
ment by the physician. Our study also showed that there is a delay in seeking
medical advice and that students with higher acne grade were more likely to visit
a dermatologist. The importance of having patient’s knowledge and treatment
practices regarding their acne is fundamental in creating awareness about the
treatments effectiveness. This will also lead to the prevention of unnecessary
suffering from acne scaring or pigmentation, which was highly prevalent in pa-
tients with moderate to severe acne in our study.

Acknowledgements
Thanks to Prof. Talal Zari for performing the statistical analysis for this study.

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Appendix
Questionnaire content distributed to medical students:
1) How would you rate your current acne?
1. ☐ None 2. ☐ Mild 3. ☐ Moderate 4. ☐ Severe
2) Do you have pimples in your back?
1. ☐ Yes 2. ☐ No
3) Do you have pimples in your chest?
1. ☐ Yes 2. ☐ No
4) Where is the location of your acne on the face?
0. none 1. ☐ forehead 2. ☐ Right cheek 3. ☐ Left cheek
4. ☐ Nose 5. ☐ Chin 6. More than one side
5) Have you visited a dermatologist regarding your acne in the past year?
1. ☐ Yes 2. ☐ No
6) Have you visited a pharmacy and got medicine without a prescription?
1. ☐ Yes 2. ☐ No
7) How long did you wait before seeing a doctor?
0. none 1. ☐ Less than 3 months 2. ☐ 3 to 6 months
3. ☐ 6 to 12 months 4. ☐ More than 1 year
8) How long do you expect your acne treatment to take?
0. none 1. ☐ Less than 1 week 2. ☐ 1 week to 1 month
3. ☐ 1 - 2 months 4. ☐ more than 2 months
9) Did any of your parents have acne in the past?
1. ☐ Yes 2. ☐ No
10) Did any of your brothers and sisters have acne in the past?
1. ☐ Yes 2. ☐ No
11) Is your acne causing any scars?
1. ☐ Yes 2. ☐ No
12) Is your acne causing any pigmentation?
1. ☐ Yes 2. ☐ No

76
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