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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 1  |  Page : 34-42

Prevalence and psychosocial effects of acne vulgaris among secondary school students


1 Department of Internal Medicine, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
2 Department of Community Health, School of Medicine, University of Benin, Benin City, Edo State, Nigeria

Date of Submission13-Apr-2020
Date of Decision20-Jun-2020
Date of Acceptance24-Aug-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Benson Uchechukwu Okwara
Department of Internal Medicine, University of Benin Teaching Hospital, P.M.B. 1111, Benin City, Edo State
Nigeria
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DOI: 10.4103/smj.smj_32_20

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  Abstract 


Background: Acne vulgaris is a common dermatological disease which affects a wide range of ages; however, it occurs more in the adolescent years with its attendant psychosocial effects. Aim: The aim of the study was to determine the prevalence and psychosocial effects of acne vulgaris among secondary school students in Egor Local Government Area, Benin City, South–South Nigeria. Materials and Methods: Four hundred and ten students (263 females and 147 males) from two secondary schools were enrolled in this descriptive cross-sectional study using a simple random sampling technique. A structured open- and close-ended interviewer-administered questionnaire was used and each student was examined and a clinical diagnosis was made by a dermatologist. Data were analyzed using the IBM SPSS Version 20 and P < 0.05 was set for statistical significance. Results: The overall prevalence of acne vulgaris was 37.3% with a slightly higher prevalence in females (37.6%) than in males (36.7%). A higher percentage of acne was observed among students in the private school (51.4%) compared to those in public school (32.2%). An increased prevalence (41.2%) was also observed in the higher age group (15–19 years) compared to (35.8%) in the 10–14 years age group. Psychological disorder was found in 170 (41.5%) respondents. The type of school (P < 0.001), class of student (P < 0.014), depression (P < 0.004), anxiety (P < 0.015), worry (P < 0.001), fear (P < 0.001), and anger (P < 0.001) were found to be statistically associated with acne vulgaris. Similarly, the type of school (P < 0.007) and marriage type of parents (P < 0.001) were found to be statistically associated with psychological disorder. Conclusion: School health education about this condition is imperative in order to significantly reduce its psychosocial effects.

Keywords: Acne vulgaris, adolescents, associated factors, psychosocial effects


How to cite this article:
Okwara BU, Ofili AN, Effiong EF, Ekhator U. Prevalence and psychosocial effects of acne vulgaris among secondary school students. Sahel Med J 2021;24:34-42

How to cite this URL:
Okwara BU, Ofili AN, Effiong EF, Ekhator U. Prevalence and psychosocial effects of acne vulgaris among secondary school students. Sahel Med J [serial online] 2021 [cited 2021 Apr 15];24:34-42. Available from: https://www.smjonline.org/text.asp?2021/24/1/34/312738




  Introduction Top


Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit of the skin which presents with seborrhea, comedones, erythematous papules and pustules, nodules, pseudocyst, and scarring.[1] It is not physically debilitating; however, the swellings, pain, hyperpigmentation, and scars on the face, neck, and upper trunk of some affected persons may cause some psychological and social problems. Acne vulgaris can be mild, moderate, or severe.[2] It can also be noninflammatory (open or closed comedones) and inflammatory (papules, pustules, nodules, and cyst).[2]

Acne vulgaris is common with a prevalence ranging between 90.7% and (94.7%) in two population studies. [3],[4] A wide range of ages are affected; however, adolescents are significantly most affected with more than 80%–90% of teenagers developing the condition. A higher incidence was reported among boys, but girls were noted to have more severe lesions.[3] At 40–49 years, 3% of men and 5% of women still had definite, although mild, clinical acne.[5]

Predisposing factors include genetic/hereditary factors, puberty/hormonal changes, infection, foods, drugs, and some disease conditions. There is a higher risk of having acne vulgaris among first degree relatives.[6] During puberty, an increase in androgen-like testosterone causes an increase in sebum production which is necessary for acne formation.[7] Hormonal changes during pregnancy and menstrual cycles also contribute to acne formation.[8] Propionibacterium acnes, a natural commensal of the skin and an anaerobic bacterium, cause acne when it invades the pilosebaseous unit of the skin.[7] Acne can also result from use of certain comedogenic medications such as anabolic steroids, lithium, phenytoin,[9] ingestion of foods that have high glycemic index,[10] disease conditions like polycystic ovarian syndrome in adult females, [2],[11] and psychological stress.[12]

Acne develops as a result of the interplay between four key processes: excess sebum production as a result of an increase in the level of androgen (like testosterone), follicular hyperkeratinization and subsequent plugging or clogging of the follicle, follicular colonization by  Propionibacterium acnes Scientific Name Search s inflammation, and release of inflammatory mediators into the skin.[13]

An increase in androgen levels that leads to excess sebum production (seborrhea) occurs during puberty. Excess keratin combines with the secreted sebum forming a small plug (microcomedo)[14] which clogs the hair follicle causing a blockade or impaction of the hair follicles. As more sebum is secreted, the plug continues to enlarge and then becomes visible. Infection with Propionibacterium acnes causes an inflammation of the hair follicles due to the production of pro-inflammatory mediators which eventually leads to the formation of pustular lesions that can be painful.

Adolescence is a transitory stage of physical and psychological human development.[15] Acne vulgaris occurs more in individuals during this stage; thus, it could be termed, “the disease of the teenagers.” Acne vulgaris is not physically debilitating; however, its immense psychological, emotional, and social effects on adolescents can affect their development. Psychological disorders such as depression, anxiety, social withdrawal, low self-esteem and self-worth, lack of confidence, and feeling of embarrassment [16],[17] are not uncommon in these individuals.

Despite its high prevalence among adolescents and an array of information available about acne, poor information/lack of knowledge about the skin disorder among teenagers, seeking of treatment from non-experts in addition to negative attitudes from the general public often leads to a vicious cycle of worsening of the condition and attendant psychosocial problems. It has been reported that acne patients have a higher unemployment rate than normal individuals, [15],[18] participate poorly in sporting activities, and have poor academic performance due to lack of self-confidence and poor feeling of self-worth[19] which may, rarely, lead to development of suicidal thoughts. [20],[21]

This study was carried out to evaluate the prevalence of acne vulgaris and its attendant psychosocial effects among secondary school students in Egor, Benin City, Nigeria.


  Materials and Methods Top


Study area

The study was carried out at the Enina Mixed Secondary School and Uselu Secondary School, both in Egor Local Government Area of Benin City, Edo State, South–South Nigeria.

Study design

This was a descriptive cross-sectional study carried out between May 2015 and April 2016.

The study population were male and female students of Enina Mixed Secondary School(a private secondary school) and Uselu Secondary School (a public secondary school) in Egor Local Government Area, Benin City, Edo State, and students who were present as at the time of administration of questionnaires and gave consent to be interviewed were the study participants.

Sample size determination

The sample size was calculated using Cochran[22] formula for sample size determination for descriptive studies.



Where,

n = minimum sample size

Z = standard normal deviation usually set at 1.96 for 95% confidence interval

P = Proportion of sample with characteristic of interest. In this case, the prevalence of acne was 59.82% (based on prevalence of acne vulgaris among students from a previous study done in Yaoundé, Cameroon in 2006).[23]

q=1-p= 1-0.5982 = 0.4018

d = degree of precision (0.05)



n = 369.3418

This was approximated to 369.

However, to account for lost and unfilled questionnaires, 10% nonresponse was calculated and added.



Where nf was final minimum sample size

nw is nonresponse rate



Therefore, the final minimum sample size that was used for this study was 410.

A total of 410 respondents who meet the inclusion criteria were interviewed.

Sampling technique

Egor Local Government Area has a total of 155 approved and verified private and 13 public secondary schools. By simple random sampling technique, Enina Mixed Secondary School was selected out of the 155 private schools using table of random numbers and Uselu Secondary School (a mixed school) was selected out of the 13 public schools also using table of random numbers. The number of respondents from each school was determined by proportionate allocation based on the population of students from the school. Finally, the number of respondents to be interviewed from each class was then determined by proportionate allocation as follows:

Enina Mixed Secondary School had a total of 400 students from JSS 1 to SS 2, while Uselu Secondary School had a total of 1100 students from JSS 1 to SS 2. As at the time of collecting these data, SS 3 students had finished writing their Senior Secondary School Certificate Examination and were absent, so they were excluded from the study.



≈ 109



≈ 301

The sample used in individual classes was also calculated as shown:

Enina Mixed Secondary School (n = 109)

There were 37 students in JSS 1, 151 students in JSS 2, 99 students in JSS 3, 29 students in SS 1, and 84 students in SS 2.











Uselu Secondary School (n = 301)

There were 252 students in JSS 1, 168 students in JSS 2, 179 students in JSS 3, 285 students in SS 1, and 216 students in SS 2.











Questionnaires were then distributed to students in each class by simple random method through the use of table of random numbers with the help of the class register.

Tools and method of data collection

Information for this study was obtained by means of structured open- and close-ended interviewer-administered questionnaires which were administered to all eligible respondents. A validated instrument the General Health Questionnaire 28 (GHQ 28) developed by David Goldberg was used to assess the psychological health of the respondents.[22],[24],[25]

Statistical analysis

Data obtained from respondents were entered into a spreadsheet and analyzed using the IBM SPSS version 20.0 statistical software (IBM Corps, Armonk, NY). Univariate tables were drawn for all variables; bivariate analysis was also drawn to determine the relationship between variables. Descriptive statistics (means, median, mode, and standard deviation) was also utilized. Chi-square was used to test the association. The level of statistical significance (P-value) was set at 0.05. A composite GHQ score was obtained using the 0-0-1-1 scoring system for the four responses possible for each item. A composite GHQ score of 4 and above implied presence of psychological disorder. GHQ score less than 4 implied the absence of psychological disorder (psychologically healthy).[22],[24],[25]

Pretesting

The questionnaires were pretested on students of the University Demonstration Secondary School, Ugbowo, Benin City. The school was located in Ovia North-East Local Government Area.

Subsequently, the questionnaires were checked for adequacy and all errors were corrected before the final approval and administration.

Ethical Consideration

Institutional and parental consent

Approval for the study was provided by the Department of Community Health, School of Medicine, University of Benin.

Permission was obtained from school authorities of both schools and from the parents of the students.

Ethnical clearance

Ethical clearance to conduct this study was sought and obtained from the University of Benin Ethics and Research Committee.

Individual assent

Assent was obtained from respondents before conducting the interview after full explanation of the aim and objectives of the study. The respondents were informed that full participation in the study was voluntary. Confidentiality and privacy of the respondents was respected during the interview.

Respondents were informed that there were no penalties for refusal to participate in the study or withdrawal from it.


  Results Top


The mean age of respondents was 12.8 ± 0.449 years with the highest proportion of 296 (72.2%) seen in the 10–15 age group. There were more females (263, 64.1%) than males (147, 35.9%). Christianity was the major religion (97.3%), with nuclear (78.5%) and monogamous family lifestyle (87.6%) being the dominant background. Bini was the major tribe (53.7%) and 77 (18.8%) of the respondents lived with guardians [Table 1].
Table 1: Sociodemographic variables of respondents

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The prevalence of acne found in this study was 37.3% [Table 2]. Acne vulgaris was more prevalent in the private (51.4%) than in the public (32.2%) secondary school. This association was statistically significant (P < 0.001). The association between the presence of acne vulgaris and age or sex of respondents was not statistically significant. The greatest proportion of respondents with acne vulgaris were in the JSS3 class 36 (47.4%), while the least (19, 24.1%) were in JSS1 class. The observed association between the presence of acne vulgaris and class of students was found to be statistically significant (P = 0.014). One hundred and twenty-three (38.2%) students with acne vulgaris were raised in nuclear family setting, while 30 (34.1%) were raised in the extended family setting. The observed difference between the presence of acne vulgaris and type of family was not statistically significant. Similarly, there was no statistical significant association between the presence of acne vulgaris and type of marriage of parents of the respondents [Table 3].
Table 2: Prevalence of acne vulgaris among respondents

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Table 3: Presence of acne vulgaris and sociodemographic variables of respondents

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A higher proportion (240, 58.5%) of the respondents were psychologically healthy, while less than half 170 (41.5%) were considered to have psychological disorder [Table 4].
Table 4: Psychological Health of respondents

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Relating the presence of acne vulgaris and sociodemographic variables with psychological disorder, students in private school (48.6%) were found to have more psychological disorder than students in public school (37.5%). This difference was found to be statistically significant (P = 0.007). Similarly, respondents in polygamy settings (66.7%) had more psychological disorder than those in monogamy setting (37.9%). The difference was again found to be statistically significant (P < 0.001). A higher proportion of those with acne had psychological disorder than those who did not have. This was not found to be statistically significant. P = 0.076. [Table 5].
Table 5: Presence of acne vulgaris, sociodemographic variables and psychological disorder of respondents

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Fifty respondents (12.2%) reported that they were depressed, while 65 (15.9%), 59 (14.4%), 86 (21.0%), 64 (15.6%), and 53 (12.9%) reported that anxiety, worry, fear, anger, and suicidal ideation, respectively, were their concerns. Furthermore, 57 (13.9%) reported that they had difficulty associating with friends, while 75 (18.3%) reported that they were unable to maintain eye contact when interacting with people [Table 6].
Table 6: Presence of mental health disorder and social effects among respondents

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Twenty-eight respondents with acne vulgaris (18.3%), when compared with 22 those without acne (8.6%), suffered from depression. This was statistically significant (P = 0.004). Persons with acne (33, 21.6%) reported anxiety compared to 32 (12.5%) respondents without acne. This was also statistically significant (P = 0.015). Thirty-six (23.5%) respondents with acne reported that they were worried, while 23 (8.9%) respondents without acne vulgaris reported the same. The association between the presence of acne and worry among respondents studied was statistically significant (P < 0.001). Fear (P < 0.001) and anger (P = 0.001) were also found to be associated with the presence of acne vulgaris. There was no statistical significance in the association between the presence of acne and feeling of low self-worth or suicidal ideation: P = 0.124 and 0.199, respectively [Table 7].
Table 7: Presence/absence of acne and corresponding mental health disorder

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  Discussion Top


The prevalence of acne vulgaris in this study was 37.3% which is in contrast with a study done in Kaduna, Northern Nigeria, in 2009 among 539 secondary school students in which the prevalence of acne was found to be 90.7%.[4] Differences in weather conditions in Benin City (Southern Nigeria) and Kaduna (Northern Nigeria) in addition to lifestyle differences may explain the contrasting prevalence.

Another study in Aydin, Turkey, in 2008 had an overall prevalence of 63.6%.[26] The Turkey study involved more age groups which included those who were in the 10–12 year age group; however, the prevalence of acne in this age group in the Turkey study particular was significantly low.

Acne prevalence in this study is similar to another study[27] done in Australia which had an overall prevalence of 36.1%.

The prevalence of acne was observed to be higher in the private school than in the public school. This finding is comparable to the study[28] done in rural and urban schools in Accra, Ghana, in 2012 where a higher prevalence of acne was noted among students in the urban school. In this study, the greater population of students attending private schools were from relatively comfortable families. Such families find it easier to afford houses in the urban areas as noted in the aforementioned study. The significance of this is that students from such homes have increased chances of consuming fatty foods due to snacking as they can easily afford such foods. Diet, more so fatty meals, has also been mentioned as contributory to the pathogenesis of acne vulgaris.

There was a relative increase in the prevalence of acne vulgaris with progression from JSS 1 through to the SS 2 class in this study. Hormonal influence in the pathogenesis of acne may peak/plateau at the later adolescent years which correlates with increased age and progression in class.

In this study, acne was more prevalent in the 10–15 year age group and with more females than males affected. This finding is similar to a study[29] done in Southern KwaZulu-Natal, South Africa. Early adolescence, which correlates with changes in sex hormones (androgen and estrogen), onset of puberty, and development of acne, particularly in females, may be an explanation for this finding (For instance, the hormonal changes cited, which hormones and were they of negative or positive influence in the development of acne, etc.). Androgens and estrogen have effect on the development of acne. Androgens produced in the adrenal cortex and the ovaries cause increased sebum production and follicular plugging[30] which are factors in the pathogenesis of acne. Estrogen counters the effect of androgen on sebum production by its inhibitory effect of androgen (testosterone) production and direct opposition of androgen within the sebaceous gland, although at much higher levels required to inhibit ovulation. [31],[32]

Respondents in this study were largely Christians from monogamous homes. This could be because the study was carried out in Benin City, South–South Nigeria which has a predominantly Christian population and monogamous family practice.

The dominant ethnic group in this study was the Binis who are largely from the nuclear family structure. Bini is the predominant ethnic group in Benin City where this study was carried out. The increasing influence of westernization in Nigeria also explains the shift of family structure from the extended to nuclear families.

The prevalence of acne vulgaris in this study was 37.3% which is in contrast with a study done in Kaduna, Northern Nigeria, in 2009 among 539 secondary school students in which the prevalence of Acne was found to be 90.7%.[4] Differences in weather conditions in Benin City (Southern Nigeria) and Kaduna (Northern Nigeria) in addition to lifestyle differences may explain the contrasting prevalence.

Another study in Aydin, Turkey, in 2008 had an overall prevalence of 63.6%.[26] The Turkey study involved more age groups which included those who were in the 10–12 year age group; however, the prevalence of acne in this age group in the Turkey study particular was significantly low.

Acne prevalence in this study is similar to another study[27] done in Australia which had an overall prevalence of 36.1%.

The prevalence of acne was observed to be higher in the private school than in the public school. This finding is comparable to the study[28] done in rural and urban schools in Accra, Ghana, in 2012 where a higher prevalence of acne was noted among students in the urban school. In this study, the greater population of students attending private schools were from relatively comfortable families. Such families find it easier to afford houses in the urban areas as noted in the aforementioned study. The significance of this is that students from such homes have increased chances of consuming fatty foods due to snacking as they can easily afford such foods. Diet, more so fatty meals, has also been mentioned as contributory to the pathogenesis of acne vulgaris.

There was a relative increase in the prevalence of acne vulgaris with progression from JSS 1 through to the SS 2 class in this study. Hormonal influence in the pathogenesis of acne may peak/plateau at the later adolescent years which correlate with increased age and progression in class.

A higher proportion of respondents who had acne vulgaris had psychological disorders than those who did not have, although this was not found to be statistically significant. Studies carried out in Italy,[21] Serbia,[33] and Turkey,[34] showed that more respondents with acne vulgaris had psychological disorders ranging from depression, anxiety through to even suicidal ideation.

Depression, anxiety, worry, fear, low self-worth, and anger were observed to be more in respondents with acne. This finding is similar to a study[35] done among Japanese students. This may be as a result of significant emphasis by adolescents on their facial appearance, hence the placement of their self-worth. Depending on the severity, facial acne could be disfiguring and this may be a cause of concern and worry which would overtime progress to anxiety and depression. Psychological disorders are therefore more likely to be common among those with acne than those without the lesion.

Although more respondents who had acne vulgaris reported had suicidal thoughts, this association was not statistically significant and could have occurred by chance. Acne has been reported to cause embarrassment, stigma, shame, guilt, and low self-esteem, which are likely to cause psychosocial problems. Acne may cause depression, which then results in impaired social functioning and suicidal ideation.[36]

More respondents in the public school were psychologically healthier than respondents in the private school. This could be because acne vulgaris was more prevalent in the private school than in the public school. This finding is similar to a study[37] done in Calabar which showed that acne vulgaris was more prevalent in private schools than in public schools. An increase in the prevalence of acne could mean an increase in psychological effects experienced by those with acne.

More students in the private schools had parents or guardians who belonged to a higher social class than parents of students in public school. This means that students in private school would be more concerned about their looks considering their social class. Persons in higher social class are likely to be more concerned about their looks than those in lower social classes; hence, psychological effects of acne may be directly proportional to social status.

Respondents in monogamous families were psychologically healthier than respondents in polygamous families. Large family size, inadequate care, and support for children in polygamous homes are factors that could contribute to the greater psychological problems experienced by adolescents growing in polygamous homes. Acne vulgaris in this setting is likely to play an additive role in psychological problems in respondents from polygamous homes. In monogamous family settings, psychological support could be provided to adolescents because of smaller family sizes and concern showed by parents to these children.

More male respondents were psychologically healthier than female counterparts. This finding was however not found to be statistically significant. Findings from studies [30],[31] done in Turkey and Japan showed that female students with acne significantly had lower psychological health than male students with acne. Females more than males have been observed to be concerned about their facial looks; hence, they believe that they look less attractive.


  Conclusion and Recommendation Top


The prevalence of acne vulgaris was found to be 37.3%. Type of school, class of student, depression, anxiety, worry, fear, and anger were found to be statistically associated with acne vulgaris.

The prevalence of psychological disorder among the respondents was found to be 41.5%. Type of school and marriage type of parents were found to be associated with psychological disorder. Acne vulgaris, although a chronic disorder of the pilosebaceous unit affecting more obviously the skin of the face, is on its own non-life threatening. However, the presence of psychological disorders in young persons with moderate-to-severe acne which at its extreme may lead to suicidal ideations calls for early intervention among these age groups.

School health education about this condition is imperative to significantly enhance the need to seek medical intervention for treatment/cure and ultimately reduce to the barest minimum the psychosocial effects of acne vulgaris, particularly among teenagers who account for the most vulnerable group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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