|Year : 2020 | Volume
| Issue : 1 | Page : 13-17
Acne vulgaris in Saudi Arabia: A systematic review
Aishah Zayed J. Alanazi
College of Medicine, Al Jouf University, Sakakah, Saudi Arabia
|Date of Submission||29-Aug-2019|
|Date of Acceptance||08-Nov-2019|
|Date of Web Publication||27-Mar-2020|
Dr. Aishah Zayed J. Alanazi
College of Medicine, Al Jouf University, Sakakah
Source of Support: None, Conflict of Interest: None
Introduction: Acne vulgaris (AV) is one of the most common dermatological disorders. However, data of AV in Saudi Arabia are not well documented. Purpose: To determine the prevalence, potential risk factors, psychological impact, and treatment modality of AV in the Kingdom of Saudi Arabia and highlights the gaps of knowledge related to this disease. Methods: The literature search was performed using the keywords “acne vulgaris,” “Saudi Arabia,” and “KSA” in four electronic databases: PubMed, Google Scholar, Web of Science, and Embase. The search was restricted by the locational filter of Saudi Arabia and a timeframe of 2010–2019. Results: 453 potentially relevant titles and abstracts being identified, of which 18 articles met the inclusion criteria. AV is becoming more prevalent among the Saudi population, particularly among Saudi women. The knowledge and awareness of the public is relatively low. Conclusion: Community-based interventions on acne are needed to increase the awareness and to improve the perception and belief of acne patients. Further studies are needed to evaluate the effects and side effects of different complementary medicine and over-the-counter modalities.
Keywords: Acne, acne vulgaris, review, Saudi Arabia
|How to cite this article:|
Alanazi AZ. Acne vulgaris in Saudi Arabia: A systematic review. J Dermatol Dermatol Surg 2020;24:13-7
| Introduction|| |
Acne vulgaris (AV) is one of the most common dermatological disorders. AV is a chronic inflammatory skin disease characterized by the inflammation of the pilosebaceous unit. Around 90% of adolescent have AV, and symptoms of acne continue to appear in half of them in there adulthood. Genetic and environmental factors play an important role in the pathogenesis of acne. Depression is more predominant in patients with acne than in patients without and can have a negative influence on their self-confidence, mood, and quality of life (QOL).
However, data of AV in Saudi Arabia are not well documented. These data are significant in relation to planning control interventions on the disease. Thus, the purpose of this review is to examine the available studies and data on AV in Saudi Arabia and determine the prevalence, potential risk factors, psychological impact, and treatment modality of AV and to highlight the gaps in the knowledge of different aspects of this disease.
| Methods|| |
A systematic review of the included articles was done for the present study.
The literature search was conducted from May 13, 2019, to May 16, 2019. The research was performed using the keywords “acne vulgaris,” “Saudi Arabia,” and “KSA” in four electronic databases: PubMed, Google Scholar, Web of Science, and Embase. The search was restricted by the locational filter of Saudi Arabia and a timeframe of 2010–2019 [Appendix 1].
- English language literature
- Studies that reported on or were conducted in Saudi Arabia during the past 10 years.
- Studies without clear description of AV
- Studies conducted in the areas neighboring Saudi Arabia.
Data collection and analysis
The literature selection was based on abstracts and titles of research articles.
The following data from each article were checked and recorded:
- Prevalence of AV
- Level of knowledge, attitude, and practices (KAP)
- Risk factors
- Psychological impact
- Treatment modality.
The search resulted in 453 potentially relevant titles and abstracts being identified, of which 18 met the inclusion criteria. These studies assessed different aspects of AV in Saudi Arabia, including prevalence, risk factors, psychological impact, treatment, and the knowledge and awareness of the public.
The prevalence of acne vulgaris in Saudi Arabia
The current review confirms that the prevalence of AV is high among the Saudi population.
Five of the articles reviewed the prevalence of AV in Saudi Arabia. The findings from national studies indicated that the mean AV prevalence was 54% among males and that the prevalence ranged from 54% to 84% among females.,, Regarding regional variations, one article, involving medical students, observed that Jeddah had the highest prevalence of AV compared to others. Another national study conducted on female Saudis between the ages of 14 and 21 years indicated that AV prevalence was lowest in the southern region of Saudi Arabia.
Level of knowledge, attitude, and practices
Five studies reporting KAP of AV among the Saudi population used questionnaires that were used in previous publications, and,,, only one study uses a pilot study to ensure the reliability and validity of the questionnaire. The mean number of participants in the five studies was 383.8. The level of KAP was generally low.,,,
Risk factors of acne vulgaris
The present review shows the most important risk factors for AV among the Saudi population. The most important factors are stress, oxidants and antioxidants, milk and dairy product consumption, hygiene, and menstrual periods.,,,,,
Psychological impact of acne vulgaris
It is very noticeable from the finding of this review that as the severity of acne increases, the psychological effect of it increases.,,
Treatment of acne vulgaris
Three of the articles discussed three different treatment modalities of AV which are:
- Complementary medicine (CAM)
- Over-the-counter (OTC)
The present review found that the most common type of CAM used was honey and the most common OTC medications used were cleansers.
| Discussion|| |
Based on the number of published articles in this systematic review, AV research in Saudi Arabia has grown substantially over the past decade.
The characteristics of acne
All the included articles in the present study used the Global Acne Grading System (GAGS) to classify acne. The most common form was mild.,,, The most common location of acne on the body was multiple locations,, followed by on the face only., Regarding the presence of scarring and postinflammatory hyperpigmentation (PIH), one study found that 60.9% of participants had scarring and 72.8% had PIH, whereas other studies found that 8.7% had scarring and 11.6% had PIH. Factors that contribute in the variations in the presence of PIH and scarring include differences in age group, puberty (beginning of menstruation), genetic variation, skin type, use of cosmetics, environmental factors, and mode of diagnosis of acne (self-reporting and diagnosis by general clinicians or by dermatologists).
Level of knowledge, attitude, and practices
The present review found that the level of KAP was generally low.,,, Only one study reported good KAP. This study was the only study that investigated the knowledge between acne patients attending the dermatology clinics, and this indicates the importance of establishing a good doctor–patient relationship which enhances knowledge of AV patients about their disease.
All the studies in the present review used questionnaires, which included questions on the participants' knowledge about acne and the factors influencing the disease.
The main source of participants' knowledge about acne was the Internet (65.6%), followed by doctors and other medical staff (62.4%) and TV and radio (47.7%).,,,
Perceptions about the causes of acne
The majority of the Saudi population believes that the most important cause of AV is hormonal disturbances, followed by diet.,,
Perceptions about exacerbating factors
Stress was thought to make acne worse in 58.4% of participants. The most known and cited exacerbating factors in most of the studies, in descending order, included the scratching (88.5%) and squeezing of pimples (82.1%) and eating chocolate (56.2%), whereas the most ameliorating factors were regular face washing with cleansers and drinking mineral water.,,
Perceptions and attitudes about acne care and treatment
The findings of this review showed that the majority of the Saudi population believes that acne is a curable disease,, and some of them consider acne a transient disorder that does not need management and improves spontaneously., Some participants believe that acne requires short-term management and needs only one or a few visits to the doctor. Another study found that 61.3% of participants agreed that some acne medications initially might make acne worse. However, 61.9% assumed that treating acne would prevent scarring. Picking or squeezing acne was thought to improve acne by 11.1% of participants, whereas 76.8% did not think so.
Perceptions about the psychological impact of acne
As with any physically disfiguring skin condition, acne causes a harmful impact on body image and self-esteem. This may cause depression, low self-confidence, and difficulty in social relationships. Some individuals thought that having acne affected their marriage.,, A cross-sectional self-administered questionnaire study was conducted on acne patients in Jeddah (311 responses) reported that 17% of them had suicidal attempts due to psychological impact of AV.
Factors that influence acne vulgaris
Understanding the risk factors behind AV is very important for applying effective intervention plans for the prevention of AV in Saudi society. The main risk factors discussed in the included articles were stress, oxidants and antioxidants, milk and dairy product consumption, hygiene, and menstrual periods.,,,,,
Antioxidants whose plasma activity was found to positively correlate with AV were superoxide dismutase, catalase, and malondialdehyde.
A case–control study using interview questionnaire conducted at the dermatology clinics at King Fahd Hospital of the University in Al-Khobar, Saudi Arabia, found that the consumption of French fries and butter increased the risk for acne, and a statistically significant difference was found between the severity of acne and the consumption of milk (P = 0.033). This is due to comedogenic effects of milk. The consumption of milk increases the level of insulin-like growth factor-1 (IGF-1) and therefore increases comedogenesis, sebaceous lipogenesis, follicular inflammation, and androgenic stimulation. Moreover, IGF-1 stimulates the production of androgens. Both IGF-1 and androgens promote sebum production, which is one of the pathogenic factors of acne formation.
Combination skin, family history of acne (74.6%), drinking one to four cups per day, and bad hygiene associate with AV., Furthermore, an increase in stress was strongly correlated with an increase in acne severity.,
Meanwhile, the factors that were believed to be negatively associated with acne were the levels of lipid peroxidation. There were no statistically significant differences (P < 0.05) found between the severity of acne and any dietary factors, including chocolate milk, ice cream, yogurt, halloumi cheese, cream cheese, hard cheese, milkshakes, butter, any other type of milk, French fries, pizza, chocolate, rice, or white bread.
Psychological impact of acne vulgaris
As the severity of acne increases, the psychological effect of it increases.
Three different methods were used to estimate the psychological impact of acne:
- The Cardiff Acne Disability Index (CADI) (Motley and Finlay, 1992) is a short, five-item questionnaire derived from the longer Acne Disability Index, which is designed to evaluate disability caused by acne.
- The Dermatology Life Quality Index is a ten-question questionnaire used to measure the impact of a skin disease on the QOL of an affected person. It was originally developed and published in a dermatology clinic at the University Hospital of Wales.
- The Hospital Anxiety and Depression Scale is a self-screening tool for anxiety and depression which has demonstrated good validity and reliability when used in different languages. It includes 14 questions: seven for each of anxiety and depression.
The psychological impact significantly increased with increased severity, the presence of PIH, scarring, and acne in multiple locations on the body. Furthermore, embarrassment and sexual difficulties were reported.,
Regarding the CADI, one study found that there was no correlation between the CADI score and the GAGS severity. Another study found that the highest number of recorded cases were medium grade (45.6%), followed by high grade (42.5), and the least were low grade (11.9%).
Anxiety and depression affected most of the QOL domains of the patients who had acne. Highly statistically significant associations were found between the presence of morbid depression and each of self-perception, social role, and emotional role QOL domains.
Treatment of acne vulgaris
Out of the 18 studies included in this review, three studies discussed the treatment modality of AV, such as CAM, drug therapies, and OTC, and prescription medications.
A national study conducted during an acne awareness campaign to assess the usage of CAM found that 77% of AV patients were using CAM. Interestingly, in the same study, Saudi females over 34 years old were using CAM at a much higher rate comparing to males in the same age group.
The most common type of CAM used was honey, followed by yogurt, and the least common type of CAM used was cinnamon.
About 52.4% of AV patients used some form of self-medication or OTC medication at least once. The most common OTC medications used were cleansers. One of the important reasons for this was most of the patients believed that OTC medication was effective and safe.
In Western Saudi Arabia, the Dermatology Department in the Faculty of Medicine at King Abdulaziz University evaluated dermatologists' attitudes and practices regarding isotretinoin in the Western area of Saudi Arabia. The majority of dermatologists used isotretinoin to treat severe nodular acne with 0.5 mg per kg for 3–6 months.
Regarding follow-up, the majority of dermatologists tested for liver enzymes and lipid profile before starting therapy. If there were mild elevations in cholesterol or triglycerides, half of the dermatologists advised patients about their diets and repeated laboratory tests after 1 month.
Regarding laser resurfacing, most dermatologists would wait for 1–2 months, and generally, none thought that laser hair removal should be delayed more than 1–2 months posttreatment.
| Summary and Conclusion|| |
AV is becoming prevalent among the Saudi population, particularly among Saudi women. In addition, the knowledge and awareness of the public is relatively low, which negatively affects the prognosis and treatment outcomes. Furthermore, data from this review suggest that isotretinoin is an accepted therapy for AV.
- Community-based health awareness programs on acne are needed to increase the awareness and to improve perception and belief of acne patients
- More studies are needed to evaluate the effects and side effects of different CAM and OTC modalities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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