|Year : 2017 | Volume
| Issue : 3 | Page : 196-201
Epidemiological patterns of acne vulgaris among adolescents in North India: A cross-sectional study and brief review of literature
Reena Kumari Sharma1, Sunil Dogra1, Amarjeet Singh2, Amrinder J Kanwar1
1 Departments of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Community Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||7-Jun-2017|
Reena Kumari Sharma
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Background: Acne is a common skin disorder that affects both adolescents and adults. Epidemiological data on acne are limited from developing countries.
Objective: The objective of this study is to estimate the prevalence and pattern of acne vulgaris among adolescent students of Chandigarh (India), and to study the impact of acne on quality of life.
Materials and Methods: Children from three schools were enrolled to investigate the demographic profile, severity and causative factors of acne and its impact on quality of life using a predesigned questionnaire and followed by examination for presence, site and severity of acne.
Results: Acne was present in 72.3% of 1032 children included in this study. Mild acne was present in 81.9% students, moderate in 17.1%, and severe in 0.9%. There was a significant association of acne with stress (P = 0.001) and premenstrual flare (P = 0.000). No association was found between acne and diet, hygiene, weather, family history, and smoking. The quality of life was affected in 29% of children and was directly related to the severity of acne (P = 0.000). No difference of impact on quality of life was seen between boys and girls.
Conclusions: This study presents the demographic features and clinical characteristics of acne in school children. This large-scale analysis reveals that acne is a very common dermatosis among Indian school children having a significant impact on their quality of life.
Keywords: Acne, adolescents, epidemiology
|How to cite this article:|
Sharma RK, Dogra S, Singh A, Kanwar AJ. Epidemiological patterns of acne vulgaris among adolescents in North India: A cross-sectional study and brief review of literature. Indian J Paediatr Dermatol 2017;18:196-201
|How to cite this URL:|
Sharma RK, Dogra S, Singh A, Kanwar AJ. Epidemiological patterns of acne vulgaris among adolescents in North India: A cross-sectional study and brief review of literature. Indian J Paediatr Dermatol [serial online] 2017 [cited 2018 Feb 25];18:196-201. Available from: http://www.ijpd.in/text.asp?2017/18/3/196/206086
| Introduction|| |
Acne vulgaris (acne) is one of the most common dermatoses seen in clinical practice. It commonly affects adolescents and young adults and is characterized by open and closed comedones, erythematous papules and pustules, and in severe cases nodules, deep pustules, and pseudocysts. Data from population-based epidemiologic studies of acne are important in quantifying social burden, distribution of the disease in the community and its social and psychological impact, particularly in adolescent age group. Despite these facts, data based on community-based samples, including an actual dermatological examination of acne patients are lacking from India. This study reports the prevalence and severity of acne in adolescent school children of North India. We also studied the risk factors associated with acne and the impact it has on quality of life of children.
| Materials and Methods|| |
The study was conducted in union territory of Chandigarh, India (30.75° N, 76.78° E) from August 2011 to July 2013. Chandigarh city has a population of about 12 lakh and has people of all socioeconomic strata. This city of North India has extremes of temperature (−1°C–46°C), hot summers, and chilly winters. Three schools: government model high school (School A), government high school (School B), and public DAV school (School C) were randomly selected from the list of schools of Chandigarh. This was done to ensure proper socioeconomic representation of study population. All students (boys and girls) of Classes VIII–X of the selected schools (Class VII and IX were also included in schools where number of students were less to attain desired sample size), with or without acne, constituted the study population. Only excluded were the students who were absent on the day of examination. The study was approved by the Ethical Committee of the Institution.
The permission of director of public instruction, Chandigarh, was sought for conducting the study in three schools of Chandigarh. The diagnosis of acne was clinical, and no laboratory investigation was performed to corroborate the diagnosis. Students were examined for the presence of acne, site and severity, and lesions present were graded as mild, moderate, and severe according to the classification of the American Academy of Dermatology.
- Mild acne: Characterized by the presence of a few papules and pustules mixed with comedones, but no nodules
- Moderate acne: Characterized by the presence of many papules and pustules, together with a few nodules
- Severe acne: Characterized by the presence of numerous or extensive papules and pustules as well as many nodules. Moreover, the clinical diagnosis of severe acne was based on the presence of any of the following criteria:
- Persistent or recurrent inflammatory nodules
- Extensive papulopustular lesions
- Ongoing scarring
- Persistent purulent and/or serosanguinous discharge
- Sinus tracks.
Other parameters evaluated were age (11–19 years), gender, age of onset (<10 years/10–14 years/>14 years), duration of lesion (<1 month, <6 months or >6 months), site of lesion (face/back/arms/chest alone or more than one site), relation with menstrual cycle in girls (flare of acne 7–10 days before menstruation), effect of diet (high glycemic/high fatty diet), stress (sleeping <8 h/study pressure/examination related stress/any anxiety disorder/other stress), hygiene (good/poor hygiene depending upon – (a) frequency of face cleaning per day, (b) use of face cleaning products, and (c) frequency of hair cleaning per week), previous drug intake (for the last 1 month or more, which would have been related to occurrence of acne), effect of weather (exacerbation during summer/winter/or rainy season), and family history (correlated by the presence of acne in siblings, persistence of acne in parents or postacne scarring in parents).
Impact on quality of life was assessed on the basis of Children's Dermatology Life Quality Index (CDLQI) questionnaire. Score of CDLQI was calculated and result reported as:
The severity banding for CDLQI scores:
- 0–1 = no effect on child's life
- 2–6 = small effect
- 7–12 = moderate effect
- 13–30 = extremely large effect.
The statistical analysis was carried out using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA, version 15.0 for Windows). All quantitative variables, for example, age, total duration, and no of lesions were estimated using measures of central location mean, median, and measures of dispersion-standard deviation and standard error. The prevalence of acne vulgaris was calculated as percentage. Qualitative or categorical variables were described as frequencies and proportions. Proportions were compared using Chi-square or Fisher's exact test or whichever is applicable. The mean and standard deviation were used to see the impact on quality of life of students. Impact on quality of life of boys and girls was compared by applying Student's t-test. All statistical tests were two-sided and were performed at a significance level of α = 0.05.
| Results|| |
A total of 1032 students were included in the study, 300 (29.1%) from School A, 426 (41.3%) from School B, and 306 (29.7%) from School C. Boys (602) to girls (430) ratio were 1.4:1. Sixteen percent (169) of students were in the age group of 11–13 years, 69.2% (714) in 14–16 years, and 14.4% (149) in 17–19 years age group. Mean age of the study population was 14.8 ± 1.4 years (11–19 years).
The overall prevalence of acne was 72.3%; 74.6% in School A, 76.0% in School B, and 65.03% in School C. The prevalence in boys was slightly more (73.2%) as compared to girls (71.1%). Acne was more prevalent in 14–16 years age group; 74.3% (531/714) students in this age group had acne (P = 0.01). There was younger age of onset of acne in girls in comparison to boys; 19.2% (59/306) in girls and 10.6% (47/441) in boys in 11–13 years age group [Table 1]. The initial site of onset was face in 62.7% (469) cases. Sites of distribution were face, which was most commonly involved in 71.4% (737), followed by back in 4.6% (47) and arms and chest in <1% cases.
Acne was mild in most of the students (81.9%), followed by moderate and severe acne [Table 2]. Almost all the lesions were in the form of papules (99.6% (744)), followed by pustules (12% (91)), nodules (9.5% (71)), and cysts (0.5% ). We also noted various types of comedones; closed comedones, open comedones, sandpaper comedones, and submarine comedones along with papules, pustules, and nodules. Acne excoriée and postacne scarring were also noted.
There was a significant relation between acne and stress (P = 0.001). There was flare of acne lesion before menstruation in 21.1% girls (P = 0.000). No significant association of acne with hygiene or diet was established. Only 7 students gave a history of smoking, out of which 5 were having acne vulgaris. No relation was noted between acne and any long-term drug intake. Summer exacerbation was noted in 19% (143) students while 9% (67) students had winter exacerbation. Acne was present in siblings in 12.5% (94) students. Twenty-nine percent (219) students had some impact of acne on their quality of life and were proportional to their severity of acne (P = 0.000) [Figure 1]. No association was present between gender and impact on quality of life.
|Figure 1: Impact of acne on quality of life (Children's Dermatology Life Quality Index)|
Click here to view
| Discussion|| |
For a country with a billion plus population, with an estimated 200–300 million acne sufferers, there are no community-based epidemiological studies on acne from India. In a previous community-based epidemiological study of skin diseases in children (6–14 years), the point prevalence of acne was found to be 0.93%. There are few hospital-based studies which show the prevalence of acne in children in India, but in our study; we, for the first time, studied the epidemiological features of acne in a community setting and our data confirmed that acne is a very common disorder among adolescents in Indian population. To date, few similar epidemiological studies have been reported in the literature [Table 3].,,,,,,,,,,
|Table 3: Prevalence of acne vulgaris in adolescent age; review of community-based large studies worldwide|
Click here to view
According to a population-based study by Kilkenny et al. (Australia), the overall prevalence rate of acne was 36.1%, ranging from 27.7% in 10–12-year-old to 93.3% in 16–18-year-old. Yahya  in Nigeria studied 539 students aged 11–19 years with mean age 16 years, and the prevalence of acne was reported to be 90.7%. No significant gender difference was noted. Prevalence increased with age (76.7% at age 10–13 years, 88.2% at 14–16 years, and 97.1% at 17–19 years). Mild acne was present in 93.1% students while 6.9% had moderate to severe acne. In another study from Japan by Kubota et al., the prevalence of acne was 55.5% in junior high school students (aged 13–15 years) and 62.7% in senior high school students (aged 16–19 years). The prevalence of acne in different studies varies partly depending on the method of classification used. In the present study, we surveyed and examined for morphology of lesions using the classification of the American Academy of Dermatology. The prevalence of acne in our study was 72.3%, commonly affecting the age group of 14–16 years and acne prevalence did not increase with increasing age. The size of the problem is also influenced by patients' beliefs and perception. In a study by Rademaker et al., 12% of teenage boys denied the presence of clinical acne. In our study also 157 (21.0%) students with mild acne were unaware of the presence of acne.
Acne occurs most commonly on the face (99%) and to a lesser extent on the back (60%) and chest (15%). In a study by Adityan and Thappa  (India) involving 309 patients with acne vulgaris, face was involved in all patients, followed by back, chest, neck, and arms. In our study, face was most commonly involved (98.6%), followed by back (4.6%) arms and chest in <1% cases.
It is a common perception that diet is strongly associated with the development of acne and its exacerbation. Diet in the Western civilization has a high glycemic index which can lead to hyperinsulinemia. Cordain et al. stated that hyperinsulinemia results in a cascade of endocrine triggers, including increased insulin-like growth factor-1, altered retinoid signaling, and increased androgens, thereby mediating acne pathogenesis. Milk consumption is also associated with increased acne risk by increased insulin-like growth factor-1 (IGF-1) production, which has been associated with ovarian androgen production in premenarchal girls and acne in adult women. In recent observational studies, skimmed milk was consistently associated with acne, suggesting that the fat content of milk does not appear to affect its acne-causing ability. Some authors have reported that the hormones in milk, such as IGF-1, 5α-reduced steroids, and α-lactalbumin, may survive milk processing and affect the pilosebaceous unit. In this study, we studied relation of acne vulgaris to dietary factors such as food with high fat and high glycemic index. Only 53% of students could specify their dietary pattern regarding high fat and high glycemic diet, and no significant association was found between acne and diet in this study.
We also tried to study the influence of hygiene to acne vulgaris; it was found that most of the students were maintaining good or average hygiene. It was difficult to establish any relation of hygiene to acne vulgaris, as information about hygiene status was subjective and not reliable, as nobody would be comfortable to reveal poor status of hygiene.
Some studies have shown smoking to aggravate acne by increasing insulin/IGF-1 signaling. In the present study, the number of students with a history of smoking were very less, not sufficient to show any significant relation with severity of acne, and further requires a study having significant number of smokers and controls in relation to acne vulgaris for establishing a statistically significant relation.
Khunger and Kumar  suggested chronic stress as a cause of increased androgen secretion, increased sebum production, and reducing the immune status. Increased stress during examination causes exacerbation of acne severity in a predictable manner. Although other changes occur in a student's life during examination period, i.e., changes in diet and sleep habits that can affect the acne severity. In our study, we found a significant association between acne and stress (P = 0.001).
Female students reported premenstrual flare of their acne in 21.1% cases which were statistically significant. Williams and Cunliffe  in 1973 stated that acne worsens premenstrually in 60%–70% of females. Although they hypothesized about changes of surface lipid composition in the premenstrual phase, changes in hydration or the molecular structure of keratins or prostaglandin effects through its vasoactive properties, the exact hormonal cause for this flare is still to be elucidated. We did not find a significant relation between acne and weather change, medicine intake, and family history. Further large-scale studies need to be done with controls to establish any relation between acne and these factors.
Several studies have demonstrated increased levels of anxiety and anger in acne patients compared with controls, whereas others have demonstrated impaired self-image in acne sufferers. The degree of anxiety and extent of self-image impairment is directly related to acne severity. More than a cosmetic nuisance, acne affects every aspect of one's life: social, vocational, and academic. Patients with severe acne have, on average, worse academic functioning, and higher unemployment rates compared to those without acne. The quality of life worsens with the severity of acne and also based on the individual's perception. The impact of acne on quality of life is more common among young adults due to the social and occupational functioning and worsens as age advances. In our study, 219 (29%) students had some impact of acne on the quality of life and impact increased with the severity of acne, but there was no difference of impact of acne between boys and girls and were equally concerned about acne.
| Conclusions|| |
This large-scale analysis presents the demographic features, prevalence, pattern, and effect on quality of life of acne among adolescent school children. Acne was found to be a common dermatosis in Indian school children with overall prevalence of 72.3% and having significant impact on their quality of life. Further interventional studies focusing on education and timely treatment should be planned for minimizing psychological morbidity due to acne and its sequelae in this age group.
There are no conflicts of interest.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Cunliffe WJ, Gollnick H. Acne: Pathophysiology – Clinic – Diagnosis and Therapy. London: Martin Dunitz; 2004. p. 2-47.
Pochi PE, Shalita AR, Strauss JS, Webster SB, Cunliffe WJ, Katz HI, et al.
Report of the consensus conference on acne classification. Washington, D.C., March 24 and 25, 1990. J Am Acad Dermatol 1991;24:495-500.
Lewis-Jones MS, Finlay AY. The Children's Dermatology Life Quality Index (CDLQI): Initial validation and practical use. Br J Dermatol 1995;132:942-9.
Kubba R, Bajaj AK, Thappa DM, Sharma R, Vedamurthy M, Dhar S, et al.
Acne in India: Guidelines for management – IAA consensus document. Indian J Dermatol Venereol Leprol 2009;75 Suppl 1:1-62.
Dogra S, Kumar B. Epidemiology of skin diseases in school children: A study from Northern India. Pediatr Dermatol 2003;20:470-3.
Lello J, Pearl A, Arroll B, Yallop J, Birchall NM. Prevalence of acne vulgaris in Auckland senior high school students. N Z Med J 1995;108:287-9.
Kilkenny M, Merlin K, Plunkett A, Marks R. The prevalence of common skin conditions in Australian school students: 3. acne vulgaris. Br J Dermatol 1998;139:840-5.
Hogewoning AA, Koelemij I, Amoah AS, Bouwes Bavinck JN, Aryeetey Y, Hartgers F, et al.
Prevalence and risk factors of inflammatory acne vulgaris in rural and urban Ghanaian schoolchildren. Br J Dermatol 2009;161:475-7.
Yahya H. Acne vulgaris in Nigerian adolescents – Prevalence, severity, beliefs, perceptions, and practices. Int J Dermatol 2009;48:498-505.
Ghodsi SZ, Orawa H, Zouboulis CC. Prevalence, severity, and severity risk factors of acne in high school pupils: A community-based study. J Invest Dermatol 2009;129:2136-41.
Wei B, Pang Y, Zhu H, Qu L, Xiao T, Wei HC, et al.
The epidemiology of adolescent acne in North East China. J Eur Acad Dermatol Venereol 2010;24:953-7.
Kubota Y, Shirahige Y, Nakai K, Katsuura J, Moriue T, Yoneda K. Community-based epidemiological study of psychosocial effects of acne in Japanese adolescents. J Dermatol 2010;37:617-22.
Law MP, Chuh AA, Lee A, Molinari N. Acne prevalence and beyond: Acne disability and its predictive factors among Chinese late adolescents in Hong Kong. Clin Exp Dermatol 2010;35:16-21.
Karciauskiene J, Valiukeviciene S, Gollnick H, Stang A. The prevalence and risk factors of adolescent acne among schoolchildren in Lithuania: A cross-sectional study. J Eur Acad Dermatol Venereol 2014;28:733-40.
Bagatin E, Timpano DL, Guadanhim LR, Nogueira VM, Terzian LR, Steiner D, et al.
Acne vulgaris: Prevalence and clinical forms in adolescents from São Paulo, Brazil. An Bras Dermatol 2014;89:428-35.
Park SY, Kwon HH, Min S, Yoon JY, Suh DH. Epidemiology and risk factors of childhood acne in Korea: A cross-sectional community based study. Clin Exp Dermatol 2015;40:844-50.
Rademaker M, Garioch JJ, Simpson NB. Acne in schoolchildren: No longer a concern for dermatologists. BMJ 1989;298:1217-9.
Adityan B, Thappa DM. Profile of acne vulgaris – A hospital-based study from South India. Indian J Dermatol Venereol Leprol 2009;75:272-8.
] [Full text]
Cordain L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller J. Acne vulgaris: A disease of Western civilization. Arch Dermatol 2002;138:1584-90.
Spencer EH, Ferdowsian HR, Barnard ND. Diet and acne: A review of the evidence. Int J Dermatol 2009;48:339-47.
Melnik BC, Schmitz G. Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Exp Dermatol 2009;18:833-41.
Khunger N, Kumar C. A clinico-epidemiological study of adult acne: Is it different from adolescent acne? Indian J Dermatol Venereol Leprol 2012;78:335-41. [Full text]
Chiu A, Chon SY, Kimball AB. The response of skin disease to stress: Changes in the severity of acne vulgaris as affected by examination stress. Arch Dermatol 2003;139:897-900.
Williams M, Cunliffe WJ. Explanation for premenstrual acne. Lancet 1973;2:1055-7.
Uhlenhake E, Yentzer BA, Feldman SR. Acne vulgaris and depression: A retrospective examination. J Cosmet Dermatol 2010;9:59-63.
Durai PC, Nair DG. Acne vulgaris and quality of life among young adults in South India. Indian J Dermatol 2015;60:33-40.
] [Full text]
[Table 1], [Table 2], [Table 3]