The effect of face washing frequency on acne vulgaris patients

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Journal of General - Procedural Dermatology & Venereology Journal of General - Procedural Dermatology & Venereology Indonesia

Indonesia

Volume 3

Number 2 June Edition Article 7

6-30-2019

The effect of face washing frequency on acne vulgaris patients The effect of face washing frequency on acne vulgaris patients

Rini Hastuti

Department of Dermatovenerology, Medical Faculty of Sebelas Maret University, Dr. Moewardi General Hospital, Surakarta, Indonesia

Etty Farida Mustifah

Imroatul Ulya

Muhammad Risman

Prasetyadi Mawardi

Follow this and additional works at: https://scholarhub.ui.ac.id/jdvi

Part of the Dermatology Commons, Integumentary System Commons, and the Skin and Connective Tissue Diseases Commons

Recommended Citation Recommended Citation

Hastuti, Rini; Mustifah, Etty Farida; Ulya, Imroatul; Risman, Muhammad; and Mawardi, Prasetyadi (2019)

"The effect of face washing frequency on acne vulgaris patients," Journal of General - Procedural Dermatology & Venereology Indonesia: Vol. 3: No. 2, Article 7.

DOI: 10.19100/jdvi.v3i2.105

Available at: https://scholarhub.ui.ac.id/jdvi/vol3/iss2/7

This Article is brought to you for free and open access by UI Scholars Hub. It has been accepted for inclusion in Journal of General - Procedural Dermatology & Venereology Indonesia by an authorized editor of UI Scholars Hub.

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Original Article

The effect of face washing frequency on acne vulgaris patients

Rini Hastuti, Etty Farida Mustifah, Imroatul Ulya, Muhammad Risman, Prasetyadi Mawardi

Email: rinihastuti1402@gmail.com

Abstract

Background: Patients with acne often wash their faces twice a day, but there are not many studies supporting this practice.

Methods: A single-blind randomized clinical trial was conducted in 38 subjects, divided into three groups based on face washing frequency (once, twice, and thrice a day). All groups used the same cleanser. The acne vulgaris severity and the number of lesions were assessed prior to study. After eight weeks, we re- assessed the acne severity, the number of lesions, the adverse event and patient’s self-evaluation. SPSS 17 was used to analyze the face washing frequency and the number of acne lesions.

Results: Reduction in the average number of acne lesions was found in once and twice face washing groups, while the thrice group had increased number of acne lesions. The frequency of face washing with the number of lesions provided significant result in group 1, but it only reduced the number of comedones (p value = 0.041).

Conclusion: Acne patients with only comedones lesions can be advised to wash their faces once a day.

Keywords: acne vulgaris, face washing, frequency

Background

Acne vulgaris (AV) is a chronic inflammatory disease of the pilosebaceous follicles, that is characterized by comedones, papules, pustules, cysts, nodules, and occasionally scars.¹ The prevalence is high in adolescents and it mostly affects the face in (99%) of patients and less frequently the trunk, back (60%), chest (15%), shoulders and buttocks.^2,3

The etiologic factors of acne are increased sebum production, hypercornification of pilosebaceous ducts, colonization of skin micro flora and inflammation.⁴ Several factors known to be implicated in AV include stress, menstrual period facial hygiene, and foods, such as fatty food, sweets and spices,^5,6

Diagnosis of AV is established by physical examination. The medical personnel need to assess the severity of acne.⁷ Several rating scales have been developed with the aim of trying to grade the severity of the individual`s condition. No method has yet gained universal acceptance and

most literatures simply grade the severity of acne as mild, moderate, and severe.⁸

The primary goals of acne therapy are to achieve initial control, maintain therapy to prevent flares, and prevent persistent or permanent sequelae such as scarring. An important aspect of AV management that is often forgotten by physicians is to dispel any myths and misperceptions that the patients may have about the cause of their AV.⁹ A survey of patient’s perception of AV showed that they thought that acne was caused by poor skin hygiene.¹⁰

In order to prepare the skin to receive topical medications and to improve drug absorption, the regular using of mild cleanser is an important component in effective acne management.

Routine cleansing not only increases the antimicrobial activity, but it also decreases the risk of infection, removes excess sebum, and prevents hair follicular obstruction.^11,12

Patients with acne often mistakenly believe that aggressive scrubbing of their skin with soap and water several times a day can reduce the oiliness

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J Gen Proced Dermatol Venereol Indones. 2019:3(2);35-40. 36 of their skin.¹³ The doctors usually give

recommendation to wash the face twice daily with a mild cleanser, even though, there is not much published literature to support this practice.¹⁴

This study was conducted to determine the effect of face washing frequency on acne vulgaris, so that we could provide the right education to the patients about the optimal face washing frequency to reduce the prevalence of acne.

Methods

This research is a single blind, randomized, and clinical trial study, conducted during the period of November 20, 2016 until January 15, 2017 at Al Muayyad Boarding School Surakarta. A total of sixty subjects were recorded to participate in the beginning of the study. The inclusion criteria are as followed: male, aged 12-18 years old, willing to not use other cleansing products and acne treatments during the study, classified into mild and moderate acne criteria according to Global Acne Grading System (GAGS), and willing to sign an informed consent. The criteria of mild and moderate acne were based on the GAGS scoring system, in which its system can be assessed quickly and easily (Figure 1 and Table 1).

Subsequently, subjects were divided into three groups, each consisted of twenty subjects, in which group 1, group 2 and group 3 washed the face with a cleansing soap for once a day, twice a day, and thrice a day, in orderly manner.

Prior to the study, an assessment of the degree of acne severity by using GAGS and by counting the

number of lesions including blackheads, papules, pustules, and nodules was conducted. This grading system considers six locations on the face and chest/upper back (Figure 1), with a factor for each location based roughly on surface area, distribution, and density of pilosebaceous units.

Each location is graded separately on a 0 to 4 scale, with the most severe lesion on the location determines the local score. The global score is a summation of all local scores. (Table 1).¹⁵

All subjects were given the same cleanser. It is a cleansing soap with no antiseptic nor anti- bacterial content, namely Primaderma® Normal Skin Face Wash with composition of aqua, sodium laureate sulfate, cocamidopropyl betaine, cocamide DEA, decyl glucoside, PEG-150 distearate, PEG-12 dimethicone, sodium PCA, phenoxyethanol, tetrasodium EDTA, methylparaben, citric acid, perfume, butylparaben, ethylparaben and propylparaben. There was no wash out period before the study began.

At the end of the study, at week 8, re-assessment of the severity of acne, lesion count, side effects (e.g. red, scaly, dry, stinging, hot, or itchy) and patient’s self-evaluation with history taking by asking the subjects if there was a change in the number of acne lesions (improvement, no improvement, or worsen).

Statistical analysis was performed to determine the relationship between face washing frequency and number of acne vulgaris lesions using SPSS with T-test and Anova test (significance level p

<0,05).

Figure 1. Six Locations in Global Acne Grading System (GAGS)¹⁵

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Table 1. The Global Acne Grading System (GAGS)¹⁵

Location Factor x Grading (0-4)* = Local Score

I. Forehead 2

II. Right Cheek 2

III. Left Cheek 2

IV. Nose 1

V. Chin 1

VI. Chest and upper trunk 3

*Grading: 0 = No lesion; 1 = Comedones; 2 = Papules; 3 = Pustules; 4 = Nodules

GAGS Score: 0 = Zero; 1-18 = Mild; 19-30 = Moderate; 31-38 = Severe; >39 = Very Severe

Results

Initially, sixty subjects were divided into three groups and each group consisted of twenty people. After 8 weeks, subjects who discontinued research protocol were excluded from the study (drop-out subjects), Meanwhile, the subjects who did not follow the procedure properly were moved to another suitable group. Thus, the number of subjects for group 1 was nine people, group 2 was nineteen people and group 3 was ten people (Figure 2). The average age of subjects in group 1 was 16 years old, group 2 was 15.4 years old, and group 3 was 13.9 years old

The degree of severity of subject’s acne based on GAGS before and after the study is shown in Table 2. After 8 weeks of study, group 1 and 2 had more subjects with mild acne severity and decreased number of subjects with moderate

acne severity. While group 3 showed there was a decrease in the number of subjects with mild acne severity. On the other hand, there were more subjects with moderate acne severity.

The average number of comedones, papules, pustules, and nodules lesions before and after the study is shown in Table 3. On group 1, there was a significant reduction in the number of comedones with p value = 0.041, meanwhile the other groups did not give significant result.

Table 4 shows the results of the assessment of adverse event, in which most subjects felt no complaints. Table 5 shows the self-evaluation assessment in which most subjects felt no change in the number of acne lesions either before or after the study.

Figure 2. Study Flow Chart

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J Gen Proced Dermatol Venereol Indones. 2019:3(2);35-40. 38 Table 2. Severity of Acne According to Global Acne Grading System (GAGS) in Each Group Before and After Treatment

Treatment Group Before After

Mild Moderate Mild Moderate

Group 1 (once daily) 8 1 9 -

Group 2 (twice daily) 15 4 17 2

Group 3 (thrice daily) 10 - 9 1

Table 3. Frequency of Face Washing and Average Number of Acne Lesions Before and After the Treatment

Comedones Papules Pustules Nodules

Before After Before After Before After Before After

Group 1 (once daily) 18.2 13 6.4 4.7 0.7 0.1 0.5 0

Group 2 (twice daily) 21.3 20.1 5.7 6.7 0.7 0.3 0.3 0.2

Group 3 (thrice daily) 13.3 18.4 2.7 4.6 - 0.5 0.1 0

Table 4. Adverse Event in Each Treatment Group

Itchy Dryness Scaly No Complaint

Group 1 (once daily) 3 - - 6

Group 2 (twice daily) 2 4 4 10

Group 3 (thrice daily) 4 - - 6

Total 9 4 4 22

Table 5. Self-evaluation According to Change in the Number of Acne Lesion in Each Treatment Group

Improvement No Improvement Worsen

Group 1 (once daily) 3 5 1

Group 2 (twice daily) 8 9 2

Group 3 (thrice daily) 3 5 3

Total 14 19 6

Discussion

AV is a multifactorial disorder of the pilosebaceous unit.¹⁶It is a common skin disease especially in adolescents and young adults.⁵ The prevalence of acne among adolescent was 82,9%,¹⁷ affecting over 90% of males and 80% of females in all ethnic groups.¹⁸In this study, all selected subjects were males in order to avoid menstrual cycle that might have influenced the study result.

A survey of patient’s perception of AV showed that they thought that acne was caused by poor skin hygiene (29%), infection (18%), and dirt as an aggravating factor (61%). Even among medical students, 25% of them thought that poor facial hygiene was an exacerbating factor.¹⁰This study was conducted to provide the right education to the patients about the optimal face washing frequency to reduce the prevalence of acne.

Methods of measuring the severity of AV include simple grading based on clinical examination, lesion counting, and those that require complicated instruments such as photography, fluorescent photography, polarized light photography, video microscopy, and measurement of sebum production. The first person to use a scoring system for AV was Carmen Thomas of Philadelphia, by using lesion counting. In 1956, Pillsbury, Shelley and Kligman published the earliest known grading system.

After that, Burke, Cunliffe and Gibson presented the Leeds technique.¹⁹Doshi et al¹⁵ introduced Global Acne Grading System (GAGS).

In this study, inclusion criteria included mild and moderate acne based on the GAGS scoring system, in which the scoring system can be assessed quickly and easily. The acne severity was assessed by counting the number of each lesion. The relationship between facial washing and AV has not been clearly established. Acne patients usually believe that lack of skin care and

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facial dirt aggravate acne, while dermatologists used to believe that excessive facial washing exacerbates acne and weakens the skin barrier functions.²⁰

A study by Kairavee et al.²¹ concluded that washing face with soap is one of the triggers and can be an aggravating factor of acne. In comparison to our study, most subjects (93%) in that study, the subjects washed their face only with plain water regularly, because they had experienced flares of their acne due to usage of soaps and over time had become more comfortable with plain water usage only.²¹ Another literature also mentioned that washing and scrubbing face vigorously could cause skin irritation and worsen the acne. Washing the face with a cleanser twice a day was recommended to increase and improve therapy results.²²

A study by Choi et al.²⁰ clarified the effect of frequency of face washing on AV. Twenty four subjects were assigned to perform face washing for once, twice, or four times a day for the duration of six weeks. Significant improvement in both open comedones and total non-inflammatory lesions were observed in the group of twice face washing in a day. Worsened condition was observed in once face washing daily group. This study gave recommendation to wash face twice daily with a mild cleanser.²⁰

In this study, group 1 and 2 experienced a reduction in the average number of acne lesions, while on group 3 had increased number of lesions. The result of data analysis between face washing frequency and number of lesions gave significant result in group 1 and only on reduction of comedones with p value <0.05. In addition, most subjects did not experience the side effects that usually arise as a result of washing the face (redness/erythema, scaly, dry, stinging, hot, or itchy). The result on self-evaluation gave out that most subjects felt no improvement in acne lesions.

Limitations of this study included that there were no evaluations conducted between week 0 until week 8 that may cause subjects’ non-adherence, and also objective measurement such as measuring the soap amount before and after the study, and provision of checklist form to ensure subjects’ compliance. These factors may affect the number of drop out subjects in this study.

Conclusion

There were significant results found on group 1 (face washing for once daily) and only supported by reduction of comedones. Most subjects had no complaints and in the self-evaluation assessment, most subjects felt no change in the number of acne lesions before and after the study. In accordance to the results of this study, we recommend to wash the face once daily for acne patients with comedones lesion.

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